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Nebhwani M, Chaibekava K, Achten A, Oerlemans MIFJ, Michels M, van der Meer P, Nienhuis HLA, Weerts J, van Empel V, Rocca HPBL, Wijk SSV, van der Pol J, Knackstedt C. Detection of cardiac amyloidosis on routine bone scintigraphy: an important gatekeeper role for the nuclear medicine physician. Int J Cardiovasc Imaging 2024; 40:1183-1192. [PMID: 38520623 PMCID: PMC11213735 DOI: 10.1007/s10554-024-03085-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 03/11/2024] [Indexed: 03/25/2024]
Abstract
Cardiac amyloidosis (CA)-mostly transthyretin-related (ATTR-CA)-has recently gained interest in cardiology. Bone scintigraphy (BS) is one of the main screening tools for ATTR-CA but also used for various other reasons. The objective was to evaluate whether all CA cases are detected and what happens during follow-up. All routine BS performed at the Maastricht University Medical Center (May 2012-August 2020) were screened for the presence of CA. Scans performed for suspected CA were excluded. A Perugini stage ≥1 was classified as positive necessitating further examination. The electronic medical record system was evaluated for any contact with cardiology or other specialists until 2021. Of the 2738 BS evaluated, 40 scans (1.46%; median age 73.5 [IQR: 65.8-79.5], 82.5% male) were positive (Perugini grade 1: 31/77.5%, grade 2: 6/15%, grade 3: 3/7.5%); the potential diagnosis ATTR-CA was not seen in 38 patients (95%) by the nuclear medicine specialist. During follow-up, 19 out of those 40 patients (47.5%) underwent cardiac evaluation without diagnosing CA. Available echocardiograms of patients with a positive BS showed left ventricular hypertrophy, a preserved ejection fraction, and diastolic dysfunction ≥2 in 9/47%, 10/53%, and 4/21% of patients, respectively. Additionally, 20 (50%) patients presented to at least one specialty with symptoms indicative of cardiac amyloidosis. The prevalence of a positive BS indicating potential CA in an unselected population is low but substantial. The majority was not detected which asks for better awareness for CA of all involved specialists to ensure appropriate treatment and follow-up.
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Affiliation(s)
- Mohit Nebhwani
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Karina Chaibekava
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Anouk Achten
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | | | - Michelle Michels
- Department of Cardiology, Erasmus MC, Cardiovascular Institute, Thoraxcenter, Rotterdam, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Center, Groningen, The Netherlands
| | - Hans L A Nienhuis
- Department of Rheumatology & Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jerremy Weerts
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Vanessa van Empel
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | | | - Jochem van der Pol
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
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2
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Tingen HSA, Berends M, Tubben A, Bijzet J, Houwerzijl EJ, Muntinghe FLH, Kroesen BJ, van der Zwaag PA, van der Meer P, Slart RHJA, Hazenberg BPC, Nienhuis HLA. High-Sensitivity Cardiac Troponin T to Exclude Cardiac Involvement in TTR Variant Carriers and ATTRv Amyloidosis Patients. J Clin Med 2024; 13:810. [PMID: 38337504 PMCID: PMC10856062 DOI: 10.3390/jcm13030810] [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: 12/22/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: Individuals carrying a pathogenic transthyretin gene variant (TTRv) are at high risk for developing hereditary transthyretin (ATTRv) amyloidosis and are routinely screened for the development of cardiomyopathy (ATTRv-CM). This study aims to evaluate whether the cardiac biomarkers N-terminal pro B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) can be used to rule out ATTRv-CM. (2) Methods: In this retrospective case-control study, data from 46 ATTRv-CM patients and 101 TTRv carriers and ATTRv amyloidosis patients without cardiomyopathy were included. Binary logistic regression models were used to assess the ability of NT-proBNP and hs-cTnT to predict the diagnosis of ATTRv-CM. An optimal cutoff for the relevant biomarker(s) was determined based on a sensitivity of ≥99% and the highest possible percentage of additional tests avoided (%ATA) in the index dataset. (3) Results: Hs-cTnT demonstrated the highest predictive capabilities for ATTRv-CM. The addition of NT-proBNP did not improve the predictive model. A hs-cTnT cutoff of <6 ng/L resulted in a 97% sensitivity and a negative predictive value of 95% with a %ATA of 30% in the validation dataset. (4) Conclusion: In conclusion, hs-cTnT is a useful biomarker for excluding cardiac involvement in TTRv carriers and ATTRv amyloidosis patients and it has the potential to prevent unnecessary diagnostic procedures.
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Affiliation(s)
- Hendrea S. A. Tingen
- Department of Nuclear Medicine and Molecular Imaging, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Milou Berends
- Department of Internal Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands (H.L.A.N.)
| | - Alwin Tubben
- Department of Cardiology, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Johan Bijzet
- Department of Laboratory Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Ewout J. Houwerzijl
- Department of Internal Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands (H.L.A.N.)
| | - Friso L. H. Muntinghe
- Department of Internal Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands (H.L.A.N.)
| | - Bart-Jan Kroesen
- Department of Laboratory Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Paul A. van der Zwaag
- Department of Genetics, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Riemer H. J. A. Slart
- Department of Nuclear Medicine and Molecular Imaging, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Biomedical Photonic Imaging Group, Faculty of Science and Technology, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
| | - Bouke P. C. Hazenberg
- Department of Rheumatology & Clinical Immunology, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Hans L. A. Nienhuis
- Department of Internal Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands (H.L.A.N.)
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Saro R, Pavan D, Porcari A, Sinagra G, Mojoli M. Lights and Shadows of Clinical Applications of Cardiac Scintigraphy with Bone Tracers in Suspected Amyloidosis. J Clin Med 2023; 12:7605. [PMID: 38137674 PMCID: PMC10743682 DOI: 10.3390/jcm12247605] [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: 10/13/2023] [Revised: 11/20/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Radionuclide bone scintigraphy is the cornerstone of an imaging-based algorithm for accurate non-invasive diagnosis of transthyretin cardiac amyloidosis (ATTR-CA). In patients with heart failure and suggestive echocardiographic and/or cardiac magnetic resonance imaging findings, the positive predictive value of Perugini grade 2 or 3 myocardial uptake on a radionuclide bone scan approaches 100% for the diagnosis of ATTR-CA as long as there is no biochemical evidence of a clonal dyscrasia. The technetium-labelled tracers that are currently validated for non-invasive diagnosis of ATTR-CA include pyrophosphate (99mTc-PYP); hydroxymethylene diphosphonate (99mTc-HMDP); and 3,3-diphosphono-1,2-propanodicarboxylate (99mTc-DPD). Although nuclear scintigraphy has transformed the contemporary diagnostic approach to ATTR-CA, a number of grey areas remains, including the mechanism for binding tracers to the infiltrated heart, differences in the kinetics and distribution of these radiotracers, differences in protocols of image acquisition worldwide, the clinical significance of extra-cardiac uptake, and the use of this technique for prognostic stratification, monitoring disease progression and assessing the response to disease-modifying treatments. This review will deal with the most relevant unmet needs and clinical questions concerning scintigraphy with bone tracers in ATTR-CA, providing expert opinions on possible future developments in the clinical application of these radiotracers in order to offer practical information for the interpretation of nuclear images by physicians involved in the care of patients with this ATTR-CA.
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Affiliation(s)
- Riccardo Saro
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100 Trieste, Italy; (R.S.); (A.P.); (G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Giuliano Isontina University Health Authority, 34149 Trieste, Italy
| | - Daniela Pavan
- Ospedale Santa Maria degli Angeli, Azienda Ospedaliera Friuli Occidentale (ASFO), 33170 Pordenone, Italy;
| | - Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100 Trieste, Italy; (R.S.); (A.P.); (G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Giuliano Isontina University Health Authority, 34149 Trieste, Italy
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100 Trieste, Italy; (R.S.); (A.P.); (G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Giuliano Isontina University Health Authority, 34149 Trieste, Italy
| | - Marco Mojoli
- Ospedale Santa Maria degli Angeli, Azienda Ospedaliera Friuli Occidentale (ASFO), 33170 Pordenone, Italy;
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Brito D, Albrecht FC, de Arenaza DP, Bart N, Better N, Carvajal-Juarez I, Conceição I, Damy T, Dorbala S, Fidalgo JC, Garcia-Pavia P, Ge J, Gillmore JD, Grzybowski J, Obici L, Piñero D, Rapezzi C, Ueda M, Pinto FJ. World Heart Federation Consensus on Transthyretin Amyloidosis Cardiomyopathy (ATTR-CM). Glob Heart 2023; 18:59. [PMID: 37901600 PMCID: PMC10607607 DOI: 10.5334/gh.1262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/12/2023] [Indexed: 10/31/2023] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive and fatal condition that requires early diagnosis, management, and specific treatment. The availability of new disease-modifying therapies has made successful treatment a reality. Transthyretin amyloid cardiomyopathy can be either age-related (wild-type form) or caused by mutations in the TTR gene (genetic, hereditary forms). It is a systemic disease, and while the genetic forms may exhibit a variety of symptoms, a predominant cardiac phenotype is often present. This document aims to provide an overview of ATTR-CM amyloidosis focusing on cardiac involvement, which is the most critical factor for prognosis. It will discuss the available tools for early diagnosis and patient management, given that specific treatments are more effective in the early stages of the disease, and will highlight the importance of a multidisciplinary approach and of specialized amyloidosis centres. To accomplish these goals, the World Heart Federation assembled a panel of 18 expert clinicians specialized in TTR amyloidosis from 13 countries, along with a representative from the Amyloidosis Alliance, a patient advocacy group. This document is based on a review of published literature, expert opinions, registries data, patients' perspectives, treatment options, and ongoing developments, as well as the progress made possible via the existence of centres of excellence. From the patients' perspective, increasing disease awareness is crucial to achieving an early and accurate diagnosis. Patients also seek to receive care at specialized amyloidosis centres and be fully informed about their treatment and prognosis.
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Affiliation(s)
- Dulce Brito
- Department of Cardiology, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL@RISE, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Fabiano Castro Albrecht
- Dante Pazzanese Institute of Cardiology – Cardiac Amyloidosis Center Dante Pazzanese Institute, São Paulo, Brazil
| | | | - Nicole Bart
- St Vincent’s Hospital, Victor Chang Cardiac Research Institute, University of New South Wales, Sydney, Australia
| | - Nathan Better
- Cabrini Health, Malvern, Royal Melbourne Hospital, Parkville, Monash University and University of Melbourne, Victoria, Australia
| | | | - Isabel Conceição
- Department of Neurosciences and Mental Health, CHULN – Hospital de Santa Maria, Portugal
- Centro de Estudos Egas Moniz Faculdade de Medicina da Universidade de Lisboa Portugal, Portugal
| | - Thibaud Damy
- Department of Cardiology, DHU A-TVB, CHU Henri Mondor, AP-HP, INSERM U955 and UPEC, Créteil, France
- Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Reseau amylose, Créteil, France. Filière CARDIOGEN
| | - Sharmila Dorbala
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Cardiac Amyloidosis Program, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Julian D. Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom
| | - Jacek Grzybowski
- Department of Cardiomyopathy, National Institute of Cardiology, Warsaw, Poland
| | - Laura Obici
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Claudio Rapezzi
- Cardiovascular Institute, University of Ferrara, Ferrara, Italy
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Fausto J. Pinto
- Department of Cardiology, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL@RISE, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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Ferkh A, Tjahjadi C, Stefani L, Geenty P, Byth K, De Silva K, Boyd AC, Richards D, Mollee P, Korczyk D, Taylor MS, Kwok F, Kizana E, Ng ACT, Thomas L. Cardiac "hypertrophy" phenotyping: differentiating aetiologies with increased left ventricular wall thickness on echocardiography. Front Cardiovasc Med 2023; 10:1183485. [PMID: 37465456 PMCID: PMC10351962 DOI: 10.3389/fcvm.2023.1183485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/15/2023] [Indexed: 07/20/2023] Open
Abstract
Aims Differentiating phenotypes of cardiac "hypertrophy" characterised by increased wall thickness on echocardiography is essential for management and prognostication. Transthoracic echocardiography is the most commonly used screening test for this purpose. We sought to identify echocardiographic markers that distinguish infiltrative and storage disorders that present with increased left ventricular (LV) wall thickness, namely, cardiac amyloidosis (CA) and Anderson-Fabry disease (AFD), from hypertensive heart disease (HHT). Methods Patients were retrospectively recruited from Westmead Hospital, Sydney, and Princess Alexandra Hospital, Brisbane. LV structural, systolic, and diastolic function parameters, as well as global (LVGLS) and segmental longitudinal strains, were assessed. Previously reported echocardiographic parameters including relative apical sparing ratio (RAS), LV ejection fraction-to-strain ratio (EFSR), mass-to-strain ratio (MSR) and amyloidosis index (AMYLI) score (relative wall thickness × E/e') were evaluated. Results A total of 209 patients {120 CA [58 transthyretin amyloidosis (ATTR) and 62 light-chain (AL) amyloidosis], 31 AFD and 58 HHT patients; mean age 64.1 ± 13.7 years, 75% male} comprised the study cohort. Echocardiographic measurements differed across the three groups, The LV mass index was higher in both CA {median 126.6 [interquartile range (IQR) 106.4-157.9 g/m2]} and AFD [median 134 (IQR 108.8-152.2 g/m2)] vs. HHT [median 92.7 (IQR 79.6-102.3 g/m2), p < 0.05]. LVGLS was lowest in CA [median 12.29 (IQR 10.33-15.56%)] followed by AFD [median 16.92 (IQR 14.14-18.78%)] then HHT [median 18.56 (IQR 17.51-19.97%), p < 0.05]. Diastolic function measurements including average e' and E/e' were most impaired in CA and least impaired in AFD. Indexed left atrial volume was highest in CA. EFSR and MSR differentiated secondary (CA + AFD) from HHT [receiver operating curve-area under the curve (ROC-AUC) of 0.80 and 0.91, respectively]. RAS and AMYLI score differentiated CA from AFD (ROC-AUC of 0.79 and 0.80, respectively). A linear discriminant analysis with stepwise variable selection using linear combinations of LV mass index, average e', LVGLS and basal strain correctly classified 79% of all cases. Conclusion Simple echocardiographic parameters differentiate between different "hypertrophic" cardiac phenotypes. These have potential utility as a screening tool to guide further confirmatory testing.
