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Bravo PE, Fujikura K, Kijewski MF, Jerosch-Herold M, Jacob S, El-Sady MS, Sticka W, Dubey S, Belanger A, Park MA, Di Carli MF, Kwong RY, Falk RH, Dorbala S. Relative Apical Sparing of Myocardial Longitudinal Strain Is Explained by Regional Differences in Total Amyloid Mass Rather Than the Proportion of Amyloid Deposits. JACC Cardiovasc Imaging 2018; 12:1165-1173. [PMID: 30121266 DOI: 10.1016/j.jcmg.2018.06.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/15/2018] [Accepted: 06/26/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study sought to test whether relative apical sparing (RELAPS) of left ventricular (LV) longitudinal strain (LS) in cardiac amyloidosis (CA) is explained by regional differences in markers of amyloid burden (18F-florbetapir uptake by positron emission tomography [PET] and/or extracellular volume fraction [ECV] by cardiac magnetic resonance (CMR)]. BACKGROUND Further knowledge of the pathophysiological basis for RELAPS can help understand the adverse outcomes associated with apical LS impairment. METHODS This was a prospective study of 32 subjects (age 62 ± 7 years; 50% males) with light chain CA. All subjects underwent two-dimensional echocardiography for LS estimation and 18F-florbetapir PET for quantification of LV florbetapir retention index (RI). A subset also underwent CMR (n = 22) for ECV quantification. Extracellular LV mass (LV mass*ECV) and total florbetapir binding (extracellular LV mass*florbetapir RI) were also calculated. All parameters were measured globally and regionally (base, mid, and apex). RESULTS There was a significant base-to-apex gradient in LS (-7.4 ± 3.2% vs. -8.6 ± 4.0% vs. -20.8 ± 6.6%; p < 0.0001), maximal LV wall thickness (15.7 ± 1.9 cm vs. 15.4 ± 2.9 cm vs. 10.1 ± 2.4 cm; p < 0.0001), and LV mass (74.8 ± 21.2 g vs. 60.8 ± 17.3 g vs. 23.4 ± 6.2 g; p < 0.0001). In contrast, florbetapir RI (0.089 ± 0.03 μmol/min/g vs. 0.097 ± 0.03 μmol/min/g vs. 0.085 ± 0.03 μmol/min/g; p = 0.45) and ECV (0.53 ± 0.08 vs. 0.49 ± 0.08 vs. 0.49 ± 0.07; p = 0.15) showed no significant base-to-apex gradient in the tissue concentration or proportion of amyloid infiltration, whereas markers of total amyloid load, such as total florbetapir binding (3.4 ± 1.7 μmol/min vs. 2.8 ± 1.5 μmol/min vs. 0.93 ± 0.49 μmol/min; p < 0.0001) and extracellular LV mass (40.0 ± 15.6 g vs. 30.2 ± 10.9 g vs. 11.6 ± 3.9 g; p < 0.0001), did show a marked base-to-apex gradient. CONCLUSIONS Segmental differences in the distribution of the total amyloid mass, rather than the proportion of amyloid deposits, appear to explain the marked regional differences in LS in CA. Although these 2 matrices are clearly related concepts, they should not be used interchangeably.
