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Gallo-Bernal S, Patino-Jaramillo N, Calixto CA, Higuera SA, Forero JF, Lara Fernandes J, Góngora C, Gee MS, Ghoshhajra B, Medina HM. Nephrogenic Systemic Fibrosis in Patients with Chronic Kidney Disease after the Use of Gadolinium-Based Contrast Agents: A Review for the Cardiovascular Imager. Diagnostics (Basel) 2022; 12:diagnostics12081816. [PMID: 36010167 PMCID: PMC9406537 DOI: 10.3390/diagnostics12081816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/11/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022] Open
Abstract
Gadolinium-enhanced cardiac magnetic resonance has revolutionized cardiac imaging in the last two decades and has emerged as an essential and powerful tool for the characterization and treatment guidance of a wide range of cardiovascular diseases. However, due to the high prevalence of chronic renal dysfunction in patients with cardiovascular conditions, the risk of nephrogenic systemic fibrosis (NSF) after gadolinium exposure has been a permanent concern. Even though the newer macrocyclic agents have proven to be much safer in patients with chronic kidney disease and end-stage renal failure, clinicians must fully understand the clinical characteristics and risk factors of this devastating pathology and maintain a high degree of suspicion to prevent and recognize it. This review aimed to summarize the existing evidence regarding the physiopathology, clinical manifestations, diagnosis, and prevention of NSF related to the use of gadolinium-based contrast agents.
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Affiliation(s)
- Sebastian Gallo-Bernal
- Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA;
- Department of Radiology, Harvard Medical School, Boston, MA 02115, USA;
- Correspondence:
| | - Nasly Patino-Jaramillo
- Division of Cardiology, Fundacion Cardioinfantil-LaCardio, Bogota 110131, Colombia; (N.P.-J.); (S.A.H.); (H.M.M.)
| | - Camilo A. Calixto
- Department of Radiology, Harvard Medical School, Boston, MA 02115, USA;
- Department of Radiology Boston Children’s Hospital, Boston, MA 02115, USA
| | - Sergio A. Higuera
- Division of Cardiology, Fundacion Cardioinfantil-LaCardio, Bogota 110131, Colombia; (N.P.-J.); (S.A.H.); (H.M.M.)
| | - Julian F. Forero
- Division of Radiology, Fundacion Cardioinfantil-LaCardio, Bogota 110131, Colombia;
| | - Juliano Lara Fernandes
- Jose Michel Kalaf Research Institute, Radiologia Clinica de Campinas, São Paulo 13092-123, Brazil;
| | - Carlos Góngora
- Department of Radiology, Harvard Medical School, Boston, MA 02115, USA;
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, USA; (C.G.); (B.G.)
| | - Michael S. Gee
- Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA;
- Department of Radiology, Harvard Medical School, Boston, MA 02115, USA;
| | - Brian Ghoshhajra
- Department of Radiology, Harvard Medical School, Boston, MA 02115, USA;
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, USA; (C.G.); (B.G.)
| | - Hector M. Medina
- Division of Cardiology, Fundacion Cardioinfantil-LaCardio, Bogota 110131, Colombia; (N.P.-J.); (S.A.H.); (H.M.M.)
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Korosoglou G, Giusca S, André F, Aus dem Siepen F, Nunninger P, Kristen AV, Frey N. Diagnostic Work-Up of Cardiac Amyloidosis Using Cardiovascular Imaging: Current Standards and Practical Algorithms. Vasc Health Risk Manag 2021; 17:661-673. [PMID: 34720583 PMCID: PMC8550552 DOI: 10.2147/vhrm.s295376] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/07/2021] [Indexed: 01/15/2023] Open
Abstract
Among non-ischemic cardiomyopathies, cardiac amyloidosis is one of the most common, being caused by extracellular depositions of amyloid fibrils in the myocardium. Two main forms of cardiac amyloidosis are known so far, including 1) light-chain (AL) amyloidosis caused by monoclonal production of light-chains, and 2) transthyretin (ATTR) amyloidosis, caused by dissociation of the transthyretin tetramer into monomers. Both AL and ATTR amyloidosis are progressive diseases with median survival from diagnosis of less than 6 months and 3 to 5 years, respectively, if untreated. In this regard, death occurs in most patients due to cardiac causes, mainly congestive heart failure, which can be prevented due to the presence of effective, life-saving treatment regimens. Therefore, early diagnosis of cardiac amyloidosis is crucial more than ever. However, diagnosis of cardiac amyloidosis may be challenging due to variable clinical manifestations and the perceived rarity of the disease. In this regard, clinical and laboratory reg flags are available, which may help clinicians to raise suspicion of cardiac amyloidosis. In addition, advances in cardiovascular imaging have already revealed a higher prevalence of cardiac amyloidosis in specific populations, so that the diagnosis especially of ATTR amyloidosis has experienced a >30-fold increase during the past ten years. The goal of our review article is to summarize these findings and provide a practical approach for clinicians on how to use cardiovascular imaging techniques, such as echocardiography, cardiac magnetic resonance, bone scintigraphy and, if required, organ biopsy within predefined diagnostic algorithms for the diagnostic work-up of patients with suspected cardiac amyloidosis. In addition, two clinical cases and practical tips are provided in this context.
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Affiliation(s)
- Grigorios Korosoglou
- GRN Hospital Weinheim, Department of Cardiology, Vascular Medicine and Pneumology, Weinheim, Germany.,Cardiac Imaging Center Weinheim, Hector Foundation, Weinheim, Germany
| | - Sorin Giusca
- GRN Hospital Weinheim, Department of Cardiology, Vascular Medicine and Pneumology, Weinheim, Germany.,Cardiac Imaging Center Weinheim, Hector Foundation, Weinheim, Germany
| | - Florian André
- Department of Cardiology, Pneumology and Angiology, University Hospital Heidelberg, Heidelberg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
| | - Fabian Aus dem Siepen
- Department of Cardiology, Pneumology and Angiology, University Hospital Heidelberg, Heidelberg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
| | | | - Arnt V Kristen
- Department of Cardiology, Pneumology and Angiology, University Hospital Heidelberg, Heidelberg, Germany.,Cardiovascular Center Darmstadt, Darmstadt, Germany
| | - Norbert Frey
- Department of Cardiology, Pneumology and Angiology, University Hospital Heidelberg, Heidelberg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
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Minutoli F, Di Bella G, Mazzeo A, Laudicella R, Gentile L, Russo M, Vita G, Baldari S. Serial scanning with 99mTc-3, 3-diphosphono-1, 2-propanodicarboxylic acid ( 99mTc-DPD) for early detection of cardiac amyloid deposition and prediction of clinical worsening in subjects carrying a transthyretin gene mutation. J Nucl Cardiol 2021; 28:1949-1957. [PMID: 31741327 DOI: 10.1007/s12350-019-01950-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/07/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND To determine the capability of 99mTc-DPD scintigraphy to detect early cardiac involvement and predict clinical worsening in transthyretin (TTR) gene mutation patients. METHODS Eleven mutated subjects with normal interventricular septum (IVS) thickness, NT-proBNP level and no cardiac symptoms underwent three seriate 99mTc-DPD scans (visually and semiquantitatively analyzed), and was followed-up for 5-8-years. RESULTS Six patients showed no myocardial accumulation in all scans. Increased IVS thickness occurring in one patient 4 years after the last scan was the only abnormal finding in these patients; no cardiac symptoms developed during the follow-up. In three patients, cardiac radiotracer uptake was found at enrollment; other laboratory/instrumental abnormal findings occurred later and cardiac symptoms developed during the follow-up period. Two patients had a negative 99mTc-DPD scan at enrollment and showed cardiac uptake in the following scans. Increased mean left-ventricular (LV) wall thickness was found 3 years after positive scintigraphy; NT-proBNP increased later in one patient. These patients developed cardiac symptoms during the follow-up period. CONCLUSIONS 99mTc-DPD scan detects cardiac involvement in subjects with TTR gene mutation earlier than ECG, echocardiography and biochemical markers, occurring some years before the fulfillment of current diagnostic criteria for cardiac amyloidosis. A positive 99mTc-DPD scan predicts cardiac symptoms onset.