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Affiliation(s)
- Aaisha Ferkh
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
| | - Catherina Tjahjadi
- Cardiology Department, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Luke Stefani
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
| | - Paul Geenty
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
| | - Karen Byth
- WSLHD Research and Education Network, Westmead Hospital, Westmead, NSW, Australia
| | - Kasun De Silva
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
| | - Anita C. Boyd
- Westmead Private Cardiology, Westmead, NSW, Australia
| | | | - Peter Mollee
- Haematology Department, Princess Alexandra Hospital, Brisbane, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Dariusz Korczyk
- Cardiology Department, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Mark S. Taylor
- Department of Clinical Immunology and Allergy, Westmead Hospital, Westmead, NSW, Australia
| | - Fiona Kwok
- Haematology Department, Westmead Hospital, Westmead, NSW, Australia
| | - Eddy Kizana
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
- Centre for Heart Research, The Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Arnold C. T. Ng
- Cardiology Department, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Liza Thomas
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
- Cardiology Department, Westmead Hospital, Westmead, NSW, Australia
- South-West Clinical School, University of New South Wales, Liverpool, NSW, Australia
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Asif T, Vij A, Radzik B, Stern H, Simples P, Ghadiali Q, Malhotra S. Multimodality imaging for diagnosis of subclinical hereditary transthyretin cardiac amyloidosis. J Nucl Cardiol 2023; 30:792-799. [PMID: 34873643 DOI: 10.1007/s12350-021-02865-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 10/29/2021] [Indexed: 11/28/2022]
Abstract
We present a case of a patient with worsening visual acuity and dense vitreal debris who was found to have vitreal transthyretin amyloid (ATTR) infiltration. Cardiac workup, performed to identify systemic amyloidosis, demonstrated focal myocardial amyloid infiltration on pyrophosphate (PYP) scintigraphy and cardiac magnetic resonance (CMR), resulting in a diagnosis of subclinical ATTR cardiac amyloidosis (ATTR-CA). Patient was identified as a carrier of p.S70R mutation which results in an aggressive ATTR phenotype. Patient is tolerating transthyretin silencer therapy well. Through this case, we discuss the role of a multimodality imaging approach for the diagnosis of subclinical ATTR-CA.
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Affiliation(s)
- Talal Asif
- Division of Cardiology, Truman Medical Center, University of Missouri, Kansas City, USA
- Division of Cardiology, Cook County Health, Chicago, USA
| | - Aviral Vij
- Division of Cardiology, Cook County Health, Chicago, USA
- Division of Cardiology, Rush Medical College, Chicago, USA
| | - Bartlomiej Radzik
- Division of Pathology, Cook County Health, 1901 W. Harrison Street, Suite 3620, Chicago, 60612, USA
| | - Hudson Stern
- Division of Ophthalmology, Cook County Health, Chicago, USA
| | - Patricia Simples
- Division of Pathology, Cook County Health, 1901 W. Harrison Street, Suite 3620, Chicago, 60612, USA
| | | | - Saurabh Malhotra
- Division of Cardiology, Cook County Health, Chicago, USA.
- Division of Cardiology, Rush Medical College, Chicago, USA.
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Cersosimo A, Bonelli A, Lombardi CM, Moreo A, Pagnesi M, Tomasoni D, Arabia G, Vizzardi E, Adamo M, Farina D, Metra M, Inciardi RM. Multimodality imaging in the diagnostic management of concomitant aortic stenosis and transthyretin-related wild-type cardiac amyloidosis. Front Cardiovasc Med 2023; 10:1108696. [PMID: 36998972 PMCID: PMC10043370 DOI: 10.3389/fcvm.2023.1108696] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 02/21/2023] [Indexed: 03/17/2023] Open
Abstract
Severe aortic stenosis (AS) is the most common valvular heart disease with a prevalence rate of more than 4% in 75-year-old people or older. Similarly, cardiac amyloidosis (CA), especially "wild-type transthyretin" (wTTR), has shown a prevalence rate ranging from 22% to 25% in people older than 80 years. The detection of the concomitant presence of CA and AS is challenging primarily because of the similar type of changes in the left ventricle caused by AS and CA, which share some morphological characteristics. The aim of this review is to identify the imaging triggers in order to recognize occult wtATTR-CA in patients with AS, clarifying the crucial step of the diagnostic process. Multimodality imaging methods such as echocardiography, cardiac magnetic resonance, cardiac computed tomography, and DPD scintigraphy will be analyzed as part of the available diagnostic workup to identify wtATTR-CA early in patients with AS.
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Affiliation(s)
- Angelica Cersosimo
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Andrea Bonelli
- ASST Grande Ospedale Metropolitano Niguarda, "A. De Gasperis" Department, Cardiology IV, Milan, Italy
| | - Carlo M Lombardi
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Antonella Moreo
- ASST Grande Ospedale Metropolitano Niguarda, "A. De Gasperis" Department, Cardiology IV, Milan, Italy
| | - Matteo Pagnesi
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Gianmarco Arabia
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Enrico Vizzardi
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Davide Farina
- ASST Spedali Civili di Brescia, Division of Radiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo M Inciardi
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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Kessler L, Fragoso Costa P, Kersting D, Jentzen W, Weber M, Lüdike P, Carpinteiro A, Oubari S, Hagenacker T, Thimm A, Rassaf T, Herrmann K, Papathanasiou M, Rischpler C. Quantitative 99mTc-DPD-SPECT/CT assessment of cardiac amyloidosis. J Nucl Cardiol 2023; 30:101-111. [PMID: 35562639 PMCID: PMC9984322 DOI: 10.1007/s12350-022-02960-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 02/06/2022] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Transthyretin (ATTR) amyloidosis is responsible for the majority of cardiac amyloidosis (CA) cases and can be reliably diagnosed with bone scintigraphy and the visual Perugini score. We aimed to implement a quantification method of cardiac amyloid deposits in patients with suspected cardiac amyloidosis and to compare performance to visual scoring. METHODS AND MATERIALS 136 patients received 99mTc-DPD-bone scintigraphy including SPECT/CT of the thorax in case of suspicion of cardiac amyloidosis. Imaging phantom studies were performed to determine the scaling factor for standardized uptake value (SUV) quantification from SPECT/CT. Myocardial tracer uptake was quantified in a whole heart volume of interest. RESULTS Forty-five patients were diagnosed with CA. A strong relationship between cardiac SUVmax and Perugini score was found (Spearman r 0.75, p < 0.0001). Additionally, tracer uptake in bone decreased with increasing cardiac SUVmax and Perugini score (p < 0.0001). ROC analysis revealed good performance of the SUVmax for the detection of ATTR-CA with AUC of 0.96 ± 0.02 (p < 0.0001) with sensitivity 98.7% and specificity 87.2%. CONCLUSION We demonstrate an accessible and accurate quantitative SPECT approach in CA. Quantitative assessment of the cardiac tracer uptake may improve diagnostic accuracy and risk classification. This method may enable monitoring and assessment of therapy response in patients with ATTR amyloidosis.
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Affiliation(s)
- Lukas Kessler
- Department of Nuclear Medicine, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany.
| | - Pedro Fragoso Costa
- Department of Nuclear Medicine, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - David Kersting
- Department of Nuclear Medicine, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Walter Jentzen
- Department of Nuclear Medicine, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Manuel Weber
- Department of Nuclear Medicine, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Peter Lüdike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Alexander Carpinteiro
- Department of Hematology and Stem Cell Transplantation, West German Tumor Center, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
- Department of Molecular Biology, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Sara Oubari
- Department of Hematology and Stem Cell Transplantation, West German Tumor Center, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Tim Hagenacker
- Department of Neurology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Andreas Thimm
- Department of Neurology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Maria Papathanasiou
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Christoph Rischpler
- Department of Nuclear Medicine, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
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9
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Khor YM, Cuddy SAM, Singh V, Falk RH, Di Carli MF, Dorbala S. 99mTc Bone-Avid Tracer Cardiac Scintigraphy: Role in Noninvasive Diagnosis of Transthyretin Cardiac Amyloidosis. Radiology 2023; 306:e221082. [PMID: 36537896 PMCID: PMC9885342 DOI: 10.1148/radiol.221082] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/11/2022] [Accepted: 09/15/2022] [Indexed: 12/24/2022]
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) is an overlooked cause of heart failure, with substantial morbidity and mortality. The emergence of several novel therapies has fueled the interest in early and accurate diagnosis of ATTR-CA so that potentially life-saving pharmacologic therapy can be administered in a timely manner. The most promising imaging modality and biomarker is SPECT imaging with technetium 99m (99mTc)-radiolabeled bone-seeking tracers, which have high specificity in the diagnosis of ATTR-CA, potentially obviating biopsy. In this article, the authors provide a focused review on the use of 99mTc pyrophosphate (PYP), 3,3-diphosphono-1,2-propanodicarboxylic acid (DPD), and hydroxymethylene diphosphonate (HMDP) for diagnosis of ATTR-CA, present a systematic approach to interpretation of the scans, and highlight several common pitfalls to illustrate important diagnostic principles for accurate interpretation of these images. The authors indicate when to use endomyocardial biopsy for the diagnosis of cardiac amyloidosis and conclude with a section on quantitation of 99mTc-PYP/DPD/HMDP imaging.
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Affiliation(s)
- Yiu Ming Khor
- From the Department of Nuclear Medicine and Molecular Imaging,
Singapore General Hospital, Singapore (Y.M.K.); Division of Nuclear Medicine and
Molecular Imaging, Department of Radiology (Y.M.K., V.S., M.F.D.C., S.D.),
Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine
(S.A.M.C., R.H.F., S.D.), and CV Imaging Program, Cardiovascular Division and
Department of Radiology (S.A.M.C., V.S., M.F.D.C., S.D.), Brigham and
Women’s Hospital and Harvard Medical School, 70 Francis St, Boston, MA
02115; and Midwest Heart and Vascular Specialists, HCA Midwest Health, Kansas
City, Mo (V.S.)
| | - Sarah A. M. Cuddy
- From the Department of Nuclear Medicine and Molecular Imaging,
Singapore General Hospital, Singapore (Y.M.K.); Division of Nuclear Medicine and
Molecular Imaging, Department of Radiology (Y.M.K., V.S., M.F.D.C., S.D.),
Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine
(S.A.M.C., R.H.F., S.D.), and CV Imaging Program, Cardiovascular Division and
Department of Radiology (S.A.M.C., V.S., M.F.D.C., S.D.), Brigham and
Women’s Hospital and Harvard Medical School, 70 Francis St, Boston, MA
02115; and Midwest Heart and Vascular Specialists, HCA Midwest Health, Kansas
City, Mo (V.S.)
| | - Vasvi Singh
- From the Department of Nuclear Medicine and Molecular Imaging,
Singapore General Hospital, Singapore (Y.M.K.); Division of Nuclear Medicine and
Molecular Imaging, Department of Radiology (Y.M.K., V.S., M.F.D.C., S.D.),
Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine
(S.A.M.C., R.H.F., S.D.), and CV Imaging Program, Cardiovascular Division and
Department of Radiology (S.A.M.C., V.S., M.F.D.C., S.D.), Brigham and
Women’s Hospital and Harvard Medical School, 70 Francis St, Boston, MA
02115; and Midwest Heart and Vascular Specialists, HCA Midwest Health, Kansas
City, Mo (V.S.)
| | - Rodney H. Falk
- From the Department of Nuclear Medicine and Molecular Imaging,
Singapore General Hospital, Singapore (Y.M.K.); Division of Nuclear Medicine and
Molecular Imaging, Department of Radiology (Y.M.K., V.S., M.F.D.C., S.D.),
Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine
(S.A.M.C., R.H.F., S.D.), and CV Imaging Program, Cardiovascular Division and
Department of Radiology (S.A.M.C., V.S., M.F.D.C., S.D.), Brigham and
Women’s Hospital and Harvard Medical School, 70 Francis St, Boston, MA
02115; and Midwest Heart and Vascular Specialists, HCA Midwest Health, Kansas
City, Mo (V.S.)
| | - Marcelo F. Di Carli
- From the Department of Nuclear Medicine and Molecular Imaging,
Singapore General Hospital, Singapore (Y.M.K.); Division of Nuclear Medicine and
Molecular Imaging, Department of Radiology (Y.M.K., V.S., M.F.D.C., S.D.),
Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine
(S.A.M.C., R.H.F., S.D.), and CV Imaging Program, Cardiovascular Division and
Department of Radiology (S.A.M.C., V.S., M.F.D.C., S.D.), Brigham and
Women’s Hospital and Harvard Medical School, 70 Francis St, Boston, MA
02115; and Midwest Heart and Vascular Specialists, HCA Midwest Health, Kansas
City, Mo (V.S.)
| | - Sharmila Dorbala
- From the Department of Nuclear Medicine and Molecular Imaging,
Singapore General Hospital, Singapore (Y.M.K.); Division of Nuclear Medicine and
Molecular Imaging, Department of Radiology (Y.M.K., V.S., M.F.D.C., S.D.),
Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine
(S.A.M.C., R.H.F., S.D.), and CV Imaging Program, Cardiovascular Division and
Department of Radiology (S.A.M.C., V.S., M.F.D.C., S.D.), Brigham and
Women’s Hospital and Harvard Medical School, 70 Francis St, Boston, MA
02115; and Midwest Heart and Vascular Specialists, HCA Midwest Health, Kansas
City, Mo (V.S.)
