Catastrophic cardiac amyloidosis

Need for Early Recognition of Amyloidosis in Cases of Unexplained Heart Failure: A Case Report

Amyloidosis is a plasma cell dyscrasia that leads to the excessive production and deposition of mutant protein fragments in various organs. Cardiac amyloidosis is often implicated in two main subtypes: transthyretin (ATTR) and light chain (AL). While both subtypes increase the risk of restrictive cardiomyopathy, cardiogenic shock, and arrhythmias, poorer outcomes are seen in those with cardiac infiltration secondary to AL amyloidosis. Prognosis depends on the timing of diagnosis and the extent of the disease burden prior to recognition and treatment. The following case report describes a young patient who was admitted to the intensive care unit (ICU) for concerns of decompensated heart failure of unknown etiology, later determined to be due to amyloidosis. We describe her clinical course prior to and during hospital admission, along with the proposed physiologic factors that may have contributed to her poor outcome.

Predictors of survival to orthotopic heart transplant in patients with light chain amyloidosis

BACKGROUND

Orthotopic heart transplant (OHT), followed by myeloablative chemotherapy and autologous stem cell transplant (ASCT), has been successful in the treatment of amyloid light-chain (AL) cardiac amyloidosis. The purpose of this study was to identify predictors of survival to OHT in patients with end-stage heart failure due to AL amyloidosis and compare post-OHT survival of cardiac amyloid patients with survival of other cardiomyopathy patients undergoing OHT.

METHODS

From January 2000 to June 2011, 31 patients with end-stage heart failure secondary to AL amyloidosis were listed for OHT at Massachusetts General Hospital. Univariate and multivariate regression analyses identified predictors of survival to OHT. Kaplan-Meier analysis compared survival between the Massachusetts General Hospital amyloidosis patients and non-amyloid cardiomyopathy patients from the Scientific Registry of Transplant Recipients (SRTR).

RESULTS

Low body mass index was the only predictor of survival to OHT in patients with end-stage heart failure caused by cardiac amyloidosis. Survival of cardiac amyloid patients who died before receiving a donor heart was only 63 ± 45 days after listing. Patients who survived to OHT received a donor organ at 53 ± 48 days after listing. Survival of AL amyloidosis patients on the waiting list was less than patients on the waiting list for all other non-amyloid diagnoses. The long-term survival of amyloid patients who underwent OHT was no different than the survival of non-amyloid, restrictive (p = 0.34), non-amyloid dilated (p = 0.34), or all non-amyloid cardiomyopathy patients (p = 0.22) in the SRTR database.

CONCLUSIONS

Amyloid patients who survive to OHT, followed by ASCT, have a survival rate similar to other cardiomyopathy patients undergoing OHT; however, 35% of the patients died awaiting OHT. The only predictor of survival to OHT in AL amyloidosis patients was a low body mass index, which correlated with a shorter time on the waiting list. To optimize the survival of these patients, access to donor organs must be improved.