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Affiliation(s)
- F Minutoli
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - G Di Bella
- Department of Clinical and Experimental Medicine, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - A Mazzeo
- Department of Clinical and Experimental Medicine, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - R Laudicella
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy.
| | - L Gentile
- Department of Clinical and Experimental Medicine, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - M Russo
- Nemo Sud Clinical Centre, University Hospital "G. Martino", Messina, Italy
| | - G Vita
- Department of Clinical and Experimental Medicine, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - S Baldari
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
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Licordari R, Minutoli F, Recupero A, Campisi M, Donato R, Mazzeo A, Dattilo G, Baldari S, Vita G, Zito C, Di Bella G. Early Impairment of Right Ventricular Morphology and Function in Transthyretin-Related Cardiac Amyloidosis. J Cardiovasc Echogr 2021; 31:17-22. [PMID: 34221881 PMCID: PMC8230159 DOI: 10.4103/jcecho.jcecho_112_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/06/2020] [Indexed: 11/30/2022] Open
Abstract
Background: Our study aimed to evaluate right ventricular (RV) morphology and strain (S) in the early stage of familial transthyretin (TTR) cardiac amyloidosis (CA). Methods and Results: Thirty-seven patients with transthyretin mutation underwent 99mTc-3,3-diphosphono-1,2 propanodicarboxylic acid (99mTc-DPD) scans and/or cardiac magnetic resonance (CMR) to identify TTR CA. Each patient underwent echocardiography to quantify RV dimensions, tricuspid annular plane systolic excursion (TAPSE), systolic pulmonary artery pressure (sPAP), longitudinal (L) strain of the RV free wall, left ventricular (LV) septal thickness (ST), ejection fraction, E/E', LV global (G) L, radial (R), and circumferential (C) S. 99mTc-DPD and CMR revealed the accumulation in 22 of 37 patients (CA group) and no accumulation in 15 patients (no-CA group). Left ventricular (LV) septal thickness (ST) was higher (P < 0.0001) while LV ejection fraction and E/E' were lower (P < 0.05) in the CA group than the no-CA group. LV-global longitudinal strain (LS) was lower (P < 0.0001) in the CA-group than the no CA-group, whereas LV-global circumferential strain and LV-global radial strain were similar. The CA group showed higher values of RV dimensions (P < 0.05) and sPAP (0.02) and a lower (P = 0.002) TAPSE. Globally, RV-LS was lower (P = 0.005) in the CA group than the no-CA group. Basal and mid segments of the RV free wall showed a lower LS in the CA group than the no-CA group (P < 0.01), while apical S was similar between groups. Conclusions: RV deformation, particularly in basal and mid segments, is early impaired in CA.
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Affiliation(s)
- Roberto Licordari
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, AOU "Policlinico G. Martino," Messina, Italy
| | - Fabio Minutoli
- Department of Biomedical Sciences and Morphologic and Functional Images, University of Messina, Messina, Italy
| | - Antonino Recupero
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, AOU "Policlinico G. Martino," Messina, Italy
| | - Mariapaola Campisi
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, AOU "Policlinico G. Martino," Messina, Italy
| | - Rocco Donato
- Department of Biomedical Sciences and Morphologic and Functional Images, University of Messina, Messina, Italy
| | - Anna Mazzeo
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Messina, AOU "Policlinico G. Martino," Messina, Italy
| | - Giuseppe Dattilo
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, AOU "Policlinico G. Martino," Messina, Italy
| | - Sergio Baldari
- Department of Biomedical Sciences and Morphologic and Functional Images, University of Messina, Messina, Italy
| | - Giuseppe Vita
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Messina, AOU "Policlinico G. Martino," Messina, Italy
| | - Concetta Zito
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, AOU "Policlinico G. Martino," Messina, Italy
| | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, AOU "Policlinico G. Martino," Messina, Italy
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Russo M, Cucinotta F, Gentile L, Fabrizi GM, Taioli F, Vita G, Toscano A, Mazzeo A. Very Early Onset of ATTRE89Q Amyloidosis in a Homozygous Patient. Open Neurol J 2021. [DOI: 10.2174/1874205x02115010021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Case Presentarion:
Hereditary transthyretin amyloidosis is a progressive, fatal disease that generally involves the peripheral nervous system, the autonomic nervous system, and the heart. It is autosomal dominant with different penetrance depending on the mutation and the genetic background. Many other missense mutations of the TTR gene may cause the disease. Being an overall rare disease is very rare to observe the condition of homozygosity. In particular, cases of homozygosity have been described in patients with ATTRV30M and ATTRV122I amyloidosis. In the former, the phenotype does not seem to be aggravated, having an age of onset and disease course that does not appear to differ from those of heterozygotes, while in the latter, the onset appears to be earlier.
Conclusion:
We report the first case of ATTRE89Q amyloidosis in a patient that was homozygous for the E89Q mutation in the TTR gene. The clinical phenotype resulted in the earlier disease onset reported in this form of amyloidosis, suggesting that the homozygous condition may be prognostically negative.
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Russo M, Gentile L, Di Stefano V, Di Bella G, Minutoli F, Toscano A, Brighina F, Vita G, Mazzeo A. Use of Drugs for ATTRv Amyloidosis in the Real World: How Therapy Is Changing Survival in a Non-Endemic Area. Brain Sci 2021; 11:brainsci11050545. [PMID: 33925301 PMCID: PMC8146901 DOI: 10.3390/brainsci11050545] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/24/2021] [Accepted: 04/24/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Over the past decade, three new drugs have been approved for the treatment of hereditary amyloid transthyretin (ATTRv) polyneuropathy. The aim of this work was to analyze whether current therapies prolong survival for patients affected by ATTRv amyloidosis. Methods: The study was conducted retrospectively, analyzing the medical records of 105 patients with genetic diagnoses of familial amyloidotic polyneuropathy followed at the two referral centers for the disease in Sicily, Italy. Of these, 71 received disease-modifying therapy, while 34 received only symptomatic treatment or no therapy. Results: The most used treatment in our patient cohort was tafamidis, followed by liver transplantation, patisiran, inotersen, and diflunisal. The median survival was significantly longer for treated vs. untreated patients (12 years vs. 8 years). In the 71 patients who received disease-modifying treatment, the presence of cardiac involvement, weight loss, or autonomic dysfunction at diagnosis was not related to survival. Conversely, patients diagnosed in the early stage of the disease (PND 1) had significantly longer survival than those diagnosed in the late stage (PND 2–4).
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Affiliation(s)
- Massimo Russo
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (L.G.); (A.T.); (G.V.); (A.M.)
- Correspondence: ; Tel.: +39-09-0221-3504
| | - Luca Gentile
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (L.G.); (A.T.); (G.V.); (A.M.)
| | - Vincenzo Di Stefano
- Department of Biomedicine, Neuroscience and Advanced Diagnostic (BIND), University of Palermo, 90133 Palermo, Italy; (V.D.S.); (F.B.)
| | - Gianluca Di Bella
- Cardiology Unit, Department of Clinical and Experimental Medicine, AOU Policlinico G. Martino, University of Messina, 98122 Messina, Italy;
| | - Fabio Minutoli
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98122 Messina, Italy;
| | - Antonio Toscano
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (L.G.); (A.T.); (G.V.); (A.M.)
| | - Filippo Brighina
- Department of Biomedicine, Neuroscience and Advanced Diagnostic (BIND), University of Palermo, 90133 Palermo, Italy; (V.D.S.); (F.B.)
| | - Giuseppe Vita
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (L.G.); (A.T.); (G.V.); (A.M.)
| | - Anna Mazzeo
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (L.G.); (A.T.); (G.V.); (A.M.)
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Vergaro G, Aimo A, Barison A, Genovesi D, Buda G, Passino C, Emdin M. Keys to early diagnosis of cardiac amyloidosis: red flags from clinical, laboratory and imaging findings. Eur J Prev Cardiol 2020; 27:1806-1815. [DOI: 10.1177/2047487319877708] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Abstract
Cardiac involvement in systemic amyloidosis, due either to immunoglobulin light-chain or transthyretin amyloidosis, influences clinical presentation and is a strong predictor of unfavourable outcome. Until recently considered as a rare, incurable disease, cardiac amyloidosis, is still mis/underdiagnosed, although treatments effective in improving patient survival are now available for both subtypes, including chemotherapy regimens for immunoglobulin light-chain amyloidosis and tetramer stabiliser for transthyretin amyloidosis. Achieving a timely diagnosis allows initiating life-saving therapies and requires the early recognition of clinical, laboratory and imaging signs of cardiac involvement, some of them may be apparent well before the disease becomes clinically manifest. Given the systemic nature of amyloidosis, a close interaction among experts in multiple specialties is also required, including cardiologists, nephrologists, haematologists, neurologists, radiologists, nuclear medicine specialists and internists. As an increased awareness about disease presentation is required to ameliorate diagnostic performance, we aim to provide the clinician with a guide to the screening and early diagnosis of cardiac amyloidosis, and to review the clinical, biohumoral and instrumental ‘red flags’ that should raise the suspicion of cardiac amyloidosis.