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10
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Wollenweber T, Kretschmer-Chott E, Wurm R, Rasul S, Kulterer O, Rettl R, Duca F, Bonderman D, Sühs KW, Hacker M, Traub-Weidinger T. Does [99mTc]-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) soft tissue uptake allow the identification of patients with the diagnosis of cardiac transthyretin-related (ATTR) amyloidosis with higher risk for polyneuropathy? J Nucl Cardiol 2023; 30:357-367. [PMID: 35817943 PMCID: PMC9984356 DOI: 10.1007/s12350-022-02986-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/26/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND With the introduction of several drugs for the therapy of transthyretin-related amyloidosis (ATTR) which slow down the disease, early detection of polyneuropathy (PNP) is becoming increasingly of interest. [99mTc]-3,3-Diphosphono-1,2-Propanodicarboxylic Acid (DPD) bone scintigraphy, which is used for the diagnosis of cardiac (c)ATTR, can possibly make an important contribution in the identification of patients at risk for PNP. METHODS Fifty patients with cATTR, who underwent both planar whole-body DPD scintigraphy and nerve conduction studies (NCS) were retrospectively evaluated. A subgroup of 22 patients also underwent quantitative SPECT/CT of the thorax from which Standardized Uptake Values (SUVpeak) in the subcutaneous fat tissue of the left axillar region were evaluated. RESULTS The Perugini score was significantly increased in patients with cATTR and additional diagnosis of PNP compared to patients without (2.51 ± 0.51 vs 2.13 ± 0.52; P = 0.03). Quantitative SPECT/CT revealed that DPD uptake in the subcutaneous fat of the left axillar region was significantly increased in cATTR patients with compared to patients without (1.36 ± 0.60 vs 0.74 ± 0.52; P = 0.04). CONCLUSION This study suggests that DPD bone scintigraphy is a useful tool for identification of patients with cATTR and a risk for PNP due to increased DPD soft tissue uptake.
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Affiliation(s)
- Tim Wollenweber
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Kretschmer-Chott
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Raphael Wurm
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Sazan Rasul
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Oana Kulterer
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Rene Rettl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Diana Bonderman
- 5th Medical Department with Cardiology, Clinic Favoriten, Vienna, Austria
| | | | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Tatjana Traub-Weidinger
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
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11
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Role of Diphosphonates Bone Scintigraphy in Correlation with Biomarkers for a Personalized Approach to ATTR Cardiac Amyloidosis in North-Eastern Romania. Diagnostics (Basel) 2022; 13:diagnostics13010083. [PMID: 36611375 PMCID: PMC9818064 DOI: 10.3390/diagnostics13010083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/13/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022] Open
Abstract
Transthyretin cardiac amyloidosis (ATTR) is a rare cardiac protein deposition disease characterized by progressive thickening of both ventricles, the inter-atrial-ventricular septum and the atrioventricular valves. The gold standard method for diagnosing this rare pathology is endomyocardial biopsy. If this method cannot be used, the alternative is a mixture of clinical and paraclinical tests. Over the course of five years, we examined 58 patients suspected of cardiac amyloidosis based on electrocardiography and ultrasonography criteria, who had been sent for bone scintigraphy in order to determine the presence of ATTR cardiac amyloidosis. However, the final diagnosis was set by correlating the bone scan with genetic testing, free light chain dosage or soft tissue biopsy. Based on the final diagnosis we analyzed the patients' predominant biomarkers in order to determine a possible correlation between them. This analysis is designed to help the general practitioner set a possible cardiac amyloidosis diagnosis.
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12
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Roshankar G, White GC, Cadet S, Fine NM, Chan D, White JA, Jimenez-Zepeda V, Slomka PJ, Miller RJH. Quantitative technetium pyrophosphate and cardiovascular magnetic resonance in patients with suspected cardiac amyloidosis. J Nucl Cardiol 2022; 29:2679-2690. [PMID: 34604925 DOI: 10.1007/s12350-021-02806-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/27/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Quantitation of myocardial 99m Tc-pyrophosphate activity may have high diagnostic accuracy, but its correlation with disease burden is unknown. We examined the relationship between 99m Tc-pyrophosphate quantitation and cardiac magnetic resonance (CMR) measures in patients with suspected transthyretin cardiac amyloidosis (ATTR-CM) or light chain cardiac amyloidosis (AL-CM). METHODS Consecutive patients who underwent 99mTc-pyrophosphate imaging and CMR were included. ATTR-CM and AL-CM were diagnosed using standard criteria. 99mTc-pyrophosphate images were assessed with standard parameters and quantified with cardiac pyrophosphate activity (CPA) and volume of involvement (VOI). We assessed the association between 99mTc-pyrophosphate image interpretation and CMR tissue characteristics. RESULTS Seventy patients were identified, mean age 70.4 ± 11.4 years, with ATTR-CM and AL-CM diagnosed in 22 (31%) and 11 (16%) patients, respectively. In patients with ATTR-CM, there were significant correlations between CPA (r2 = 0.509, P < 0.001) and VOI (r2 = 0.586, P < 0.001) with native myocardial T1 mapping values. Additionally, CPA (adjusted hazard ratio (aHR) 1.04, P = 0.016), VOI (aHR 1.12, P = 0.034), and average myocardial T1 (aHR 1.12, P = 0.025) were associated with incidence of heart failure hospitalization or death. CONCLUSION CPA and VOI were correlated with CMR measures of myocardial fibrosis in patients with ATTR-CM. 99mTc-pyrophosphate quantitation may have a role in ATTR-CM disease staging, guiding treatment, or following response to therapy.
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Affiliation(s)
- Golnaz Roshankar
- Department of Cardiac Sciences, University of Calgary, GAA08, 3230 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada
| | - Geneva C White
- Department of Cardiac Sciences, University of Calgary, GAA08, 3230 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada
| | - Sebastien Cadet
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nowell M Fine
- Department of Cardiac Sciences, University of Calgary, GAA08, 3230 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada
| | - Denise Chan
- Department of Nuclear Medicine, University of Calgary, Calgary, AB, Canada
| | - James A White
- Department of Cardiac Sciences, University of Calgary, GAA08, 3230 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada
| | | | - Piotr J Slomka
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert J H Miller
- Department of Cardiac Sciences, University of Calgary, GAA08, 3230 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada.
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13
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Transthyretin Cardiac Amyloidosis. Cardiol Clin 2022; 40:541-558. [DOI: 10.1016/j.ccl.2022.06.008] [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: 11/18/2022]
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14
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Bay K, Gustafsson F, Maiborg M, Bagger‐Bahnsen A, Strand AM, Pilgaard T, Poulsen SH. Suspicion, screening, and diagnosis of wild-type transthyretin amyloid cardiomyopathy: a systematic literature review. ESC Heart Fail 2022; 9:1524-1541. [PMID: 35343098 PMCID: PMC9065854 DOI: 10.1002/ehf2.13884] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/11/2022] [Accepted: 02/25/2022] [Indexed: 01/15/2023] Open
Abstract
Wild-type transthyretin amyloid cardiomyopathy (ATTRwt CM) is a more common disease than previously thought. Awareness of ATTRwt CM and its diagnosis has been challenged by its unspecific and widely distributed clinical manifestations and traditionally invasive diagnostic tools. Recent advances in echocardiography and cardiac magnetic resonance (CMR), non-invasive diagnosis by bone scintigraphy, and the development of disease-modifying treatments have resulted in an increased interest, reflected in multiple publications especially during the last decade. To get an overview of the scientific knowledge and gaps related to patient entry, suspicion, diagnosis, and systematic screening of ATTRwt CM, we developed a framework to systematically map the available evidence of (i) when to suspect ATTRwt CM in a patient, (ii) how to diagnose the disease, and (iii) which at-risk populations to screen for ATTRwt CM. Articles published between 2010 and August 2021 containing part of or a full diagnostic pathway for ATTRwt CM were included. From these articles, data for patient entry, suspicion, diagnosis, and screening were extracted, as were key study design and results from the original studies referred to. A total of 50 articles met the inclusion criteria. Of these, five were position statements from academic societies, while one was a clinical guideline. Three articles discussed the importance of primary care providers in terms of patient entry, while the remaining articles had the cardiovascular setting as point of departure. The most frequently mentioned suspicion criteria were ventricular wall thickening (44/50), carpal tunnel syndrome (42/50), and late gadolinium enhancement on CMR (43/50). Diagnostic pathways varied slightly, but most included bone scintigraphy, exclusion of light-chain amyloidosis, and the possibility of doing a biopsy. Systematic screening was mentioned in 16 articles, 10 of which suggested specific at-risk populations for screening. The European Society of Cardiology recommends to screen patients with a wall thickness ≥12 mm and heart failure, aortic stenosis, or red flag symptoms, especially if they are >65 years. The underlying evidence was generally good for diagnosis, while significant gaps were identified for the relevance and mutual ranking of the different suspicion criteria and for systematic screening. Conclusively, patient entry was neglected in the reviewed literature. While multiple red flags were described, high-quality prospective studies designed to evaluate their suitability as suspicion criteria were lacking. An upcoming task lies in defining and evaluating at-risk populations for screening. All are steps needed to promote early detection and diagnosis of ATTRwt CM, a prerequisite for timely treatment.
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Affiliation(s)
- Katrine Bay
- Bay WritingCopenhagenDenmark
- Pfizer DenmarkBallerupDenmark
| | - Finn Gustafsson
- The Heart CenterCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Michael Maiborg
- Odense Amyloidosis Center & Department of CardiologyOdense University HospitalOdenseDenmark
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15
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Correlation of Quantitative 99mTc DPD Scintigraphy With Echocardiographic Alterations in Left Atrial Parameters in Transthyretin Amyloidosis. Heart Lung Circ 2022; 31:804-814. [PMID: 35181228 DOI: 10.1016/j.hlc.2022.01.006] [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: 04/20/2021] [Revised: 11/28/2021] [Accepted: 01/09/2022] [Indexed: 11/21/2022]
Abstract
AIM Cardiac transthyretin amyloidosis (ATTR) patients have high rates of atrial arrhythmias. We evaluated echocardiographic structural and functional left atrial (LA) parameters and correlated these with technetium-99m 3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) bone scintigraphy tracer uptake within the LA in ATTR patients. METHODS ATTR patients (wild-type, hereditary and asymptomatic transthyretin [TTR] variant carriers) who had undergone 99mTc-DPD and transthoracic echocardiogram (TTE) were selected. Quantitative 99mTc-DPD uptake analysis and echocardiographic evaluation of LA structural and functional parameters was performed. RESULTS Forty (40) ATTR patients (wild-type n=17; hereditary ATTR and TTR variant carriers n=23; median age 68.8±22 years) were included. TTE parameters including indexed LA minimum (LAVmin) (r=0.66), and LA maximum volumes (LAVmax) (r=0.64), LA emptying fraction (LAEF) (r=-0.68), LA function index (LAFI) (r=-0.70) and reservoir strain (ƐR) (r=-0.70) (p<0.001 for all) demonstrated good correlation to LA tracer uptake. Normal LA volume (LAVmin and LAVmax) and function (LAEF, LAFI and ƐR) was observed in hereditary ATTR and TTR variant carriers without cardiac tracer uptake. The subgroup of ATTR patients with atrial fibrillation/flutter demonstrated increased LAVmin and LAVmax with further reduction in LA function (LAEF, LAFI and ƐR). Receiver operating characteristic curves demonstrated strong diagnostic accuracies for LA structural (LAVmin and LAVmax; area under the curve [AUC] of 0.83 and 0.84 respectively) and functional (LAEF, LAFI and ƐR; AUC 0.81, 0.88 and 0.85, respectively) parameters. CONCLUSION Left atrial structural and functional parameters demonstrated good correlations with quantitative 99mTc-DPD tracer LA uptake. Echocardiography and 99mTc-DPD scintigraphy may have significant roles in identification and surveillance of ATTR patients likely to develop atrial arrhythmias.
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16
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Suomalainen O, Pilv J, Loimaala A, Mätzke S, Heliö T, Uusitalo V. Prognostic significance of incidental suspected transthyretin amyloidosis on routine bone scintigraphy. J Nucl Cardiol 2022; 29:1021-1029. [PMID: 33094472 PMCID: PMC9163012 DOI: 10.1007/s12350-020-02396-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/14/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Transthyretin amyloidosis (ATTR) is an occasional incidental finding on bone scintigraphy. We studied its prognostic impact in elderly patients. METHODS The study population consisted of 2000 patients aged over 70 years who underwent bone scintigraphies with clinical indications in three nuclear medicine departments (Kymenlaakso, Jorvi and Meilahti hospitals) in Finland. All studies were performed using 99mTechnetium labeled hydroxymethylene diphosphonate (HMDP). ATTR was suspected in patients with ≥grade 2 Perugini grade uptake (grade 0-3). Heart-to-contralateral ratio (H/CL) of ≥ 1.30 was considered positive for ATTR. The overall and cardiovascular mortality were obtained from the Finnish National Statistical Service. RESULTS There were a total of 1014 deaths (51%) and 177 cardiovascular deaths (9%) during median follow-up of 4 ± 2 years. ATTR was suspected in 69 patients (3.6%) of which 54 (2.7%) had grade 2 and 15 (.8%) had grade 3 uptake and in 47 patients (2.4%) by H/CL ratio. In multivariate analyses age, bone metastasis, H/CL ratio and grade 3 uptake were independent predictors of overall and cardiovascular mortality. Grade 2 uptake was a predictor of cardiovascular mortality. CONCLUSIONS A suspected ATTR as an incidental finding on bone scintigraphy predicts elevated overall and cardiovascular mortality in elderly patients.
