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Aus dem Siepen F, Meissner C, Hofmann E, Hein S, Nagel C, Hegenbart U, Schönland SO, Andre F, Frey N, Kristen AV. Response to therapy with tafamidis 61 mg in patients with cardiac transthyretin amyloidosis: real-world experience since approval. Amyloid 2024; 31:226-231. [PMID: 39018203 DOI: 10.1080/13506129.2024.2376202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 06/16/2024] [Accepted: 07/01/2024] [Indexed: 07/19/2024]
Abstract
AIMS Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive disease that causes heart failure due to amyloid fibril deposition. Tafamidis was approved as the first causal treatment in 2020. We here report on real-world data in patients treated with tafamidis for at least 12 months according to the recently defined European Society for Cardiology (ESC) consensus criteria for disease progression. METHODS AND RESULTS Three hundred and eight wildtype and 31 hereditary ATTR-CM patients were prospectively enrolled after first diagnosis of ATTR-CM and initiation of tafamidis 61 mg once daily treatment. After 12 months, significant deterioration in Karnofsky Index, estimated glomerular filtration rate (eGFR), N-terminal brain natriuretic peptide (NT-proBNP), septum thickness and left ventricular ejection fraction (LVEF) could be observed, significant disease progression was only detected in 25 patients (9%) using ESC consensus criteria. Mean survival time was 37 months with no differences between responders and non-responders. NT-proBNP was the only independent predictor for poor therapy response (p = .008). CONCLUSIONS The majority of patients showed no significant disease progression according to the ESC consensus criteria after 12 months of therapy with tafamidis. However, at 12 months, treatment response based on the ESC consensus criteria was not associated with improved survival. Moreover, higher levels of NT-proBNP at diagnosis of ATTR-CM appears to predict poorer treatment response, confirming that timely initiation of therapy is advantageous.
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Affiliation(s)
- Fabian Aus dem Siepen
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Christopher Meissner
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Eva Hofmann
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Selina Hein
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Nagel
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Ute Hegenbart
- Department of Hematology, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan O Schönland
- Department of Hematology, University Hospital Heidelberg, Heidelberg, Germany
| | - Florian Andre
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Arnt V Kristen
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Dasari AKR, Coats MF, Ali AB, Lim KH. Identification of the interfacial regions in misfolded transthyretin oligomers. BIOCHIMICA ET BIOPHYSICA ACTA. PROTEINS AND PROTEOMICS 2024; 1872:141027. [PMID: 38796131 PMCID: PMC11283945 DOI: 10.1016/j.bbapap.2024.141027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 03/14/2024] [Accepted: 05/22/2024] [Indexed: 05/28/2024]
Abstract
Misfolding and aggregation of transthyretin (TTR) is associated with numerous ATTR amyloidosis. TTR aggregates extracted from ATTR patients consist of not only full-length TTR, but also N-terminally truncated TTR fragments that can be produced by proteolytic cleavage, suggesting the presence of multiple misfolding pathways. Here, we report mechanistic studies of an early stage of TTR aggregation to probe the oligomerization process for the full-length as well as N-terminally truncated TTR. Our kinetic analyses using size exclusion chromatography revealed that amyloidogenic monomers dissociated from wild-type (WT) as well as pathogenic variants (V30M and L55P) form misfolded dimers, which self-assemble into oligomers, precursors of fibril formation. Dimeric interfaces in the full-length misfolded oligomers were investigated by examining the effect of single-point mutations on the two β-strands (F and H). The single-point mutations on the two β-strands (E92P on strand F and T119W on strand H) inhibited the dimerization of misfolded monomers, while the TTR variants can still form native dimers through the same F and H strands. These results suggest that the two strands are involved in intermolecular associations for both native and misfolded dimers, but detailed intermolecular interactions are different in the two forms of dimers. In the presence of a proteolytic enzyme, TTR aggregation is greatly accelerated. The two mutations on the two β-strands, however, inhibited TTR aggregation even in the presence of a proteolytic enzyme, trypsin. These results suggest that the two β-strands (F and H) play a critical role in aggregation of the N-terminally truncated TTR as well.
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Affiliation(s)
- Anvesh K R Dasari
- Department of Chemistry, East Carolina University, Greenville, NC 27858, USA
| | - Matthew F Coats
- Department of Chemistry, East Carolina University, Greenville, NC 27858, USA
| | | | - Kwang Hun Lim
- Department of Chemistry, East Carolina University, Greenville, NC 27858, USA.
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Cianci V, Cianci A, Sapienza D, Cracò A, Germanà A, Ieni A, Gualniera P, Asmundo A, Mondello C. Epidemiological Changes in Transthyretin Cardiac Amyloidosis: Evidence from In Vivo Data and Autoptic Series. J Clin Med 2024; 13:5140. [PMID: 39274353 PMCID: PMC11396392 DOI: 10.3390/jcm13175140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 08/27/2024] [Accepted: 08/28/2024] [Indexed: 09/16/2024] Open
Abstract
Cardiac amyloidosis is an infiltrative disease that causes progressive myocardial impairment secondary to amyloid fibril deposition in the extracellular space of the myocardium. Many amyloid precursors, including transthyretin protein, are known to determine cardiac damage by aggregating and precipitating in cardiac tissue. Transthyretin cardiac amyloidosis may be either caused by rare genetic mutations of the transthyretin gene in the hereditary variant, or may arise as a consequence of age-related mechanisms in the acquired form. Although it has been labeled as a rare disease, in recent years, transthyretin cardiac amyloidosis has stood out as an emerging cause of aortic stenosis, unexplained left ventricular hypertrophy and heart failure with preserved ejection fraction, particularly in the elderly. Indeed, the integration of data deriving from both in vivo imaging techniques (whose advancement in the last years has allowed to achieve an easier and more accessible non-invasive diagnosis) and forensic studies (showing a prevalence of amyloid deposition in cardiac tissue of elderly patients up to 29%) suggests that cardiac amyloidosis is a more common disease than traditionally considered. Thanks to all the improvements in non-invasive diagnostic techniques, along with the development of efficacious therapies offering improvements in survival rates, transthyretin cardiac amyloidosis has been transformed from an incurable and infrequent condition to a relatively more diffuse and treatable disease, which physicians should take into consideration in the differential diagnostic processes in daily clinical practice.
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Affiliation(s)
- Vincenzo Cianci
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Legal Medicine, University of Messina, Via Consolare Valeria, 1, 98125 Messina, Italy
| | - Alessio Cianci
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Daniela Sapienza
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Legal Medicine, University of Messina, Via Consolare Valeria, 1, 98125 Messina, Italy
| | - Annalisa Cracò
- Department of Biomedical Sciences and Morphological and Functional Imaging, Diagnostic and Interventional Radiology Unit, University Hospital Messina, 98168 Messina, Italy
| | - Antonino Germanà
- Zebrafish Neuromorphology Lab, Department of Veterinary Sciences, Via Palatucci snc, University of Messina, 98168 Messina, Italy
| | - Antonio Ieni
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", Section of Pathology, University of Messina, 98125 Messina, Italy
| | - Patrizia Gualniera
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Legal Medicine, University of Messina, Via Consolare Valeria, 1, 98125 Messina, Italy
| | - Alessio Asmundo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Legal Medicine, University of Messina, Via Consolare Valeria, 1, 98125 Messina, Italy
| | - Cristina Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Legal Medicine, University of Messina, Via Consolare Valeria, 1, 98125 Messina, Italy
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Llerena-Velastegui J, Zumbana-Podaneva K. Advances in the Diagnosis and Management of Cardiac Amyloidosis: A Literature Review. Cardiol Res 2024; 15:211-222. [PMID: 39205961 PMCID: PMC11349137 DOI: 10.14740/cr1664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 06/10/2024] [Indexed: 09/04/2024] Open
Abstract
Cardiac amyloidosis, increasingly recognized for its significant impact on global heart health and patient survival, demands a thorough review to understand its complexity and the urgency of improved management strategies. As a cause of cardiomyopathy and heart failure, particularly in patients with aortic stenosis and atrial fibrillation, this condition also relates to higher incidences of dementia in the affected populations. The objective of this review was to integrate and discuss the latest advancements in diagnostics and therapeutics for cardiac amyloidosis, emphasizing the implications for patient prognosis. We evaluated the latest literature from major medical databases such as PubMed and Scopus, focusing on research from 2020 to 2024, to gather comprehensive insights into the current landscape of this condition. Insights from our review highlight the complex pathophysiology of cardiac amyloidosis and the diagnostic challenges it presents. We detail the effectiveness of emerging treatments, notably gene silencing therapies like patisiran and vutrisiran, which offer transformative potential by targeting the production of amyloidogenic proteins. Additionally, the stabilization therapy acoramidis shows promise in modifying disease progression and improving clinical outcomes. This review underscores the critical need for updated clinical guidelines and further research to expand access to groundbreaking therapies and enhance disease management. Advocating for continued research and policy support, we emphasize the importance of advancing diagnostic precision and treatment effectiveness, which are vital for improving patient outcomes and addressing this debilitating disease globally.
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Affiliation(s)
- Jordan Llerena-Velastegui
- Medical School, Pontifical Catholic University of Ecuador, Quito, Ecuador
- Research Center, Center for Health Research in Latin America (CISeAL), Quito, Ecuador.
| | - Kristina Zumbana-Podaneva
- Medical School, Pontifical Catholic University of Ecuador, Quito, Ecuador
- Research Center, Center for Health Research in Latin America (CISeAL), Quito, Ecuador.
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Maurer MS, Soman P, Hernandez A, Garcia-Pavia P, Signorovitch J, Wei LJ, Hanna M, Ruberg FL, Kittleson M, Kazi D, Dorbala S, Hsu K, Lousada I, Adigun R, Dunnmon P, Kelly J, Gillmore J. Advancing Transthyretin Amyloidosis Drug Development in an Evolving Treatment Landscape: Amyloidosis Forum Meeting Proceedings. Adv Ther 2024; 41:2723-2742. [PMID: 38833142 PMCID: PMC11334214 DOI: 10.1007/s12325-024-02891-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/29/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Hereditary transthyretin amyloidosis (ATTRv, also referred to as hATTR; ORPHA 271861) and wild-type ATTR amyloidosis (ATTRwt; ORPHA 330001) are rare, progressive, systemic protein misfolding disorders with heterogeneous clinical presentations. ATTRv and ATTRwt amyloidosis are characterized by the deposition of amyloid fibrils in multiple organs including the heart, nerves, eyes, and soft tissues. The management of ATTR amyloidosis is complex because of its multisystemic nature and progression despite available treatment options. Morbidity is high and there are many unmet medical needs for patients. While contemporary ATTR amyloidosis cohorts are diagnosed earlier, have lower risk disease and lower mortality compared with the previous era, these advances coupled with the emergence of effective disease-modifying therapies have confounded the design of future prospective clinical trials and interpretation of historical control data. MAIN BODY The Amyloidosis Forum is a public-private partnership between the US Food and Drug Administration Center for Drug Evaluation and Research and the nonprofit Amyloidosis Research Consortium ( www.arci.org ). This article summarizes proceedings from the 21 June 2023 Amyloidosis Forum on advancing drug development in ATTR amyloidosis in an evolving treatment landscape. The Forum focused on elements of clinical trial design to address these challenges and discussed their strengths and weaknesses from multiple stakeholder perspectives (i.e., patient, sponsor, statistician, clinician, and regulatory authorities). CONCLUSION Given rapid evolution of natural history in ATTR amyloidosis, the utility of historical control data is limited. Leveraging contemporary real-world data is essential for clinical trial design. Evidence generation from clinical trials should address clinically relevant questions. Key factors in successful trial design must be informed by up-to-date data on natural history, prognostic factors, clinically meaningful thresholds, and sharing available clinical trial data. The Amyloidosis Forum includes the community of patients with ATTR amyloidosis, the physicians who treat them, and the sponsors and regulators who collectively stand ready to support further studies in order to develop novel effective therapies.
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Affiliation(s)
- Mathew S Maurer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Prem Soman
- University of Pittsburgh Medical Center, UPMC Heart and Vascular Institute, Cardiac Amyloidosis Center, Pittsburg, PA, USA
| | - Adrian Hernandez
- Duke University School of Medicine, Duke Clinical Research Center, Durham, NC, USA
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, Madrid, Spain
- Spanish National Cardiovascular Research Institute (CNIC), Madrid, Spain
| | | | - L J Wei
- T.H. Chan School of Public Health, Biostatistics, Harvard University, Boston, MA, USA
| | - Mazen Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Frederick L Ruberg
- Chobanian and Avedisian School of Medicine, Department of Medicine, Boston University, Boston, MA, USA
| | | | - Dhruv Kazi
- Beth Israel Deaconess Medical Center, Cardiac Critical Care Unit; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Health Economics, Boston, MA, USA
| | - Sharmila Dorbala
- Brigham and Women's Hospital, Cardiovascular Medicine, Nuclear Radiology, Boston, MA, USA
| | - Kristen Hsu
- Amyloidosis Research Consortium, 320 Nevada Street, Suite 210, Newton, MA, 02460, USA
| | - Isabelle Lousada
- Amyloidosis Research Consortium, 320 Nevada Street, Suite 210, Newton, MA, 02460, USA.
| | - Rosalyn Adigun
- Center for Drug Evaluation and Research, Division of Cardiology and Nephrology, US Food and Drug Administration, Silver Spring, MD, USA
| | - Preston Dunnmon
- Janssen Research and Development Data Sciences, Cardiovascular/Metabolic and Pulmonary Hypertension, Raritan, NJ, USA
| | - Jeffery Kelly
- Department of Chemistry, Scripps Research Institute, San Diego, CA, USA
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6
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Gannon NP, Ward CM. Results of Implementation of Amyloidosis Screening for Patients Undergoing Carpal Tunnel Release. J Hand Surg Am 2024; 49:675-680. [PMID: 36646584 DOI: 10.1016/j.jhsa.2022.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/16/2022] [Accepted: 09/12/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE Many patients with amyloidosis undergo carpal tunnel release (CTR) before amyloidosis diagnosis and before developing cardiac or other serious disease manifestations. The purposes of this study were to examine if our patient population had a similar prevalence of positive amyloidosis diagnoses to that in prior studies and to describe the results of implementing a screening program for amyloidosis. METHODS We retrospectively reviewed the biopsy results and subsequent interventions for all patients who underwent screening tenosynovial biopsy during CTR from March 2020 through December 2021. Amyloid screening was offered to patients who met the criteria for increased risk of disease using an appropriateness screening algorithm. RESULTS Seventy-five (48%) of 156 patients who underwent CTR met the eligibility criteria for amyloidosis testing. Of the 62 patients who agreed to undergo tenosynovial biopsy, 14 had amyloid-positive biopsy specimens (10 men and 4 women). All patients with positive tenosynovial biopsies had bilateral carpal tunnel syndrome and wild-type transthyretin amyloid subtype. One patient was diagnosed and started treatment for otherwise asymptomatic cardiac amyloidosis. CONCLUSIONS The incidence of amyloid-positive tenosynovial biopsy results from CTR was 22.5% in patients using the criteria from an appropriateness screening algorithm, which was higher than previously reported. Implementation of a screening program for patients undergoing CTR requires a multidisciplinary approach and may result in early diagnosis and lifesaving interventions for patients with amyloidosis. TYPE OF STUDY/LEVEL OF EVIDENCE Differential diagnosis/symptom prevalence study, II.
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Affiliation(s)
- Nicholas P Gannon
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN
| | - Christina M Ward
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN; Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN.