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Affiliation(s)
- Giuseppe Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
| | - Andrea Barison
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | - Gabriele Buda
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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Grajewski KG, Stojanovska J, Ibrahim ESH, Sayyouh M, Attili A. Left Ventricular Hypertrophy: Evaluation With Cardiac MRI. Curr Probl Diagn Radiol 2020; 49:460-475. [DOI: 10.1067/j.cpradiol.2019.09.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/12/2019] [Accepted: 09/03/2019] [Indexed: 01/20/2023]
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Teng C, Li P, Bae JY, Pan S, Dixon RAF, Liu Q. Diagnosis and treatment of transthyretin-related amyloidosis cardiomyopathy. Clin Cardiol 2020; 43:1223-1231. [PMID: 32725834 PMCID: PMC7661658 DOI: 10.1002/clc.23434] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/15/2020] [Accepted: 07/17/2020] [Indexed: 12/29/2022] Open
Abstract
Transthyretin-related amyloidosis (ATTR) is a subgroup of amyloidosis that results from extracellular misassembled and toxic amyloid deposits affecting multiple organ systems, and cardiac tissues in particular. Because ATTR often presents as heart failure with preserved ejection fraction (HFpEF), it has been largely underdiagnosed. Once considered incurable with a grave prognosis, ATTR cardiomyopathy has seen the development of promising alternatives for diagnosis and treatment, with early diagnosis and treatment of ATTR cardiomyopathy highly beneficial due to its high mortality rate. For instance, diagnosing ATTR cardiomyopathy previously required a cardiac biopsy, but new modalities, such as cardiac magnetic resonance imaging and radionuclide bone scans, show promise in accurately diagnosing ATTR cardiomyopathy. Ongoing research and clinical trials have focused on identifying new treatments which primarily target amyloid fiber formation by inhibiting TTR gene expression, stabilizing the TTR tetramer, preventing oligomer aggregation, or affecting degradation of amyloid fibers. In this review, we describe the advances made in the diagnosis and treatment of ATTR in order to increase awareness of the disease and encourage a lower threshold for ATTR workup. Our review also highlights the need for improving the screening, diagnosis, and treatment guidelines for ATTR cardiomyopathy.
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Affiliation(s)
- Catherine Teng
- Department of MedicineYale New Haven Health‐Greenwich HospitalGreenwichConnecticutUSA
| | - Pengyang Li
- Department of MedicineSaint Vincent HospitalWorcesterMassachusettsUSA
| | - Ju Young Bae
- Department of MedicineYale New Haven Health‐Greenwich HospitalGreenwichConnecticutUSA
| | - Su Pan
- Molecular Cardiology ResearchTexas Heart InstituteHoustonTexasUSA
| | | | - Qi Liu
- Molecular Cardiology ResearchTexas Heart InstituteHoustonTexasUSA
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Frantellizzi V, Cosma L, Pani A, Pontico M, Conte M, De Angelis C, De Vincentis G. Role of Nuclear Imaging in Cardiac Amyloidosis Management: Clinical Evidence and Review of Literature. Curr Med Imaging 2020; 16:957-966. [PMID: 33081658 DOI: 10.2174/1573405615666191210103452] [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: 06/28/2019] [Revised: 10/28/2019] [Accepted: 11/19/2019] [Indexed: 11/22/2022]
Abstract
Cardiac amyloidosis (CA) is an infiltrative disease characterized by the extracellular deposition of fibrils, amyloid, in the heart. The vast majority of patients with CA has one of two types between transthyretin amyloid (ATTR) and immunoglobulin light chain associated amyloid (AL), that have different prognosis and therapeutic options. CA is often underdiagnosed. The histological analysis of endomyocardial tissue is the gold standard for the diagnosis, although it has its limitations due to its invasive nature. Nuclear medicine now plays a key role in the early and accurate diagnosis of this disease, and in the ability to distinguish between the two forms. Recent several studies support the potential advantage of bone-seeking radionuclides as a screening technique for the most common types of amyloidosis, in particular ATTR form. This review presents noninvasive modalities to diagnose CA and focuses on the radionuclide imaging techniques (bone-seeking agents scintigraphy, cardiac sympathetic innervation and positron emission tomography studies) available to visualize myocardial amyloid involvement. Furthermore, we report the case of an 83-year old male with a history of prostate cancer, carcinoma of the cecum and kidney cancer, submitted to bone scan to detect bone metastasis, that revealed a myocardial uptake of 99mTC-HMPD suggestive of ATTR CA. An accurate and early diagnosis of CA able to distinguish beyween AL and ATTR CA combined to the improving therapies could improve the survival of patients with this disease.
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Affiliation(s)
- Viviana Frantellizzi
- Department of Molecular Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Laura Cosma
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Arianna Pani
- School of Clinical Pharmacology and Toxicology, University of Milan, Milan, Italy
| | - Mariano Pontico
- Program in Morphogenesis & Tissue Engineering, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Miriam Conte
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Cristina De Angelis
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Giuseppe De Vincentis
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
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11
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Grigoratos C, Aimo A, Rapezzi C, Genovesi D, Barison A, Aquaro GD, Vergaro G, Pucci A, Passino C, Marzullo P, Gimelli A, Emdin M. Diphosphonate single-photon emission computed tomography in cardiac transthyretin amyloidosis. Int J Cardiol 2020; 307:187-192. [PMID: 32081469 DOI: 10.1016/j.ijcard.2020.02.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/26/2020] [Accepted: 02/10/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Planar diphosphonate scintigraphy is an established diagnostic tool for amyloid transthyretin (ATTR) cardiomyopathy. Characterization of the amyloid burden up to the segmental level by single photon emission computed tomography (SPECT) has not been evaluated so far. METHODS Data from consecutive patients undergoing cardiac 99mTc-hydroxymethylene diphosphonate (99mTc-HMDP) SPECT and diagnosed with ATTR cardiomyopathy at a tertiary referral center from June 2016 to April 2019 were collected. RESULTS Thirty-eight patients were included (median age 81 years, 79% men, 92% with wild-type ATTR). In patients with Perugini score 1, the most intense diphosphonate regional uptake was found in septal segments, particularly in infero-septal segments. Among patients scoring 2, the amyloid burden in the septum became more significant, and extended to inferior and apical segments. Finally, patients scoring 3 displayed an intense and widespread tracer uptake. All patients with Perugini score 1 had LGE in at least one antero-septal, one infero-septal, and one infero-lateral segment. All patients with score 2 displayed LGE in infero-septal, inferior, and infero-lateral segments. LGE became extensive in patients scoring 3, with all patients having at least one LGE-positive segment in each region. CONCLUSIONS When assimilating different Perugini grades to evolutive stages of the disease, amyloid deposition seem to progress from the septum to the inferior wall and then to the other regions and from the basis to the apex. The potential of segmental analysis might be particularly relevant in patients with very limited cardiac uptake at planar scintigraphy (Perugini score 1).
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Affiliation(s)
- Chrysanthos Grigoratos
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Claudio Rapezzi
- Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna, Italy
| | | | - Andrea Barison
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - Giuseppe Vergaro
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Angela Pucci
- Histopathology Department, University Hospital of Pisa, Italy
| | - Claudio Passino
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | - Michele Emdin
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
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12
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Traynor BP, Shamsi A, Voon V. Multi-modality imaging in transthyretin amyloid cardiomyopathy. World J Cardiol 2019; 11:266-276. [PMID: 31798793 PMCID: PMC6885447 DOI: 10.4330/wjc.v11.i11.266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 09/08/2019] [Accepted: 10/07/2019] [Indexed: 02/06/2023] Open
Abstract
Transthyretin amyloid (TTR) cardiomyopathy is a disease of insidious onset, which is often accompanied by debilitating neurological and/or cardiac complications. The true prevalence is not fully known due to its elusive presentation, being often under-recognized and usually diagnosed only late in its natural history and in older patients. Because of this, effective treatment options are usually precluded by multiple comorbidities and frailty associated with such patients. Therefore, high clinical suspicion with earlier and better detection of this disease is needed. In this review, the novel applications of multimodality imaging in the diagnostic pathway of TTR cardiomyopathy are explored. These include the complimentary roles of transthoracic echocardiography, cardiac magnetic resonance, nuclear scintigraphy and positron emission tomography in quantifying cardiac dysfunction, diagnosis and risk stratification. Recent advances in novel therapeutic options for TTR have further enhanced the importance of a timely and accurate diagnosis of this disease.
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Affiliation(s)
- Bryan Paul Traynor
- Department of Cardiology, Connolly Hospital Blanchardstown, Abbottstown, Dublin D15X40D, Ireland
| | - Aamir Shamsi
- Department of Cardiology, St George’s University Hospital NHS Foundation Trust, London SW170QT, United Kingdom
| | - Victor Voon
- Department of Cardiology, St George’s University Hospital NHS Foundation Trust, London SW170QT, United Kingdom
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13
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Puig-Carrion GD, Reyentovich A, Katz SD. Diagnosis and treatment of heart failure in hereditary transthyretin amyloidosis. Clin Auton Res 2019; 29:45-53. [PMID: 31452023 PMCID: PMC6763576 DOI: 10.1007/s10286-019-00629-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 08/02/2019] [Indexed: 01/15/2023]
Abstract
Amyloidosis describes a family of related disease states associated with the extracellular tissue deposition of fibrils composed of low-molecular-weight subunits of a variety of proteins circulating as constituents of plasma. Depending on the disease subtype, fibrillar deposits in a several organs including the heart, kidney, liver, and peripheral nerves cause organ dysfunction and associated morbidity and mortality. The most common amyloid fibril deposits associated with cardiac manifestations are of monoclonal light-chain or transthyretin (ATTR) types. This review will focus on the ATTR types of cardiac amyloidosis. ATTR amyloidosis may be associated with abnormal metabolism of wild-type transthyretin (previously called senile systemic amyloidosis) or with hereditary variants in the transthyretin gene. Cardiac amyloidosis is often under-recognized in its early stages, and when a diagnosis of cardiac amyloidosis is made, patients are often at the advanced stages of the disease. Treatments now available appear to exert their benefit predominantly in individuals with the early stages of disease. Increased awareness and early diagnosis of cardiac amyloidosis and continued discovery of effective therapies will increase opportunities to improve clinical outcomes in this patient population.
