1
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Antonelli J, Neveu A, Kosmala W, L'Official G, Curtis E, Oger E, Donal E. Evolution and prognostic value of left ventricular deformation and myocardial work parameters in transthyretin amyloid cardiomyopathy. Eur Heart J Cardiovasc Imaging 2024; 25:469-479. [PMID: 37988605 DOI: 10.1093/ehjci/jead318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 10/08/2023] [Accepted: 11/13/2023] [Indexed: 11/23/2023] Open
Abstract
AIMS Wild-type transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly recognized condition. It remains challenging to estimate the extent of disease and the prognosis for most patients. Myocardial work is a sensitive echocardiographic approach that improves the characterization of myocardial damage. We investigate the parameters of myocardial deformation and work in ATTR-CM patients and their changes over time. METHODS AND RESULTS We analysed clinical, electrocardiographic, biological, and echocardiographic characteristics in 113 patients [median age 82 (77-85), 90.4% male] diagnosed with wild-type ATTR-CM based on international consensus at a single centre. We compared the data at baseline and 18-month follow-up. Thirty-four patients died and 12 were hospitalized for heart failure at a median follow-up of 935 days (interquartile range 691-1159 days). Left ventricular end-diastolic diameter, left atrial strain during reservoir phase (LASRES), left ventricular longitudinal strain, global work index (GWI), global constructive work significantly decreased from baseline to 18 months, while left ventricular wall thickness increased. Left ventricular ejection fraction, right ventricular free wall strain (FWS), global wasted work (GWW), and global work efficiency did not alter significantly. Strain parameters were identified as prognostic on baseline evaluation using a multivariate analysis: GWI, GWW, FWS, and LASRES. They were significantly associated with the risk of death and hospitalization for heart failure. CONCLUSION Multi-chamber strain assessment may improve the surveillance of patients with ATTR-CM, and myocardial work parameters may improve clinical risk stratification in this population.
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Affiliation(s)
- Jerome Antonelli
- Cardiologie, CHU de RENNES, LTSI UMR1099, INSERM, Université de Rennes-1, Rennes, France
| | - Antoine Neveu
- Cardiologie, CHU de RENNES, LTSI UMR1099, INSERM, Université de Rennes-1, Rennes, France
| | | | - Guillaume L'Official
- Cardiologie, CHU de RENNES, LTSI UMR1099, INSERM, Université de Rennes-1, Rennes, France
| | - Elizabeth Curtis
- Cardiologie, CHU de RENNES, LTSI UMR1099, INSERM, Université de Rennes-1, Rennes, France
| | - Emmanuel Oger
- EA Reperes, CHU Rennes, University Rennes, Rennes, France
| | - Erwan Donal
- Cardiologie, CHU de RENNES, LTSI UMR1099, INSERM, Université de Rennes-1, Rennes, France
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2
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Orlov FI, Ansheles AA, Nasonova SN, Saidova MA, Zhirov IV, Stepanova EA, Suvorina MY, Shoshina AA, Tereshchenko SN, Sergienko VB. [Difficulties in differential diagnosis of the AL- and ATTR-cardiac amyloidosis. Case report]. TERAPEVT ARKH 2023; 95:789-795. [PMID: 38158923 DOI: 10.26442/00403660.2023.09.202376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Indexed: 01/03/2024]
Abstract
The article presents a clinical case describing a complex differential diagnosis of cardiac amyloidosis types and verification of the diagnosis of AL-amyloidosis.