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Morfino P, Aimo A, Franzini M, Vergaro G, Castiglione V, Panichella G, Limongelli G, Emdin M. Pathophysiology of Cardiac Amyloidosis. Heart Fail Clin 2024; 20:261-270. [PMID: 38844297 DOI: 10.1016/j.hfc.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
Amyloidosis refers to a heterogeneous group of disorders sharing common pathophysiological mechanisms characterized by the extracellular accumulation of fibrillar deposits consisting of the aggregation of misfolded proteins. Cardiac amyloidosis (CA), usually caused by deposition of misfolded transthyretin or immunoglobulin light chains, is an increasingly recognized cause of heart failure burdened by a poor prognosis. CA manifests with a restrictive cardiomyopathy which progressively leads to biventricular thickening, diastolic and then systolic dysfunction, arrhythmias, and valvular disease. The pathophysiology of CA is multifactorial and includes increased oxidative stress, mitochondrial damage, apoptosis, impaired metabolism, and modifications of intracellular calcium balance.
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Affiliation(s)
| | - Alberto Aimo
- Fondazione Toscana Gabriele Monasterio, via G. Moruzzi 1, 56124, Pisa, Italy; Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Maria Franzini
- Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Pisa, Italy
| | - Giuseppe Vergaro
- Fondazione Toscana Gabriele Monasterio, via G. Moruzzi 1, 56124, Pisa, Italy; Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Vincenzo Castiglione
- Fondazione Toscana Gabriele Monasterio, via G. Moruzzi 1, 56124, Pisa, Italy; Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Giorgia Panichella
- Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Michele Emdin
- Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, via G. Moruzzi 1, 56124, Pisa, Italy.
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Del Franco A, Biagioni G, Mazzoni C, Argirò A, Zampieri M, Cappelli F. Standard Therapy in Cardiac Amyloidosis: What is Known, What is "Gray". Heart Fail Clin 2024; 20:325-331. [PMID: 38844303 DOI: 10.1016/j.hfc.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
Amyloidosis is a systemic disease due to the accumulation of misfolded amyloid fibrils that damage the heart and worsen the prognosis. Heart failure (HF), a condition frequently linked with an advanced stage of this disease, is the most prevalent clinical manifestation that leads to its diagnosis. However, due to the growing awareness of the occurrence of cardiac amyloidosis (CA), it is now possible to perform an early diagnosis and have a positive impact on its natural course. This study aims to highlight the most compelling issues concerning patients' clinical management with HF and CA.
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Affiliation(s)
- Annamaria Del Franco
- Cardiomyopathy Division, Careggi University Hospital, Aou Careggi, Largo Brambilla 3, Florence 50134, Italy.
| | - Giulia Biagioni
- Cardiomyopathy Division, Careggi University Hospital, Aou Careggi, Largo Brambilla 3, Florence 50134, Italy
| | - Carlotta Mazzoni
- Cardiomyopathy Division, Careggi University Hospital, Aou Careggi, Largo Brambilla 3, Florence 50134, Italy
| | - Alessia Argirò
- Cardiomyopathy Division, Careggi University Hospital, Aou Careggi, Largo Brambilla 3, Florence 50134, Italy
| | - Mattia Zampieri
- Cardiology Division, IRCCS Meyer Children's Hospital, Pieraccini Street 24, Florence, Florence 50139, Italy
| | - Francesco Cappelli
- Cardiomyopathy Division, Careggi University Hospital, Aou Careggi, Largo Brambilla 3, Florence 50134, Italy; University of Florence, Florence, Italy
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Tore D, Faletti R, Palmisano A, Salto S, Rocco K, Santonocito A, Gaetani C, Biondo A, Bozzo E, Giorgino F, Landolfi I, Menchini F, Esposito A, Fonio P, Gatti M. Cardiac computed tomography with late contrast enhancement: A review. Heliyon 2024; 10:e32436. [PMID: 38933964 PMCID: PMC11200357 DOI: 10.1016/j.heliyon.2024.e32436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 05/19/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
Cardiac computed tomography (CCT) has assumed an increasingly significant role in the evaluation of coronary artery disease (CAD) during the past few decades, whereas cardiovascular magnetic resonance (CMR) remains the gold standard for myocardial tissue characterization. The discovery of late myocardial enhancement following intravenous contrast administration dates back to the 1970s with ex-vivo CT animal investigations; nevertheless, the clinical application of this phenomenon for cardiac tissue characterization became prevalent for CMR imaging far earlier than for CCT imaging. Recently the technical advances in CT scanners have made it possible to take advantage of late contrast enhancement (LCE) for tissue characterization in CCT exams. Moreover, the introduction of extracellular volume calculation (ECV) on cardiac CT images combined with the possibility of evaluating cardiac function in the same exam is making CCT imaging a multiparametric technique more and more similar to CMR. The aim of our review is to provide a comprehensive overview on the role of CCT with LCE in the evaluation of a wide range of cardiac conditions.
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Affiliation(s)
- Davide Tore
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Riccardo Faletti
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Anna Palmisano
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Salto
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Katia Rocco
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Ambra Santonocito
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Clara Gaetani
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Andrea Biondo
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Elena Bozzo
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Fabio Giorgino
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Ilenia Landolfi
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Francesca Menchini
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Antonio Esposito
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Fonio
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Marco Gatti
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
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Zhang Y, Wang X, Ren C, Shen K, Huo L. 18 F-Florbetapir PET/CT and 68 Ga-FAPI PET/CT in a Case of Light Chain Amyloidosis With Predominant Multiple Tumor-Like Deposits. Clin Nucl Med 2024; 49:486-488. [PMID: 38465960 DOI: 10.1097/rlu.0000000000005145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
ABSTRACT A 66-year-old man presented with multiple masses in different regions, including the left groin, back subcutaneous area, and lungs. Pathological examination confirmed localized amyloid deposits after 3 surgeries. Serum-free λ light chains were elevated. To evaluate systemic involvement, the patient underwent 18 F-Florbetapir PET/CT and 68 Ga-FAPI-04 PET/CT. Both scans showed increased uptake in multiple masses and nodules throughout the body. This report presents a rare case of light chain (AL) amyloidosis, primarily characterized by multiple localized tumor-like deposits with high activity on 18 F-Florbetapir PET/CT and 68 Ga-FAPI-04 PET/CT.
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Affiliation(s)
- Yuke Zhang
- From the Departments of Nuclear Medicine
| | | | - Chao Ren
- From the Departments of Nuclear Medicine
| | - Kaini Shen
- Hematology, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Center for Rare Diseases Research, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li Huo
- From the Departments of Nuclear Medicine
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11
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aus dem Siepen F, Hein S, Hofmann E, Nagel C, Schwarting SK, Hegenbart U, Schönland SO, Weiler M, Frey N, Kristen AV. Prognostic Value of Standard Heart Failure Medication in Patients with Cardiac Transthyretin Amyloidosis. J Clin Med 2024; 13:2257. [PMID: 38673530 PMCID: PMC11051169 DOI: 10.3390/jcm13082257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/24/2024] [Accepted: 04/02/2024] [Indexed: 04/28/2024] Open
Abstract
Introduction: Cardiac transthyretin amyloidosis (ATTR) is a progressive, fatal disease leading to heart failure due to accumulation of amyloid fibrils in the interstitial space and may occur as a hereditary (ATTRv) or wild-type (ATTRwt) form. Guidelines recommend the use of ACE inhibitors (ACEis) and beta-blockers (BBs) as heart failure therapy (HFT) in all patients with symptomatic heart failure and reduced ejection fraction, independent of the underlying etiology. However, the prognostic benefit of ACEis and BBs in ATTR has not been elucidated in detail yet. We thus sought to retrospectively investigate the outcome of patients with ATTRwt or ATTRv under HFT. Methods: Medical records of 403 patients with cardiac ATTR (ATTRwt: n = 268, ATTRv: n = 135) were screened for long-term medication as well as clinical, laboratory, electrocardiographic and echocardiographic data. Patients were assessed between 2005 and 2020 at the University Hospital Heidelberg. Kaplan-Meier analysis was used to analyze potential differences in survival among different subgroups. Results: The mean follow-up was 28 months. In total, 43 patients (32%) with ATTRv and 140 patients (52%) with ATTRwt received HFT. Survival was significantly shorter in patients receiving HFT in ATTRv (46 vs. 83 months, p = 0.0007) vs. non-HFT. A significantly better survival was observed in patients with comorbidities (coronary artery disease, arterial hypertension) and HFT among ATTRwt patients (p = 0.004). No significant differences in survival were observed in the other subgroups. Conclusions: Survival analysis revealed a potential benefit of HFT in patients with ATTRwt and cardiac comorbidities such as coronary artery disease and/or arterial hypertension. In contrast, HFT should be used with caution in patients with ATTRv.
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Affiliation(s)
- Fabian aus dem Siepen
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany; (S.H.); (E.H.); (C.N.); (S.K.S.); (N.F.); (A.V.K.)
| | - Selina Hein
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany; (S.H.); (E.H.); (C.N.); (S.K.S.); (N.F.); (A.V.K.)
| | - Eva Hofmann
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany; (S.H.); (E.H.); (C.N.); (S.K.S.); (N.F.); (A.V.K.)
| | - Christian Nagel
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany; (S.H.); (E.H.); (C.N.); (S.K.S.); (N.F.); (A.V.K.)
| | - Stéphanie K. Schwarting
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany; (S.H.); (E.H.); (C.N.); (S.K.S.); (N.F.); (A.V.K.)
| | - Ute Hegenbart
- Department of Hematology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (U.H.); (S.O.S.)
| | - Stefan O. Schönland
- Department of Hematology, University Hospital Heidelberg, 69120 Heidelberg, Germany; (U.H.); (S.O.S.)
| | - Markus Weiler
- Department of Neurology, University Hospital Heidelberg, 69120 Heidelberg, Germany;
| | - Norbert Frey
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany; (S.H.); (E.H.); (C.N.); (S.K.S.); (N.F.); (A.V.K.)
| | - Arnt V. Kristen
- Department of Cardiology, Angiology and Respiratory Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany; (S.H.); (E.H.); (C.N.); (S.K.S.); (N.F.); (A.V.K.)
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12
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Wang J, Chen D, Dong F, Chi H. Diagnostic Sensitivity of Abdominal Fat Aspiration Biopsy for Cardiac Amyloidosis: A Systematic Review and Meta-Analysis. Int J Surg Pathol 2024; 32:286-293. [PMID: 37282575 DOI: 10.1177/10668969231177603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Introduction. Cardiac amyloidosis is a lethal disease, the incidence of which is increasing every year. Early diagnosis and treatment are the keys to reducing the mortality of this disease. Methods. Relevant English literature published in Embase, PubMed, Cochrane Library, and Web of Science were searched until December 1, 2022. Meta-analysis was performed with Stata 17.0 software. Results. A total of 1060 patients with 5 articles were included in this study. The sensitivity of abdominal fat aspiration biopsy for the diagnosis of cardiac amyloidosis was 0.66 (0.48-0.84) and the sensitivity for light chain amyloidosis cardiomyopathy and transthyretin amyloidosis cardiomyopathy was 0.90 (0.80-0.97) and 0.39 (0.18-0.60), respectively. Conclusion. Abdominal fat aspiration biopsy has high sensitivity and clinical value in the diagnosis of light chain amyloidosis cardiomyopathy, whereas there are limitations in the diagnosis of transthyretin amyloidosis cardiomyopathy.
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Affiliation(s)
- Jiaqi Wang
- Department of Pathology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dong Chen
- Department of Pathology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Fang Dong
- Department of Pathology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haochen Chi
- Department of Neurology, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
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13
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Del Carmen Mallón Araujo M, Casas EAJ, Casas CAJ, Monzonis MAM, Morell ÁR, Núñez VP. Cardiac scintigraphy and echocardiography assessment in the diagnosis of transthyretin cardiac amyloidosis. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:415-424. [PMID: 37943369 DOI: 10.1007/s10554-023-02987-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/14/2023] [Indexed: 11/10/2023]
Abstract
The aim is to evaluate the diagnostic yield of echocardiography and [99mTc]Tc-DPD scintigraphy in the detection of amyloid cardiomyopathy (CM) and define potential prognostic echocardiographic parameters. 133 patients were retrospectively studied, from 2016 to 2021, with a mean age of 80.2 ± 7.5 years. The final diagnosis was established according to international consensus. Patients had a transthoracic echocardiogram (TTE) and [99mTc]Tc-DPD scintigraphy; RWT, E/e, LS, TAPSE, SAB, and IWT scores were calculated. All patients with ATTR-CM were classified into 3 prognostic stages and were compared with Perugini grades and echocardiographic parameters. CM was confirmed in 85 cases (63.9%), 76 (57.1%) ATTR-CM, and 9 (6.8%) AL-CM. The diagnostic yield of [99mTc]Tc-DPD scintigraphy and echocardiography were calculated, with a sensitivity of 90.7%, specificity of 100%, PPV of 100%, and NPV of 87.2% in myocardial scintigraphy, versus 74.6%, 62.5%, 75.6%, 61.2% in the echocardiogram. According to the IWT score, most patients were classified in the intermediate group; 33 presented with grade 2-3 uptakes. Significant results were obtained when comparing Perugini score with IWT (p: 0.02) and SAB (p: 0.03); and between biomarkers stages and LVEF (p: 0.028), E/e´ (p: 0.001), and GLS% (p: 0.022). [99mTc]Tc-DPD scintigraphy is superior in diagnosing CA. SAB could be the most reliable parameter in an early diagnostic phase, showing a strong correlation with Perugini grades 2 and 3.
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Affiliation(s)
| | - Estephany Abou Jokh Casas
- Nuclear Medicine Department, Lucus Augusti University Hospital, Rúa Dr. Ulises Romero, 1, 27003, Lugo, Spain.
| | | | | | - Álvaro Ruibal Morell
- Nuclear Medicine Department, Santiago de Compostela University Hospital, 15706, A Coruña, Spain
| | - Virginia Pubul Núñez
- Nuclear Medicine Department, Santiago de Compostela University Hospital, 15706, A Coruña, Spain
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14
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Santiago LE, Alvi AT, Melnychuk V, Mesquita P, Aneja P. Light-Chain (AL) Cardiac Amyloidosis Presenting as Heart Failure With Reduced Ejection Fraction. Cureus 2024; 16:e55271. [PMID: 38558722 PMCID: PMC10981542 DOI: 10.7759/cureus.55271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Systemic amyloidosis is caused by the extracellular deposition of misfolded proteins in various organs and usually leads to organ dysfunction. The two common subtypes include light-chain amyloidosis and transthyretin amyloidosis. Deposition of these proteins in the heart can lead to infiltrative and restrictive cardiomyopathy, commonly manifesting as heart failure with preserved ejection fraction. However, systolic heart failure with reduced ejection fraction is mainly seen in the advanced stages of the disease. Here, we present the case of a 53-year-old female who presented with new-onset heart failure with reduced ejection fraction with no prior symptoms or diagnosis of amyloidosis and diastolic dysfunction.