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Affiliation(s)
- Gisela D Puig-Carrion
- Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York University Langone Health, 530 First Avenue, Skirball Suite 9 N, New York, NY, 10016, USA
| | - Alex Reyentovich
- Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York University Langone Health, 530 First Avenue, Skirball Suite 9 N, New York, NY, 10016, USA
| | - Stuart D Katz
- Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York University Langone Health, 530 First Avenue, Skirball Suite 9 N, New York, NY, 10016, USA.
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14
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Abstract
PURPOSE OF REVIEW The aim is to provide a description of the most important echocardiographic features in systemic amyloidosis. RECENT FINDINGS Amyloidosis is a heterogeneous group of multisystem disorders, characterized by an extracellular deposition of amyloid fibrils. Several imaging tests are available for the diagnosis; however, echocardiography is the cornerstone of the non-invasive imaging modality for cardiac amyloidosis. So far, little is known about the diagnosis of cardiac amyloidosis through imaging modalities. We summarized the most important echocardiographic findings in cardiac amyloidosis. Hence, we offered a systematic report of the diagnostic performance of cardiac amyloidosis using echocardiography.
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15
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Di Bella G, Pizzino F. Myocardial Deformation Analysis and Late-Gadolinium Enhancement: Important Markers of Cardiac Amyloidosis Involvement That Can Masquerade as a False-Negative Diagnosis. Circ J 2018; 82:2687. [DOI: 10.1253/circj.cj-17-1392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Gianluca Di Bella
- Clinical and Experimental Department of Medicine and Pharmacology, University of Messina
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16
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Habib G, Bucciarelli-Ducci C, Caforio ALP, Cardim N, Charron P, Cosyns B, Dehaene A, Derumeaux G, Donal E, Dweck MR, Edvardsen T, Erba PA, Ernande L, Gaemperli O, Galderisi M, Grapsa J, Jacquier A, Klingel K, Lancellotti P, Neglia D, Pepe A, Perrone-Filardi P, Petersen SE, Plein S, Popescu BA, Reant P, Sade LE, Salaun E, Slart RHJA, Tribouilloy C, Zamorano J. Multimodality Imaging in Restrictive Cardiomyopathies: An EACVI expert consensus document In collaboration with the "Working Group on myocardial and pericardial diseases" of the European Society of Cardiology Endorsed by The Indian Academy of Echocardiography. Eur Heart J Cardiovasc Imaging 2018; 18:1090-1121. [PMID: 28510718 DOI: 10.1093/ehjci/jex034] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 02/14/2017] [Indexed: 12/11/2022] Open
Abstract
Restrictive cardiomyopathies (RCMs) are a diverse group of myocardial diseases with a wide range of aetiologies, including familial, genetic and acquired diseases and ranging from very rare to relatively frequent cardiac disorders. In all these diseases, imaging techniques play a central role. Advanced imaging techniques provide important novel data on the diagnostic and prognostic assessment of RCMs. This EACVI consensus document provides comprehensive information for the appropriateness of all non-invasive imaging techniques for the diagnosis, prognostic evaluation, and management of patients with RCM.
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Affiliation(s)
- Gilbert Habib
- Aix- Aix-Marseille Univ, URMITE, Aix Marseille Université-UM63, CNRS 7278, IRD 198, INSERM 1095.,Cardiology Department, APHM, La Timone Hospital, Boulevard Jean Moulin, 13005 Marseille, France
| | - Chiara Bucciarelli-Ducci
- Bristol Heart Institute, National Institute of Health Research (NIHR) Bristol Cardiovascular Biomedical Research Unit (BRU), University of Bristol, Bristol, UK
| | - Alida L P Caforio
- Cardiology, Department of Cardiological Thoracic and Vascular Sciences, University of Padova, Italy
| | - Nuno Cardim
- Multimodality Cardiac Imaging Department, Sports Cardiology and Cardiomyopathies Centre-Hospital da Luz; Lisbon, Portugal
| | - Philippe Charron
- Université Versailles Saint Quentin, INSERM U1018, Hôpital Ambroise Paré, Boulogne-Billancourt, France.,Centre de référence pour les maladies cardiaques héréditaires, APHP, ICAN, Hôpital de la Pitié Salpêtrière, Paris, France
| | | | - Aurélie Dehaene
- Department of Radiology and Cardiovascular Imaging, APHM, Hôpitaux de la Timone, Pôle d'imagerie Médicale, 13005 Marseille, France
| | - Genevieve Derumeaux
- Department of Physiology, INSERM U955, Université Paris-Est Creteil, Henri Mondor Hospital, DHU-ATVB, AP-HP, Créteil, France
| | - Erwan Donal
- Cardiologie-CHU Rennes & CIC-IT 1414 & LTSI INSERM 1099 - Université Rennes-1
| | - Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh
| | - Thor Edvardsen
- Department of Cardiology, Center for Cardiological Innovation and Institute for Surgical Research, Oslo University Hospital, Oslo, Norway.,University of Oslo, Oslo, Norway
| | - Paola Anna Erba
- Regional Center of Nuclear Medicine, Department of Translational Research and New Technology in Medicine, University of Pisa, Pisa, Italy
| | - Laura Ernande
- Department of Physiology, INSERM U955, Université Paris-Est Creteil, Henri Mondor Hospital, DHU-ATVB, AP-HP, Créteil, France
| | - Oliver Gaemperli
- University Heart Center Zurich, Interventional Cardiology and Cardiac Imaging 19, Zurich
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Julia Grapsa
- Department of Cardiovascular Sciences, Imperial College of London, London, UK
| | - Alexis Jacquier
- Department of Radiology and Cardiovascular Imaging, APHM, Hôpitaux de la Timone, Pôle d'imagerie Médicale, Aix-Marseille Université, CNRS, CRMBM UMR 7339, 13385 Marseille, France
| | - Karin Klingel
- Department of Molecular Pathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany
| | - Patrizio Lancellotti
- Departments of Cardiology, Heart Valve Clinic, University of Liège Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, Liège, Belgium.,Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| | - Danilo Neglia
- Cardiovascular Department, Fondazione Toscana G. Monasterio, CNR Institute of Clinical Physiology, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Alessia Pepe
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio C.N.R.-Regione Toscana Pisa, Italy
| | | | - Steffen E Petersen
- Department of Advanced Cardiovascular Imaging, William Harvey Research Institute, National Institute for Health Research Cardiovascular Biomedical Research Unit at Barts, London, UK
| | - Sven Plein
- Division of Biomedical Imaging, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine LIGHT Laboratories, University of Leeds, UK
| | - Bogdan A Popescu
- University of Medicine and Pharmacy 'Carol Davila'-Euroecolab, Institute of Cardiovascular Diseases, Bucharest, Romania
| | | | | | - Erwan Salaun
- Cardiology Department, La Timone Hospital, Marseille France
| | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, The Netherlands.,Department of Biomedical Photonic Imaging, University of Twente, PO Box 217, 7500 AEEnschede, The Netherlands
| | - Christophe Tribouilloy
- Department of Cardiology, University Hospital Amiens, Amiens, France and INSERM U-1088, Jules Verne University of Picardie, Amiens, France
| | - Jose Zamorano
- University Hospital Ramon y Cajal Carretera de Colmenar Km 9,100, 28034 Madrid, Spain
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17
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Diagnostic accuracy of bone scintigraphy in the assessment of cardiac transthyretin-related amyloidosis: a bivariate meta-analysis. Eur J Nucl Med Mol Imaging 2018; 45:1945-1955. [PMID: 29687207 DOI: 10.1007/s00259-018-4013-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 04/06/2018] [Indexed: 01/15/2023]
Abstract
PURPOSE Cardiac transthyretin-related amyloidosis (ATTR) is a progressive and fatal cardiomyopathy. The diagnosis of this disease is frequently delayed or missed due to the limited specificity of echocardiography. An increasing amount of data in the literature demonstrate the ability of bone scintigraphy with bone-seeking radiopharmaceuticals to detect myocardial amyloid deposits, in particular in patients with ATTR. Therefore we performed a systematic review and bivariate meta-analysis of the diagnostic accuracy of bone scintigraphy in patients with suspected cardiac ATTR. METHODS A comprehensive computer literature search of studies published up to 30 November 2017 on the role of bone scintigraphy in patients with ATTR was performed using the following search algorithm: (a) "amyloid" OR "amyloidosis" AND (b) "TTR" OR "ATTR" OR "transthyretin" AND (c) "scintigraphy" OR "scan" OR "SPECT" OR "SPET" OR "bone" OR "skeletal" OR "skeleton" OR "PYP" OR "DPD" OR "HMDP" OR "MDP" OR "HDP". Pooled sensitivity, specificity, positive and negative likelihood ratios (LR+ and LR-) and diagnostic odds ratio (DOR) of bone scintigraphy were calculated. RESULTS The meta-analysis of six selected studies on bone scintigraphy in cardiac ATTR including 529 patients provided the following results: sensitivity 92.2% (95% CI 89-95%), specificity 95.4% (95% CI 77-99%), LR+ 7.02 (95% CI 3.42-14.4), LR- 0.09 (95% CI 0.06-0.14), and DOR 81.6 (95% CI 44-153). Mild heterogeneity was found among the selected studies. CONCLUSION Our evidence-based data demonstrate that bone scintigraphy using technetium-labelled radiotracers provides very high diagnostic accuracy in the non-invasive assessment of cardiac ATTR.