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Affiliation(s)
- F I Orlov
- Chazov National Medical Research Center of Cardiology
| | - A A Ansheles
- Chazov National Medical Research Center of Cardiology
| | - S N Nasonova
- Chazov National Medical Research Center of Cardiology
| | - M A Saidova
- Chazov National Medical Research Center of Cardiology
| | - I V Zhirov
- Chazov National Medical Research Center of Cardiology
- Russian Medical Academy of Continuous Professional Education
| | - E A Stepanova
- Russian Medical Academy of Continuous Professional Education
| | | | - A A Shoshina
- Chazov National Medical Research Center of Cardiology
| | | | - V B Sergienko
- Chazov National Medical Research Center of Cardiology
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3
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Stern LK, Ivey PA, Lum CJ, Zaidi S, Luthringer D, Velleca A, Kobashigawa JA, Patel JK, Kittleson MM. Wild-Type Transthyretin Cardiac Amyloidosis in a Transplanted Heart. JACC Case Rep 2023; 19:101935. [PMID: 37593594 PMCID: PMC10429282 DOI: 10.1016/j.jaccas.2023.101935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/25/2023] [Indexed: 08/19/2023]
Abstract
Wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM) is more prevalent than appreciated in the elderly. We present the case of an 88-year-old woman who underwent heart transplantation for ischemic cardiomyopathy and then presented 21 years later with new onset atrial flutter, found on endomyocardial biopsy to have new ATTRwt-CM. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Lily K. Stern
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Pamela A. Ivey
- Department of Cardiology, Intermountain Healthcare, Las Vegas, Nevada, USA
| | - Corey J. Lum
- Department of Cardiology, Intermountain Healthcare, Las Vegas, Nevada, USA
| | - Shayaan Zaidi
- Department of Cardiology, Intermountain Healthcare, Las Vegas, Nevada, USA
| | - Daniel Luthringer
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Angela Velleca
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jon A. Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jignesh K. Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michelle M. Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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4
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Dzhioeva ON. [Functional methods of amyloid cardiomyopathy diagnostic in practice and in expert centers: A review]. TERAPEVT ARKH 2023; 95:96-102. [PMID: 37167121 DOI: 10.26442/00403660.2023.01.202081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 02/24/2023] [Indexed: 05/13/2023]
Abstract
The article is a set of recommendations for the interpretation of electrocardiography and echocardiography data in patients with suspected amyloidosis of the heart. Amyloid cardiomyopathy is a progressive disease characterized by a detailed picture of congestive heart failure, poor quality of life and poor prognosis. Currently, medications have appeared that can improve the prognosis in patients with amyloidosis of the heart. Therefore, raising awareness of specialists about specific instrumental signs of the disease is an important and urgent task.
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Affiliation(s)
- O N Dzhioeva
- National Research Center for Therapy and Preventive Medicine
- Yevdokimov Moscow State University of Medicine and Dentistry
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5
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Novosad O, Rudiuk T, Shevchuk L, Kundina V, Schmidt A. Outcome of clinical experience of introducing a patient with secondary systemic AL amyloidosis associated with multiple myeloma. Carcinogenesis 2023; 44:46-53. [PMID: 36661216 DOI: 10.1093/carcin/bgad004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 12/15/2022] [Accepted: 01/18/2023] [Indexed: 01/21/2023] Open
Abstract
This research is relevant, as AL-amyloidosis refers to a systemic type of disease characterised by aggregation of an improperly folded light chain of immunoglobulin, mainly in the heart and kidneys, causing organ failure. This study describes the clinical experience of introducing a patient with cardiac amyloidosis associated with multiple myeloma. A clinical case of a patient diagnosed with amyloidosis was considered. MRI signs of cardiac amyloidosis were confirmed due to the presence of concentric biventricular hypertrophy without dilation, atrial septal hypertrophy, a tendency to atrial dilation, thickening of valve flaps and atrial walls. Upon admission to the research institute, the patient had an anasarca. More accurate recognition of AL-amyloidosis by cardiologists allows prescribing earlier treatment and improving results. Conventional treatment of multiple myeloma and AL-amyloidosis includes a combination of dexamethasone with bortezomib and endoxan. Hematopoietic stem cell transplantation after taking high doses of melphalan has become another treatment option and has led to remission in some patients. The novelty of the study is that an example of a timely complete diagnosis and treatment of a combination of these two diseases was presented, as a result of which the patient has achieved a complete haematological and partial organ response to the underlying disease.