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Affiliation(s)
- Paco E Bravo
- Noninvasive Cardiovascular Imaging Program, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Divisions of Nuclear Medicine and Cardiology, Departments of Radiology and Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kana Fujikura
- Noninvasive Cardiovascular Imaging Program, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marie Foley Kijewski
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael Jerosch-Herold
- Noninvasive Cardiovascular Imaging Program, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sophia Jacob
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mohamed Samir El-Sady
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - William Sticka
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shipra Dubey
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anthony Belanger
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mi-Ae Park
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marcelo F Di Carli
- Noninvasive Cardiovascular Imaging Program, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Raymond Y Kwong
- Noninvasive Cardiovascular Imaging Program, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rodney H Falk
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Amyloidosis Program, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sharmila Dorbala
- Noninvasive Cardiovascular Imaging Program, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Amyloidosis Program, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Gallego-Delgado M, González-López E, Muñoz-Beamud F, Buades J, Galán L, Muñoz-Blanco JL, Sánchez-González J, Ibáñez B, Mirelis JG, García-Pavía P. Extracellular Volume Detects Amyloidotic Cardiomyopathy and Correlates With Neurological Impairment in Transthyretin-familial Amyloidosis. ACTA ACUST UNITED AC 2016; 69:923-930. [PMID: 27291669 DOI: 10.1016/j.rec.2016.02.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 02/22/2016] [Indexed: 12/29/2022]
Abstract
INTRODUCTION AND OBJECTIVES Cardiac involvement determines prognosis and treatment options in transthyretin-familial amyloidosis. Cardiac magnetic resonance T1 mapping techniques are useful to assess myocardial extracellular volume. This study hypothesized that myocardial extracellular volume allows identification of amyloidotic cardiomyopathy and correlates with the degree of neurological impairment in transthyretin-familial amyloidosis. METHODS A total of 31 transthyretin-familial amyloidosis patients (19 mean age, 49 ± 12 years; 26 with the Val30Met mutation) underwent a T1 mapping cardiac magnetic resonance study and a neurological evaluation with Neuropathy Impairment Score of the Lower Limb score, Norfolk Quality of Life questionnaire, and Karnofsky index. RESULTS Five patients had cardiac amyloidosis (all confirmed by 99mTc-DPD scintigraphy). Mean extracellular volume was increased in patients with cardiac amyloidosis (0.490 ± 0.131 vs 0.289 ± 0.035; P = .026). Extracellular volume correlated with age (R = 0.467; P = .008), N-terminal pro-B-type natriuretic peptide (RS = 0.846; P < .001), maximum wall thickness (R = 0.621; P < .001), left ventricular mass index (R = 0.685; P < .001), left ventricular ejection fraction (R = -0.378; P = .036), Neuropathy Impairment Score of the Lower Limb (RS = 0.604; P = .001), Norfolk Quality of Life questionnaire (RS = 0.529; P = .003) and Karnofsky index (RS= -0.517; P = .004). A cutoff value of extracellular volume of 0.357 was diagnostic of cardiac amyloidosis with 100% sensitivity and specificity (P < .001). Extracellular volume and N-terminal pro-B-type natriuretic peptide were the only cardiac parameters that significantly correlated with neurologic scores. CONCLUSIONS Extracellular volume quantification allows identification of cardiac amyloidosis and correlates with the degree of neurological impairment in transthyretin-familial amyloidosis. This noninvasive technique could be a useful tool for early diagnosis of cardiac amyloidosis and to track cardiac and extracardiac amyloid disease.