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18
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Tuzovic M, Yang EH, Baas AS, Depasquale EC, Deng MC, Cruz D, Vorobiof G. Cardiac Amyloidosis: Diagnosis and Treatment Strategies. Curr Oncol Rep 2018; 19:46. [PMID: 28528458 DOI: 10.1007/s11912-017-0607-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cardiac amyloidosis in the United States is most often due to myocardial infiltration by immunoglobulin protein, such as in AL amyloidosis, or by the protein transthyretin, such as in hereditary and senile amyloidosis. Cardiac amyloidosis often portends a poor prognosis especially in patients with systemic AL amyloidosis. Despite better understanding of the pathophysiology of amyloid, many patients are still diagnosed late in the disease course. This review investigates the current understanding and new research on the diagnosis and treatment strategies in patients with cardiac amyloidosis. Myocardial amyloid infiltration distribution occurs in a variety of patterns. Structural and functional changes on echocardiography can suggest presence of amyloid, but CMR and nuclear imaging provide important complementary information on amyloid burden and the amyloid subtype, respectively. While for AL amyloid, treatment success largely depends on early diagnosis, for ATTR amyloid, new investigational agents that reduce production of transthyretin protein may have significant impact on clinical outcomes. Advancements in the non-invasive diagnostic detection and improvements in early disease recognition will undoubtedly facilitate a larger proportion of patients to receive early therapy when it is most effective.
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Affiliation(s)
- Mirela Tuzovic
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Eric H Yang
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Arnold S Baas
- Ahmanson-UCLA Cardiomyopathy Center, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Eugene C Depasquale
- Ahmanson-UCLA Cardiomyopathy Center, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Mario C Deng
- Ahmanson-UCLA Cardiomyopathy Center, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Daniel Cruz
- Ahmanson-UCLA Cardiomyopathy Center, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Gabriel Vorobiof
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA. .,Cardiovascular Center, 100 Medical Plaza, Suite 545, 100 UCLA Medical Plaza, Los Angeles, CA, 90095, USA.
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19
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Recupero A, Di Bella G, Pugliatti P, de Gregorio C. Left atrial (dys)function in patients with light chain amyloidosis: A pathophysiological model with challenging prognostic significance. J Cardiol 2018; 72:367-368. [PMID: 29566935 DOI: 10.1016/j.jjcc.2018.01.019] [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: 01/15/2018] [Accepted: 01/24/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Antonino Recupero
- Clinical and Experimental Department of Medicine and Pharmacology, University of Messina, Messina, Italy
| | - Gianluca Di Bella
- Clinical and Experimental Department of Medicine and Pharmacology, University of Messina, Messina, Italy.
| | - Pietro Pugliatti
- Clinical and Experimental Department of Medicine and Pharmacology, University of Messina, Messina, Italy
| | - Cesare de Gregorio
- Clinical and Experimental Department of Medicine and Pharmacology, University of Messina, Messina, Italy
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20
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Piekarski E, Chequer R, Algalarrondo V, Eliahou L, Mahida B, Vigne J, Adams D, Slama MS, Le Guludec D, Rouzet F. Cardiac denervation evidenced by MIBG occurs earlier than amyloid deposits detection by diphosphonate scintigraphy in TTR mutation carriers. Eur J Nucl Med Mol Imaging 2018; 45:1108-1118. [PMID: 29511839 DOI: 10.1007/s00259-018-3963-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/24/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE Cardiac involvement in familial transthyretin (TTR) amyloidosis is of major prognostic value, and the development of early-diagnostic tools that could trigger the use of new disease-modifying treatments is crucial. The aim of our study was to compare the respective contributions of 99mTc-diphosphonate scintigraphy (DPD, detecting amyloid deposits) and 123I-MIBG (MIBG, assessing cardiac sympathetic denervation) in patients with genetically proven TTR mutation referred for the assessment of cardiac involvement. METHODS We prospectively studied 75 consecutive patients (classified as symptomatic or asymptomatic carriers), using clinical evaluation, biomarkers (troponin and BNP), echocardiography, and nuclear imaging. Patients were classified as having normal heart-to-mediastinum (HMR) MIBG uptake ratio 4 h after injection (defined by HM4 ≥ 1.85) or abnormal HM4 < 1.85, and positive DPD uptake (grade ≥ 1 of Perugini classification) or negative DPD uptake. RESULTS Among 75 patients, 49 (65%) presented with scintigraphic sympathetic cardiac denervation and 29 (39%) with myocardial diphosphonate uptake. When MIBG was normal, DPD was negative except for two patients. Age was an independent predictor of abnormal scintigraphic result of both MIBG and DPD (HR 1.08 and 1.15 respectively), whereas echocardiographic-derived indicators of increased left ventricular filling pressure (E/e' ratio) was an independent predictor of abnormal MIBG (HR 1.33) and global longitudinal strain of positive DPD (HR 1.45). In asymptomatic patients (n = 31), MIBG was abnormal in 48% (n = 15) among whom 50% had a normal DPD; all those with a normal MIBG (n = 16) had a normal DPD. CONCLUSIONS In TTR mutation carriers, cardiac sympathetic denervation evidenced by decreased MIBG uptake is detected earlier than amyloid burden evidenced by DPD. These results raise the possibility of a diagnostic role for MIBG scintigraphy at an early stage of cardiac involvement in TTR-mutated carriers, in addition to its well-established prognostic value.
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Affiliation(s)
- Eve Piekarski
- Nuclear Medicine Department, Bichat Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), DHU FIRE, Inserm UMR-S 1148, Paris Diderot University, Paris, France
| | - Renata Chequer
- Nuclear Medicine Department, Bichat Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), DHU FIRE, Inserm UMR-S 1148, Paris Diderot University, Paris, France
| | - Vincent Algalarrondo
- Cardiology Department, Antoine Béclère Hospital, AP-HP, Paris-Sud University, Clamart, France
- French Referent Center for Rare Diseases for FAP (Familial Amyloid Polyneuropathy) (CRMR-NNERF), Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Ludivine Eliahou
- Cardiology Department, Antoine Béclère Hospital, AP-HP, Paris-Sud University, Clamart, France
- French Referent Center for Rare Diseases for FAP (Familial Amyloid Polyneuropathy) (CRMR-NNERF), Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Besma Mahida
- Nuclear Medicine Department, Bichat Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), DHU FIRE, Inserm UMR-S 1148, Paris Diderot University, Paris, France
| | - Jonathan Vigne
- Nuclear Medicine Department, Bichat Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), DHU FIRE, Inserm UMR-S 1148, Paris Diderot University, Paris, France
| | - David Adams
- French Referent Center for Rare Diseases for FAP (Familial Amyloid Polyneuropathy) (CRMR-NNERF), Bicêtre Hospital, Le Kremlin-Bicêtre, France
- Neurology Department, AP-HP, Paris-Sud University, Le Kremlin-Bicêtre, France
| | - Michel S Slama
- Cardiology Department, Antoine Béclère Hospital, AP-HP, Paris-Sud University, Clamart, France
- French Referent Center for Rare Diseases for FAP (Familial Amyloid Polyneuropathy) (CRMR-NNERF), Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Dominique Le Guludec
- Nuclear Medicine Department, Bichat Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), DHU FIRE, Inserm UMR-S 1148, Paris Diderot University, Paris, France
| | - Francois Rouzet
- Nuclear Medicine Department, Bichat Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), DHU FIRE, Inserm UMR-S 1148, Paris Diderot University, Paris, France.