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Affiliation(s)
- Olli Suomalainen
- Cardiology Department, Kymenlaakso Central Hospital, Kotkantie 41, 48210 Kotka, Finland
| | - Jaagup Pilv
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Antti Loimaala
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sorjo Mätzke
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tiina Heliö
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Valtteri Uusitalo
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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17
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Halme HL, Ihalainen T, Suomalainen O, Loimaala A, Mätzke S, Uusitalo V, Sipilä O, Hippeläinen E. Convolutional neural networks for detection of transthyretin amyloidosis in 2D scintigraphy images. EJNMMI Res 2022; 12:27. [PMID: 35524861 PMCID: PMC9079204 DOI: 10.1186/s13550-022-00897-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transthyretin amyloidosis (ATTR) is a progressive disease which can be diagnosed non-invasively using bone avid [99mTc]-labeled radiotracers. Thus, ATTR is also an occasional incidental finding on bone scintigraphy. In this study, we trained convolutional neural networks (CNN) to automatically detect and classify ATTR from scintigraphy images. The study population consisted of 1334 patients who underwent [99mTc]-labeled hydroxymethylene diphosphonate (HMDP) scintigraphy and were visually graded using Perugini grades (grades 0-3). A total of 47 patients had visual grade ≥ 2 which was considered positive for ATTR. Two custom-made CNN architectures were trained to discriminate between the four Perugini grades of cardiac uptake. The classification performance was compared to four state-of-the-art CNN models. RESULTS Our CNN models performed better than, or equally well as, the state-of-the-art models in detection and classification of cardiac uptake. Both models achieved area under the curve (AUC) ≥ 0.85 in the four-class Perugini grade classification. Accuracy was good in detection of negative vs. positive ATTR patients (grade < 2 vs grade ≥ 2, AUC > 0.88) and high-grade cardiac uptake vs. other patients (grade < 3 vs. grade 3, AUC = 0.94). Maximum activation maps demonstrated that the automated deep learning models were focused on detecting the myocardium and not extracardiac features. CONCLUSION Automated convolutional neural networks can accurately detect and classify different grades of cardiac uptake on bone scintigraphy. The CNN models are focused on clinically relevant image features. Automated screening of bone scintigraphy images using CNN could improve the early diagnosis of ATTR.
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Affiliation(s)
- Hanna-Leena Halme
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Toni Ihalainen
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Olli Suomalainen
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Antti Loimaala
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Sorjo Mätzke
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Valtteri Uusitalo
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Outi Sipilä
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Eero Hippeläinen
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland. .,Department of Physics, University of Helsinki, Helsinki, Finland.
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Uusitalo V, Suomalainen O, Loimaala A, Mätzke S, Heliö T. Prognostic Value of 99mTc-HMDP Scintigraphy in Elderly Patients With Chronic Heart Failure. Heart Lung Circ 2022; 31:629-637. [PMID: 35063379 DOI: 10.1016/j.hlc.2021.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 11/20/2021] [Accepted: 11/28/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND This study evaluated the prevalence and prognostic significance of cardiac transthyretin amyloidosis (ATTR) diagnosed using 99mTc- hydroxymethylene-diphosphonate (99mTc-HMDP) scintigraphy in an elderly heart failure population. METHODS This retrospective study included 335 patients aged >70 years with heart failure and who underwent 99mTc-HMDP scintigraphy due to non-cardiac reasons in three imaging centres in Finland (Kymenlaakso Central Hospital, Jorvi Central Hospital, and Meilahti University Hospital). A Perugini grade >2 and heart-to-contralateral ratio (H/CL) of ≥1.30 were considered positive for cardiac ATTR. The overall and cardiovascular mortality were obtained from the national statistical service (Statistics Finland). RESULTS There were 234 deaths, of which 70 were classified as being due to cardiovascular causes during a median follow-up of 1 (1-3) year. Transthyretin amyloidosis was diagnosed in 22 patients (6.6%) using visual analysis and 17 patients using the H/CL ratio (5.1%). Patients with ATTR were older (85±5 vs 80±5 yrs; p=0.002) and had higher N-terminal pro-brain natriuretic peptide (NT-ProBNP) levels (1,451 [813-3,799] vs 6,192 [2,030-8,833] ng/L; p=0.02). Age, bone metastases, and glomerular filtration rate were independent predictors of overall mortality in multivariable analysis. Age, glomerular filtration rate, ≥grade 2 visual cardiac uptake, and H/CL ratio were independent predictors of cardiovascular mortality. CONCLUSIONS Cardiac uptake suggestive of ATTR was found in 5% of elderly patients with chronic heart failure. The presence of cardiac uptake on bone scintigraphy did not convey independent prognostic value on overall mortality but was independently associated with cardiovascular mortality.
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Affiliation(s)
- Valtteri Uusitalo
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Olli Suomalainen
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Antti Loimaala
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sorjo Mätzke
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tiina Heliö
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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19
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Bellevre D, Bailliez A, Delelis F, Blaire T, Agostini D, Mouquet F, Maréchaux S, Manrique A. Quantitation of myocardial 99mTc-HMDP uptake with new SPECT/CT cadmium zinc telluride (CZT) camera in patients with transthyretin-related cardiac amyloidosis: Ready for clinical use? J Nucl Cardiol 2022; 29:506-514. [PMID: 32715418 DOI: 10.1007/s12350-020-02274-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/14/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The aim of this study was to investigate the feasibility of assessing absolute myocardial 99mTc-HMDP uptake in patients with suspected cardiac ATTR using SUV with a whole-body CZT SPECT-CT camera (DNM670CZT). METHODS Fifteen patients with suspected cardiac ATTR (Perugini ≥ 2) underwent a conventional 99mTc-HMDP planar imaging and a thoracic SPECT/CT using a DNM 670CZT. A control group consisted of 15 patients with negative scintigraphy (Perugini < 2). SUVmax (mg·L-1) and percentage of injected dose (%ID) were calculated in a cardiac volume of interest (VOI) encompassing the left ventricle. VOIs were also placed in the lung, the right pectoris major, and the sternum. A heart-to-lung SUVmax ratio (HLR) was calculated. RESULTS All ATTR patients demonstrated an increased cardiac HMDP SUVmax (12.2 ± 3.7 mg·L-1) vs controls (3.5 ± 1.2, P < .0001). Percentage of ID, pectoral uptake and HLR were significantly higher in the ATTR group (1.1 ± 0.3 vs 0.15 ± 0.8, P < .0001; 1.5 ± 0.3 vs 0.9 ± 0.3, P < .0001; 9.7 ± 3 vs 4.3 ± 2.2, P < .0001). Bone uptake was not statistically different between the two groups. CONCLUSION This study demonstrated the feasibility of quantitative 99mTc-HMDP SUVmax measurement using a whole-body SPECT/CT CZT camera in patients with suspected cardiac ATTR.
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Affiliation(s)
- Dimitri Bellevre
- Normandie Univ, UNICAEN, Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, FHU REMOD-VHF, Caen, France.
- Department of Nuclear Medicine, UF 5881, Groupement des Hôpitaux de l'Institut Catholique de Lille, Lomme, France.
- Department of Nuclear Medicine, IRIS, Hôpital Privé Le Bois, Lille, France.
| | - Alban Bailliez
- Department of Nuclear Medicine, UF 5881, Groupement des Hôpitaux de l'Institut Catholique de Lille, Lomme, France
- Department of Nuclear Medicine, IRIS, Hôpital Privé Le Bois, Lille, France
| | - François Delelis
- Department of Cardiology, Groupement des Hopitaux de l'instituts catholiques de Lille, Lomme, France
| | - Tanguy Blaire
- Department of Nuclear Medicine, UF 5881, Groupement des Hôpitaux de l'Institut Catholique de Lille, Lomme, France
- Department of Nuclear Medicine, IRIS, Hôpital Privé Le Bois, Lille, France
| | - Denis Agostini
- Normandie Univ, UNICAEN, Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, FHU REMOD-VHF, Caen, France
- Department of Nuclear Medicine, CHU Cote de Nacre, Normandy University, Caen, France
| | | | - Sylvestre Maréchaux
- Department of Cardiology, Groupement des Hopitaux de l'instituts catholiques de Lille, Lomme, France
| | - Alain Manrique
- Normandie Univ, UNICAEN, Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, FHU REMOD-VHF, Caen, France
- Department of Nuclear Medicine, CHU Cote de Nacre, Normandy University, Caen, France
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20
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Amyloid Cardiomyopathy in Older Adults. CURRENT GERIATRICS REPORTS 2022. [DOI: 10.1007/s13670-022-00374-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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21
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Caobelli F, Popescu CE. Cardiac amyloid imaging (DPD scans). Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00019-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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22
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Schatka I, Bingel A, Schau F, Bluemel S, Messroghli DR, Frumkin D, Knebel F, Diekmann SM, Elsanhoury A, Tschöpe C, Hahn K, Amthauer H, Rogasch JMM, Wetz C. An optimized imaging protocol for [ 99mTc]Tc-DPD scintigraphy and SPECT/CT quantification in cardiac transthyretin (ATTR) amyloidosis. J Nucl Cardiol 2021; 28:2483-2496. [PMID: 34331215 PMCID: PMC8709821 DOI: 10.1007/s12350-021-02715-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/14/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND In [99mTc]Tc-DPD scintigraphy for myocardial ATTR amyloidosis, planar images 3 hour p.i. and SPECT/CT acquisition in L-mode are recommended. This study investigated if earlier planar images (1 hour p.i.) are beneficial and if SPECT/CT acquisition should be preferred in H-mode (180° detector angle) or L-mode (90°). METHODS In SPECT/CT phantom measurements (NaI cameras, N = 2; CZT, N = 1), peak contrast recovery (CRpeak) was derived from sphere inserts or myocardial insert (cardiac phantom; signal-to-background ratio [SBR], 10:1 or 5:1). In 25 positive and 38 negative patients (reference: endomyocardial biopsy or clinical diagnosis), Perugini scores and heart-to-contralateral (H/CL) count ratios were derived from planar images 1 hour and 3 hour p.i. RESULTS In phantom measurements, accuracy of myocardial CRpeak at SBR 10:1 (H-mode, 0.95-0.99) and reproducibility at 5:1 (H-mode, 1.02-1.14) was comparable for H-mode and L-mode. However, L-mode showed higher variability of background counts and sphere CRpeak throughout the field of view than H-mode. In patients, sensitivity/specificity were ≥ 95% for H/CL ratios at both time points and visual scoring 3 hour. At 1 hour, visual scores showed specificity of 89% and reduced reader's confidence. CONCLUSIONS Early DPD images provided no additional value for visual scoring or H/CL ratios. In SPECT/CT, H-mode is preferred over L-mode, especially if quantification is applied apart from the myocardium.
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Affiliation(s)
- Imke Schatka
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Anne Bingel
- Department of Internal Medicine and Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Franziska Schau
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Stephanie Bluemel
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Daniel R Messroghli
- Department of Internal Medicine and Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - David Frumkin
- Medical Clinic for Cardiology, Angiology, Pneumology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Charité Mitte (CCM), Berlin, Germany
| | - Fabian Knebel
- Medical Clinic for Cardiology, Angiology, Pneumology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Charité Mitte (CCM), Berlin, Germany
| | - Sonja M Diekmann
- Department of Cardiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum (CVK), Berlin, Germany
| | - Ahmed Elsanhoury
- Berlin Institute of Health (BIH) Berlin-Brandenburger Center for Regenerative Therapies (BCRT), Charité, Berlin, Germany
| | - Carsten Tschöpe
- Department of Cardiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow Klinikum (CVK), Berlin, Germany
- Berlin Institute of Health (BIH) Berlin-Brandenburger Center for Regenerative Therapies (BCRT), Charité, Berlin, Germany
| | - Katrin Hahn
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Holger Amthauer
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Julian M M Rogasch
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Berlin Institute of Health (BIH), Berlin, Germany.
| | - Christoph Wetz
- Department of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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23
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Stassen J, van der Bijl P, Bax JJ. Optimizing 99mTc-DPD scintigraphy: Adding value to the diagnosis and treatment of cardiac transthyretin amyloidosis. J Nucl Cardiol 2021; 28:2497-2499. [PMID: 34331216 DOI: 10.1007/s12350-021-02716-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 03/18/2021] [Indexed: 01/15/2023]
Affiliation(s)
- Jan Stassen
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Pieter van der Bijl
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
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24
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Cuscaden C, Ramsay SC, Prasad S, Goodwin B, Smith J. Estimation of prevalence of transthyretin (ATTR) cardiac amyloidosis in an Australian subpopulation using bone scans with echocardiography and clinical correlation. J Nucl Cardiol 2021; 28:2845-2856. [PMID: 32385832 DOI: 10.1007/s12350-020-02152-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 04/05/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Bone scans differentiate transthyretin (ATTR) cardiac amyloidosis from light chain amyloidosis and other causes of increased left ventricular (LV) wall thickness. We examined the prevalence and implications of cardiac uptake in the general population. METHODS Patients were included based on having undertaken a bone scan for non-cardiac indications using Technetium 99m hydroxymethylene diphosphonate (HMDP) or Technetium 99m methylene diphosphonate (MDP). Blinded image review was undertaken. Positive was defined as cardiac uptake ≥ rib AND heart/whole body ratio (H/WB) > 0.0388. Echocardiography and clinical records were reviewed. RESULTS 6918 patients were included. 15/3472 HMDP scans were positive (14 males, 1 female): none in individuals aged < 65; 1.44% in males and 0.17% in females ≥ 65; 6.15% in males and 1.69% in females ≥ 85. Only 1/3446 MDP scans were positive. All HMDP positive patients had increased septal wall thickness on echocardiography. H/WB correlated positively with LV mass, and negatively with LV ejection fraction. No individual had an explanation other than ATTR for their positive scan. CONCLUSION In this Australian subpopulation, the prevalence of positive bone scans consistent with cardiac ATTR is 0% in individuals aged < 65. Prevalence increased with age, reaching 6.15% in men ≥ 85. The amount of HMDP uptake correlated with echocardiographic features of more advanced cardiac involvement. MDP does not appear useful in ATTR.