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Affiliation(s)
- Luis E Santiago
- Internal Medicine, HCA Florida Northwest Hospital, Margate, USA
- Internal Medicine, HCA Florida Westside Hospital, Plantation, USA
| | - Ali Tariq Alvi
- Internal Medicine, HCA Florida Northwest Hospital, Margate, USA
- Internal Medicine, HCA Florida Westside Hospital, Plantation, USA
| | - Veniamin Melnychuk
- Internal Medicine, HCA Florida Northwest Hospital, Margate, USA
- Internal Medicine, HCA Florida Westside Hospital, Plantation, USA
| | - Philip Mesquita
- Internal Medicine, HCA Florida Northwest Hospital, Margate, USA
- Internal Medicine, HCA Florida Westside Hospital, Plantation, USA
| | - Pallavi Aneja
- Internal Medicine, HCA Florida Northwest Hospital, Margate, USA
- Internal Medicine, HCA Florida Westside Hospital, Plantation, USA
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15
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Smith MA, Feinglass NG. Perioperative implications of amyloidosis and amyloid cardiomyopathy: A review for anesthesiologists. J Clin Anesth 2024; 92:111271. [PMID: 37820520 DOI: 10.1016/j.jclinane.2023.111271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/17/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023]
Abstract
It is well recognized that amyloid protein can infiltrate many regions of the body. This can include the peripheral nerves, the liver, kidney, spleen, the gastrointestinal tract, and most importantly the myocardium. The amyloid proteins that cause cardiomyopathy may come from genetically altered liver genes (transthyretin amyloid, ATTR) or from the bone marrow with malignant plasma cells (light chain amyloid, AL) generating the aberrant protein. These two types of amyloidosis cause significant damaging effects on both the myocardial cells as well as the conduction system of the heart. The resultant changes can produce dyspnea and exercise intolerance which is thought to be secondary to diastolic dysfunction and reduced stroke volume. This subclinical decompensation poses a significant problem for members of a care team as it often goes unrecognized. In the operating room patients are exposed to dramatic hemodynamic changes and may have difficult airways, autonomic dysfunction, and conduction abnormalities. Although the topic of amyloidosis is well described in cardiology literature, it is underdiagnosed. The purpose of this review is to describe some of the pathophysiology behind the principle proteins that cause cardiac amyloidosis and to comprehensively describe perioperative considerations for anesthesia providers.
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Affiliation(s)
- Michael A Smith
- Mayo Clinic Dept. Anesthesiology and Perioperative Medicine, Critical Care Medicine, Mayo Graduate School of Medicine, USA.
| | - Neil G Feinglass
- Mayo Clinic Dept. Anesthesiology and Perioperative Medicine, Mayo Graduate School of Medicine, USA
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16
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Brownell D, Pillai AJ, Nair N. Cardiac Amyloidosis: A Contemporary Review of Medical and Surgical Therapy. Curr Cardiol Rev 2024; 20:72-81. [PMID: 38682372 PMCID: PMC11107466 DOI: 10.2174/011573403x240302230925043500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 07/18/2023] [Accepted: 08/28/2023] [Indexed: 05/01/2024] Open
Abstract
Amyloidosis is a systemic disease initiated by deposition of misfolded proteins in the extracellular space, due to which multiple organs may be affected concomitantly. Cardiac amyloidosis, however, remains a major cause of morbidity and mortality in this population due to infiltrative /restrictive cardiomyopathy. This review attempts to focus on contemporary medical and surgical therapies for the different types of cardiac amyloidosis. Amyloidosis affecting the heart are predominantly of the transthyretin type (acquired in the older or genetic in the younger patients), and the monoclonal immunoglobulin light chain (AL) type which is solely acquired. A rare form of secondary amyloidosis AA type can also affect the heart due to excessive production and accumulation of the acute-phase protein called Serum Amyloid A" (SAA) in the setting of chronic inflammation, cancers or autoinflammatory disease. More commonly AA amyloidosis is seen in the liver and kidney. Other rare types are Apo A1 and Isolated Atrial Amyloidosis (AANF). Medical therapies have made important strides in the clinical management of the two common types of cardiac amyloidosis. Surgical therapies such as mechanical circulatory support and cardiac transplantation should be considered in appropriate patients. Future research using AI driven algorithms for early diagnosis and treatment as well as development of newer genetic engineering technologies will drive improvements in diagnosis, treatment and patient outcomes.
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Affiliation(s)
- Drew Brownell
- Division of Cardiology, Department of Medicine, Texas Tech Health Science Center, Lubbock, TX, 79430, USA
| | - Aiswarya J. Pillai
- Division of Cardiology, Department of Medicine, Texas Tech Health Science Center, Lubbock, TX, 79430, USA
| | - Nandini Nair
- Division of Cardiology, Department of Medicine, Texas Tech Health Science Center, Lubbock, TX, 79430, USA
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17
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Argon A, Nart D, Yılmaz Barbet F. Cardiac Amyloidosis: Clinical Features, Pathogenesis, Diagnosis, and Treatment. Turk Patoloji Derg 2024; 40:1-9. [PMID: 38111336 PMCID: PMC10823787 DOI: 10.5146/tjpath.2023.12923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/02/2023] [Indexed: 12/20/2023] Open
Abstract
Cardiac amyloidosis is a type of amyloidosis that deserves special attention as organ involvement significantly worsens the prognosis. Cardiac amyloidosis can be grouped under three main headings: immunoglobulin light chain (AL) amyloidosis that is dependent on amyloidogenic monoclonal light chain production; hereditary Transthyretin (TTR) amyloidosis that results from accumulation of mutated TTR; and wild-type (non-hereditary) TTR amyloidosis formerly known as senile amyloidosis. Although all three types cause morbidity and mortality due to severe heart failure when untreated, they contain differences in their pathogenesis, clinical findings, and treatment. In this article, the clinical features, pathogenesis, diagnosis, and treatment methods of cardiac amyloidosis will be explained with an overview, and an awareness will be raised in the diagnosis of this disease.
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Affiliation(s)
- Asuman Argon
- Department of Pathology, Health Sciences University, Izmir Faculty of Medicine, Izmir, Turkey
| | - Deniz Nart
- Ege University, Faculty of Medicine, Izmir, Turkey
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18
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Zhou XY, Tang CX, Guo YK, Chen WC, Guo JZ, Ren GS, Li X, Li JH, Lu GM, Huang XH, Wang YN, Zhang LJ, Yang GF. Late gadolinium enhanced cardiac MR derived radiomics approach for predicting all-cause mortality in cardiac amyloidosis: a multicenter study. Eur Radiol 2024; 34:402-410. [PMID: 37552255 DOI: 10.1007/s00330-023-09999-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 05/03/2023] [Accepted: 06/05/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVES To evaluate the prognostic value of radiomics features based on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) images in patients with cardiac amyloidosis (CA). METHODS This retrospective study included 120 CA patients undergoing CMR at three institutions. Radiomics features were extracted from global and three different segments (base, mid-ventricular, and apex) of left ventricular (LV) on short-axis LGE images. Primary endpoint was all-cause mortality. The predictive performance of the radiomics features and semi-quantitative and quantitative LGE parameters were compared by ROC. The AUC was used to observe whether Rad-score had an incremental value for clinical stage. The Kaplan-Meier curve was used to further stratify the risk of CA patients. RESULTS During a median follow-up of 12.9 months, 30% (40/120) patients died. There was no significant difference in the predictive performance of the radiomics model in different LV sections in the validation set (AUCs of the global, basal, middle, and apical radiomics model were 0.75, 0.77, 0.76, and 0.77, respectively; all p > 0.05). The predictive performance of the Rad-score of the base-LV was better than that of the LGE total enhancement mass (AUC:0.77 vs. 0.54, p < 0.001) and LGE extent (AUC: 0.77 vs. 0.53, p = 0.004). Rad-score combined with Mayo stage had better predictive performance than Mayo stage alone (AUC: 0.86 vs. 0.81, p = 0.03). Rad-score (≥ 0.66) contributed to the risk stratification of all-cause mortality in CA. CONCLUSIONS Compared to quantitative LGE parameters, radiomics can better predict all-cause mortality in CA, while the combination of radiomics and Mayo stage could provide higher predictive accuracy. CLINICAL RELEVANCE STATEMENT Radiomics analysis provides incremental value and improved risk stratification for all-cause mortality in patients with cardiac amyloidosis. KEY POINTS • Radiomics in LV-base was superior to LGE semi-quantitative and quantitative parameters for predicting all-cause mortality in CA. • Rad-score combined with Mayo stage had better predictive performance than Mayo stage alone or radiomics alone. • Rad-score ≥ 0.66 was associated with a significantly increased risk of all-cause mortality in CA patients.
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Affiliation(s)
- Xi Yang Zhou
- Department of Nuclear Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Chun Xiang Tang
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Ying Kun Guo
- Department of Radiology, West China Second University Hospital, Sichuan University, 20# South Renmin Road, Chengdu, 610041, Sichuan, China
| | - Wen Cui Chen
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, Jiangsu, China
| | - Jin Zhou Guo
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, Jiangsu, China
| | - Gui Sheng Ren
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, Jiangsu, China
| | - Xiao Li
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Jun Hao Li
- Department of Nuclear Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Guang Ming Lu
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Xiang Hua Huang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, Jiangsu, China
| | - Yi Ning Wang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Long Jiang Zhang
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China.
| | - Gui Fen Yang
- Department of Nuclear Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China.
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Ali GMS, Seme WAE, Dudhat K. Examining the Difficulties in Identifying and Handling Cardiac Amyloidosis; Acquiring Important Knowledge and Robust Treatment Methods. Cardiovasc Hematol Disord Drug Targets 2024; 24:65-82. [PMID: 39075963 DOI: 10.2174/011871529x301954240715041558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 06/20/2024] [Accepted: 07/04/2024] [Indexed: 07/31/2024]
Abstract
Systemic amyloidosis is a rare protein misfolding and deposition condition that causes slow organ failure. Each of the more than 15 exclusive sorts of systemic amyloidosis, which encourage amyloid production and tissue deposition, is introduced by a unique precursor protein. Amyloidosis can affect various organs, including the heart, kidneys, liver, nerves, gastrointestinal tract, lungs, muscles, skin, and soft tissues. It can either be acquired or hereditary. Insidious and doubtful signs often cause a put-off in diagnosis. In the closing decade, noteworthy progressions have been made in the identity, prediction, and handling of amyloidosis. Shotgun proteomics based on mass spectrometry has revolutionized amyloid typing and enabled the identification of novel amyloid forms. It is critical to correctly identify the precursor protein implicated in amyloidosis because the kind of protein influences the proper treatment strategy. Cardiac amyloidosis is a disorder characterized by the systemic accumulation of amyloid protein in the myocardium's extracellular space, which causes a variety of symptoms. The buildup of amyloid aggregates precipitates myocardial thickening and stiffening, culminating in diastolic dysfunction and, in due course, heart failure. We examine every kind of systemic amyloidosis in this text to offer practitioners beneficial equipment for diagnosing and treating those unusual diseases. This review presents a comprehensive analysis of cardiac amyloidosis and consolidates current methods for screening, diagnosis, evaluation, and treatment alternatives.
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Affiliation(s)
| | | | - Kiran Dudhat
- School of Pharmacy, RK University, Kasturbadham, Rajkot, Gujarat, 360020, India
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20
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Pack AP, Zuleta A, Daugerdas E, Huang W, Batio S, Svoboda S, Zeitler EP, Kumar N, Watt S, Fernandez-Arias MI, Bader M, Assaf AR, Bailey SC. Developing, optimizing, and evaluating patient infographics for diagnosing cardiac amyloidosis. PEC INNOVATION 2023; 3:100212. [PMID: 37743956 PMCID: PMC10514075 DOI: 10.1016/j.pecinn.2023.100212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 09/26/2023]
Abstract
Objective Advancements in diagnostics and treatment options for cardiac amyloidosis have improved patient outcomes, yet few patient education materials exist to help patients understand the disease and diagnosis process. We sought to develop and evaluate a set of plain language, patient-centered infographics describing the condition and common diagnostic tests. Methods Using health literacy best practices, we developed 7 infographics which were further revised based on multilevel stakeholder feedback. To evaluate the materials, we recruited 100 patients from healthcare settings in Chicago, IL; participants completed a web-assisted interview during which they were randomized 1:1 to first view either our infographics or a standard material. Participants completed a knowledge assessment on their assigned material and subsequently reported impressions of both materials. Results No differences were found between study arms in knowledge. The infographics took significantly less time to read and were more highly rated by participants in terms of appearance and understandability. Over two-thirds of participants preferred the infographics to the standard. Conclusions The infographics created may improve the learning process about a complex condition and diagnosis process unknown to most adults. Innovation These infographics are the first of their kind for cardiac amyloidosis and were created using health literacy best practices.
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Affiliation(s)
- Allison P. Pack
- Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, United States of America
| | - Andrea Zuleta
- Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, United States of America
| | - Eleanor Daugerdas
- Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, United States of America
| | - Wei Huang
- Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, United States of America
| | - Stephanie Batio
- Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, United States of America
| | - Sophia Svoboda
- Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, United States of America
| | - Emily P. Zeitler
- Dartmouth Hitchcock Medical Center, Heart and Vascular Center, Cardiovascular Section, The Dartmouth Institute, Geisel School of Medicine at Dartmouth, United States of America
| | | | | | | | | | - Annlouise R. Assaf
- Pfizer, Inc, United States of America
- Brown University School of Public Health, United States of America
| | - Stacy Cooper Bailey
- Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, United States of America
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21
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Orlov FI, Ansheles AA, Nasonova SN, Saidova MA, Zhirov IV, Stepanova EA, Suvorina MY, Shoshina AA, Tereshchenko SN, Sergienko VB. [Difficulties in differential diagnosis of the AL- and ATTR-cardiac amyloidosis. Case report]. TERAPEVT ARKH 2023; 95:789-795. [PMID: 38158923 DOI: 10.26442/00403660.2023.09.202376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Indexed: 01/03/2024]
Abstract
The article presents a clinical case describing a complex differential diagnosis of cardiac amyloidosis types and verification of the diagnosis of AL-amyloidosis.
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Affiliation(s)
- F I Orlov
- Chazov National Medical Research Center of Cardiology
| | - A A Ansheles
- Chazov National Medical Research Center of Cardiology
| | - S N Nasonova
- Chazov National Medical Research Center of Cardiology
| | - M A Saidova
- Chazov National Medical Research Center of Cardiology
| | - I V Zhirov
- Chazov National Medical Research Center of Cardiology
- Russian Medical Academy of Continuous Professional Education
| | - E A Stepanova
- Russian Medical Academy of Continuous Professional Education
| | | | - A A Shoshina
- Chazov National Medical Research Center of Cardiology
| | | | - V B Sergienko
- Chazov National Medical Research Center of Cardiology
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22
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Dou X, Liu Y, Liao A, Zhong Y, Fu R, Liu L, Cui C, Wang X, Lu J. Patient Journey Toward a Diagnosis of Light Chain Amyloidosis in a National Sample: Cross-Sectional Web-Based Study. JMIR Form Res 2023; 7:e44420. [PMID: 37917132 PMCID: PMC10654903 DOI: 10.2196/44420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Systemic light chain (AL) amyloidosis is a rare and multisystem disease associated with increased morbidity and a poor prognosis. Delayed diagnoses are common due to the heterogeneity of the symptoms. However, real-world insights from Chinese patients with AL amyloidosis have not been investigated. OBJECTIVE This study aimed to describe the journey to an AL amyloidosis diagnosis and to build an in-depth understanding of the diagnostic process from the perspective of both clinicians and patients to obtain a correct and timely diagnosis. METHODS Publicly available disease-related content from social media platforms between January 2008 and April 2021 was searched. After performing data collection steps with a machine model, a series of disease-related posts were extracted. Natural language processing was used to identify the relevance of variables, followed by further manual evaluation and analysis. RESULTS A total of 2204 valid posts related to AL amyloidosis were included in this study, of which 1968 were posted on haodf.com. Of these posts, 1284 were posted by men (median age 57, IQR 46-67 years); 1459 posts mentioned renal-related symptoms, followed by heart (n=833), liver (n=491), and stomach (n=368) symptoms. Furthermore, 1502 posts mentioned symptoms related to 2 or more organs. Symptoms for AL amyloidosis most frequently mentioned by suspected patients were nonspecific weakness (n=252), edema (n=196), hypertrophy (n=168), and swelling (n=140). Multiple physician visits were common, and nephrologists (n=265) and hematologists (n=214) were the most frequently visited specialists by suspected patients for initial consultation. Additionally, interhospital referrals were also commonly seen, centralizing in tertiary hospitals. CONCLUSIONS Chinese patients with AL amyloidosis experienced referrals during their journey toward accurate diagnosis. Increasing awareness of the disease and early referral to a specialized center with expertise may reduce delayed diagnosis and improve patient management.