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21
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Non-invasive cardiac imaging in patients with systemic amyloidosis: a practical approach with emphasis on clinical contribution of bone-seeking radiotracers. Clin Transl Imaging 2017. [DOI: 10.1007/s40336-017-0255-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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22
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Di Bella G, Pizzino F, Aquaro GD. A negative LGE is inconclusive to exclude an early cardiac amyloidosis: it’s the time for a T1 mapping in clinical practice. Int J Cardiol 2017; 247:45. [DOI: 10.1016/j.ijcard.2017.06.085] [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: 06/12/2017] [Accepted: 06/20/2017] [Indexed: 11/25/2022]
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Bhogal S, Ladia V, Sitwala P, Cook E, Bajaj K, Ramu V, Lavie CJ, Paul TK. Cardiac Amyloidosis: An Updated Review With Emphasis on Diagnosis and Future Directions. Curr Probl Cardiol 2017; 43:10-34. [PMID: 29173805 DOI: 10.1016/j.cpcardiol.2017.04.003] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Cardiac amyloidosis occurs because of abnormal protein (amyloid) deposition in the cardiac tissue. Even with advanced diagnostic techniques and treatments, the prognosis of amyloidosis remains poor. The diagnosis of cardiac amyloidosis particularly needs to be in the differential in patients presenting with heart failure with preserved ejection fraction. This entity remains underdiagnosed due to lack of suspicion on the part of many clinicians. Involvement of cardiac tissue is the utmost determinant factor for available treatment options and prognosis. Many cases of cardiac amyloidosis usually remain undiagnosed or diagnosed only in advanced stages when treatment options are limited and associated with poor survival. Hence, early recognition of cardiac amyloidosis is indispensable in halting the disease process before irreversible changes occur. The purpose of this review is to summarize the recent updates in the evaluation and management of cardiac amyloidosis and to discuss potential future treatments options.
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Pawar S, Haq M, Ruberg FL, Miller EJ. Imaging Options in Cardiac Amyloidosis: Differentiating AL from ATTR. CURRENT CARDIOVASCULAR IMAGING REPORTS 2017. [DOI: 10.1007/s12410-017-9399-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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25
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Di Bella G, Minutoli F, Piaggi P, Casale M, Mazzeo A, Zito C, Oreto G, Baldari S, Vita G, Pingitore A, Khandheria BK, Carerj S. Quantitative Comparison Between Amyloid Deposition Detected by (99m)Tc-Diphosphonate Imaging and Myocardial Deformation Evaluated by Strain Echocardiography in Transthyretin-Related Cardiac Amyloidosis. Circ J 2016; 80:1998-2003. [PMID: 27477961 DOI: 10.1253/circj.cj-16-0209] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Management of cardiac amyloidosis (CA) is related to amyloid deposition. Our aim was to assess the effect of amyloid deposition on myocardial function. METHODS AND RESULTS Twenty-eight patients with transthyretin mutation and a group of 14 controls underwent echocardiography to quantify left ventricular (LV) dimensions, function, and global (G) longitudinal (L), radial (R) and circumferential (C) strain (S). (99m)Tc-3,3-diphosphono-1,2-propanodicarboxylic-acid-scintigraphy ((99m)Tc-DPD) was used to quantify CA. (99m)Tc-DPD revealed accumulation in 14/28 patients (CA group) and no accumulation (no-CA group) in 14. Cardiac accumulation was lower-than-bone uptake in 5 (mild-CA group) and higher-than-bone uptake in 9 (severe-CA group). Ejection fraction was similar among groups. GLS was lower (P<0.001) in the severe-CA group (-12.2±4.5) with respect to the no-CA group (-19.3±3.0) and to the control group (-20.9±2.5). Conversely, GCS and GRS were lower (P<0.05) in the mild-CA group (-10.8±4.1 and 9.5±5.7, respectively) with respect to the severe-CA group (-18.9±5.1 and 23.9±6.3 respectively), no-CA group (-19.2±4.1 and 28.4±10.2, respectively) and the control group (-23.9±4.4 and 29.9±8.7, respectively). A correlation was found between the scintigraphic heart retention index (HRI) and LV septal thickness (ρ=0.72), E/E' (ρ=0.46) and GLS (ρ=-0.40). CONCLUSIONS Myocardial deformation is impaired in a different stage of CA. The (99m)Tc-DPD HRI correlated well with morphologic, diastolic and strain abnormalities. (Circ J 2016; 80: 1998-2003).
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Affiliation(s)
- Gianluca Di Bella
- Clinical and Experimental Medicine Department, Cardiology Unit, University of Messina, AOU "Policlinico G. Martino"
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Gertz MA, Benson MD, Dyck PJ, Grogan M, Coelho T, Cruz M, Berk JL, Plante-Bordeneuve V, Schmidt HHJ, Merlini G. Diagnosis, Prognosis, and Therapy of Transthyretin Amyloidosis. J Am Coll Cardiol 2016; 66:2451-2466. [PMID: 26610878 DOI: 10.1016/j.jacc.2015.09.075] [Citation(s) in RCA: 298] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/24/2015] [Accepted: 09/25/2015] [Indexed: 02/08/2023]
Abstract
Transthyretin amyloidosis is a fatal disorder that is characterized primarily by progressive neuropathy and cardiomyopathy. It occurs in both a mutant form (with autosomal dominant inheritance) and a wild-type form (with predominant cardiac involvement). This article guides clinicians as to when the disease should be suspected, describes the appropriate diagnostic evaluation for those with known or suspected amyloidosis, and reviews the interventions currently available for affected patients.
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Affiliation(s)
- Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota.
| | | | - Peter J Dyck
- Division of Peripheral Nerve, Mayo Clinic, Rochester, Minnesota
| | - Martha Grogan
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - Marcia Cruz
- Federal University of Rio de Janeiro of Brazil, University Hospital, Rio de Janeiro, Brazil
| | - John L Berk
- Amyloidosis Center, Boston University School of Medicine, Boston, Massachusetts
| | | | | | - Giampaolo Merlini
- Department of Molecular Medicine, University of Pavia, Pavia, Lombardy, Italy
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Di Bella G, Minutoli F, Madaffari A, Mazzeo A, Russo M, Donato R, Zito C, Aquaro GD, Piccione MC, Pedri S, Vita G, Pingitore A, Carerj S. Left atrial function in cardiac amyloidosis. J Cardiovasc Med (Hagerstown) 2016; 17:113-21. [DOI: 10.2459/jcm.0000000000000188] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Di Bella G, Minutoli F, Piaggi P, Casale M, Mazzeo A, Zito C, Oreto G, Baldari S, Vita G, Pingitore A, Khandheria BK, Carerj S. Usefulness of Combining Electrocardiographic and Echocardiographic Findings and Brain Natriuretic Peptide in Early Detection of Cardiac Amyloidosis in Subjects With Transthyretin Gene Mutation. Am J Cardiol 2015; 116:1122-7. [PMID: 26253999 DOI: 10.1016/j.amjcard.2015.07.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/03/2015] [Accepted: 07/03/2015] [Indexed: 10/23/2022]
Abstract
Early noninvasive identification of cardiac amyloidosis (CA) is of growing clinical importance. Low voltage on electrocardiogram (ECG), increased left ventricular (LV) septal thickness (ST), and global longitudinal strain (GLS) on echocardiography, and elevated brain natriuretic peptides (BNP) are used as surrogates of CA. Thirty-five patients (50 ± 14 years, 22 women) underwent electrocardiography to analyze low-voltage QRS (<15 mV) pathologic Q waves, poor R-wave progression, ST-T abnormalities, and left bundle branch block. An ECG was considered abnormal if at least one ECG alteration was present. Echocardiography was used to analyze LVST, E/E', and GLS. All participants also had BNP blood testing. (99m)Tc-3,3-diphosphono-1,2 propanodicarboxylic acid scintigraphy assumed as a reference method showed CA in 18 patients (51%, CA group) and no accumulation in 17 patients (no CA group). In descending order of accuracy, LVST >14 mm, E/E' >6.6, GLS <14.1, BNP >129 pg/ml, and an overall abnormal ECG showed good capability to distinguish patients with and without CA. All these parameters were predictors of CA in univariate analysis, whereas low-voltage QRS showed the worst performance. LVST >14 mm (p = 0.002) was the best independent predictor of CA, achieving sensitivity of 78% and accuracy of 89%. However, an LVST >14 mm (p = 0.005) plus an abnormal ECG (p = 0.03) show together a greater sensitivity, equal to 89%, in identifying CA. An integrated evaluation of ECG and echocardiography is a sensitive and low-cost technical approach to identify CA in patients with transthyretin gene mutation.
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Abstract
We report here the case of a 56-year-old man with well-documented cardiac light chain amyloidosis successfully imaged with F-flutemetamol PET/CT in 2011. A matched pair healthy volunteer was imaged in the same conditions, and no specific heart uptake could be detected. The present report suggests the potential benefit of this new pharmaceutical in this indication, as it has been recently reported for C-Pittsburgh compound B, but with the main advantage to benefit from the more practical half-life of F. Further prospective trials would, however, be required to define the potential impact of F-flutemetamol PET/CT in cardiac amyloidosis.