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Affiliation(s)
- Claire Cuscaden
- Department of Medical Imaging, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, QLD, 4102, Australia
- Faculty of Medicine, University of Queensland, St Lucia, Australia
| | - Stuart C Ramsay
- Department of Nuclear Medicine and Specialised PET Service, Royal Brisbane and Women's Hospital (RBWH), Ned Hanlon Building, Herston, QLD, 4029, Australia.
- School of Medicine, James Cook University, 1 James Cook Dr, Douglas, QLD, 4814, Australia.
| | - Sandhir Prasad
- Department of Cardiology, RBWH, Herston, QLD, 4029, Australia
| | - Bruce Goodwin
- Department of Nuclear Medicine, Queensland Children's Hospital, 501 Stanley St, South Brisbane, QLD, 4101, Australia
| | - Jye Smith
- Department of Nuclear Medicine and Specialised PET Service, Royal Brisbane and Women's Hospital (RBWH), Ned Hanlon Building, Herston, QLD, 4029, Australia
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25
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Palmiero G, Vetrano E, Rubino M, Monda E, Dongiglio F, Lioncino M, Di Fraia F, Caiazza M, Verrillo F, Capodicasa L, Cerciello G, Manganelli F, Catalano M, D'Arienzo D, De Rimini ML, Ascione R, Golino P, Caso P, Ascione L, Limongelli G. The Role of New Imaging Technologies in the Diagnosis of Cardiac Amyloidosis. Heart Fail Clin 2021; 18:61-72. [PMID: 34776084 DOI: 10.1016/j.hfc.2021.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cardiac amyloidosis is an infiltrative disorder caused by transthyretin or immunoglobulin free light-chain deposition, which determines clinical disease with similar phenotype but different time course, prognosis and therapy. Multimodality imaging is the cornerstone for disease diagnosis and management. Multimodality imaging has revolutionized the approach to the disease favoring its awareness and simplifying its diagnosis, especially in ATTR cardiac amyloidosis. This describes the different imaging tools, from the traditional to the more novel ones, and highlights the different approach in each different setting (prognosis, subtyping, prognosis, monitoring disease progression, and response to therapy).
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Affiliation(s)
- Giuseppe Palmiero
- Department of Cardiology, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy; Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy.
| | - Erica Vetrano
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Marta Rubino
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Emanuele Monda
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Francesca Dongiglio
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Michele Lioncino
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Francesco Di Fraia
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Martina Caiazza
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Federica Verrillo
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Laura Capodicasa
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Giuseppe Cerciello
- Haematology Unit (Building n. 2), Department of Clinical Medicine and Surgery, AOU Policlinico "Federico II", via Sergio Pansini 5, 80131 Naples, Italy
| | - Fiore Manganelli
- Neurology Unit (Building n. 17), Department of Neurosciences, Reproductive Medicine and Odontostomatology, AOU Policlinico "Federico II", via Sergio Pansini 5, 80131 Naples, Italy
| | - Mara Catalano
- Department of Nuclear Imaging, AORN Cardarelli Hospital, via Antonio Cardarelli 9, 80131 Naples, Italy
| | - Davide D'Arienzo
- Department of Nuclear Medicine, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Maria Luisa De Rimini
- Department of Nuclear Medicine, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Raffaele Ascione
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Paolo Golino
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Pio Caso
- Department of Cardiology, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Luigi Ascione
- Department of Cardiology, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy; Institute of Cardiovascular Sciences, University College of London and St. Bartholomew's Hospital, London, UK
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26
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Lioncino M, Monda E, Palmiero G, Caiazza M, Vetrano E, Rubino M, Esposito A, Salerno G, Dongiglio F, D'Onofrio B, Verrillo F, Cerciello G, Manganelli F, Pacileo G, Bossone E, Golino P, Calabrò P, Limongelli G. Cardiovascular Involvement in Transthyretin Cardiac Amyloidosis. Heart Fail Clin 2021; 18:73-87. [PMID: 34776085 DOI: 10.1016/j.hfc.2021.07.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) is a systemic disorder resulting from the extracellular deposition of amyloid fibrils of misfolded transthyretin protein in the heart. ATTR-CA is a life-threatening disease, which can be caused by progressive deposition of wild type transthyretin (wtATTR) or by aggregation of an inherited mutated variant of transthyretin (mATTR). mATTR Is a rare condition transmitted in an autosomal dominant manner with incomplete penetrance, causing heterogenous phenotypes which can range from predominant neuropathic involvement, predominant cardiomyopathy, or mixed. Diagnosis of ATTR-CA is complex and requires integration of different imaging tools (echocardiography, bone scintigraphy, magnetic resonance) with genetics, clinical signs, laboratory tests, and histology. In recent years, new therapeutic agents have shown good efficacy and impact on survival and quality of life in this subset of patients, nevertheless patients affected by ATTR-CA may still carry an unfavorable prognosis, thus highlighting the need for new therapies. This review aims to assess cardiovascular involvement, diagnosis, and management of patients affected by ATTR-CA.
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Affiliation(s)
- Michele Lioncino
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Emanuele Monda
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Giuseppe Palmiero
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Martina Caiazza
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Erica Vetrano
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy; Internal Medicine Unit, Department of Translational Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marta Rubino
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Augusto Esposito
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Gemma Salerno
- Vanvitelli Cardiology Unit, Monaldi Hospital, Naples 80131, Italy
| | - Francesca Dongiglio
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Barbara D'Onofrio
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Federica Verrillo
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Giuseppe Cerciello
- Haematology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Fiore Manganelli
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples 'Federico II', Via Pansini, 5, Naples 81025, Italy
| | - Giuseppe Pacileo
- Heart Failure and Cardiac Rehabilitation Unit, Department of Cardiology, AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Eduardo Bossone
- Division of Cardiology, "Antonio Cardarelli" Hospital, Naples 80131, Italy
| | - Paolo Golino
- Vanvitelli Cardiology Unit, Monaldi Hospital, Naples 80131, Italy; Department of Translational Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paolo Calabrò
- Department of Translational Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna & San Sebastiano", Caserta I-81100, Italy
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy; Institute of Cardiovascular Sciences, University College of London and St. Bartholomew's Hospital, London WC1E 6DD, UK.
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27
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Harapoz M, Evans S, Geenty P, Kwok F, Stewart G, Taylor MS, Farlow D, Thomas L. Correlation Between Quantitative Uptake of 99mTC-DPD and Echocardiographic Parameters in Cardiac ATTR: A Novel Follow-Up Strategy. Front Cardiovasc Med 2021; 8:663929. [PMID: 34722650 PMCID: PMC8553935 DOI: 10.3389/fcvm.2021.663929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 09/13/2021] [Indexed: 11/25/2022] Open
Abstract
Aims: There has been a paradigm shift in diagnosis of cardiac transthyretin amyloidosis (ATTR) with non-invasive techniques including technetium-99m 3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) bone scintigraphy. We evaluated structural and functional biventricular alterations by transthoracic echocardiography (TTE) and determined the correlation with 99mTc-DPD tracer uptake in ATTR. Materials and Methods: ATTR patients (wild-type, hereditary or asymptomatic transthyretin [TTR] variant carriers) with 99mTc-DPD and TTE were selected; 99mTc-DPD uptake was analyzed quantitatively. TTE assessment of left ventricle (LV) and right ventricle (RV) parameters was performed. Results: Forty ATTR patients (wild-type n = 17; hereditary ATTR and TTR variant carriers n = 23; median age 68.8 ± 22 years) were included. TTE parameters displaying good correlation with 99mTc-DPD tracer uptake included LV average wall thickness (r = 0.837), LV indexed mass (LVMI; r = 0.802), RV wall thickness (r = 0.610), average e' (r = -0.830), E/e' ratio (r = 0.786), LV global longitudinal strain (GLS; r = 0.714) and RV GLS (r = 0.632; p < 0.001 for all). Hereditary ATTR and TTR variant carriers without cardiac tracer uptake had normal echocardiographic parameters. Receiver operating characteristic curves demonstrated strong diagnostic accuracies for structural (LV wall thickness, LVMI and RV wall thickness; area under the curve (AUC) of 0.96 for all) and functional (LV and RV GLS; AUC of 0.86 and 0.88, respectively) parameters. Conclusion: Good correlations between TTE biventricular structural and functional parameters were demonstrated with quantitative 99mTc-DPD uptake. Echocardiography may potentially assume a significant role in longitudinal follow-up for monitoring disease progression and for evaluating treatment response.
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Affiliation(s)
- Mehmet Harapoz
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Scott Evans
- Department of Nuclear Medicine, Westmead Hospital, Sydney, NSW, Australia
| | - Paul Geenty
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Fiona Kwok
- Westmead Amyloidosis Service, Westmead Hospital, Sydney, NSW, Australia
- Department of Haematology, Westmead Hospital, Sydney, NSW, Australia
| | - Graeme Stewart
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
- Westmead Amyloidosis Service, Westmead Hospital, Sydney, NSW, Australia
- Department of Clinical Immunology and Allergy, Westmead Hospital, Sydney, NSW, Australia
| | - Mark S. Taylor
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
- Westmead Amyloidosis Service, Westmead Hospital, Sydney, NSW, Australia
- Department of Clinical Immunology and Allergy, Westmead Hospital, Sydney, NSW, Australia
| | - David Farlow
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Nuclear Medicine, Westmead Hospital, Sydney, NSW, Australia
| | - Liza Thomas
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
- Westmead Amyloidosis Service, Westmead Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
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28
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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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29
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Miller RJH, Cadet S, Mah D, Pournazari P, Chan D, Fine NM, Berman DS, Slomka PJ. Diagnostic and prognostic value of Technetium-99m pyrophosphate uptake quantitation for transthyretin cardiac amyloidosis. J Nucl Cardiol 2021; 28:1835-1845. [PMID: 33689152 PMCID: PMC8497047 DOI: 10.1007/s12350-021-02563-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/06/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND 99mTc-pyrophosphate imaging has emerged as an important non-invasive method to diagnose transthyretin cardiac amyloidosis (ATTR-CM). Quantitation of 99mTc-pyrophosphate activity, on SPECT images, could be a marker of ATTR-CM disease burden. We assessed the diagnostic accuracy and clinical significance of 99mTc-pyrophosphate quantitation. METHODS AND RESULTS Patients who underwent 99mTc-pyrophosphate imaging for suspected ATTR-CM were included. Using SPECT images, radiotracer activity in the myocardium was calculated using cardiac pyrophosphate activity (CPA) and volume of involvement (VOI), with thresholds for abnormal activity derived from LVBP activity. Diagnostic accuracy was assessed using area under the receiver operating characteristic curve (AUC). In total, 124 patients were identified, mean age 73.9 ± 11.4, with ATTR-CM diagnosed in 43 (34.7%) patients. CPA had the highest diagnostic accuracy (AUC .996, 95% CI .987-1.00), and was significantly higher compared to the Perugini score (AUC .952, P = .016). In patients with ATTR-CM, CPA was associated with reduced left ventricular ejection fraction (adjusted odds ratio 1.28, P = .035) and heart failure hospitalizations (adjusted hazard ratio 1.29, P = .006). CONCLUSION Quantitative assessment of myocardial radiotracer activity with CPA or VOI have high diagnostic accuracy for ATTR-CM. Both measures are potential non-invasive markers to follow progression of disease or response to therapy.
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Affiliation(s)
- Robert J H Miller
- Department of Cardiac Sciences, University of Calgary, GAA08, 3230 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada.
| | - Sebastien Cadet
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Darren Mah
- Department of Nuclear Medicine, University of Calgary, Calgary, AB, Canada
| | - Payam Pournazari
- Department of Cardiac Sciences, University of Calgary, GAA08, 3230 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada
| | - Denise Chan
- Department of Nuclear Medicine, University of Calgary, Calgary, AB, Canada
| | - Nowell M Fine
- Department of Cardiac Sciences, University of Calgary, GAA08, 3230 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada
| | - Daniel S Berman
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Piotr J Slomka
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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30
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Cho SG, Kim HY, Bom HS. What is the optimal cardiac screening for asymptomatic transthyretin gene mutation carriers? J Nucl Cardiol 2021; 28:1958-1960. [PMID: 31768901 DOI: 10.1007/s12350-019-01970-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 11/13/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Sang-Geon Cho
- Department of Nuclear Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Hyung Yoon Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Hee-Seung Bom
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital, 322, Seoyang-ro Hwasun-eup, Hwasun-gun, Jeonnam, 58128, Republic of Korea.