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Affiliation(s)
- Xuelin Dou
- Hematology Department, Peking University People's Hospital, Beijing, China
| | - Yang Liu
- Hematology Department, Peking University People's Hospital, Beijing, China
| | - Aijun Liao
- Hematology Department, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yuping Zhong
- Hematology Department, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
| | - Rong Fu
- Hematology Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Lihong Liu
- Hematology Department, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Canchan Cui
- Medical Affairs, Xi'an Janssen Pharmaceutical Ltd, Beijing, China
| | - Xiaohong Wang
- Medical Affairs, Xi'an Janssen Pharmaceutical Ltd, Shanghai, China
| | - Jin Lu
- Hematology Department, Peking University People's Hospital, Beijing, China
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23
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Ye M, Liu X, Gu Z, Sun J, Dong Y, Chen Y, Liu C, Wu Z, Zhu W. A simple ATTR-CM score to identify transthyretin amyloid cardiomyopathy burden in HFpEF patients. Eur J Clin Invest 2023; 53:e14045. [PMID: 37357789 DOI: 10.1111/eci.14045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/06/2023] [Accepted: 06/15/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Transthyretin amyloid cardiomyopathy (ATTR-CM) is often found in patients with heart failure with preserved ejection fraction (HFpEF). However, the evidence regarding ATTR-CM and prognosis in HFpEF remains scarce. This study sought to determine whether the ATTR-CM burden was associated with clinical outcomes in HFpEF patients. METHODS We evaluated the associations of baseline ATTR-CM score with adverse outcomes in HFpEF patients from the TOPCAT trial using the Cox proportional hazards model or the competing risk regression model. The discriminatory ability of the ATTR-CM score was assessed using the area under the time-dependent receiver operating characteristic curve (AUC). RESULTS We included 870 HFpEF patients, 18.9% of which had an ATTR-CM score ≥6. Per 1 increment in the ATTR-CM score was significantly associated with an increased risk of the primary outcome (adjusted hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.12-1.27) with an AUC of 0.652 (0.594-0.711), whereas patients with ATTR-CM score ≥6 presented higher risks of the primary outcome (adjusted HR 2.20, 95% CI 1.65-2.95). Similar results were observed toward the secondary outcomes. CONCLUSIONS The simple ATTR-CM score identified an 18.9% ATTR-CM burden in HFpEF patients, and a higher ATTR-CM burden might predict adverse outcomes with moderate discriminatory abilities in HFpEF.
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Affiliation(s)
- Min Ye
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, People's Republic of China
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Xiao Liu
- Department of Cardiology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Zhenbang Gu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Junyi Sun
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Yugang Dong
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, People's Republic of China
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Yili Chen
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, People's Republic of China
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Chen Liu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, People's Republic of China
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Zexuan Wu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, People's Republic of China
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Wengen Zhu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, People's Republic of China
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
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24
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Imakhanova A, Ideguchi R, Chiba A, Kudo T. Assessment of Interobserver Agreement in the Interpretation of 99mTc-PYP SPECT Imaging of Cardiac Amyloidosis. ANNALS OF NUCLEAR CARDIOLOGY 2023; 9:48-53. [PMID: 38058579 PMCID: PMC10696151 DOI: 10.17996/anc.23-00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 12/08/2023]
Abstract
Background: Technetium-99m pyrophosphate single photon emission computed tomography (99mTc-PYP SPECT) imaging is widely used to diagnose cardiac amyloidosis, a disease characterized by amyloid protein deposits in the myocardium. The effects of viewing perspectives on interobserver agreement in the interpretation of 99mTc-PYP SPECT images for the diagnosis of cardiac amyloidosis remain unclear. Methods: A retrospective analysis of 32 consecutive patients who underwent 99mTc-PYP imaging for the diagnosis of cardiac amyloidosis at Nagasaki University Hospital between October 2017 and February 2020 was performed. Four evaluators independently reviewed coronal, sagittal, and transaxial images and then all images together and made a categorical diagnosis based on predefined criteria. Interobserver agreement was analyzed using Cohen's Kappa analysis. Results: Kappa coefficient values in the four-grade grading system (grades 0-3) ranged between 0.31 and 0.95, while those in the binary grading system (positive/negative) ranged between 0.88 and 1. The sagittal view showed the highest value in the four-grade grading system (0.95) and the lowest in the binary grading system (0.88). The transaxial view was more likely to show a consistently high kappa value in both the four-grade and binary grading systems. The use of the multiplanar view reduced the number of subjects classified as grade 1. Conclusion: Our study demonstrates that the transaxial view provides the most consistent interpretation of 99mTc-PYP SPECT images for the diagnosis of cardiac amyloidosis. The use of the multiplanar view may also reduce equivocal interpretations, which are graded as grade 1. Further studies with larger sample sizes and a quantitative analysis are needed to confirm the present results.
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Affiliation(s)
- Aiganym Imakhanova
- Department of Radioisotope Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Reiko Ideguchi
- Department of Radioisotope Medicine, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki, Japan
| | - Akiyo Chiba
- Department of Cardiovascular Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Takashi Kudo
- Department of Radioisotope Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
- Department of Radioisotope Medicine, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki, Japan
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25
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Foster JS, Balachandran M, Hancock TJ, Martin EB, Macy S, Wooliver C, Richey T, Stuckey A, Williams AD, Jackson JW, Kennel SJ, Wall JS. Development and characterization of a prototypic pan-amyloid clearing agent - a novel murine peptide-immunoglobulin fusion. Front Immunol 2023; 14:1275372. [PMID: 37854603 PMCID: PMC10580800 DOI: 10.3389/fimmu.2023.1275372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/13/2023] [Indexed: 10/20/2023] Open
Abstract
Introduction Systemic amyloidosis is a progressive disorder characterized by the extracellular deposition of amyloid fibrils and accessory proteins in visceral organs and tissues. Amyloid accumulation causes organ dysfunction and is not generally cleared by the immune system. Current treatment focuses on reducing amyloid precursor protein synthesis and slowing amyloid deposition. However, curative interventions will likely also require removal of preexisting amyloid deposits to restore organ function. Here we describe a prototypic pan-amyloid binding peptide-antibody fusion molecule (mIgp5) that enhances macrophage uptake of amyloid. Methods The murine IgG1-IgG2a hybrid immunoglobulin with a pan amyloid-reactive peptide, p5, fused genetically to the N-terminal of the immunoglobulin light chain was synthesized in HEK293T/17 cells. The binding of the p5 peptide moiety was assayed using synthetic amyloid-like fibrils, human amyloid extracts and amyloid-laden tissues as substrates. Binding of radioiodinated mIgp5 with amyloid deposits in vivo was evaluated in a murine model of AA amyloidosis using small animal imaging and microautoradiography. The bioactivity of mIgp5 was assessed in complement fixation and in vitro phagocytosis assays in the presence of patient-derived amyloid extracts and synthetic amyloid fibrils as substrates and in the presence or absence of human serum. Results Murine Igp5 exhibited highly potent binding to AL and ATTR amyloid extracts and diverse types of amyloid in formalin-fixed tissue sections. In the murine model of systemic AA amyloidosis, 125I-mIgp5 bound rapidly and specifically to amyloid deposits in all organs, including the heart, with no evidence of non-specific uptake in healthy tissues. The bioactivity of the immunoglobulin Fc domain was uncompromised in the context of mIgp5 and served as an effective opsonin. Macrophage-mediated uptake of amyloid extract and purified amyloid fibrils was enhanced by the addition of mIgp5. This effect was exaggerated in the presence of human serum coincident with deposition of complement C5b9. Conclusion Immunostimulatory, amyloid-clearing therapeutics can be developed by incorporating pan-amyloid-reactive peptides, such as p5, as a targeting moiety. The immunologic functionality of the IgG remains intact in the context of the fusion protein. These data highlight the potential use of peptide-antibody fusions as therapeutics for all types of systemic amyloidosis.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Jonathan S. Wall
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, United States
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26
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Damy T, Zaroui A, de Tournemire M, Kharoubi M, Gounot R, Galat A, Guendouz S, Funalot B, Itti E, Roulin L, Audard V, Fanen P, Leroy V, Poulot E, Belhadj K, Mallet S, Deep Singh Chadah G, Planté-Bordeneuve V, Gendre T, Chevalier X, Guignard S, Bequignon E, Bartier S, Folliguet T, Lemonier F, Audureau E, Tixier D, Canoui-Poitrine F, Lefaucheur JP, Souvannanorath S, Authier FJ, Maupou S, Hittinger L, Molinier-Frenkel V, David JP, Broussier A, Oghina S, Teiger E. Changes in amyloidosis phenotype over 11 years in a cardiac amyloidosis referral centre cohort in France. Arch Cardiovasc Dis 2023; 116:433-446. [PMID: 37640624 DOI: 10.1016/j.acvd.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 07/07/2023] [Accepted: 07/17/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Early cardiac amyloidosis (CA) diagnosis enables patients to access effective treatments for better long-term outcomes, yet it remains under-recognised, misdiagnosed and inadequately managed. AIM To reduce diagnostic delays, we aimed to describe the epidemiological and clinical characteristics and changes over an 11-year period. METHODS This was a retrospective, observational cohort study of all patients referred to the Henri-Mondor Hospital for suspected CA. RESULTS Overall, 3194 patients were identified and 3022 were included and analysed. Our patients came from varied ethnic backgrounds, and more than half (55.2%) had confirmed CA. Over 11 years, referrals increased 4.4-fold, mostly from cardiologists. Notably, wild-type transthyretin amyloidosis (ATTRwt) became the predominant diagnosis, with referrals increasing 15-fold from 20 in 2010-2012 to 308 in 2019-2020. The number of amyloid light chain (AL) diagnoses increased, whilst variant transthyretin amyloidosis (ATTRv) numbers remained relatively stable. Concerning disease severity, AL patients presented more frequently with severe cardiac involvement whereas an increasing number of ATTRwt patients presented with National Amyloid Centre stage I (22.0% in 2013-2014 to 45.9% in 2019-2020). Lastly, among patients diagnosed with ATTRv in 2019-2020, 83.9% had ATTR Val122Ile cardiac phenotype. CONCLUSIONS This study shows that increasing cardiologist awareness and referrals have increased CA diagnoses. With improved awareness and non-invasive diagnostic techniques, more patients with ATTRwt with milder disease and more ATTRv Val122Ile mutations are being referred and diagnosed. Although more AL cases are being recognised, patients are diagnosed with severe cardiac involvement.
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Affiliation(s)
- Thibaud Damy
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Cardiology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France; Clinical Epidemiology and Ageing (CEpiA) Geriatrics, Primary Care and Public Health, 94010 Créteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France.
| | - Amira Zaroui
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Cardiology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France; Clinical Epidemiology and Ageing (CEpiA) Geriatrics, Primary Care and Public Health, 94010 Créteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France
| | - Marie de Tournemire
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Cardiology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France; Clinical Epidemiology and Ageing (CEpiA) Geriatrics, Primary Care and Public Health, 94010 Créteil, France
| | - Mounira Kharoubi
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Cardiology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France; Clinical Epidemiology and Ageing (CEpiA) Geriatrics, Primary Care and Public Health, 94010 Créteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France
| | - Romain Gounot
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Lymphoid Malignancies Unit, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Arnault Galat
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Cardiology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Soulef Guendouz
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Cardiology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Benoit Funalot
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Genetic Department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Emmanuel Itti
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Nuclear Medicine, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Louise Roulin
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Lymphoid Malignancies Unit, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Vincent Audard
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Nephrology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France; Hepatology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Pascale Fanen
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Cardiology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France; Genetic Department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Vincent Leroy
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Cardiology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France; Hepatology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Elsa Poulot
- Genetic Department, Henri-Mondor Teaching Hospital, 94010 Creteil, France; Pathology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Karim Belhadj
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Lymphoid Malignancies Unit, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Sophie Mallet
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Cardiology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Gagan Deep Singh Chadah
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Cardiology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Violaine Planté-Bordeneuve
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Neurology Department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Thierry Gendre
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Neurology Department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Xavier Chevalier
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Rheumatology Department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Sandra Guignard
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Rheumatology Department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Emilie Bequignon
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Otorhinolaryngologist Department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Sophie Bartier
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Otorhinolaryngologist Department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Thierry Folliguet
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Cardiovascular Surgery Department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - François Lemonier
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Lymphoid Malignancies Unit, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Etienne Audureau
- Clinical Epidemiology and Ageing (CEpiA) Geriatrics, Primary Care and Public Health, 94010 Créteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France
| | - Denis Tixier
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; DMU care, Henri Mondor Teaching Hospital, 94010 Creteil, France
| | - Florence Canoui-Poitrine
- Clinical Epidemiology and Ageing (CEpiA) Geriatrics, Primary Care and Public Health, 94010 Créteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France
| | - Jean-Pascal Lefaucheur
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Neurophysiology Department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Sarah Souvannanorath
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Neurohistomyology Department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Francois-Jerome Authier
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Neurohistomyology Department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Steven Maupou
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Cardiology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Luc Hittinger
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Cardiology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France
| | - Valérie Molinier-Frenkel
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Immunology Department, Henri-Mondor Teaching Hospital, 94010 Creteil, France
| | - Jean-Philippe David
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Clinical Epidemiology and Ageing (CEpiA) Geriatrics, Primary Care and Public Health, 94010 Créteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Department of Geriatrics, AP-HP, Hopitaux Henri-Mondor/Emile-Roux, 94456 Limeil-Brevannes, France
| | - Amaury Broussier
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Clinical Epidemiology and Ageing (CEpiA) Geriatrics, Primary Care and Public Health, 94010 Créteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France; Department of Geriatrics, AP-HP, Hopitaux Henri-Mondor/Emile-Roux, 94456 Limeil-Brevannes, France
| | - Silvia Oghina
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Cardiology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France; Clinical Epidemiology and Ageing (CEpiA) Geriatrics, Primary Care and Public Health, 94010 Créteil, France
| | - Emmanuel Teiger
- French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, all at Henri-Mondor Teaching Hospital, AP-HP, 94010 Creteil, France; Cardiology department, Henri-Mondor Teaching Hospital, 94010 Creteil, France; Clinical Epidemiology and Ageing (CEpiA) Geriatrics, Primary Care and Public Health, 94010 Créteil, France; Université Paris Est Creteil, Inserm, IMRB, 94010 Creteil, France
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Wang Y, Jia H, Song J. Accurate Classification of Non-ischemic Cardiomyopathy. Curr Cardiol Rep 2023; 25:1299-1317. [PMID: 37721634 PMCID: PMC10651539 DOI: 10.1007/s11886-023-01944-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 09/19/2023]
Abstract
PURPOSE OF REVIEW This article aims to review the accurate classification of non-ischemic cardiomyopathy, including the methods, basis, subtype characteristics, and prognosis, especially the similarities and differences between different classifications. RECENT FINDINGS Non-ischemic cardiomyopathy refers to a myocardial disease that excludes coronary artery disease or ischemic injury and has a variety of etiologies and high incidence. Recent studies suggest that traditional classification methods based on primary/mixed/acquired or genetic/non-genetic cannot meet the precise needs of contemporary clinical management. This article systematically describes the history of classifications of cardiomyopathy and presents etiological and genetic differences between cardiomyopathies. The accurate classification is described from the perspective of morphology, function, and genomics in hypertrophic cardiomyopathy, dilated cardiomyopathy, restrictive cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, left ventricular noncompaction, and partially acquired cardiomyopathy. The different clinical characteristics and treatment needs of these cardiomyopathies are elaborated. Some single-gene mutant cardiomyopathies have unique phenotypes, and some cardiomyopathies have mixed phenotypes. These special classifications require personalized precision treatment, which is worthy of independent research. This article describes recent advances in the accurate classification of non-ischemic cardiomyopathy from clinical phenotypes and causative genes, discusses the advantages and usage scenarios of each classification, compares the differences in prognosis and patient management needs of different subtypes, and summarizes common methods and new exploration directions for accurate classification.