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Affiliation(s)
| | - Esther González-López
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Madrid, Spain; Área de Fisiopatología del Miocardio, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | | | - Juan Buades
- Servicio de Medicina Interna, Hospital Son Llàtzer, Palma de Mallorca, Spain
| | - Lucía Galán
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Javier Sánchez-González
- Philips Healthcare Iberia, Madrid, Spain; Unidad de Imagen Cardiaca Avanzada, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Borja Ibáñez
- Unidad de Imagen Cardiaca Avanzada, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Jesus G Mirelis
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Madrid, Spain; Unidad de Imagen Cardiaca Avanzada, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Pablo García-Pavía
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Madrid, Spain; Área de Fisiopatología del Miocardio, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
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Gianolio E, Arena F, Di Gregorio E, Pagliarin R, Delbianco M, Baio G, Aime S. MEMRI and tumors: a method for the evaluation of the contribution of Mn(II) ions in the extracellular compartment. NMR IN BIOMEDICINE 2015; 28:1104-1110. [PMID: 26174622 DOI: 10.1002/nbm.3349] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 05/21/2015] [Accepted: 05/29/2015] [Indexed: 06/04/2023]
Abstract
The purpose of the work was to set-up a simple method to evaluate the contribution of Mn(2+) ions in the intra- and extracellular tumor compartments in a MEMRI experiment. This task has been tackled by "silencing" the relaxation enhancement arising from Mn(2+) ions in the extracellular space. In vitro relaxometric measurements allowed assessment of the sequestering activity of DO2A (1,4,7,10-tetraazacyclododecane-1,7-diacetic acid) towards Mn(2+) ions, as the addition of Ca-DO2A to a solution of MnCl2 causes a drop of relaxivity upon the formation of the highly stable and low-relaxivity Mn-DO2A. It has been proved that the sequestering ability of DO2A towards Mn(2+) ions is also fully effective in the presence of serum albumin. Moreover, it has been shown that Mn-DO2A does not enter cell membranes, nor does the presence of Ca-DO2A in the extracellular space prompt migration of Mn ions from the intracellular compartment. On this basis the in vivo, instantaneous, drop in SE% (percent signal enhancement) in T1 -weighted images is taken as evidence of the sequestration of extracellular Mn(2+) ions upon addition of Ca-DO2A. By applying the method to B16F10 tumor bearing mice, T1 decrease is readily detected in the tumor region, whereas a negligible change in SE% is observed in kidneys, liver and muscle. The relaxometric MRI results have been validated by ICP-MS measurements.
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Affiliation(s)
- Eliana Gianolio
- Department of Molecular Biotechnologies and Health Sciences & Molecular Imaging Center, University of Torino, Torino, Italy
| | - Francesca Arena
- Department of Molecular Biotechnologies and Health Sciences & Molecular Imaging Center, University of Torino, Torino, Italy
| | - Enza Di Gregorio
- Department of Molecular Biotechnologies and Health Sciences & Molecular Imaging Center, University of Torino, Torino, Italy
| | | | | | - Gabriella Baio
- Diagnostic Imaging and Senology Unit, National Cancer Institute - IST, Azienda Ospedaliera Universitaria San Martino - IRCCS, Genova, Italy
- Aberdeen Biomedical Imaging Centre, University of Aberdeen, Aberdeen, UK
| | - Silvio Aime
- Department of Molecular Biotechnologies and Health Sciences & Molecular Imaging Center, University of Torino, Torino, Italy
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Abstract
Systemic amyloid A (AA) amyloidosis is a serious complication of chronic inflammation. Serum AA protein (SAA), an acute phase plasma protein, is deposited extracellularly as insoluble amyloid fibrils that damage tissue structure and function. Clinical AA amyloidosis is typically preceded by many years of active inflammation before presenting, most commonly with renal involvement. Using dose-dependent, doxycycline-inducible transgenic expression of SAA in mice, we show that AA amyloid deposition can occur independently of inflammation and that the time before amyloid deposition is determined by the circulating SAA concentration. High level SAA expression induced amyloidosis in all mice after a short, slightly variable delay. SAA was rapidly incorporated into amyloid, acutely reducing circulating SAA concentrations by up to 90%. Prolonged modest SAA overexpression occasionally produced amyloidosis after long delays and primed most mice for explosive amyloidosis when SAA production subsequently increased. Endogenous priming and bulk amyloid deposition are thus separable events, each sensitive to plasma SAA concentration. Amyloid deposits slowly regressed with restoration of normal SAA production after doxycycline withdrawal. Reinduction of SAA overproduction revealed that, following amyloid regression, all mice were primed, especially for rapid glomerular amyloid deposition leading to renal failure, closely resembling the rapid onset of renal failure in clinical AA amyloidosis following acute exacerbation of inflammation. Clinical AA amyloidosis rarely involves the heart, but amyloidotic SAA transgenic mice consistently had minor cardiac amyloid deposits, enabling us to extend to the heart the demonstrable efficacy of our unique antibody therapy for elimination of visceral amyloid.
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