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31
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Ben-Haim S, Chicheportiche A, Goshen E, Arad M, Smekhov M, Menezes LJ, Elliott PM, O'Mahoney E, Stern E, Yuzefovich B, Bomanji JB. Quantitative SPECT/CT parameters of myocardial 99mTechnetium-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) uptake in suspected cardiac transthyretin amyloidosis. EJNMMI Res 2021; 11:86. [PMID: 34487268 PMCID: PMC8421473 DOI: 10.1186/s13550-021-00828-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/23/2021] [Indexed: 01/15/2023] Open
Abstract
Background 99mTc-labelled bisphosphonates are used for imaging assessment of patients with transthyretin cardiac amyloidosis (ATTR). Present study evaluates whether quantitative SPECT/CT measurement of absolute myocardial 99mTc-labelled 3,3-diphosphono-1,2-propanodicarboxylic acid (Tc-DPD) uptake can diagnose patients with suspected ATTR. Methods Twenty-eight patients (25 male, age 80.03 ± 6.99 years) with suspected ATTR referred for Tc-DPD imaging had planar and SPECT/CT imaging of the chest. Three operators independently obtained Tc-DPD myocardial SUVmax and SUVmean above threshold (SMaT) (20, 40 and 60% of SUVmax), using a semi-automated threshold segmentation method. Results were compared to visual grading (0–3) of cardiac uptake. Results Twenty-two patients (78%) had cardiac uptake (2 grade 1, 15 grade 2, 5 grade 3). SUVmax and SMaT segmentation thresholds enabled separating grades 2/3 from 0/1 with excellent inter- and intra-reader correlation. Cut-off values 6.0, 2.5, 3 and 4 for SUVmax, SMaT20,40,60, respectively, separated between grades 2/3 and 0 /1 with PPV and NPV of 100%. SMaT20,40,60(cardiac)/SUVmean (liver) and SMaT20,40,60(cardiac)/SUVmean(liver/lung) separated grades 2 and 3. Conclusion Quantitative SPECT/CT parameters of cardiac Tc-DPD uptake are robust, enabling separation of patients with grades 2 and 3 cardiac uptake from grades 0 and 1. Larger patient cohorts will determine the incremental value of SPECT/CT quantification for ATTR management.
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Affiliation(s)
- Simona Ben-Haim
- Hadassah Medical Center, Hebrew University, Jerusalem, Israel. .,NIHR Biomedical Research Centre, UCL Institute of Nuclear Medicine, London, UK.
| | | | - E Goshen
- Wolfson Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Arad
- Chaim Sheba Medical Center, Ramat Gan, Israel
| | - M Smekhov
- Chaim Sheba Medical Center, Ramat Gan, Israel
| | - L J Menezes
- NIHR Biomedical Research Centre, UCL Institute of Nuclear Medicine, London, UK
| | - P M Elliott
- NIHR Biomedical Research Centre, UCL Institute of Nuclear Medicine, London, UK
| | - E O'Mahoney
- NIHR Biomedical Research Centre, UCL Institute of Nuclear Medicine, London, UK
| | - E Stern
- GE Healthcare, Haifa, Israel
| | | | - J B Bomanji
- NIHR Biomedical Research Centre, UCL Institute of Nuclear Medicine, London, UK
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32
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Ionescu TM, Jalloul W, Stolniceanu CR, Iacob R, Grecu LP, Stătescu AM, Grierosu I, Guțu M, Gavrilescu A, Daniela C, Petriș A, Ciocoiu M, Ungureanu C, Ștefănescu C. Transthyretin cardiac amyloidosis: a review of the nuclear imaging findings with emphasis on the radiotracers mechanisms. Ann Nucl Med 2021; 35:967-993. [PMID: 34275068 DOI: 10.1007/s12149-021-01650-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 06/27/2021] [Indexed: 10/20/2022]
Abstract
Cardiac amyloidosis is a protein deposition disease characterized by the infiltration of the myocardium and coronary arteries resulting in a progressive thickening of both ventricles, interatrial septum and atrioventricular valves, eventually leading to organ failure. It is a disease hard to diagnose, due to the lack of diagnostic investigations. However, development of new and more accurate examinations is undergoing. Endomyocardial biopsy is the gold standard investigation for this disease, but it has its limitations (invasive and not widely available). Other investigations may be able to detect the presence of cardiac amyloidosis but cannot specify the type involved. To that end, nuclear medicine through bone scanning offers a simple, non-invasive solution to detect, differentiate and diagnose transthyretin cardiac amyloidosis (ATTR) from other types of cardiac amyloidosis. In order to demonstrate the importance of bone scanning we will present a few methods of image processing based on literature and a personalized method, followed by a few important examples of positive cases. The aim of this review was to present the current methods of ATTR detection with emphasis on nuclear medicine bone scanning and its important place in the decision algorithm of the cardiologist for a personalized approach to this pathology.
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Affiliation(s)
- Teodor M Ionescu
- Nuclear Medicine Laboratory, County Emergency Hospital "Sf. Spiridon", Iași, Romania.
- University of Medicine and Pharmacy U.M.F "Grigore T. Popa", Iași, Romania.
| | - Wael Jalloul
- Nuclear Medicine Laboratory, County Emergency Hospital "Sf. Spiridon", Iași, Romania
- University of Medicine and Pharmacy U.M.F "Grigore T. Popa", Iași, Romania
| | - Cati R Stolniceanu
- Nuclear Medicine Laboratory, County Emergency Hospital "Sf. Spiridon", Iași, Romania
- University of Medicine and Pharmacy U.M.F "Grigore T. Popa", Iași, Romania
| | - Roxana Iacob
- Nuclear Medicine Laboratory, County Emergency Hospital "Sf. Spiridon", Iași, Romania
- University of Medicine and Pharmacy U.M.F "Grigore T. Popa", Iași, Romania
| | - Laura P Grecu
- Nuclear Medicine Laboratory, County Emergency Hospital "Sf. Spiridon", Iași, Romania
| | - Ana-Maria Stătescu
- Nuclear Medicine Laboratory, County Emergency Hospital "Sf. Spiridon", Iași, Romania
| | - Irena Grierosu
- Nuclear Medicine Laboratory, County Emergency Hospital "Sf. Spiridon", Iași, Romania
- University of Medicine and Pharmacy U.M.F "Grigore T. Popa", Iași, Romania
| | - Mihai Guțu
- Nuclear Medicine Laboratory, County Emergency Hospital "Sf. Spiridon", Iași, Romania
- University of Medicine and Pharmacy U.M.F "Grigore T. Popa", Iași, Romania
| | - Adrian Gavrilescu
- Cardiology Department, County Emergency Hospital "Sf. Spiridon", Iași, Romania
| | - Crișu Daniela
- Cardiology Department, County Emergency Hospital "Sf. Spiridon", Iași, Romania
| | - Antoniu Petriș
- Cardiology Department, County Emergency Hospital "Sf. Spiridon", Iași, Romania
- University of Medicine and Pharmacy U.M.F "Grigore T. Popa", Iași, Romania
| | - Manuela Ciocoiu
- University of Medicine and Pharmacy U.M.F "Grigore T. Popa", Iași, Romania
| | - Cristina Ungureanu
- Endocrinology Department, County Emergency Hospital "Sf. Spiridon", Iași, Romania
| | - Cipriana Ștefănescu
- Nuclear Medicine Laboratory, County Emergency Hospital "Sf. Spiridon", Iași, Romania
- University of Medicine and Pharmacy U.M.F "Grigore T. Popa", Iași, Romania
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33
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Abe T, Olanipekun T, Khoury M, Egbuche O, Effoe V, Ghali J. Trends, Associations, and Impact of Atrial Fibrillation in Patients With Light-chain Cardiac Amyloidosis. Crit Pathw Cardiol 2021; 20:168-172. [PMID: 33606412 DOI: 10.1097/hpc.0000000000000257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In this study, we investigated the temporal trends in the prevalence and prognostic implication of atrial fibrillation (AF) in patient with light-chain cardiac amyloidosis (AL-CA). METHODS We identified 3030 patients with AL-CA from the 2015 to 2017 National Inpatient Sample, of which 1577 (52%) had AF. We used trend analysis to assess the temporal trends in the prevalence of AF by subtype from 2015 to 2017. We compared inhospital mortality, acute on chronic heart failure, stroke, length of stay (LOS), and total cost in patients with to those without AF, stratified by subtype of AF. RESULTS The prevalence of AF among patients with AL-CA was unchanged from 2015 to 2017 (50%-53%; adjusted odds ratio, 1.1 [0.9-1.5]; P = 0.3). The trend was unchanged in the stratified analysis by subtype of AF. Patients with AF were older and had more comorbidities. After propensity matching, acute on chronic heart failure was significantly higher in patients with AL-CA and AF, compared with those with AL-CA alone (55.6% vs. 48.3%; P < 0.0001). There was no difference in inhospital mortality (7.5% vs. 7.5%; P = 0.9), stroke (2.0% vs. 2.5%; P = 0.5), median LOS (5 [3-9] vs. 5 [3-8]; P = 0.3), and median total hospital cost $42,469 ([$21,309-$92,855] vs. $44,008 [$22,889-$94,200]; P = 0.6). In the stratified analysis, acute on chronic heart failure remained significant higher in patients with paroxysmal and nonparoxysmal AF, while LOS became significantly longer in patients with paroxysmal AF. CONCLUSIONS Among patients with AL-CA, AF is associated with a higher risk of acute on chronic heart failure.
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Affiliation(s)
- Temidayo Abe
- From the Internal Medicine Residency Program, Morehouse School of Medicine, Atlanta, GA
| | | | - Mtanis Khoury
- Department of Medicine, Mount Sinai Hospital, Chicago, IL
| | - Obiora Egbuche
- Department of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA
| | - Valery Effoe
- Department of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA
| | - Jalal Ghali
- Department of Medicine, Morehouse School of Medicine, Atlanta, GA
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Dorbala S, Ando Y, Bokhari S, Dispenzieri A, Falk RH, Ferrari VA, Fontana M, Gheysens O, Gillmore JD, Glaudemans AWJM, Hanna MA, Hazenberg BPC, Kristen AV, Kwong RY, Maurer MS, Merlini G, Miller EJ, Moon JC, Murthy VL, Quarta CC, Rapezzi C, Ruberg FL, Shah SJ, Slart RHJA, Verberne HJ, Bourque JM. ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 1 of 2-Evidence Base and Standardized Methods of Imaging. Circ Cardiovasc Imaging 2021; 14:e000029. [PMID: 34196223 DOI: 10.1161/hci.0000000000000029] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Sharmila Dorbala
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Sabahat Bokhari
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, NY
| | - Angela Dispenzieri
- Division of Hematology, Division of Cardiovascular Diseases, and Department of Radiology, Division of Nuclear Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Victor A Ferrari
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Olivier Gheysens
- Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Andor W J M Glaudemans
- Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mazen A Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Bouke P C Hazenberg
- Department of Rheumatology & Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Arnt V Kristen
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Raymond Y Kwong
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mathew S Maurer
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, NY
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Italy
| | - Edward J Miller
- Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - James C Moon
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | | | - C Cristina Quarta
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Claudio Rapezzi
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Bologna, Italy
| | - Frederick L Ruberg
- Amyloidosis Center and Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Sanjiv J Shah
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Riemer H J A Slart
- Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hein J Verberne
- Division of Hematology, Division of Cardiovascular Diseases, and Department of Radiology, Division of Nuclear Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Jamieson M Bourque
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Molecular Medicine, University of Pavia, Italy
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35
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Delaney FT, Dempsey P, Welaratne I, Buckley B, O'Sullivan D, O'Connell M. Incidental cardiac uptake in bone scintigraphy: increased importance and association with cardiac amyloidosis. BJR Case Rep 2021; 7:20200161. [PMID: 34131495 PMCID: PMC8171131 DOI: 10.1259/bjrcr.20200161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/01/2021] [Accepted: 01/08/2021] [Indexed: 11/05/2022] Open
Abstract
Extraosseous radiotracer uptake during bone scintigraphy must be carefully assessed and it offers the potential to detect previously undiagnosed disease processes. A range of neoplastic, metabolic, traumatic, ischaemic and inflammatory disorders can cause soft tissue accumulation of bone avid radiopharmaceuticals. Accordingly, cardiac uptake in bone scintigraphy has a broad differential diagnosis and is commonly attributed to ischaemia/infarction related to coronary artery disease. However, there has been renewed focus on incidental cardiac uptake in recent years in light of significant developments in the diagnosis and management of cardiac amyloidosis.