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Affiliation(s)
- Yifan Wang
- Beijing Key Laboratory of Preclinical Research and Evaluation for Cardiovascular Implant Materials, Animal Experimental Centre, National Centre for Cardiovascular Disease, Department of Cardiac Surgery, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Hao Jia
- Beijing Key Laboratory of Preclinical Research and Evaluation for Cardiovascular Implant Materials, Animal Experimental Centre, National Centre for Cardiovascular Disease, Department of Cardiac Surgery, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Jiangping Song
- Beijing Key Laboratory of Preclinical Research and Evaluation for Cardiovascular Implant Materials, Animal Experimental Centre, National Centre for Cardiovascular Disease, Department of Cardiac Surgery, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.
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Treglia G, Martinello C, Dondi F, Albano D, Bertagna F, Rizzo A, Delgado Bolton RC, Tersalvi G, Muoio B, Riegger M, Cecchin D. Prevalence of Incidental Findings Suspicious for Transthyretin Cardiac Amyloidosis among Patients Undergoing Bone Scintigraphy: A Systematic Review and a Meta-Analysis. J Clin Med 2023; 12:5698. [PMID: 37685765 PMCID: PMC10488435 DOI: 10.3390/jcm12175698] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/13/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND The myocardial uptake of bone-seeking tracers suspicious for transthyretin cardiac amyloidosis (ATTR-CA) can be incidentally detected in patients undergoing bone scintigraphy for noncardiac reasons. We conducted a systematic review and meta-analysis to assess the prevalence of these scintigraphic findings. METHODS A comprehensive literature search was performed using two bibliographic databases (PubMed/MEDLINE and Cochrane Library), searching for articles related to the review question. Eligible articles were selected, and relevant data were extracted by two authors. The pooled prevalence of incidental findings suspicious for ATTR-CA among patients undergoing bone scintigraphy was calculated on a per-patient-based analysis using a random-effects model. The pooled measure was provided with 95% confidence interval (95% CI) values. RESULTS Among 219 records, 11 articles were selected for the systematic review and 10 for the meta-analysis. The pooled prevalence of incidental findings suspicious for ATTR-CA was 1.1% (95% CI: 0.7-1.4%) with heterogeneity due to the characteristics of the included studies, patients, and index tests. These findings are more prevalent in older men. CONCLUSIONS The prevalence of incidental findings of ATTR-CA among patients undergoing bone scintigraphy is low but not negligible. Nuclear medicine physicians should suggest, in the scintigraphic report, further clinical investigations when these findings are detected. Prospective studies are warranted.
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Affiliation(s)
- Giorgio Treglia
- Division of Nuclear Medicine, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, 6501 Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, 1011 Lausanne, Switzerland
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | | | - Francesco Dondi
- Division of Nuclear Medicine, Università degli Studi di Brescia and ASST Spedali Civili di Brescia, 25123 Brescia, Italy
| | - Domenico Albano
- Division of Nuclear Medicine, Università degli Studi di Brescia and ASST Spedali Civili di Brescia, 25123 Brescia, Italy
| | - Francesco Bertagna
- Division of Nuclear Medicine, Università degli Studi di Brescia and ASST Spedali Civili di Brescia, 25123 Brescia, Italy
| | - Alessio Rizzo
- Department of Nuclear Medicine, Candiolo Cancer Institute, 10060 Turin, Italy
| | - Roberto C. Delgado Bolton
- Department of Diagnostic Imaging (Radiology) and Nuclear Medicine, University Hospital San Pedro and Centre for Biomedical Research of La Rioja (CIBIR), 26006 Logroño, Spain
- Servicio Cántabro de Salud, 39011 Santander, Spain
| | - Gregorio Tersalvi
- Department of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
- Department of Internal Medicine, Ente Ospedaliero Cantonale, 6850 Mendrisio, Switzerland
| | - Barbara Muoio
- Division of Medical Oncology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, 6501 Bellinzona, Switzerland
| | - Martin Riegger
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
- Division of Orthopedics and Traumatology, Department of Surgery, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
| | - Diego Cecchin
- Nuclear Medicine Unit, Department of Medicine (DIMED), Padova University Hospital, 35128 Padua, Italy
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Tana M, Tana C, Palmiero G, Mantini C, Coppola MG, Limongelli G, Schiavone C, Porreca E. Imaging findings of right cardiac amyloidosis: impact on prognosis and clinical course. J Ultrasound 2023; 26:605-614. [PMID: 37162729 PMCID: PMC10171176 DOI: 10.1007/s40477-023-00789-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/04/2023] [Indexed: 05/11/2023] Open
Abstract
Cardiac involvement from amyloidosis is of growing interest in the overall literature. Despite cardiac amyloidosis (CA) has been considered for a long time a rare disease, the diagnostic awareness is increasing mainly thanks to the improvement of diagnostic softwares and of imaging techniques such as cardiac magnetic resonance (CMR). Some authors have observed an increase of prevalence rate of CA; moreover it's often underestimated because clinical manifestations are aspecific. The interstitial infiltration of the left ventricle has been extensively studied, while the involvement of the right ventricle (RV) has been less investigated. Involvement of the RV, even in the absence of pulmonary hypertension or clearly left ventricle infiltration, plays an important role as prognostic factor and is useful to achieve an early diagnosis. Therefore, the use of fast and low-cost diagnostic methods such as ultrasound strain of the right ventricle could be used to recognize cardiac amyloidosis early. Herein the importance of evaluating the right ventricular involvement, which can predict the most severe course of the disease also without overt clinical manifestations. The role of imaging, in particular of echocardiography, CMR, and scintigraphy is here reported.
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Affiliation(s)
- Marco Tana
- Internal Medicine Unit, Medical Department, SS. Annunziata Hospital of Chieti, Via Dei Vestini 31, 66100, Chieti, Italy.
- Cardiovascular Ultrasound Department, SS. Annunziata Hospital, Chieti, Italy.
- Department of Medical, Oral and Biotechnological Sciences, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy.
| | - Claudio Tana
- COVID-19 Medicine Unit and Geriatrics Clinic, Medical Department, SS. Annunziata Hospital, Chieti, Italy
| | - Giuseppe Palmiero
- Rare Cardiac Disease Unit, Department of Translational Medical Sciences, "Luigi Vanvitelli" University, Naples, Italy
| | - Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | | | - Giuseppe Limongelli
- Rare Cardiac Disease Unit, Department of Translational Medical Sciences, "Luigi Vanvitelli" University, Naples, Italy
| | | | - Ettore Porreca
- Internal Medicine Unit, Medical Department, SS. Annunziata Hospital of Chieti, Via Dei Vestini 31, 66100, Chieti, Italy
- Cardiovascular Ultrasound Department, SS. Annunziata Hospital, Chieti, Italy
- Department of Medical, Oral and Biotechnological Sciences, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
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30
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Monda E, Bakalakos A, Rubino M, Verrillo F, Diana G, De Michele G, Altobelli I, Lioncino M, Perna A, Falco L, Palmiero G, Elliott PM, Limongelli G. Targeted Therapies in Pediatric and Adult Patients With Hypertrophic Heart Disease: From Molecular Pathophysiology to Personalized Medicine. Circ Heart Fail 2023; 16:e010687. [PMID: 37477018 DOI: 10.1161/circheartfailure.123.010687] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/06/2023] [Indexed: 07/22/2023]
Abstract
Hypertrophic cardiomyopathy is a myocardial disease defined by an increased left ventricular wall thickness not solely explained by abnormal loading conditions. It is often genetically determined, with sarcomeric gene mutations accounting for around 50% of cases. Several conditions, including syndromic, metabolic, infiltrative, and neuromuscular diseases, may present with left ventricular hypertrophy, mimicking the hypertrophic cardiomyopathy phenotype but showing a different pathophysiology, clinical course, and outcome. Despite being rare, they are collectively responsible for a large proportion of patients presenting with hypertrophic heart disease, and their timely diagnosis can significantly impact patients' management. The understanding of disease pathophysiology has advanced over the last few years, and several therapeutic targets have been identified, leading to a new era of tailored treatments applying to different etiologies associated with left ventricular hypertrophy. This review aims to provide an overview of the existing and emerging therapies for the principal causes of hypertrophic heart disease, discussing the potential impact on patients' management and clinical outcome.
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Affiliation(s)
- Emanuele Monda
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (E.M., M.R., F.V., G.D., G.D.M., I.A., M.L., A.P., L.F., G.P., G.L.)
- Institute of Cardiovascular Sciences, University College London, United Kingdom (E.M., A.B., P.M.E., G.L.)
| | - Athanasios Bakalakos
- Institute of Cardiovascular Sciences, University College London, United Kingdom (E.M., A.B., P.M.E., G.L.)
| | - Marta Rubino
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (E.M., M.R., F.V., G.D., G.D.M., I.A., M.L., A.P., L.F., G.P., G.L.)
| | - Federica Verrillo
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (E.M., M.R., F.V., G.D., G.D.M., I.A., M.L., A.P., L.F., G.P., G.L.)
| | - Gaetano Diana
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (E.M., M.R., F.V., G.D., G.D.M., I.A., M.L., A.P., L.F., G.P., G.L.)
| | - Gianantonio De Michele
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (E.M., M.R., F.V., G.D., G.D.M., I.A., M.L., A.P., L.F., G.P., G.L.)
| | - Ippolita Altobelli
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (E.M., M.R., F.V., G.D., G.D.M., I.A., M.L., A.P., L.F., G.P., G.L.)
| | - Michele Lioncino
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (E.M., M.R., F.V., G.D., G.D.M., I.A., M.L., A.P., L.F., G.P., G.L.)
| | - Alessia Perna
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (E.M., M.R., F.V., G.D., G.D.M., I.A., M.L., A.P., L.F., G.P., G.L.)
| | - Luigi Falco
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (E.M., M.R., F.V., G.D., G.D.M., I.A., M.L., A.P., L.F., G.P., G.L.)
| | - Giuseppe Palmiero
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (E.M., M.R., F.V., G.D., G.D.M., I.A., M.L., A.P., L.F., G.P., G.L.)
| | - Perry M Elliott
- Institute of Cardiovascular Sciences, University College London, United Kingdom (E.M., A.B., P.M.E., G.L.)
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (E.M., M.R., F.V., G.D., G.D.M., I.A., M.L., A.P., L.F., G.P., G.L.)
- Institute of Cardiovascular Sciences, University College London, United Kingdom (E.M., A.B., P.M.E., G.L.)
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Bashir Z, Chen EW, Tori K, Ghosalkar D, Aurigemma GP, Dickey JB, Haines P. Insight into different phenotypic presentations of heart failure with preserved ejection fraction. Prog Cardiovasc Dis 2023; 79:80-88. [PMID: 37442358 DOI: 10.1016/j.pcad.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 07/15/2023]
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) accounts for half of all HF diagnoses, and its prevalence is increasing at an alarming rate. Lately, it has been recognized as a clinical syndrome due to diverse underlying etiology and pathophysiological mechanisms. The classic echocardiographic features of HFpEF have been well described as preserved ejection fraction (≥50%), left ventricular hypertrophy, and left atrial enlargement. However, echocardiography can play a key role in identifying the principal underlying mechanism responsible for HFpEF in the individual patient. The recognition of different phenotypic presentations of HFpEF (infiltrative, metabolic, genetic, and inflammatory) can assist the clinician in tailoring the appropriate management, and offer prognostic information. The goal of this review is to highlight several key phenotypes of HFpEF and illustrate the classic clinical scenario and echocardiographic features of each phenotype with real patient cases.
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Affiliation(s)
- Zubair Bashir
- Department of Cardiology, Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Edward W Chen
- Department of Cardiology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Dhairyasheel Ghosalkar
- Division of Cardiovascular Medicine, Department of Medicine, Stony Brook University Hospital, NY, USA
| | - Gerard P Aurigemma
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - John B Dickey
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Philip Haines
- Department of Cardiology, Warren Alpert Medical School of Brown University, Providence, RI, USA
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32
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Navarro-Saez MDC, Feijoo-Massó C, Bravo Ferrer ZDC, Oliva Morera JC, Balado González AM, Palau-Domínguez A, Guillamon Toran L, Comet Monte R, Fernández-Codina A. Trends in diagnosis of cardiac transthyretin amyloidosis: 3-year analysis of scintigraphic studies: Prevalence of myocardial uptake and its predictor factors. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023:10.1007/s10554-023-02840-y. [PMID: 37005954 DOI: 10.1007/s10554-023-02840-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/20/2023] [Indexed: 04/04/2023]
Abstract
To determine the prevalence of myocardial uptake (MU) and to identify predictors of MU in patients undergoing scintigraphy. Retrospective single-center series of technetium-99 m-labelled 3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) scans performed from March 2017 to March 2020. All patients undergoing scintigraphy were included, except those with preexisting amyloidosis. The features of MU, patients' characteristics and comorbidities were documented. Multivariate analysis was used to find items predicting MU. A total of 3,629 99mTc-DPD scans (total 11,444) were performed in patients aged > 70. The overall prevalence of MU was 2.7% (82/3,629); 1.2% in 2017-2018, to 2% in 2018-2019, and to 3.7% in 2019-2020. The prevalence of MU in patients without suspected cardiomyopathy was 1.2%; 1.1% in 2017-2018, 1.5% in 2018-2019 and 1% in 2019-2020. There is an increase in the number of requests due to suspected cardiomyopathy from 0.2% in 2017-2018 to 1.4% in 2018-2019 and to 4.8% in 2019-2020. Age, male sex, hypertension, heart failure, atrial fibrillation, atrioventricular block, aortic stenosis, and carpal tunnel syndrome were found to be predictors of MU. In patients without heart failure, only age, atrial fibrillation, and carpal tunnel syndrome were predicted MU. The prevalence of MU in scintigraphic studies surged over time due to the incremental referrals under the indication of cardiomyopathy workup. Atrial fibrillation and carpal tunnel syndrome were predictors for MU in patients without heart failure. Identifying patients with MU and no heart failure for extended screening for ATTR can lead to an earlier diagnosis and application of novel treatments.