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Dubrey S, Ackermann E, Gillmore J. The transthyretin amyloidoses: advances in therapy. Postgrad Med J 2015; 91:439-48. [PMID: 26048914 DOI: 10.1136/postgradmedj-2014-133224] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 05/20/2015] [Indexed: 11/04/2022]
Abstract
There are two forms of transthyretin (TTR) amyloidosis: non-hereditary and hereditary. The non-hereditary form (ATTRwt) is caused by native or wild-type TTR and was previously referred to as senile systemic amyloidosis. The hereditary form (ATTRm) is caused by variant TTR which results from a genetic mutation of TTR. The predominant effect of ATTRwt amyloidosis is on the heart, with patients having a greater left ventricular wall thickness at presentation than the devastating form which is light chain (AL) amyloidosis. ATTRm amyloidosis is broadly split into two categories: a type that predominantly affects the nervous system (often called familial amyloid polyneuropathy (FAP)) and one with a predilection for the heart (often called familial amyloid cardiomyopathy (FAC)). Approximately half of all TTR mutations known to express a clinical phenotype cause a cardiomyopathy. Since the introduction of orthotopic liver transplantation for ATTRm amyloidosis in 1991, several additional therapies have been developed. These therapies aim to provide a reduction or elimination of TTR from the plasma (through genetic approaches), stabilisation of the TTR molecule (to prevent deposition) and dissolution of the amyloid matrix. We describe the latest developments in these approaches to management, many of which are also applicable to wild-type amyloidosis.
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Affiliation(s)
- Simon Dubrey
- Department of Cardiology, Hillingdon & Mount Vernon Hospitals NHS Trust, Uxbridge, Middlesex, UK
| | | | - Julian Gillmore
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
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Late gadolinium enhancement in cardiac amyloidosis: attributable both to interstitial amyloid deposition and subendocardial fibrosis caused by ischemia. Heart Vessels 2015; 31:990-5. [PMID: 25794983 DOI: 10.1007/s00380-015-0658-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 03/06/2015] [Indexed: 12/27/2022]
Abstract
Gadolinium contrast agents used for late gadolinium enhancement (LGE) distribute in the extracellular space. Global diffuse myocardial LGE pronounced in the subendocardial layers is common in cardiac amyloidosis. However, the pathophysiological basis of these findings has not been sufficiently explained. A 64-year-old man was admitted to our hospital with leg edema and nocturnal dyspnea. Bence Jones protein was positive in the urine, and an endomyocardial and skin biopsy showed light-chain (AL) amyloidosis. He died of ventricular fibrillation 3 months later. 9 days before death, the patient was examined by cardiac magnetic resonance (CMR) imaging on a 3-T system. We acquired LGE data at 2, 5, 10, and 20 min after the injection of gadolinium contrast agents, with a fixed inversion time of 350 ms. Myocardial LGE developed sequentially. The myocardium was diffusely enhanced at 2 min, except for the subendocardium, but LGE had extended to almost the entire left ventricle at 5 min and predominantly localized to the subendocardial region at 10 and 20 min. An autopsy revealed massive and diffused amyloid deposits in perimyocytes throughout the myocardium. Old and recent ischemic findings, such as replacement fibrosis and coagulative myocyte necrosis, were evident in the subendocardium. In the intramural coronary arteries, mild amyloid deposits were present within the subepicardial to the mid layer of the left ventricle, but no stenotic lesions were evident. However, capillaries were obstructed by amyloid deposits in the subendocardium. In conclusion, the late phase of dynamic LGE (at 10 and 20 min) visualized in the subendocardium corresponded to the interstitial amyloid deposition and subendocardial fibrosis caused by ischemia in our patient.
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Deux JF, Damy T, Rahmouni A, Mayer J, Planté-Bordeneuve V. Noninvasive detection of cardiac involvement in patients with hereditary transthyretin associated amyloidosis using cardiac magnetic resonance imaging: a prospective study. Amyloid 2014; 21:246-55. [PMID: 25211144 DOI: 10.3109/13506129.2014.956924] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Most of the studies that described cardiac amyloidosis using cardiac magnetic resonance (CMR) imaging refer to patients with primary light chain (AL) amyloidosis. The goal of this study was to evaluate cardiac involvement in patients with hereditary transthyretin associated (ATTR) amyloidosis and asymptomatic carriers and its relationships with clinical symptoms and genotype, using CMR imaging. METHODS AND RESULTS Fifty-three patients with hereditary ATTR amyloidosis and 14 asymptomatic carriers were included in this study. Morphological, functional and late gadolinium enhancement (LGE) findings were noted on CMR images. A positive LGE suggesting cardiac amyloidosis was detected in 60% of patients. The pattern of LGE was diffuse, focal and circumferential in 32, 26 and 2% of patients, respectively. The inferior basal segment was the most frequently involved (93%) in case of focal involvement. Diffuse pattern was exclusively encountered in patients with cardiac symptoms. Nineteen percent of patients with isolated neurological symptoms and 20% of subjects without left ventricular wall thickening exhibited cardiac abnormalities on CMR. CONCLUSION Cardiac involvement can be detected in patients with hereditary ATTR amyloidosis with isolated neurological symptoms and without left ventricular wall thickening, suggesting that CMR could be useful in detecting preclinical cardiac amyloidosis.
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Affiliation(s)
- Jean-François Deux
- Radiology Department, Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris , Créteil , France
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Adams D, Théaudin M, Cauquil C, Algalarrondo V, Slama M. FAP neuropathy and emerging treatments. Curr Neurol Neurosci Rep 2014; 14:435. [PMID: 24482069 DOI: 10.1007/s11910-013-0435-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Transthyretin familial amyloid polyneuropathy (TTR-FAP) classically presents as a length dependent small fiber polyneuropathy in endemic countries like Portugal. In nonendemic countries, it may mimic a variety of chronic polyneuropathies, with several phenotypes: ataxic, upper limb onset neuropathy, or motor. In these cases, there is usually a late onset and no positive family history. TTR gene sequencing appears the most pertinent first-line test for diagnosis. Cardiac involvement of various severities is common in FAP. Liver transplantation remains the standard antiamyloid therapy with better results in Val30Met TTR-FAP of early onset. Antiamyloid medication has been developed. (1) TTR stabilizers: Tafamidis was the first drug approved in Europe in stage 1 (walking unaided) TTR-FAP to slow progression of the disease; diflunisal has been assessed in a phase 3 clinical trial; (2) TTR gene silencing is a new strategy to inhibit production of both mutant and nonmutant TTR with antisense oligonucleotides or SiRNA (2 ongoing phase 3 clinical trials).
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Affiliation(s)
- David Adams
- APHP, HUPS, Univ Paris Sud, le Kremlin Bicêtre Cedex, France,
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Di Bella G, Pizzino F, Minutoli F, Zito C, Donato R, Dattilo G, Oreto G, Baldari S, Vita G, Khandheria BK, Carerj S. The mosaic of the cardiac amyloidosis diagnosis: role of imaging in subtypes and stages of the disease. Eur Heart J Cardiovasc Imaging 2014; 15:1307-15. [PMID: 25190073 DOI: 10.1093/ehjci/jeu158] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Cardiac amyloidosis is a rare, infiltrative cardiomyopathy that presents with thickened ventricular walls and progressive heart failure. The morphological findings and clinical features are shared with many other diseases (i.e. hypertrophic cardiomyopathy, 'athlete's heart,' Fabry disease, and hypertensive cardiomyopathy), and misdiagnosis occurs frequently. Cardiologists have many instruments that can help reach a correct diagnosis in a relatively short time. As tiles of a mosaic are placed to create an image, thoughtful and smart use of the different diagnostic tools available allows the opportunity to identify amyloid infiltration of the myocardium. When the myocardium is involved, prognosis is poor, so identification of its involvement is crucial for disease management. The diagnostic process begins with an accurate evaluation of clinical elements and includes cardiovascular imaging (echocardiography, magnetic resonance, and nuclear medicine), electrocardiography, serological assays, and myocardial biopsy; only the appropriate integration of these instruments can reveal the diagnosis to an expert physician. The latest improvements in non-invasive diagnostic techniques with increased diagnostic power have reduced the need for biopsy.