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Affiliation(s)
- Francis T Delaney
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Philip Dempsey
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ivan Welaratne
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Bryan Buckley
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Donagh O'Sullivan
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Martin O'Connell
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
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36
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Rezk T, Fontana M, Gillmore JD. A review of the criteria for non-invasive diagnosis of cardiac transthyretin amyloidosis. Expert Opin Orphan Drugs 2021. [DOI: 10.1080/21678707.2021.1898371] [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: 10/21/2022]
Affiliation(s)
- Tamer Rezk
- National Amyloidosis Centre, University College London, London, UK
- Departement of Nephrology, UCL Department of Nephrology, Division of Medicine, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, London, UK
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Gallini C, Tutino F, Martone R, Ciaccio A, Costanzo EN, Taborchi G, Morini S, Bartolini S, Farsetti S, Di Mario C, Perfetto F, Cappelli F. Semi-quantitative indices of cardiac uptake in patients with suspected cardiac amyloidosis undergoing 99mTc-HMDP scintigraphy. J Nucl Cardiol 2021; 28:90-99. [PMID: 30767162 DOI: 10.1007/s12350-019-01643-w] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/11/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND 99mTc-HMDP scintigraphy has proved its efficacy in non-invasive diagnosis of cardiac amyloidosis (CA) and is currently interpreted according to the Perugini qualitative assessment. Several semi-quantitative indices have been proposed to overcome inherent possible limitations of visual grading. Our aim was to comparatively evaluate six different indices and their diagnostic performance. METHODS We retrospectively reviewed scintigraphy of 76 patients (53 ATTR, 12 AL, 11 LVH) who underwent diagnostic evaluation at our centre. ROC-curve analysis was performed to identify optimal cut-off and relative diagnostic accuracy of six different indices (of which one was proposed for the first time), both in identifying CA patients and in discriminating patients according to their Perugini score. RESULTS Heart/Whole-body ratios proved to be the most accurate (100%) in identifying CA patients. Heart/Pelvis ratio (with soft tissue background correction) offered acceptable accuracy (98%), with the largest area under the curve (AUC) (0.98) in discriminating patients with Perugini ≥ 2. Heart/Contralateral Lung ratio confirmed to be exposed to confounding background noise in case of simultaneous lung uptake. Heart/Skull ratio had the worst performance, with six false-negative patients in ATTR identification. CONCLUSION Heart/Whole-body ratios may be robust and effective semi-quantitative indices for the evaluation of CA by means of scintigraphy.
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Affiliation(s)
- Chiara Gallini
- Nuclear Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Francesca Tutino
- Nuclear Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Raffaele Martone
- Cardiovascular and Thoracic Department, Careggi University Hospital, Florence, Italy
| | - Alfonso Ciaccio
- Nuclear Medicine Unit, Careggi University Hospital, Florence, Italy
| | | | - Giulia Taborchi
- Cardiovascular and Thoracic Department, Careggi University Hospital, Florence, Italy
| | - Sofia Morini
- Cardiovascular and Thoracic Department, Careggi University Hospital, Florence, Italy
| | - Simone Bartolini
- Cardiovascular and Thoracic Department, Careggi University Hospital, Florence, Italy
| | - Silvia Farsetti
- Tuscan Regional Amyloid Centre, Careggi University Hospital, Florence, Italy
| | - Carlo Di Mario
- Interventional Structural Cardiology Division, Department of Heart, Lung and Vessels, Careggi University Hospital, Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloid Centre, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloid Centre, Careggi University Hospital, Florence, Italy.
- Intensive Cardiac Care Unit, Interventional Structural Cardiology Division, Department of Heart, Lung and Vessels, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy.
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38
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Small GR, Ruddy TD. Straightening out the wrinkles in technetium-99m-labeled bone scintigraphy tracer assessment of cardiac amyloidosis. J Nucl Cardiol 2021; 28:100-103. [PMID: 30977095 DOI: 10.1007/s12350-019-01718-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/02/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Gary R Small
- Department of Cardiac Imaging, University of Ottawa Heart Institute, Ottawa, ON, K1Y 4W7, Canada
| | - Terrence D Ruddy
- Department of Cardiac Imaging, University of Ottawa Heart Institute, Ottawa, ON, K1Y 4W7, Canada.
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Yilmaz A, Bauersachs J, Bengel F, Büchel R, Kindermann I, Klingel K, Knebel F, Meder B, Morbach C, Nagel E, Schulze-Bahr E, Aus dem Siepen F, Frey N. Diagnosis and treatment of cardiac amyloidosis: position statement of the German Cardiac Society (DGK). Clin Res Cardiol 2021; 110:479-506. [PMID: 33459839 PMCID: PMC8055575 DOI: 10.1007/s00392-020-01799-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/21/2020] [Indexed: 12/15/2022]
Abstract
Systemic forms of amyloidosis affecting the heart are mostly light-chain (AL) and transthyretin (ATTR) amyloidoses. The latter is caused by deposition of misfolded transthyretin, either in wild-type (ATTRwt) or mutant (ATTRv) conformation. For diagnostics, specific serum biomarkers and modern non-invasive imaging techniques, such as cardiovascular magnetic resonance imaging (CMR) and scintigraphic methods, are available today. These imaging techniques do not only complement conventional echocardiography, but also allow for accurate assessment of the extent of cardiac involvement, in addition to diagnosing cardiac amyloidosis. Endomyocardial biopsy still plays a major role in the histopathological diagnosis and subtyping of cardiac amyloidosis. The main objective of the diagnostic algorithm outlined in this position statement is to detect cardiac amyloidosis as reliably and early as possible, to accurately determine its extent, and to reliably identify the underlying subtype of amyloidosis, thereby enabling subsequent targeted treatment.
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Affiliation(s)
- A Yilmaz
- Sektion für Herzbildgebung, Klinik für Kardiologie, Universitätsklinikum Münster, Von-Esmarch-Str. 48, 48149, Münster, Germany.
| | - J Bauersachs
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - F Bengel
- Klinik für Nuklearmedizin, Medizinische Hochschule Hannover, Hannover, Germany
| | - R Büchel
- Klinik für Nuklearmedizin, Universitätsspital Zürich, Zurich, Switzerland
| | - I Kindermann
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
| | - K Klingel
- Institut für Pathologie und Neuropathologie, Universität Tübingen, Tübingen, Germany
| | - F Knebel
- Medizinische Klinik m.S. Kardiologie und Angiologie, Charite Universitätsmedizin Berlin Campus Mitte, Berlin, Germany
| | - B Meder
- Klinik für Innere Medizin III, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - C Morbach
- Klinik für Innere Medizin III, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - E Nagel
- Interdisziplinäres Amyloidosezentrum Nordbayern, Deutsches Zentrum für Herzinsuffizienz, Medizinische Klinik I der Universität Würzburg, Würzburg, Germany
| | - E Schulze-Bahr
- Institut für Experimentelle und translationale kardiovaskuläre Bildgebung, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - F Aus dem Siepen
- Institut für Genetik von Herzerkrankungen (IfGH), Universitätsklinikum Münster, Münster, Germany
| | - N Frey
- Klinik für Innere Medizin III, Schwerpunkt Kardiologie und Angiologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany.,Kommission für Klinische Kardiovaskuläre Medizin, Deutsche Gesellschaft für Kardiologie, Düsseldorf, Germany
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40
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Paeng JC, Choi JY. Nuclear Imaging for Cardiac Amyloidosis: Bone Scan, SPECT/CT, and Amyloid-Targeting PET. Nucl Med Mol Imaging 2021; 55:61-70. [PMID: 33968272 DOI: 10.1007/s13139-020-00681-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 12/21/2020] [Accepted: 12/29/2020] [Indexed: 02/06/2023] Open
Abstract
Cardiac amyloidosis (CA) is a type of systemic amyloidosis, in which abnormal amyloid fibril is deposited in extracellular space of myocardium. Most common subtypes of CA are amyloidosis of immunoglobulin light chain (AL) and amyloidosis of transthyretin (ATTR). With increase in incidence of CA and development of new drugs, the needs of early and accurate diagnosis of CA are increasing. In CA, bone scan and SPECT/CT have long been used for diagnosis. Currently, bone scan is included in almost all practice guidelines as one of key diagnostic examinations for ATTR CA. In some specific scenarios, bone scan can be used as even a substitute for endomyocardial biopsy. Recently, amyloid-targeting PET that is used for Alzheimer dementia has also been attempted as an imaging method for CA. Although the study results are still insufficient, amyloid-targeting has shown promising potential as an imaging method for CA, particularly in AL. Here, imaging method and clinical application and implication of bone scan, SPECT/CT, and amyloid-targeting PET/CT in CA are reviewed.
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Affiliation(s)
- Jin Chul Paeng
- Department of Nuclear Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Joon Young Choi
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, 06351 Seoul, Republic of Korea
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41
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Grandis M, Obici L, Luigetti M, Briani C, Benedicenti F, Bisogni G, Canepa M, Cappelli F, Danesino C, Fabrizi GM, Fenu S, Ferrandes G, Gemelli C, Manganelli F, Mazzeo A, Melchiorri L, Perfetto F, Pradotto LG, Rimessi P, Tini G, Tozza S, Trevisan L, Pareyson D, Mandich P. Recommendations for pre-symptomatic genetic testing for hereditary transthyretin amyloidosis in the era of effective therapy: a multicenter Italian consensus. Orphanet J Rare Dis 2020; 15:348. [PMID: 33317601 PMCID: PMC7734774 DOI: 10.1186/s13023-020-01633-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 11/27/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary transthyretin amyloidosis (ATTRv, v for variant) is a late-onset, autosomal dominant disease caused by progressive extracellular deposition of transthyretin amyloid fibrils, leading to organ damage and death. For other late-onset fatal diseases, as Huntington’s disease, protocols for pre-symptomatic genetic testing (PST) are available since decades. For ATTRv, limited experience has been reported to date, mostly gathered before the availability of approved therapies. We aimed at developing recommendations for a safe and feasible PST protocol in ATTRv in the era of emerging treatments, taking also into account Italian patients’ characteristics and healthcare system rules. After an initial survey on ongoing approaches to PST for ATTRv in Italy, two roundtable meetings were attended by 24 experts from 16 Italian centers involved in the diagnosis and care of this disease. Minimal requirements for PST offer and potential critical issues were highlighted. By November 2019, 457 families affected by ATTRv with 209 molecularly confirmed pre-symptomatic carriers were counted. The median age at PST was 41.3 years of age, regardless of the specific mutation. Half of the Italian centers had a multidisciplinary team, including a neurologist, an internist, a cardiologist, a medical geneticist and a psychologist, although in most cases not all the specialists were available in the same center. A variable number of visits was performed at each site. Experts agreed that PST should be offered only in the context of genetic counselling to at risk individuals aged 18 or older. Advertised commercial options for DNA testing should be avoided. The protocol should consist of several steps, including a preliminary clinical examination, a pre-test information session, an interval time, the genetic test and a post-test session with the disclosure of the test results, in the context of an experienced multidisciplinary team. Recommendations for best timing were also defined. Protocols for PST in the context of ATTRv can be refined to offer at risk individuals the best chance for early diagnosis and timely treatment start, while respecting autonomous decisions and promoting safe psychological adjustment to the genetic result.
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Affiliation(s)
- M Grandis
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), Section of Medical Genetics, University of Genoa, c/o DIMI Viale Benedetto XV, 6, 16132, Genova, Italy.,IRCCS Policlinico San Martino, Genova, Italy
| | - L Obici
- Amyloidosis Research and Treatment Center, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - M Luigetti
- UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - C Briani
- Department of Neuroscience, University of Padova, Padova, Italy
| | - F Benedicenti
- Medical Genetics, Azienda Sanitaria Dell'Alto Adige, Bolzano, Italy
| | - G Bisogni
- Centro Clinico Nemo Adulti-Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - M Canepa
- Cardiovascular Disease Unit, IRCCS Policlinico San Martino, Genova, and IRCCS Italian Cardiovascular Network, Department of Internal Medicine, University of Genova, Genova, Italy
| | - F Cappelli
- Tuscan Regional Amyloidosis Center, Careggi University Hospital, Firenze, Italy
| | - C Danesino
- Molecular Medicine Department, University of Pavia, Pavia, Italy
| | - G M Fabrizi
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Neurology, University of Verona and University Hospital GB Rossi, Verona, Italy
| | - S Fenu
- Unit of Rare Neurodegenerative and Neurometabolic Diseases, Department of Clinical Neurosciences, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - G Ferrandes
- IRCCS Policlinico San Martino, Genova, Italy
| | - C Gemelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), Section of Medical Genetics, University of Genoa, c/o DIMI Viale Benedetto XV, 6, 16132, Genova, Italy.,Neuromuscular Omnicentre (NEMO)-Fondazione Serena Onlus, Arenzano, GE, Italy
| | - F Manganelli
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Napoli, Italy
| | - A Mazzeo
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - L Melchiorri
- Medical Genetics Unit, Azienda Ospedaliero Universitaria Di Ferrara, Ferrara, Italy
| | - F Perfetto
- Tuscan Regional Amyloidosis Center, Careggi University Hospital, Firenze, Italy
| | - L G Pradotto
- Department of Neurosciences, University of Turin, Torino, Italy.,Division of Neurology and Neurorehabilitazion, IRCCS Istituto Auxologico Italiano, Piancavallo, VB, Italy
| | - P Rimessi
- Medical Genetics Unit, Azienda Ospedaliero Universitaria Di Ferrara, Ferrara, Italy
| | - G Tini
- Cardiovascular Disease Unit, IRCCS Policlinico San Martino, Genova, and IRCCS Italian Cardiovascular Network, Department of Internal Medicine, University of Genova, Genova, Italy
| | - S Tozza
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Napoli, Italy
| | - L Trevisan
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), Section of Medical Genetics, University of Genoa, c/o DIMI Viale Benedetto XV, 6, 16132, Genova, Italy.,IRCCS Policlinico San Martino, Genova, Italy
| | - D Pareyson
- Unit of Rare Neurodegenerative and Neurometabolic Diseases, Department of Clinical Neurosciences, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - P Mandich
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), Section of Medical Genetics, University of Genoa, c/o DIMI Viale Benedetto XV, 6, 16132, Genova, Italy. .,IRCCS Policlinico San Martino, Genova, Italy.