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Affiliation(s)
- Olga Novosad
- Department of Oncohematology, National Cancer Institute, Kyiv, Ukraine
| | - Tymur Rudiuk
- Department of Clinical Oncology, Bogomolets National Medical University, Kyiv, Ukraine
| | - Lesya Shevchuk
- Department of Radiology Diagnostics with X-ray Rooms, National Cancer Institute, Kyiv, Ukraine
| | - Viktoriia Kundina
- Department of Radiology, Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine
| | - Anna Schmidt
- Department of Pathology of the Myocardium and Transplant, Heart Institute of the Ministry of Health of Ukraine, Kyiv, Ukraine
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6
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Nuvolone M, Girelli M, Merlini G. Oral Therapy for the Treatment of Transthyretin-Related Amyloid Cardiomyopathy. Int J Mol Sci 2022; 23. [PMID: 36555787 DOI: 10.3390/ijms232416145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
The care of systemic amyloidosis has improved dramatically due to improved awareness, accurate diagnostic tools, the development of powerful prognostic and companion biomarkers, and a continuous flow of innovative drugs, which translated into the blooming of phase 2/3 interventional studies for light chain (AL) and transthyretin (ATTR) amyloidosis. The unprecedented availability of effective drugs ignited great interest across various medical specialties, particularly among cardiologists who are now recognizing cardiac amyloidosis at an extraordinary pace. In all amyloidosis referral centers, we are observing a substantial increase in the prevalence of wild-type transthyretin (ATTRwt) cardiomyopathy, which is now becoming the most common form of cardiac amyloidosis. This review focuses on the oral drugs that have been recently introduced for the treatment of ATTR cardiac amyloidosis, for their ease of use in the clinic. They include both old repurposed drugs or fit-for-purpose designed compounds which bind and stabilize the TTR tetramer, thus reducing the formation of new amyloid fibrils, such as tafamidis, diflunisal, and acoramidis, as well as fibril disruptors which have the potential to promote the clearance of amyloid deposits, such as doxycycline. The development of novel therapies is based on the advances in the understanding of the molecular events underlying amyloid cardiomyopathy.
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7
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Merlo M, Pagura L, Porcari A, Cameli M, Vergaro G, Musumeci B, Biagini E, Canepa M, Crotti L, Imazio M, Forleo C, Cappelli F, Perfetto F, Favale S, Di Bella G, Dore F, Girardi F, Tomasoni D, Pavasini R, Rella V, Palmiero G, Caiazza M, Carella MC, Igoren Guaricci A, Branzi G, Caponetti AG, Saturi G, La Malfa G, Merlo AC, Andreis A, Bruno F, Longo F, Rossi M, Varrà GG, Saro R, Di Ienno L, De Carli G, Giacomin E, Arzilli C, Limongelli G, Autore C, Olivotto I, Badano L, Parati G, Perlini S, Metra M, Michele E, Rapezzi C, Sinagra G. Unmasking the Prevalence of Amyloid Cardiomyopathy in the Real World: Results from Phase 2 of AC-TIVE Study, an Italian Nationwide Survey. Eur J Heart Fail 2022; 24:1377-1386. [PMID: 35417089 DOI: 10.1002/ejhf.2504] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/09/2022] [Accepted: 04/10/2022] [Indexed: 11/07/2022] Open
Abstract
AIM To investigate the prevalence of amyloid cardiomyopathy (AC) and the diagnostic accuracy of echocardiographic red flags of AC among consecutive adult patients undergoing transthoracic echocardiogram for reason other than AC in 13 Italian institutions. METHODS AND RESULTS This is an Italian prospective multicentric study, involving a clinical and instrumental work-up to assess AC prevalence among patients ≥ 55 years old with an "AC suggestive" echocardiogram (i.e. at least one echocardiographic red flag of AC in hypertrophic, non-dilated left ventricles with preserved ejection fraction). The study was registered at ClinicalTrials.gov (#NCT04738266). 381 patients with an "AC suggestive" echocardiogram were identified among a cohort of 5315 screened subjects. 217 patients completed the investigations. A final diagnosis of AC was made in 62 patients with an estimated prevalence of 29% (95% CI: 23%-35%). Transthyretin-related AC (ATTR-AC) was diagnosed in 51 and light chain related AC (AL-AC) in 11 patients. Either apical sparing or a combination of ≥ 2 other echocardiographic red flags, excluding interatrial septum thickness, provided a diagnostic accuracy > 70%. CONCLUSION In a cohort of consecutive adults with echocardiographic findings suggestive of AC and preserved LVEF, the prevalence of AC (either ATTR or AL) was 29%. Easily available echocardiographic red flags, when combined together, demonstrated good diagnostic accuracy.