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Affiliation(s)
- María Del Carmen Navarro-Saez
- Acute Geriatric Unit and Complex Chronic Patient, Institut d' Investigació i Innovació Parc Taulí (I3PT), Parc Taulí Hospital Universitari, Sabadell, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos Feijoo-Massó
- Universitat Autònoma de Barcelona, Barcelona, Spain.
- Department of Internal Medicine, Institut d' Investigació i Innovació Parc Taulí (I3PT), Parc Taulí Hospital Universitari, Sabadell, Spain, Parc Taulí S/N, 08208.
| | | | - Joan Carles Oliva Morera
- Clinical Trials Unit, Institut d' Investigació i Innovació Parc Taulí (I3PT), Parc Taulí Hospital Universitari, Sabadell, Spain
| | - Andrea María Balado González
- Department of Internal Medicine, Institut d' Investigació i Innovació Parc Taulí (I3PT), Parc Taulí Hospital Universitari, Sabadell, Spain, Parc Taulí S/N, 08208
| | - Alba Palau-Domínguez
- Department of Internal Medicine, Institut d' Investigació i Innovació Parc Taulí (I3PT), Parc Taulí Hospital Universitari, Sabadell, Spain, Parc Taulí S/N, 08208
| | - Laura Guillamon Toran
- Department of Cardiology, Institut d' Investigació i Innovació Parc Taulí (I3PT), Parc Taulí Hospital Universitari, Sabadell, Spain
| | - Ricard Comet Monte
- Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Internal Medicine, Institut d' Investigació i Innovació Parc Taulí (I3PT), Parc Taulí Hospital Universitari, Sabadell, Spain, Parc Taulí S/N, 08208
| | - Andreu Fernández-Codina
- Divisions of Rheumatology (London and Windsor Campuses) and General Internal Medicine (Windsor Campus), Western University, London, ON, Canada
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Hoerbrand IA, Volz MJ, Aus dem Siepen F, Aurich M, Schlegel P, Geis NA, Hegenbart U, Konstandin MH, Frey N, Raake PW. Initial experience with transcatheter tricuspid valve repair in patients with cardiac amyloidosis. ESC Heart Fail 2023; 10:1003-1012. [PMID: 36514259 PMCID: PMC10053172 DOI: 10.1002/ehf2.14262] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/16/2022] [Accepted: 11/27/2022] [Indexed: 12/15/2022] Open
Abstract
AIMS Wildtype transthyretin amyloid cardiomyopathy is an under-recognized cause of heart failure in elderly patients. Transcatheter tricuspid valve repair is a newly emerging therapeutic option for severe tricuspid regurgitation (TR). We present first insights into safety and possible benefits of this procedure in patients with cardiac amyloidosis. METHODS AND RESULTS Eight patients with cardiac non-hereditary (wildtype) transthyretin (ATTRwt) amyloidosis and severe to torrential TR, undergoing successful transcatheter tricuspid valve repair, were included in the analysis and compared to a control group of 21 patients without cardiac amyloidosis. All patients presented with an advanced stage of amyloid cardiomyopathy. Primary endpoint was reduction in TR at 3 months follow-up. Secondary endpoints were feasibility, safety, hospitalization or death, clinical improvement, cardiac biomarkers, and structural and functional right heart parameter obtained by echocardiography. Transcatheter tricuspid valve repair resulted in a significant reduction of TR (IV to II, P = 0.008) in all eight patients with cardiac amyloidosis (100%). Device success (amyloidosis 75% vs. control group 86%, P = 0.597) and overall probability of hospitalization or death (amyloidosis 13% vs. control group 25%, P = 0.646) were similar compared with those in the control group at 3 months follow-up. Transcatheter tricuspid valve repair led to an improvement of New York Heart Association functional class (P = 0.031) and 6 min walking distance (from 313 ± 118 to 337 ± 106, P = 0.012). TR reduction in amyloidosis patients was less extensive compared with that in control group (TR-reduction 1.6 ± 0.3, P = 0.008 vs. control group 2.3 ± 0.3, P < 0.0001). Furthermore, these patients showed no significant improvement of structural right heart parameters. CONCLUSIONS Transcatheter tricuspid valve repair is a safe and feasible new treatment option in patients with amyloid cardiomyopathy and has the potential to improve TR-grade and clinical status. However, the benefit appears to be less pronounced compared with patients without cardiac amyloidosis.
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Affiliation(s)
- Isabel A. Hoerbrand
- Department of Internal Medicine III, Division of CardiologyUniversity Hospital Heidelberg, Ruprecht‐Karl University Heidelberg69120HeidelbergGermany
| | - Martin J. Volz
- Department of Internal Medicine III, Division of CardiologyUniversity Hospital Heidelberg, Ruprecht‐Karl University Heidelberg69120HeidelbergGermany
| | - Fabian Aus dem Siepen
- Department of Internal Medicine III, Division of CardiologyUniversity Hospital Heidelberg, Ruprecht‐Karl University Heidelberg69120HeidelbergGermany
| | - Matthias Aurich
- Department of Internal Medicine III, Division of CardiologyUniversity Hospital Heidelberg, Ruprecht‐Karl University Heidelberg69120HeidelbergGermany
| | - Philipp Schlegel
- Department of Internal Medicine III, Division of CardiologyUniversity Hospital Heidelberg, Ruprecht‐Karl University Heidelberg69120HeidelbergGermany
| | - Nicolas A. Geis
- Department of Internal Medicine III, Division of CardiologyUniversity Hospital Heidelberg, Ruprecht‐Karl University Heidelberg69120HeidelbergGermany
| | - Ute Hegenbart
- Department of Internal Medicine V, Division of Hematology and Oncology, Amyloidosis CenterUniversity Hospital Heidelberg, Ruprecht‐Karl University HeidelbergHeidelbergGermany
| | - Mathias H. Konstandin
- Department of Internal Medicine III, Division of CardiologyUniversity Hospital Heidelberg, Ruprecht‐Karl University Heidelberg69120HeidelbergGermany
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg/MannheimHeidelbergGermany
| | - Norbert Frey
- Department of Internal Medicine III, Division of CardiologyUniversity Hospital Heidelberg, Ruprecht‐Karl University Heidelberg69120HeidelbergGermany
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg/MannheimHeidelbergGermany
| | - Philip W. Raake
- Department of Internal Medicine III, Division of CardiologyUniversity Hospital Heidelberg, Ruprecht‐Karl University Heidelberg69120HeidelbergGermany
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg/MannheimHeidelbergGermany
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Eldhagen P, Lehtonen J, Gude E, Gustafsson F, Bagger-Bahnsen A, Vakevainen M, Pilgaard T, Wedell-Wedellsborg D, Poulsen SH. Health-related quality of life among transthyretin amyloid cardiomyopathy patients. ESC Heart Fail 2023; 10:1871-1882. [PMID: 36946241 DOI: 10.1002/ehf2.14350] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/22/2023] [Accepted: 02/26/2023] [Indexed: 03/23/2023] Open
Abstract
AIMS Transthyretin amyloid cardiomyopathy (ATTR CM) is a progressive and severe heart disease with physical and psychological implications. The Nordic PROACT study was conducted to investigate the health-related quality of life (HRQoL) in ATTR CM patients. METHODS AND RESULTS The Nordic PROACT study was a cross-sectional non-interventional study conducted in 12 cardiology hospital clinics across Norway, Sweden, Finland and Denmark. Men and women aged ≥18 years diagnosed with symptomatic ATTR CM were included. The investigator provided information on medical history, biomarkers, current treatment, co-morbidities and disease severity according to the New York Heart Association (NYHA) class and the National Amyloidosis Centre (NAC) staging. Patients completed the HRQoL questionnaires in the form of the Kansas City Cardiomyopathy Questionnaire (KCCQ), the EQ-5D-5L index with Visual Analog Scale (VAS), and the Major Depression Inventory (MDI). A total of 169 patients (mean ± SD age 77.7 ± 6.2 years) were included. Ninety-two per cent were men. Seventy-six per cent had wildtype ATTR CM (ATTRwt CM) and 15% had a hereditary form of ATTR CM (ATTRv CM) while 9% were genetically unclassified. Most patients were in NYHA class II (54%) and NAC stage 1 (53%). Participation in randomized clinical trials (RCT) was noted in 58% of the patients. The 169 ATTR CM patients had a mean ± SD KCCQ score of 64.3 ± 23.1 for total symptom score, 64.8 ± 20.9 for overall summary score (OSS) and 65.1 ± 21.5 for clinical summary score. The EQ-5D-5L total utility score was 0.8 ± 0.2 and the EQ-5D-5L VAS score was 62.9 ± 20.6. The vast majority (89%) did not report any signs of depression. Patients with ATTRv CM had a higher KCCQ OSS as compared with ATTRwt CM, while EQ-5D-5L utility score, EQ-5D-5L VAS and MDI were similar. Non-RCT participants had a poorer HRQoL as compared with RCT participants as reflected in lower KCCQ OSS and EQ-5D-5L VAS scores and a higher MDI score. Patients with higher NYHA classes and NAC disease stages had a poorer HRQoL as demonstrated by lower KCCQ and EQ-5D-5L scores and higher MDI scores. Correlation between KCCQ, EQ-5D-5L and MDI and the covariate NYHA class remained significant (P < 0.05) after adjusting for multiple testing. CONCLUSIONS KCCQ scores were lower than previously reported for patients with other heart diseases of non-ATTR CM origin. The HRQoL measures correlated well to NYHA class and NAC disease stage. The prevalence of depression appeared to be low.
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Affiliation(s)
- Per Eldhagen
- Department of Medicine, Karolinska Institute, Karolinska University Hospital, Solna, Sweden
| | - Jukka Lehtonen
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Einar Gude
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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Impaired Extracellular Proteostasis in Patients with Heart Failure. Arch Med Res 2023; 54:211-222. [PMID: 36797157 DOI: 10.1016/j.arcmed.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 01/11/2023] [Accepted: 02/02/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Proteostasis impairment and the consequent increase of amyloid burden in the myocardium have been associated with heart failure (HF) development and poor prognosis. A better knowledge of the protein aggregation process in biofluids could assist the development and monitoring of tailored interventions. AIM To compare the proteostasis status and protein's secondary structures in plasma samples of patients with HF with preserved ejection fraction (HFpEF), patients with HF with reduced ejection fraction (HFrEF), and age-matched individuals. METHODS A total of 42 participants were enrolled in 3 groups: 14 patients with HFpEF, 14 patients with HFrEF, and 14 age-matched individuals. Proteostasis-related markers were analyzed by immunoblotting techniques. Fourier Transform Infrared (FTIR) Spectroscopy in Attenuated Total Reflectance (ATR) was applied to assess changes in the protein's conformational profile. RESULTS Patients with HFrEF showed an elevated concentration of oligomeric proteic species and reduced clusterin levels. ATR-FTIR spectroscopy coupled with multivariate analysis allowed the discrimination of HF patients from age-matched individuals in the protein amide I absorption region (1700-1600 cm-1), reflecting changes in protein conformation, with a sensitivity of 73 and a specificity of 81%. Further analysis of FTIR spectra showed significantly reduced random coils levels in both HF phenotypes. Also, compared to the age-matched group, the levels of structures related to fibril formation were significantly increased in patients with HFrEF, whereas the β-turns were significantly increased in patients with HFpEF. CONCLUSION Both HF phenotypes showed a compromised extracellular proteostasis and different protein conformational changes, suggesting a less efficient protein quality control system.
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Ribeiro ASF, Zerolo BE, López-Espuela F, Sánchez R, Fernandes VS. Cardiac System during the Aging Process. Aging Dis 2023:AD.2023.0115. [PMID: 37163425 PMCID: PMC10389818 DOI: 10.14336/ad.2023.0115] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/15/2023] [Indexed: 05/12/2023] Open
Abstract
The aging process is accompanied by a continuous decline of the cardiac system, disrupting the homeostatic regulation of cells, organs, and systems. Aging increases the prevalence of cardiovascular diseases, thus heart failure and mortality. Understanding the cardiac aging process is of pivotal importance once it allows us to design strategies to prevent age-related cardiac events and increasing the quality of live in the elderly. In this review we provide an overview of the cardiac aging process focus on the following topics: cardiac structural and functional modifications; cellular mechanisms of cardiac dysfunction in the aging; genetics and epigenetics in the development of cardiac diseases; and aging heart and response to the exercise.
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Affiliation(s)
| | - Blanca Egea Zerolo
- Escuela de Enfermería y Fisioterapia San Juan de Dios. Universidad Pontificia Comillas, Madrid, Spain
| | - Fidel López-Espuela
- Metabolic Bone Diseases Research Group, Nursing and Occupational Therapy College, University of Extremadura, Caceres, Spain
| | - Raúl Sánchez
- Unidad de Cardiopatías Congénitas, Hospital Universitario La Paz, Madrid, Spain
| | - Vítor S Fernandes
- Departamento de Fisiología, Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain
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Kraus MJ, Smits JM, Meyer AL, Strelniece A, van Kins A, Boeken U, Reinecke A, Provaznik Z, Van Caenegem O, Ancion A, Berchtold-Herz M, Van Cleemput JJA, Haverich A, Laufer G, Gummert J, Karck M, Warnecke G, Raake PW, Frey N, Kreusser MM. Outcomes in patients with cardiac amyloidosis undergoing heart transplantation: the eurotransplant experience. J Heart Lung Transplant 2023; 42:778-785. [PMID: 36710093 DOI: 10.1016/j.healun.2023.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/14/2022] [Accepted: 01/04/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND When advanced heart failure occurs in cardiac amyloidosis, prognosis is poor. In this setting heart transplantation (HTX) is a treatment option for selected patients. We here present the results of post-transplantation outcomes in cardiac amyloidosis within the Eurotransplant area, investigating possible predictors of survival. METHODS Of 115 patients undergoing HTX due to cardiac amyloidosis in the Eurotransplant region between November 1987 and May 2020, detailed assessment prior to transplantation was available in 85 patients. The present study was conducted in a retrospective approach. Primary endpoint was mortality after HTX. Baseline variables were entered in a Cox proportional hazards model with the primary endpoint as a dependent variable. RESULTS Median overall survival following HTX was 6.3 years in the overall collective and the subgroup. Univariate Cox proportional hazards model revealed a significant relationship between overall survival and the transplantation period (2008 to 2020 vs 1987 to 2007; median survival 9.7 years vs 1.8 years, hazard ratio 0.45, p = 0.01). Further predictors were albumin concentration (hazard ratio 0.92, p < 0.001), and systolic blood pressure (hazard ratio 0.96, p < 0.001). The transplant period as well as albumin concentration remained significant independent predictors in the AL sub cohort in a multivariate Cox proportional hazards model. CONCLUSIONS HTX is a viable treatment option for patients at an advanced stage of cardiac amyloidosis as overall survival after transplantation has improved in the modern age. Patients at a very advanced stage of the disease, indicated by low serum albumin and blood pressure, show worse outcomes following HTX. Optimal timing and careful patient selection may therefore be particularly important to further improve post-HTX survival in amyloidosis patients.