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Affiliation(s)
- Gianluca Di Bella
- Clinical and Experimental Medicine Department, Cardiology Unit, University of Messina, Azienda Ospedaliera Universitaria 'Policlinico G. Martino', Via Consolare Valeria 1, Messina 98125, Italy
| | - Fausto Pizzino
- Clinical and Experimental Medicine Department, Cardiology Unit, University of Messina, Azienda Ospedaliera Universitaria 'Policlinico G. Martino', Via Consolare Valeria 1, Messina 98125, Italy
| | - Fabio Minutoli
- Department of Biomedical Sciences and of Morphologic and Functional Images, University of Messina, Azienda Ospedaliera Universitaria 'Policlinico G. Martino', Via Consolare Valeria 1, Messina 98125, Italy
| | - Concetta Zito
- Clinical and Experimental Medicine Department, Cardiology Unit, University of Messina, Azienda Ospedaliera Universitaria 'Policlinico G. Martino', Via Consolare Valeria 1, Messina 98125, Italy
| | - Rocco Donato
- Department of Biomedical Sciences and of Morphologic and Functional Images, University of Messina, Azienda Ospedaliera Universitaria 'Policlinico G. Martino', Via Consolare Valeria 1, Messina 98125, Italy
| | - Giuseppe Dattilo
- Clinical and Experimental Medicine Department, Cardiology Unit, University of Messina, Azienda Ospedaliera Universitaria 'Policlinico G. Martino', Via Consolare Valeria 1, Messina 98125, Italy
| | - Giuseppe Oreto
- Clinical and Experimental Medicine Department, Cardiology Unit, University of Messina, Azienda Ospedaliera Universitaria 'Policlinico G. Martino', Via Consolare Valeria 1, Messina 98125, Italy
| | - Sergio Baldari
- Department of Biomedical Sciences and of Morphologic and Functional Images, University of Messina, Azienda Ospedaliera Universitaria 'Policlinico G. Martino', Via Consolare Valeria 1, Messina 98125, Italy
| | - Giuseppe Vita
- Department of Neurosciences, University of Messina, Azienda Ospedaliera Universitaria 'Policlinico G. Martino', Via Consolare Valeria 1, Messina 98125, Italy
| | - Bijoy K Khandheria
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, University of Wisconsin School of Medicine and Public Health, 2801 W. Kinnickinnic River Parkway, #840, Milwaukee, WI 53215, USA
| | - Scipione Carerj
- Clinical and Experimental Medicine Department, Cardiology Unit, University of Messina, Azienda Ospedaliera Universitaria 'Policlinico G. Martino', Via Consolare Valeria 1, Messina 98125, Italy
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Kristen AV, Scherer K, Buss S, aus dem Siepen F, Haufe S, Bauer R, Hinderhofer K, Giannitsis E, Hardt S, Haberkorn U, Katus HA, Steen H. Noninvasive risk stratification of patients with transthyretin amyloidosis. JACC Cardiovasc Imaging 2014; 7:502-10. [PMID: 24726252 DOI: 10.1016/j.jcmg.2014.03.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 03/07/2014] [Accepted: 03/11/2014] [Indexed: 12/24/2022]
Abstract
OBJECTIVES We sought to evaluate noninvasive parameters by electrocardiography, echocardiography, technetium-99m-3,3-diphosphono-1,2-propanodicarboxylic acid ((99m)Tc-DPD) scintigraphy, and cardiac magnetic resonance for the prediction of all-cause mortality in patients with cardiac transthyretin amyloidosis (ATTR). BACKGROUND ATTR may present with highly variable symptoms, including polyneuropathy and cardiomyopathy, the latter being associated with a poor outcome. However, data on noninvasive risk stratification of ATTR are limited. METHODS A total of 70 patients with ATTR were evaluated by echocardiography, cardiac biomarkers, and (99m)Tc-DPD scintigraphy. Cardiac magnetic resonance was performed in 30 patients. Echocardiographic findings and plasma levels of biomarkers were correlated with results of quantitative analysis of scintigraphy using a region-of-interest technique (whole-body as well as heart tracer retention). Receiver-operating characteristic (ROC) analysis was performed to calculate a cutoff value of (99m)Tc-DPD scintigraphy for heart retention for the diagnosis of cardiac amyloid involvement with the highest sensitivity and specificity. Univariate and multivariate analyses were performed in patients with cardiac involvement (n = 60) to determine noninvasive predictors of all-cause mortality. RESULTS Scintigraphy findings correlated with morphological (interventricular septum thickness, left ventricular hypertrophy index) as well as functional (mitral annular systolic velocity, mitral/tricuspid annular plane systolic excursion) findings, cardiac biomarkers, renal function, and late gadolinium enhancement. The ROC-derived cutoff for the detection of cardiac amyloidosis by scintigraphic heart tracer retention was 4.8%. Univariate Cox regression revealed N-terminal pro-B-type natriuretic peptide, troponin T, mitral annular plane systolic excursion, and left ventricular hypertrophy index as predictors of all-cause mortality. However, on multivariate analysis, troponin T remained the only independent predictor of survival. The ROC-derived cutoff value of troponin T predicting all-cause mortality with the highest sensitivity (80.0%) and specificity (68.7%) was 0.0375 ng/l. CONCLUSIONS Quantitative analysis of tracer retention is capable of characterizing the severity of cardiac involvement in ATTR. By multivariate analysis, troponin T remained the only independent predictor of survival.
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Affiliation(s)
- Arnt V Kristen
- Department of Cardiology, Angiology, and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany.
| | - Katrin Scherer
- Department of Cardiology, Angiology, and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Sebastian Buss
- Department of Cardiology, Angiology, and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Fabian aus dem Siepen
- Department of Cardiology, Angiology, and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Sabine Haufe
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Ralf Bauer
- Department of Cardiology, Angiology, and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Katrin Hinderhofer
- Institute of Human Genetics, University Hospital Heidelberg, Heidelberg, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology, and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Hardt
- Department of Cardiology, Angiology, and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Uwe Haberkorn
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Department of Cardiology, Angiology, and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Henning Steen
- Department of Cardiology, Angiology, and Respiratory Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Aljaroudi WA, Desai MY, Tang WHW, Phelan D, Cerqueira MD, Jaber WA. Role of imaging in the diagnosis and management of patients with cardiac amyloidosis: state of the art review and focus on emerging nuclear techniques. J Nucl Cardiol 2014; 21:271-83. [PMID: 24347127 DOI: 10.1007/s12350-013-9800-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Amyloidosis is an infiltrative disease characterized by deposition of amyloid fibrils within the extracellular tissue of one or multiple organs. Involvement of the heart, cardiac amyloidosis, is recognized as a common cause of restrictive cardiomyopathy and heart failure. The two major types of cardiac amyloidosis are cardiac amyloid light-chain (AL) and transthyretin-related cardiac amyloidosis (ATTR, mutant and wild types) (Nat Rev Cardiol 2010;7:398-408). While early recognition of cardiac amyloidosis is of major clinical importance, so is the ability to differentiate between subtypes. Indeed, both prognosis and therapeutic options vary drastically depending on the subtype. While endomyocardial biopsy with immunostaining is considered the gold standard, advances in imaging provide an attractive non-invasive alternative. Currently, electrocardiography, echocardiography, and cardiac magnetic resonance imaging are all used in the evaluation of cardiac amyloidosis with varying diagnostic and prognostic accuracy. Yet, none of these modalities can effectively differentiate the cardiac amyloid subtypes. Recent data with (99m)Tc-phosphate derivatives, previously used as bone seeking radioactive tracers, have shown promising results; these radiotracers selectively bind ATTR, but not AL subtype, and can differentiate subtypes with high diagnostic accuracy. This review will initially present the non-radionuclide imaging techniques and then focus on the radionuclide imaging techniques, particularly (99m)Tc-DPD and (99m)Tc-PYP, mechanism of action, performance and interpretation of the study, diagnostic accuracy, prognostic value, future clinical perspective, and outlook.
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Affiliation(s)
- Wael A Aljaroudi
- Division of Cardiovascular Medicine and Imaging, American University of Beirut Medical Center, Beirut, Lebanon,
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Skeletal scintigraphy in patients with transthyretin-related amyloidosis. Int J Cardiol 2014; 171:e16-7. [DOI: 10.1016/j.ijcard.2013.11.131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 11/30/2013] [Indexed: 11/20/2022]
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Letter by Di Bella et al Regarding Article, “Effect of Combined Systolic and Diastolic Functional Parameter Assessment for Differentiation of Cardiac Amyloidosis From Other Causes of Concentric Left Ventricular Hypertrophy”. Circ Cardiovasc Imaging 2014; 7:215. [DOI: 10.1161/circimaging.113.001478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Minutoli F, Sindoni A, Baldari S. Letter by Minutoli et al Regarding Article, “Reduced Myocardial 123-Iodine Meta-Iodobenzylguanidine Uptake: A Prognostic Marker in Familial Amyloid Polyneuropathy”. Circ Cardiovasc Imaging 2013; 6:e76. [DOI: 10.1161/circimaging.113.001038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Fabio Minutoli
- Department of Biomedical Sciences and of Morphologic and Functional Images, University of Messina, Messina, Italy
| | - Alessandro Sindoni
- Department of Biomedical Sciences and of Morphologic and Functional Images, University of Messina, Messina, Italy
| | - Sergio Baldari
- Department of Biomedical Sciences and of Morphologic and Functional Images, University of Messina, Messina, Italy
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Minutoli F, Di Bella G, Sindoni A, Vita G, Baldari S. Effectiveness of skeletal scintigraphy in transthyretin-related amyloidosis. Int J Cardiol 2013; 168:4988-9. [DOI: 10.1016/j.ijcard.2013.07.130] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 07/13/2013] [Indexed: 11/27/2022]
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