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Affiliation(s)
- Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Linda Pagura
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Giuseppe Vergaro
- Istituto di Scienze della Vita, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Beatrice Musumeci
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Elena Biagini
- Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Canepa
- Department of Internal Medicine, University of Genoa, Genoa, Italy.,Cardiovascular Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Lia Crotti
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Massimo Imazio
- University Cardiology A.O.U. , Città della Salute e della Scienza di Torino, Turin, Italy.,Cardiology, Cardiothoracic Department, University Hospital Santa Maria della Misericordia, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Cinzia Forleo
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Italy Bari, Italy
| | - Francesco Cappelli
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Stefano Favale
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Italy Bari, Italy
| | | | - Franca Dore
- Department of Nuclear Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Francesca Girardi
- Department of Nuclear Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Rita Pavasini
- Cardiology Unit, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Valeria Rella
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Giuseppe Palmiero
- Department of Translational Medical Sciences, Inherited and Rare Heart Disease, Vanvitelli Cardiology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Martina Caiazza
- Department of Translational Medical Sciences, Inherited and Rare Heart Disease, Vanvitelli Cardiology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Maria Cristina Carella
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Italy Bari, Italy
| | - Andrea Igoren Guaricci
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Italy Bari, Italy
| | - Giovanna Branzi
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Angelo Giuseppe Caponetti
- Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giulia Saturi
- Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | | | - Alessandro Andreis
- University Cardiology A.O.U. , Città della Salute e della Scienza di Torino, Turin, Italy
| | - Francesco Bruno
- University Cardiology A.O.U. , Città della Salute e della Scienza di Torino, Turin, Italy
| | - Francesca Longo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Maddalena Rossi
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Guerino Giuseppe Varrà
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Riccardo Saro
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Luca Di Ienno
- Cardiology Unit, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Giuseppe De Carli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Elisa Giacomin
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Chiara Arzilli
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giuseppe Limongelli
- Department of Translational Medical Sciences, Inherited and Rare Heart Disease, Vanvitelli Cardiology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Camillo Autore
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Luigi Badano
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Stefano Perlini
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Emdin Michele
- Istituto di Scienze della Vita, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Claudio Rapezzi
- Cardiology Unit, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
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8
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Szor RS, Alencar A, Bueno BVK, Cafezeiro CRF, Alves LBDO, Hajjar LA, Martinez GA, Rocha V, Fernandes F. Amyloid Cardiomyopathy: Establishing a Patient Referral Center in Brazil. JACC CardioOncol 2021; 3:606-610. [PMID: 34729536 PMCID: PMC8543090 DOI: 10.1016/j.jaccao.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Roberta Shcolnik Szor
- Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | - Lucas Bassolli de Oliveira Alves
- Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Gracia Aparecida Martinez
- Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, Brazil
| | - Vanderson Rocha
- Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, Brazil.,Department of Hematology, Churchill Hospital, Oxford University, Oxford, United Kingdom
| | - Fabio Fernandes
- Instituto do Coração, Universidade de São Paulo, São Paulo, Brazil
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9
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Falk RH, Haddad M, Walker CR, Dorbala S, Cuddy SAM. Effect of Tafamidis on Serum Transthyretin Levels in Non-Trial Patients With Transthyretin Amyloid Cardiomyopathy. JACC CardioOncol 2021; 3:580-586. [PMID: 34729530 PMCID: PMC8543137 DOI: 10.1016/j.jaccao.2021.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/12/2021] [Accepted: 08/18/2021] [Indexed: 11/28/2022]
Abstract
Background Transthyretin amyloid (ATTR) cardiomyopathy is slowed by tafamidis, which stabilizes the TTR molecule and reduces the formation of amyloidogenic oligomers. Stabilizers in clinical doses raise serum TTR, which may be a surrogate for the degree of stabilization. Objectives This study aims to determine, in a non-trial, unselected population of patients with ATTR cardiomyopathy, the effect of tafamidis on serum levels of TTR, and to compare these with published data of changes in TTR. Methods TTR levels were measured before therapy and 3 to 12 months following initiation of tafamidis therapy in all patients seen between May 20, 2019, and March 1, 2021, who had a follow-up visits within 12 months of therapy initiation. Results Among 72 patients with ATTR cardiomyopathy (67 patients with wild-type and 5 patients with variant TTR), administration of tafamidis increased serum TTR from 21.8 mg ± 0.7 mg/dL to 29.3 ± 0.86 mg/dL, an increase of 34.5%. In 5 patients with variant TTR, the increase was 70.9%, compared to 32.0% in the wild-type patients. Mean N-terminal pro-brain natriuretic peptide increased over a mean follow-up of 21 ± 1.2 weeks, but the change was not statistically significant. Over the same period there was a small increase in high-sensitivity troponin T that was of borderline statistical significance (P = 0.057). Conclusions Tafamidis consistently increases serum TTR levels in patients with ATTR cardiomyopathy, consistent with its effect on stabilizing TTR. Measurement of TTR level change post-TTR stabilizing therapy might be a surrogate for stabilization and could be a more accurate measure of drug efficacy than an in vitro nonphysiologic test of stabilization.