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Affiliation(s)
- Martin J Kraus
- Department of Internal Medicine III, Division of Cardiology, University of Heidelberg, Heidelberg, Germany.
| | | | - Anna L Meyer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | | | | | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Alexander Reinecke
- Department of Cardiology, Angiology and Intensive Care, University of Kiel, Kiel, Germany
| | - Zdenek Provaznik
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Oliver Van Caenegem
- Cardiovascular Department, Intensive Care Unit, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium (deceased)
| | - Arnaud Ancion
- Cardiology, Centre Hospitalier Universitaire Sart-Tilman, Liège, Belgium
| | - Michael Berchtold-Herz
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Freiburg, Germany; Department of Medicine, University Heart Center Freiburg, Freiburg, Germany
| | | | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Guenther Laufer
- Department of Cardiac Surgery, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Jan Gummert
- Heart and Diabetes Center Nord-Rhein-Westfalen, Ruhr University Bochum, Bochum, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Philip W Raake
- Department of Internal Medicine III, Division of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany; Department of Cardiology, University Hospital of Augsburg, Augsburg Germany
| | - Norbert Frey
- Department of Internal Medicine III, Division of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Michael M Kreusser
- Department of Internal Medicine III, Division of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
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A rare case of sudden death due to endomyocardial fibrosis in Italy: A differential diagnosis with other causes of restrictive cardiomyopathy. J Forensic Leg Med 2023; 93:102462. [PMID: 36516716 DOI: 10.1016/j.jflm.2022.102462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 11/18/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022]
Abstract
A 45-years-old Indonesian woman was admitted to the hospital with nausea, vomiting, abdominal pain and tachyarrhythmia. Atrial fibrillation was found at ECG, blood tests showed mild hepatic function alterations. Radiological exams showed bilateral pleural effusions, ascites, hepatomegaly. Systolic and diastolic functions of the left ventricle were found to be strongly compromised at US. Physical conditions and laboratory results worsened rapidly, followed by multi organ failure. Death occurred 28 hours after admission. An autopsy was performed to clarify the cause of death and investigated medical malpractice. External examination showed jaundice skin and at internal examination bilateral pleural and pericardial effusions, ascites, mild cardiomegaly, ventricular endocardial fibrosis, a thrombus in tight junction to the left ventricular wall and hepatic necrosis were observed. Histological investigations revealed a massive endomyocardial fibrosis, detected through Azan-Mallory and Verhoef-Van-Gieson stain, and confirmed the presence of hepatic and renal necrosis. Toxicological and microbiological investigations were negative. The cause of death was a global cardiac dysfunction caused by a restrictive cardiomyopathy in an Indonesian woman affected by an undiagnosed and asymptomatic endomyocardial fibrosis. In this case, autopsy and histopathological investigations were fundamental to diagnose an occult endomyocardial fibrosis, which is an idiopathic disorder of tropical and subtropical regions of the world. The not common incidence of this disease in our country and its unusual clinical onset were at first perceived as a medical malpractice from the relatives. Consequently, the clinical aspects of the case intertwine with the medicolegal implications concerning the undiagnosed disease and the causality with the patient's death.
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39
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Role of Diphosphonates Bone Scintigraphy in Correlation with Biomarkers for a Personalized Approach to ATTR Cardiac Amyloidosis in North-Eastern Romania. Diagnostics (Basel) 2022; 13:diagnostics13010083. [PMID: 36611375 PMCID: PMC9818064 DOI: 10.3390/diagnostics13010083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/13/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022] Open
Abstract
Transthyretin cardiac amyloidosis (ATTR) is a rare cardiac protein deposition disease characterized by progressive thickening of both ventricles, the inter-atrial-ventricular septum and the atrioventricular valves. The gold standard method for diagnosing this rare pathology is endomyocardial biopsy. If this method cannot be used, the alternative is a mixture of clinical and paraclinical tests. Over the course of five years, we examined 58 patients suspected of cardiac amyloidosis based on electrocardiography and ultrasonography criteria, who had been sent for bone scintigraphy in order to determine the presence of ATTR cardiac amyloidosis. However, the final diagnosis was set by correlating the bone scan with genetic testing, free light chain dosage or soft tissue biopsy. Based on the final diagnosis we analyzed the patients' predominant biomarkers in order to determine a possible correlation between them. This analysis is designed to help the general practitioner set a possible cardiac amyloidosis diagnosis.
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Quarta CC, Fontana M, Damy T, Catini J, Simoneau D, Mercuri M, Garcia-Pavia P, Maurer MS, Palladini G. Changing paradigm in the treatment of amyloidosis: From disease-modifying drugs to anti-fibril therapy. Front Cardiovasc Med 2022; 9:1073503. [PMID: 36606280 PMCID: PMC9808970 DOI: 10.3389/fcvm.2022.1073503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022] Open
Abstract
Cardiac amyloidosis is a rare, debilitating, and usually fatal disease increasingly recognized in clinical practice despite patients presenting with non-specific symptoms of cardiomyopathy. The current standard of care (SoC) focuses on preventing further amyloid formation and deposition, either with anti-plasma cell dyscrasia (anti-PCD) therapies in light-chain (AL) amyloidosis or stabilizers of transthyretin (TTR) in transthyretin amyloidosis (ATTR). The SoC is supplemented by therapies to treat the complications arising from organ dysfunction; for example, heart failure, arrhythmia, and proteinuria. Advancements in treatments have improved patient survival, especially for those whose disease is detected and for whom treatment is initiated at an early stage. However, there still are many unmet medical needs, particularly for patients with severe disease for whom morbidity and mortality remain high. There currently are no approved treatments to reverse amyloid infiltration and deplete the amyloid fibrils already deposited in organs, which can continue to cause progressive dysfunction. Anti-fibril therapies aimed at removing the deposited fibrils are being investigated for safety and efficacy in improving outcomes for patients with severe disease. However, there is no clinical evidence yet that removing deposited amyloid fibrils will improve organ function, thereby improving quality of life or extending life. Nevertheless, anti-fibril therapies are actively being investigated in clinical trials to evaluate their ability to complement and synergize with current SoC.
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Affiliation(s)
| | | | - Thibaud Damy
- University Hospital Henri Mondor, Creteil, France
| | - Julia Catini
- Alexion, AstraZeneca Rare Disease, Boston, MA, United States
| | - Damien Simoneau
- Alexion, AstraZeneca Rare Disease, Boston, MA, United States
| | - Michele Mercuri
- Alexion, AstraZeneca Rare Disease, Boston, MA, United States
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana (IDIPHISA), Centro de Investigación Biomédica en Red Enfermedades Cardiovasulares (CIBERCV), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Mathew S. Maurer
- Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, United States
| | - Giovanni Palladini
- Department of Molecular Medicine, University of Pavia, and Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo”, Pavia, Italy
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Taylor MS, Sidiqi H, Hare J, Kwok F, Choi B, Lee D, Baumwol J, Carroll AS, Vucic S, Neely P, Korczyk D, Thomas L, Mollee P, Stewart GJ, Gibbs SDJ. Current approaches to the diagnosis and management of amyloidosis. Intern Med J 2022; 52:2046-2067. [PMID: 36478370 DOI: 10.1111/imj.15974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/06/2022] [Indexed: 12/12/2022]
Abstract
Amyloidosis is a collection of diseases caused by the misfolding of proteins that aggregate into insoluble amyloid fibrils and deposit in tissues. While these fibrils may aggregate to form insignificant localised deposits, they can also accumulate in multiple organs to the extent that amyloidosis can be an immediately life-threatening disease, requiring urgent treatment. Recent advances in diagnostic techniques and therapies are dramatically changing the disease landscape and patient prognosis. Delays in diagnosis and treatment remain the greatest challenge, necessitating physician awareness of the common clinical presentations that suggest amyloidosis. The most common types are transthyretin (ATTR) amyloidosis followed by immunoglobulin light-chain (AL) amyloidosis. While systemic AL amyloidosis was previously considered a death sentence with no effective therapies, significant improvement in patient survival has occurred over the past 2 decades, driven by greater understanding of the disease process, risk-adapted adoption of myeloma therapies such as proteosome inhibitors (bortezomib) and monoclonal antibodies (daratumumab) and improved supportive care. ATTR amyloidosis is an underdiagnosed cause of heart failure. Technetium scintigraphy has made noninvasive diagnosis much easier, and ATTR is now recognised as the most common type of amyloidosis because of the increased identification of age-related ATTR. There are emerging ATTR treatments that slow disease progression, decrease patient hospitalisations and improve patient quality of life and survival. This review aims to update physicians on recent developments in amyloidosis diagnosis and management and to provide a diagnostic and treatment framework to improve the management of patients with all forms of amyloidosis.
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Affiliation(s)
- Mark S. Taylor
- Westmead Amyloidosis Service Westmead Hospital New South Wales Sydney Australia
- Department of Immunology Liverpool Hospital New South Wales Sydney Australia
- Department of Clinical Immunology Prince of Wales Hospital New South Wales Sydney Australia
- Prince of Wales Clinical School UNSW Sydney New South Wales Sydney Australia
| | - Hasib Sidiqi
- Fiona Stanley Amyloidosis Clinic Western Australia Perth Australia
| | - James Hare
- Cardiology Unit Alfred Health Victoria Melbourne Australia
- Victorian and Tasmanian Amyloidosis Service Victoria Melbourne Australia
| | - Fiona Kwok
- Westmead Amyloidosis Service Westmead Hospital New South Wales Sydney Australia
- Westmead Clinical School University of Sydney New South Wales Sydney Australia
| | - Bo Choi
- Cardiology Unit Alfred Health Victoria Melbourne Australia
- Victorian and Tasmanian Amyloidosis Service Victoria Melbourne Australia
| | - Darren Lee
- Victorian and Tasmanian Amyloidosis Service Victoria Melbourne Australia
- Department of Renal Medicine Eastern Health Victoria Melbourne Australia
- Eastern Health Clinical School Monash University Victoria Melbourne Australia
| | - Jay Baumwol
- Fiona Stanley Amyloidosis Clinic Western Australia Perth Australia
| | - Antonia S. Carroll
- Westmead Amyloidosis Service Westmead Hospital New South Wales Sydney Australia
- Westmead Clinical School University of Sydney New South Wales Sydney Australia
- Department of Neurology St Vincent's Hospital New South Wales Darlinghurst Australia
| | - Steve Vucic
- Department of Neurology Concord Repatriation General Hospital New South Wales Sydney Australia
| | - Pat Neely
- Princess Alexandra Hospital Amyloidosis Centre Queensland Brisbane Australia
| | - Dariusz Korczyk
- Princess Alexandra Hospital Amyloidosis Centre Queensland Brisbane Australia
| | - Liza Thomas
- Westmead Amyloidosis Service Westmead Hospital New South Wales Sydney Australia
- Westmead Clinical School University of Sydney New South Wales Sydney Australia
| | - Peter Mollee
- Princess Alexandra Hospital Amyloidosis Centre Queensland Brisbane Australia
- School of Medicine University of Queensland Queensland Brisbane Australia
| | - Graeme J. Stewart
- Westmead Clinical School University of Sydney New South Wales Sydney Australia
| | - Simon D. J. Gibbs
- Victorian and Tasmanian Amyloidosis Service Victoria Melbourne Australia
- Eastern Health Clinical School Monash University Victoria Melbourne Australia
- Haematology Unit Eastern Health Victoria Melbourne Australia
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Parmar K, Benjanuwattra J, Sethi P, Tijani L, Hurst P, Pertuz GD, Argueta‐Sosa E. Cardiac amyloidosis-An underdiagnosed cause of heart failure: A case report and review of literature. Clin Case Rep 2022; 10:e6525. [PMID: 36478969 PMCID: PMC9718913 DOI: 10.1002/ccr3.6525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/14/2022] [Accepted: 10/08/2022] [Indexed: 12/04/2022] Open
Abstract
Restrictive cardiomyopathy secondary to cardiac amyloidosis is an underdiagnosed, but treatable, cause of heart failure involving an extracellular deposition of misfolded protein. Hereby, we report a case of a female patient with history of nephrotic syndrome for 1 year who subsequently presented with symptoms of heart failure. The findings on cardiac imaging supported the suspicion of cardiac amyloidosis. Further laboratory workup for amyloidosis was pursued along with endomyocardial biopsy which confirmed amyloidosis-AL type. Patient was started on chemotherapy. The case underscores the importance of a timely diagnosis with the help of symptomatology and imaging along with a multidisciplinary approach for patient care.
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Affiliation(s)
- Kanak Parmar
- Department of Internal MedicineTexas Tech University Health Sciences CenterLubbockTexasUSA
| | | | - Pooja Sethi
- Department of CardiologyTexas Tech University Health Sciences CenterLubbockTexasUSA
| | - Lukman Tijani
- Department of Hematology‐OncologyTexas Tech University Health Sciences CenterLubbockTexasUSA
| | - Philip Hurst
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | - Gaspar Del‐Rio Pertuz
- Department of Internal MedicineTexas Tech University Health Sciences CenterLubbockTexasUSA
| | - Erwin Argueta‐Sosa
- Department of CardiologyTexas Tech University Health Sciences CenterLubbockTexasUSA
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Dasari AKR, Yi S, Coats MF, Wi S, Lim KH. Toxic Misfolded Transthyretin Oligomers with Different Molecular Conformations Formed through Distinct Oligomerization Pathways. Biochemistry 2022; 61:2358-2365. [PMID: 36219173 PMCID: PMC9665167 DOI: 10.1021/acs.biochem.2c00390] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Protein aggregation is initiated by structural changes from native polypeptides to cytotoxic oligomers, which form cross-β structured amyloid. Identification and characterization of oligomeric intermediates are critically important for understanding not only the molecular mechanism of aggregation but also the cytotoxic nature of amyloid oligomers. Preparation of misfolded oligomers for structural characterization is, however, challenging because of their transient, heterogeneous nature. Here, we report two distinct misfolded transthyretin (TTR) oligomers formed through different oligomerization pathways. A pathogenic TTR variant with a strong aggregation propensity (L55P) was used to prepare misfolded oligomers at physiological pH. Our mechanistic studies showed that the full-length TTR initially forms small oligomers, which self-assemble into short protofibrils at later stages. Enzymatic cleavage of the CD loop was also used to induce the formation of N-terminally truncated oligomers, which was detected in ex vivo cardiac TTR aggregates extracted from the tissues of patients. Structural characterization of the oligomers using solid-state nuclear magnetic resonance and circular dichroism revealed that the two TTR misfolded oligomers have distinct molecular conformations. In addition, the proteolytically cleaved TTR oligomers exhibit a higher surface hydrophobicity, suggesting the presence of distinct oligomerization pathways for TTR oligomer formation. Cytotoxicity assays also revealed that the cytotoxicity of cleaved oligomers is stronger than that of the full-length TTR oligomers, indicating that hydrophobicity might be an important property of toxic oligomers. These comparative biophysical analyses suggest that the toxic cleaved TTR oligomers formed through a different misfoling pathway may adopt distinct structural features that produce higher surface hydrophobicity, leading to the stronger cytotoxic activities.