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42
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Spencer-Bonilla G, Alexander KM, Witteles RM. Advances in the Diagnosis and Management of Transthyretin Amyloid Cardiomyopathy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00844-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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43
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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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44
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Jonker DL, Hazenberg BPC, Nienhuis HLA, Slart RHJA, Glaudemans AWJM, Noordzij W. Imaging cardiac innervation in hereditary transthyretin (ATTRm) amyloidosis: A marker for neuropathy or cardiomyopathy in case of heart failure? J Nucl Cardiol 2020; 27:1774-1784. [PMID: 30374850 PMCID: PMC7599160 DOI: 10.1007/s12350-018-01477-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/01/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Nuclear imaging modalities using 123Iodine-metaiodobenzylguanidine (123I-MIBG) and bone seeking tracers identify early cardiac involvement in ATTRm amyloidosis patients. However, little is known whether results from 123I-MIBG scintigraphy actually correlate to markers for either cardiac autonomic neuropathy or cardiomyopathy. METHODS All TTR mutation carriers and ATTRm patients who underwent both 123I-MIBG and 99mTechnetium-hydroxymethylene diphosphonate (99mTc-HDP) scintigraphy were included. Cardiomyopathy was defined as NT-proBNP > 365 ng/L, and cardiac autonomic neuropathy as abnormal cardiovascular reflexes at autonomic function tests. Late 123I-MIBG heart-to-mediastinum ratio (HMR) < 2.0 or wash-out > 20%, and any cardiac 99mTc-HDP uptake were considered as abnormal. RESULTS 39 patients (13 carriers and 26 ATTRm patients) were included in this study. Patients with cardiomyopathy, with or without cardiac autonomic neuropathy, had lower late HMR than similar patients without cardiomyopathy [median 1.1 (range 1.0-1.5) and 1.5(1.2-2.6) vs 2.4 (1.4-3.8) and 2.5 (1.5-3.7), respectively, P < 0.001]. Late HMR and wash-out (inversely) correlated with NT-proBNP r = - 0.652 (P < 0.001) and r = 0.756 (P < 0.001), respectively. Furthermore, late HMR and wash-out (inversely) correlated with cardiac 99mTc-HDP uptake r = - 0.663 (P < 0.001) and r = 0.617 (P < 0.001), respectively. CONCLUSION In case of heart failure, 123I-MIBG scintigraphy reflects cardiomyopathy rather than cardiac autonomic neuropathy in ATTRm patients and TTR mutation carriers. 123I-MIBG scintigraphy may already be abnormal before any cardiac bone tracer uptake is visible.
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Affiliation(s)
- Daphne L. Jonker
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bouke P. C. Hazenberg
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hans L. A. Nienhuis
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Riemer H. J. A. Slart
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Biomedical Photonic Imaging, University of Twente, Enschede, The Netherlands
| | - Andor W. J. M. Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Walter Noordzij
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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45
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Klaassen SH, van Veldhuisen DJ, Nienhuis HLA, van den Berg MP, Hazenberg BP, van der Meer P. Cardiac Transthyretin-derived Amyloidosis: An Emerging Target in Heart Failure with Preserved Ejection Fraction? Card Fail Rev 2020; 6:e21. [PMID: 32944291 PMCID: PMC7479537 DOI: 10.15420/cfr.2019.16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/29/2020] [Indexed: 01/08/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) comprises half of the heart failure population. A specific, but underdiagnosed, cause for HFpEF is transthyretin-derived (ATTR) amyloidosis. This article reviews the clinical characteristics of cardiac ATTR amyloidosis. The clinical suspicion of cardiac ATTR amyloidosis is strong if pronounced left ventricular hypertrophy is present in the absence of hypertension. Scintigraphy with a diphosphonate tracer is a diagnostic tool for the early detection of cardiac ATTR amyloidosis with high sensitivity and specificity. First treatment options for ATTR amyloidosis recently emerged, and showed a reduction in morbidity and mortality, especially if treatment was started in the early stages of disease. In light of these results, screening for ATTR amyloidosis in the general HFpEF population with left ventricular hypertrophy might be useful.
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Affiliation(s)
- Sebastiaan Hc Klaassen
- Department of Cardiology, University of Groningen, University Medical Center Groningen Groningen, the Netherlands.,Amyloidosis Centre of Expertise, University of Groningen, University Medical Center Groningen Groningen, the Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen Groningen, the Netherlands.,Amyloidosis Centre of Expertise, University of Groningen, University Medical Center Groningen Groningen, the Netherlands
| | - Hans LA Nienhuis
- Department of Internal Medicine, Division of Vascular Medicine, University of Groningen, University Medical Center Groningen Groningen, the Netherlands.,Amyloidosis Centre of Expertise, University of Groningen, University Medical Center Groningen Groningen, the Netherlands
| | - Maarten P van den Berg
- Department of Cardiology, University of Groningen, University Medical Center Groningen Groningen, the Netherlands.,Amyloidosis Centre of Expertise, University of Groningen, University Medical Center Groningen Groningen, the Netherlands
| | - Bouke Pc Hazenberg
- Amyloidosis Centre of Expertise, University of Groningen, University Medical Center Groningen Groningen, the Netherlands
| | - Peter van der Meer
- Department of Cardiology, University of Groningen, University Medical Center Groningen Groningen, the Netherlands.,Amyloidosis Centre of Expertise, University of Groningen, University Medical Center Groningen Groningen, the Netherlands
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46
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Khor YM, Cuddy S, Falk RH, Dorbala S. Multimodality Imaging in the Evaluation and Management of Cardiac Amyloidosis. Semin Nucl Med 2020; 50:295-310. [PMID: 32540027 PMCID: PMC9440475 DOI: 10.1053/j.semnuclmed.2020.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Systemic amyloidosis is a heterogeneous group of disorders where misfolded proteins deposit in the various organs as nonbranching fibrils with a β-pleated-sheet structure called amyloid. Extensive extracellular deposition of these amyloid fibrils eventually leads to organ dysfunction. Involvement of the heart, termed as cardiac amyloidosis, leads to heart failure if left untreated and carries high morbidity and mortality. Current interest in cardiac amyloidosis is growing rapidly thanks to the recent development of effective targeted treatment options, driving the need for better and earlier detection of the condition, which is largely underdiagnosed and far commoner than recognized. Timely diagnosis of cardiac amyloidosis is challenging, but is poised to improve with emergence of newer noninvasive imaging techniques, potentially obviating the need for endomyocardial biopsy in some patients and providing prognostic information. With recent advances in the therapeutic options for cardiac amyloidosis, an area of immense interest is the adoption of imaging as biomarkers for longitudinal assessment of disease progression and treatment response. In this article, we provide an overview of cardiac amyloidosis, discuss the role of imaging modalities in cardiac amyloidosis, and explore future directions for imaging in cardiac amyloidosis.
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Affiliation(s)
- Yiu Ming Khor
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore, Singapore
| | - Sarah Cuddy
- CV imaging program, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Sharmila Dorbala
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA.
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47
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Vita GL, Aguennouz M, Polito F, Oteri R, Russo M, Gentile L, Barbagallo C, Ragusa M, Rodolico C, Di Giorgio RM, Toscano A, Vita G, Mazzeo A. Circulating microRNAs Profile in Patients With Transthyretin Variant Amyloidosis. Front Mol Neurosci 2020; 13:102. [PMID: 32655365 PMCID: PMC7325132 DOI: 10.3389/fnmol.2020.00102] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 05/12/2020] [Indexed: 12/11/2022] Open
Abstract
Transthyretin variant amyloidosis (ATTRv) is a rare autosomal dominant disease characterized by the accumulation of amyloid in many organs, mostly causing a sensory-motor neuropathy, cardiomyopathy, and dysautonomia. The aim of the study was to report microRNAs (miRNAs) expression profile identified in the blood of ATTRv patients. Ten ATTRv patients, 10 asymptomatic carriers of transthyretin variant (TTRv), 10 patients with Charcot-Marie-Tooth (CMT) disease, and 10 healthy controls were studied. Human Schwann cells cultures were used to study the regulatory effects of miR-150-5p on the expression of cAMP response element-binding protein (CREB), brain-derived neurotrophic factor (BDNF), and nerve growth factor (NGF). ATTRv patients had 33 miRNAs up-regulated and 48 down-regulated versus healthy controls; 9 miRNAs were up-regulated and 30 down-regulated versus CMT patients; 19 miRNAs were up-regulated and 38 down-regulated versus asymptomatic TTRv carriers. Twelve out of the 19 upregulated miRNAs had a fold increase higher than 100. The validation experiment indicated miR-150-5p as a valuable biomarker to differentiate ATTRv patients from asymptomatic TTRv carriers (AUC: 0.9728; p < 0.0001). Schwann cells culture model demonstrated that miR-150-5p is a powerful negative regulator of CREB, BDNF, and NGF genes. Identification of deregulated miRNAs can help in understanding the complex pathomechamism underlying the development of ATTRv and related multisystemic pathology. Further investigations are needed on the role of circulating miR-150-5p to predict the shift of TTRv carriers from an asymptomatic status to symptoms appearance.
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Affiliation(s)
- Gian Luca Vita
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina, Italy
| | - M'Hammed Aguennouz
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.,Mohammed VI University of Health Sciences, Casablanca, Morocco
| | - Francesca Polito
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Rosaria Oteri
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Massimo Russo
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Luca Gentile
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Cristina Barbagallo
- Molecular, Genome and Complex Systems BioMedicine Unit, Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Marco Ragusa
- Molecular, Genome and Complex Systems BioMedicine Unit, Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy.,Oasi Research Institute IRCCS, Troina, Italy
| | - Carmelo Rodolico
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Rosa Maria Di Giorgio
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonio Toscano
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe Vita
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina, Italy.,Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Anna Mazzeo
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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48
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Abe T, Chang EY, De Allie G, Ajose T, Nwokike C, Bakinde N. Rapid decline in ejection fraction and persistent elevation of troponin associated with cardiac amyloidosis. SAGE Open Med Case Rep 2020; 8:2050313X20923259. [PMID: 32547758 PMCID: PMC7249551 DOI: 10.1177/2050313x20923259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 04/05/2020] [Indexed: 01/15/2023] Open
Abstract
Cardiac amyloidosis is an increasingly recognized cause of heart failure. It remains underdiagnosed despite a significant morbidity and mortality rate. The mean survival in patients with cardiac amyloidosis is less than 1 year in untreated primary light-chain amyloidosis and less than 4 years in wild-type transthyretin amyloidosis. We report a unique case of a 78-year-old male with transthyretin cardiac amyloidosis, who presented with persistently elevated troponin and progressive heart failure unresponsive to conventional therapy. With this case, we would like to highlight the role of cardiac biomarkers in the early diagnosis of cardiac amyloidosis.
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Affiliation(s)
| | | | | | - Taiwo Ajose
- Morehouse School of Medicine, Atlanta, GA, USA
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49
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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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50
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Rigopoulos AG, Ali M, Abate E, Torky AR, Matiakis M, Mammadov M, Melnyk H, Vogt A, de Vecchis R, Bigalke B, Wohlgemuth W, Mavrogeni S, Noutsias M. Advances in the diagnosis and treatment of transthyretin amyloidosis with cardiac involvement. Heart Fail Rev 2020; 24:521-533. [PMID: 30790171 DOI: 10.1007/s10741-019-09776-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Amyloidosis is caused by extracellular deposition of insoluble abnormal fibrils constituted by misfolded proteins, which can modify tissue anatomy and hinder the function of multiple organs including the heart. Amyloidosis that can affect the heart includes mostly systemic amyloidosis (amyloid light chain, AL) and transthyretin amyloidosis (ATTR). The latter can be acquired in elderly patients (ATTRwt), or be inherited in younger individuals (ATTRm). The diagnosis is demanding given the high phenotypic heterogeneity of the disease. Therefore, "red flags," which are suggestive features giving support to diagnostic suspicion, are extremely valuable. However, the lack of broad awareness among clinicians represents a major obstacle for early diagnosis and treatment of ATTR. Furthermore, recent implementation of noninvasive diagnostic techniques has revisited the need for endomyocardial biopsy (EMB). In fact, unlike AL amyloidosis, which requires tissue confirmation and typing for diagnosis, ATTR can now be diagnosed noninvasively with the combination of bone scintigraphy and the absence of a monoclonal protein. Securing the correct diagnosis is pivotal for the newly available therapeutic options targeting both ATTRm and ATTRwt, and are directed to either stabilization of the abnormal protein or the reduction of the production of transthyretin. The purpose of this article is to review the contemporary aspects of diagnosis and management of transthyretin amyloidosis with cardiac involvement, summarizing also the recent therapeutic advances with tafamidis, patisiran, and inotersen.
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Affiliation(s)
- Angelos G Rigopoulos
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Muhammad Ali
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Elena Abate
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Abdel-Rahman Torky
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Marios Matiakis
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Mammad Mammadov
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Hannes Melnyk
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Alexander Vogt
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Renato de Vecchis
- Preventive Cardiology and Rehabilitation Unit, DSB 29, S. Gennaro dei Poveri Hospital, 80136, Naples, Italy
| | - Boris Bigalke
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, D-12200, Berlin, Germany
| | - Walter Wohlgemuth
- Department of Radiology, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Sophie Mavrogeni
- Onassis Cardiac Surgery Center, 50 Esperou Street, 175-61, Palaeo Faliro, Athens, Greece
| | - Michel Noutsias
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany.
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