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Affiliation(s)
- Rodney H Falk
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mia Haddad
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Crystal R Walker
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,CV Imaging Program, Cardiovascular Division, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sarah A M Cuddy
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,CV Imaging Program, Cardiovascular Division, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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10
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Saez MS, Aguirre MA, Pérez de Arenaza D, Sorroche P, Nucifora E, Posadas Martinez ML. Epidemiology of variant transthyretin amyloidosis at a reference center in Argentina. Mol Genet Genomic Med 2021; 9:e1812. [PMID: 34668655 PMCID: PMC8606196 DOI: 10.1002/mgg3.1812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/14/2021] [Accepted: 08/31/2021] [Indexed: 11/23/2022] Open
Abstract
Background In Argentina, there is limited data of prevalence of variant transthyretin amyloidosis (ATTRv) and phenotype‐genotype correlation. The laboratory of Hospital Italiano de Buenos Aires (HIBA) is a reference center for transthyretin (TTR) gene sequencing. The Institutional Amyloidosis Registry (RIA) enable us to characterize people with ATTRv. Our aim was to describe the prevalence of TTR mutations at a reference center in Argentina and the phenotypic presentations of patients with ATTRv included in an institutional registry. Methods Retrospective cohort study of consecutive patients with genetic variants in the TTR gene identified from 2012 to 2019 in the laboratory. We collected all phenotypic characteristics of patients who were clinically evaluated by HIBA doctors. Results Five hundred seventy‐six patients tested, 141 positive: p.Val50Met 107, p.Thr80Ala 16, p.Ala117Ser 9, p.Phe84Leu 2, p.Ile127Val 2, p.Tyr134Cys 2, p.Ala56Pro 2, p.Val142Ile 1. Only 20 patients were clinically evaluated. The mean age at diagnosis was 54 years; 70% had family history with a pedigree median of 4. Mutations were p.Thr80Ala 9, p.Val50Met 6, p.Ala56Pro 2, p.Val142Ile 1, p.Phe84Leu 1, and p.Tyr134Cys 1. Eleven patients presented polyneuropathy, 11 had gastrointestinal compromise, six patients had autonomic compromise, six presented cardiac symptoms and four patients presented ocular involvement. Conclusion We present the first prevalence report of TTR mutations in a reference center of amyloidosis in Argentina. The most frequent genetic variant was p.Val50Met. Our data show considerable phenotypic heterogeneity in the patients with ATTRv.