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Affiliation(s)
- Anvesh K. R. Dasari
- Department of Chemistry, East Carolina University, Greenville, NC 27858, USA
| | - Sujung Yi
- Department of Chemistry, East Carolina University, Greenville, NC 27858, USA
| | - Matthew F. Coats
- Department of Chemistry, East Carolina University, Greenville, NC 27858, USA
| | - Sungsool Wi
- Interdisciplinary Magnetic Resonance (CIMAR), National High Magnetic Field Laboratory (NHMFL), 1800 East, Paul Dirac Dr., Tallahassee, FL 32310, USA
| | - Kwang Hun Lim
- Department of Chemistry, East Carolina University, Greenville, NC 27858, USA
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Characterization of Plasma SDS-Protein Aggregation Profile of Patients with Heart Failure with Preserved Ejection Fraction. J Cardiovasc Transl Res 2022:10.1007/s12265-022-10334-w. [PMID: 36271180 DOI: 10.1007/s12265-022-10334-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/13/2022] [Indexed: 10/24/2022]
Abstract
This study characterizes the plasma levels and composition of SDS-resistant aggregates (SRAs) in patients with heart failure with preserved ejection fraction (HFpEF) to infer molecular pathways associated with disease and/or proteostasis disruption. Twenty adults (ten with HFpEF and ten age-matched individuals) were included. Circulating SRAs were resolved by diagonal two-dimensional SDS-PAGE, and their protein content was identified by mass spectrometry. Protein carbonylation, ubiquitination and ficolin-3 were evaluated. Patients with HFpEF showed higher SRA/total (36.6 ± 4.9% vs 29.6 ± 2.2%, p = 0.009) and SRA/soluble levels (58.6 ± 12.7% vs 40.6 ± 5.8%, p = 0.008). SRAs were carbonylated and ubiquitinated, suggesting they are composed of dysfunctional proteins resistant to degradation. SRAs were enriched in proteins associated with cardiovascular function/disease and with proteostasis machinery. Total ficolin-3 levels were decreased (0.77 ± 0.22, p = 0.041) in HFpEF, suggesting a reduced proteostasis capacity to clear circulating SRA. Thus, the higher accumulation of SRA in HFpEF may result from a failure or overload of the protein clearance machinery.
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Chu X, Wang M, Tang R, Huang Y, Yu J, Cao Y, Zheng Y, Xie Z, Deng J, Wang Z, Ma W, Song W, Wu Y, Lv H, Zhang W, Wang Z, Yuan Y, Liu Y, Meng L. Clinical and biochemical characterization of hereditary transthyretin amyloidosis caused by E61K mutation. Front Mol Neurosci 2022; 15:1003303. [PMID: 36311011 PMCID: PMC9596982 DOI: 10.3389/fnmol.2022.1003303] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/20/2022] [Indexed: 11/25/2022] Open
Abstract
Objects: This study was intended to find out more about the clinical characterizations of patients carrying transthyretin (TTR) E61K (p.Glu81Lys) gene mutation and the biochemical characterization of this mutant protein. Materials and methods: Five patients who had been diagnosed with hereditary transthyretin amyloidosis and two asymptomatic carriers carrying TTR E61K gene mutation were reported. Biochemical and biophysical tests were conducted to observe the thermodynamic and kinetic stability. Fibril formation tests measured by turbidity assay were performed to explore the pathogenicity of this mutation. Kinetic stabilizer responsiveness was measured to determine the inhibitory effect on protein aggregation. Results: The average age of onset for the five patients was 62 years, and the course of the disease ranged from 2 to 10 years. Cardiac disease was prominent in this group of patients. Nerve pathology revealed a mildly to moderately reduced myelinated fiber density and muscle pathology showed predominant neurogenic impairment accompanied by possible myogenic impairment. E61K-TTR was characterized as a kinetically destabilized protein compared to WT-TTR but its thermodynamic stability was not compromised. In addition, the subunit exchange of E61K with WT-TTR further destabilized the heterozygous tetramer. Meanwhile, the E61K:WT heterozygous tetramer exhibited a poor response to kinetic stabilizers in the fibril formation assay. Finally, the serum TTR tetramer concentration was low in E61K-TTR symptomatic patients and in one asymptomatic gene carrier. Vyndamax (Tafamidis) could increase the TTR tetramer concentration. Conclusions: Patients with E61K mutation tended to be late-onset. The concentration of TTR tetramer in the serum might serve as a biomarker to monitor disease progress, therapeutic window time, and therapeutic response to TTR kinetic stabilizer drugs.
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Affiliation(s)
- Xujun Chu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Mengdie Wang
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical Physics, Chinese Academy of Science, Dalian, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Ran Tang
- Dong’e County People’s Hospital, Liaocheng, China
| | - Yanan Huang
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical Physics, Chinese Academy of Science, Dalian, China
| | - Jiaxi Yu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yunfeng Cao
- Shanghai Institute for Biomedical and Pharmaceutical Technologies, NHC Key Laboratory of Reproduction Regulation, Shanghai Engineering Research Center of Reproductive Health Drug and Devices, Shanghai, China
| | - Yilei Zheng
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhiying Xie
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Jianwen Deng
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Zhi Wang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Wei Ma
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Wenjing Song
- Department of Ophthalmology, Peking University First Hospital, Beijing, China
| | - Yuan Wu
- Department of Ophthalmology, Peking University First Hospital, Beijing, China
| | - He Lv
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Wei Zhang
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Zhaoxia Wang
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yun Yuan
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yu Liu
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical Physics, Chinese Academy of Science, Dalian, China
- *Correspondence: Lingchao Meng Yu Liu orcid.org/0000-0002-0779-1488
| | - Lingchao Meng
- Department of Neurology, Peking University First Hospital, Beijing, China
- *Correspondence: Lingchao Meng Yu Liu orcid.org/0000-0002-0779-1488
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46
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Musigk N, Heidecker B. Transthyretin Amyloidosis - The Picture is Getting Clearer. Eur J Heart Fail 2022; 24:1697-1699. [PMID: 35912914 DOI: 10.1002/ejhf.2641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 07/25/2022] [Indexed: 11/11/2022] Open
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47
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Göbel S, Hobohm L, Desuki A, Gori T, Münzel T, Claudio R, Wenzel P, Keller K. Impact of cardiac amyloidosis on outcomes of patients hospitalized with heart failure. Eur J Intern Med 2022; 102:88-96. [PMID: 35584975 DOI: 10.1016/j.ejim.2022.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/27/2022] [Accepted: 05/02/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Amyloidosis is a multi-systemic disease potentially leading to failure of affected organs. We aimed to investigate prevalence and prognostic implications of cardiac amyloidosis of any etiology on outcomes of hospitalized patients with heart failure (HF) in Germany. METHODS We analyzed data of the German nationwide inpatient sample (2005-2018) of patients hospitalized for HF (including myocarditis with HF and heart transplantation with HF). HF patients with amyloidosis (defined as cardiac amyloidosis [CA]) were compared with those HF patients without amyloidosis and impact of CA on outcomes was assessed. RESULTS During this fourteen-year observational period 5,478,835 hospitalizations for HF were analyzed. Amyloidosis was coded in 5,407 HF patients (0.1%). CA prevalence was 1.87 hospitalizations per 100,000 German population. CA patients were younger (75.0[IQR 67.0-80.0]vs.79.0[72.0-85.0]years, p < 0.001), predominantly male (68.9%) and had a higher prevalence of cancer (14.8% vs. 3.6%, p < 0.001). Adverse in-hospital events including necessity of transfusions of blood constituents (7.1% vs. 5.4%, p < 0.001) and cardio-pulmonary resuscitation (CPR, 2.7% vs. 1.4%; p < 0.001) were more frequent in CA. CA was independently associated with acute kidney failure (OR 1.40 [95%CI 1.28-1.52], p < 0.001), CPR (OR 1.58 [95%CI 1.34-1.86], p < 0.001), intracerebral bleeding (OR 3.13 [95%CI 1.68-5.83], p < 0.001) and in-hospital mortality between the 5 and 8th decade of life, but in-hospital mortality was strongly influenced by cancer. CONCLUSIONS CA was identified as an independent risk factor for complications and in-hospital mortality in HF patients, whereby it has to be mentioned that amyloidosis subtypes could not differentiated in the present study. Physicians should be aware of this issue concerning treatments and monitoring of CA-patients.
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Affiliation(s)
- Sebastian Göbel
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Langenbeckstrasse 1, Mainz 55131, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Lukas Hobohm
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Langenbeckstrasse 1, Mainz 55131, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Alexander Desuki
- University Cancer Center Mainz, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Tommaso Gori
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Langenbeckstrasse 1, Mainz 55131, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany, dCardiological Centre, University of Ferrara, Italy
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Langenbeckstrasse 1, Mainz 55131, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany, dCardiological Centre, University of Ferrara, Italy
| | - Rapezzi Claudio
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany, dCardiological Centre, University of Ferrara, Italy; Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Philip Wenzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Langenbeckstrasse 1, Mainz 55131, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany, dCardiological Centre, University of Ferrara, Italy
| | - Karsten Keller
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Langenbeckstrasse 1, Mainz 55131, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany.
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48
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Tshori S, Livschitz S, Volodarsky I, Goland S, Shimoni S, Fabrikant J, George J. Transthyretin Cardiac Amyloidosis Scintigraphy Using Planar D-SPECT on Dedicated Cardiac CZT Camera. J Nucl Cardiol 2022; 29:1995-2000. [PMID: 33977371 DOI: 10.1007/s12350-021-02651-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 04/07/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Bone scintigraphy is a main diagnostic tool in suspected ATTR patients. Almost all literature is based on conventional whole body gamma cameras, and there is very sparse data evaluating the use of dedicated cardiac CZT cameras. The aim of this study was to evaluate the utility of bone scintigraphy in suspected transthyretin cardiac amyloidosis (ATTR-CA) patients on a dedicated cardiac CZT camera. METHODS Seventy-three patients with suspected ATTR-CA underwent planar and SPECT Tc-99 m pyrophosphate scintigraphy using dedicated cardiac CZT camera between May and August 2019. RESULTS Planar D-SPECT image quality was mostly good. Six patients were identified as ATTR-CA positive. Inter-observer agreement based on both Perugini score and on planar D-SPECT H/CL ratio was excellent. CONCLUSIONS ATTR-CA scintigraphy using dedicated cardiac CZT camera was feasible, and yielded planar D-SPECT images with excellent inter-observer agreement.
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Affiliation(s)
- Sagi Tshori
- Heart Center, Kaplan Medical Center, Pasternak St., 1, Rehovot, 7661041, Israel.
- Institute of Medical Research Israel-Canada, The Hebrew University, Jerusalem, Israel.
| | - Shay Livschitz
- Heart Center, Kaplan Medical Center, Pasternak St., 1, Rehovot, 7661041, Israel
| | - Igor Volodarsky
- Heart Center, Kaplan Medical Center, Pasternak St., 1, Rehovot, 7661041, Israel
| | - Sorel Goland
- Heart Center, Kaplan Medical Center, Pasternak St., 1, Rehovot, 7661041, Israel
- The Hebrew University, Jerusalem, Israel
| | - Sara Shimoni
- Heart Center, Kaplan Medical Center, Pasternak St., 1, Rehovot, 7661041, Israel
- The Hebrew University, Jerusalem, Israel
| | - Jacob Fabrikant
- Heart Center, Kaplan Medical Center, Pasternak St., 1, Rehovot, 7661041, Israel
| | - Jacob George
- Heart Center, Kaplan Medical Center, Pasternak St., 1, Rehovot, 7661041, Israel.
- The Hebrew University, Jerusalem, Israel.
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49
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Touboul O, Algalarrondo V, Oghina S, Elbaz N, Rouffiac S, Hamon D, Extramiana F, Gandjbakhch E, D'Humieres T, Marijon E, Dhanjal TS, Teiger E, Damy T, Lellouche N. Electrical cardioversion of atrial arrhythmias with cardiac amyloidosis in the era of direct oral anticogulants. ESC Heart Fail 2022; 9:3556-3564. [PMID: 35903879 DOI: 10.1002/ehf2.14082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/10/2022] [Accepted: 07/18/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS Atrial fibrillation (AF)/atrial flutter is common during cardiac amyloidosis (CA). Electrical cardioversion (EC) is a strategy to restore sinus rhythm (SR). However, left atrial thrombus (LAT) represents a contraindication for EC. CA patients with AF/atrial flutter have a high prevalence of LAT. We aimed to evaluate EC characteristics, LAT prevalence and risk factors, and AF/atrial flutter outcome in CA patients undergoing EC, predominantly treated with direct oral anticoagulants (DOACs). METHODS AND RESULTS All patients with CA and AF/atrial flutter referred for the first time to our national referral centre of amyloidosis for EC from June 2017 to February 2021 were included in this study. In total, 66 patients (median age 74.5 [70;80.75] years, 67% male) were included with anticoagulation consisted of DOAC in 74% of cases. All patients underwent cardiac imaging before EC to rule out LAT. EC was cancelled due to LAT in 14% of cases. Complete thrombus resolution was observed in only 17% of cases. The two independent parameters associated with LAT were creatinine [hazard ratio (HR) = 1.01; confidence interval (CI) = 1.00-1.03, P = 0.036] and the use of antiplatelet agents (HR = 13.47; CI = 1.85-98.02). EC acute success rate was 88%, and we observed no complication after EC. With 64% of patients under amiodarone, AF/atrial flutter recurrence rate following EC was 51% after a mean follow-up of 30 ± 27 months. CONCLUSIONS Left atrial thrombus was observed in 14% of CA patients listed for EC and mainly treated with DOAC. The acute EC success rate was high with no complication. The long-term EC success rate was acceptable (49%).
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Affiliation(s)
- Olivier Touboul
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | | | - Silvia Oghina
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - Nathalie Elbaz
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - Segolene Rouffiac
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - David Hamon
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - Fabrice Extramiana
- Department of Cardiology, AP-HP, University Hospital Bichat, Paris, France
| | - Estelle Gandjbakhch
- Department of Cardiology, AP-HP, University Hospital Pitié-Salpétrière, Paris, France
| | - Thomas D'Humieres
- Department of Physiology, AP-HP, University Hospital Henri Mondor, Creteil, France
| | - Eloi Marijon
- Department of Cardiology, AP-HP, University Hopital Européen Georges Pompidou, Paris, France
| | - Tarvinder S Dhanjal
- Department of Cardiac Electrophysiology, University of Warwick, Gibbet Hill, Coventry, UK
| | - Emmanuel Teiger
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - Thibaud Damy
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - Nicolas Lellouche
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
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50
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Lin W, Chattranukulchai P, Lee AP, Lin YH, Yu WC, Liew HB, Oomman A. Clinical recommendations to diagnose and monitor patients with transthyretin amyloid cardiomyopathy in Asia. Clin Cardiol 2022; 45:898-907. [PMID: 35795903 PMCID: PMC9451661 DOI: 10.1002/clc.23882] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/10/2022] [Accepted: 06/15/2022] [Indexed: 11/11/2022] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR‐CM) is a debilitating and life‐threatening condition with a heterogeneous clinical presentation. Recent guidelines from the United States and Europe have been published to guide clinical practice and to facilitate management conformity by covering current diagnostic and treatment strategies for patients with ATTR‐CM. These guidelines highlight the importance of an early diagnosis to optimize therapeutic outcomes, specifying the use of tests and imaging techniques to allow accurate, noninvasive diagnosis of ATTR‐CM. However, as regional practice variations across Asia may limit access to healthcare, availability of specific tests, and expertise in assessing diagnostic images, there is an ongoing need to provide an Asian perspective on these clinical guidelines. This review article provides practical recommendations for the diagnosis and monitoring of patients with ATTR‐CM in Asia, highlighting the need for additional guidelines to support a broad and diverse population, consider differing healthcare systems and diagnostic testing availability, and provide a flexible yet robust algorithm.
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Affiliation(s)
- Weiqin Lin
- Department of Cardiology, National University Heart Centre, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Pairoj Chattranukulchai
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Alex Pw Lee
- Division of Cardiology, Department of Medicine and Therapeutics, Li Ka Shing Institutes of Health Science, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, Republic of China
| | - Wen-Chung Yu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China.,Department of Internal Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Houng-Bang Liew
- Department of Cardiology, Clinical Research Centre, Queen Elizabeth Hospital II, Kota Kinabalu, Malaysia
| | - Abraham Oomman
- Department of Cardiology, Apollo Hospitals, Chennai, India
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