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Affiliation(s)
- Maria S Saez
- Biochemistry Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.,Institute of Translational Medicine and Biomedical Engineering (IMTIB), Buenos Aires, Argentina
| | - Maria A Aguirre
- Institute of Translational Medicine and Biomedical Engineering (IMTIB), Buenos Aires, Argentina.,Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Patricia Sorroche
- Biochemistry Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.,Institute of Translational Medicine and Biomedical Engineering (IMTIB), Buenos Aires, Argentina
| | - Elsa Nucifora
- Institute of Translational Medicine and Biomedical Engineering (IMTIB), Buenos Aires, Argentina.,Hematology Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Maria L Posadas Martinez
- Institute of Translational Medicine and Biomedical Engineering (IMTIB), Buenos Aires, Argentina.,Research Unit of Internal Medicine, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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11
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Hagiwara G, Arahata M, Hosokawa K, Shimojima M, Nakao S. Congestive heart failure associated with POEMS syndrome that was adequately distinguished from cardiac amyloidosis: a case report and literature review. Ann Transl Med 2021; 9:1266. [PMID: 34532403 PMCID: PMC8421946 DOI: 10.21037/atm-21-1071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 06/20/2021] [Indexed: 11/22/2022]
Abstract
Congestive heart failure (CHF) is a common complication in patients with AL amyloidosis but is rare in another plasma cell dyscrasia, POEMS syndrome. A 52-year-old man developed POEMS syndrome with a solitary plasmacytoma complicated by CHF mimicking cardiac amyloidosis (CA). His neurological symptoms and CHF did not improve after radiotherapy (50 Gy) targeting the plasmacytoma. Based on typical findings of noninvasive examinations such as elevated serum NT-proBNP (12,631 pg/mL), a pseudo-infarct pattern on electrocardiography, interventricular septal thickening with a granular sparkling appearance and an apical sparing pattern of longitudinal strain on echocardiography, and late gadolinium enhancement of the left ventricular wall on cardiac magnetic resonance imaging (MRI), severe CA ineligible for autologous peripheral blood stem cell transplantation (auto-PBSCT) was strongly suspected. However, myocardial biopsy failed to reveal amyloid deposits, and CHF markedly improved after only one cycle of chemotherapy with melphalan and dexamethasone. Accordingly, CA was denied as the etiology of his heart failure, and the patient was finally diagnosed with POEMS syndrome. As a result, high-dose melphalan followed by auto-PBSCT improved his neurological symptoms. Careful evaluation is therefore needed to appropriately treat patients with POEMS syndrome complicated by CHF, even when the results of non-invasive examinations are typical for AL amyloidosis.
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Affiliation(s)
- Goshi Hagiwara
- Department of Hematology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Masahisa Arahata
- Department of Internal Medicine, Nanto Municipal Hospital, Nanto, Japan
| | - Kohei Hosokawa
- Department of Hematology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Masaya Shimojima
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Shinji Nakao
- Department of Hematology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
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12
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Shityakov S, Hayashi K, Störk S, Scheper V, Lenarz T, Förster CY. The Conspicuous Link between Ear, Brain and Heart-Could Neurotrophin-Treatment of Age-Related Hearing Loss Help Prevent Alzheimer's Disease and Associated Amyloid Cardiomyopathy? Biomolecules 2021; 11:biom11060900. [PMID: 34204299 PMCID: PMC8235707 DOI: 10.3390/biom11060900] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/05/2021] [Accepted: 06/14/2021] [Indexed: 12/23/2022] Open
Abstract
Alzheimer's disease (AD), the most common cause of dementia in the elderly, is a neurodegenerative disorder associated with neurovascular dysfunction and cognitive decline. While the deposition of amyloid β peptide (Aβ) and the formation of neurofibrillary tangles (NFTs) are the pathological hallmarks of AD-affected brains, the majority of cases exhibits a combination of comorbidities that ultimately lead to multi-organ failure. Of particular interest, it can be demonstrated that Aβ pathology is present in the hearts of patients with AD, while the formation of NFT in the auditory system can be detected much earlier than the onset of symptoms. Progressive hearing impairment may beget social isolation and accelerate cognitive decline and increase the risk of developing dementia. The current review discusses the concept of a brain-ear-heart axis by which Aβ and NFT inhibition could be achieved through targeted supplementation of neurotrophic factors to the cochlea and the brain. Such amyloid inhibition might also indirectly affect amyloid accumulation in the heart, thus reducing the risk of developing AD-associated amyloid cardiomyopathy and cardiovascular disease.
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Affiliation(s)
- Sergey Shityakov
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, D-97080 Würzburg, Germany;
- Infochemistry Scientific Center, Laboratory of Chemoinformatics, ITMO University, 191002 Saint-Petersburg, Russia
| | - Kentaro Hayashi
- Advanced Stroke Center, Shimane University Hospital, 89-1 Enya, Shimane, Izumo 693-8501, Japan;
| | - Stefan Störk
- Comprehensive Heart Failure Q9 Center, University of Würzburg, D-97080 Würzburg, Germany;
| | - Verena Scheper
- Department of Otolaryngology, Hannover Medical School and Cluster of Excellence “Hearing4All”, 30625 Hannover, Germany;
| | - Thomas Lenarz
- Department of Otolaryngology, Hannover Medical School and Cluster of Excellence “Hearing4All”, 30625 Hannover, Germany;
- Correspondence: (T.L.); (C.Y.F.)
| | - Carola Y. Förster
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, D-97080 Würzburg, Germany;
- Correspondence: (T.L.); (C.Y.F.)
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13
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Volz MJ, Pleger ST, Weber A, Geis NA, Hamed S, Mereles D, Hegenbart U, Katus HA, Frey N, Raake PW, Kreusser MM. Initial experience with percutaneous mitral valve repair in patients with cardiac amyloidosis. Eur J Clin Invest 2021; 51:e13473. [PMID: 33326601 DOI: 10.1111/eci.13473] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/07/2020] [Accepted: 12/12/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Percutaneous mitral valve repair (PMVR) is a therapeutic option for severe mitral regurgitation (MR) in patients with heart failure due to differential aetiologies. However, only little is known about the safety and efficacy of this procedure in patients with amyloid cardiomyopathy. METHODS Five patients with cardiac amyloidosis and moderate to severe or severe MR undergoing PMVR were analysed retrospectively and compared to seven patients with cardiac amyloidosis and severe MR without intervention. Clinical and functional data, renal function and cardiac biomarkers as well as established risk scores for cardiac amyloidosis were assessed. Primary endpoint was the reduction in MR one year after PMVR. Secondary endpoints were safety, overall mortality after 12 months compared with the control group, as well as changes in clinical and functional parameters. RESULTS Amyloidosis risk assessment documented amyloid cardiomyopathy at an advanced stage in all patients. Procedural, technical and device success of PMVR were all 100% and residual MR remained mild to moderate at 12 months follow-up (P = .038 vs before PMVR). Differences in survival compared with the control (no PMVR) group pointed to a possible survival benefit in the PMVR group (P = .02). CONCLUSION PMVR is a feasible and safe procedure in patients with cardiac amyloidosis and might carry a possible survival benefit in this patient group.
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Affiliation(s)
- Martin J Volz
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Sven T Pleger
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Andreas Weber
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Nicolas A Geis
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Sonja Hamed
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Derliz Mereles
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Ute Hegenbart
- Division of Hematology and Oncology, Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Norbert Frey
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Philip W Raake
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Michael M Kreusser
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
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14
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Abstract
Amyloidoses are a family of inherited or acquired disorders characterized by the deposition of insoluble extracellular protein fibrils in various organs and tissues, thereby impairing their function. Amyloidoses are typically misfolded proteins, and on rare occasions, can deposit in the myocardium resulting in an infiltrative/restrictive cardiomyopathy. Restrictive cardiomyopathy is an underdiagnosed cause of congestive heart failure (CHF) with preserved ejection fraction, atrial and ventricular arrhythmias along with conduction defects. In elderly patients, as with this study, cardiac amyloidosis most often results from abnormalities in the liver protein transthyretin (TTR), a thyroxine and retinol-retinol binding complex transporter in blood. Mutated serum TTR results in familial systemic amyloidosis, whereas wild-type TTR results in senile cardiac amyloidosis predominantly seen in elderly males. Scintigraphy, a common non-invasive method used to facilitate early diagnosis of cardiac amyloidosis was the method used in this study. However, the gold standard for definitive diagnosis of cardiac amyloidosis is endomyocardial biopsy (EMB). Besides organ transplant, which is rarely done, therapy for cardiac amyloidosis is mainly aimed at symptomatic and supportive care. Plenty of evidence has shown that the left ventricular ejection fraction (LVEF) in patients with restrictive cardiomyopathy is usually preserved. However, in this study, we review the unique case of an 82-year-old male who was diagnosed with isolated cardiac amyloidosis with severe systolic dysfunction (decreasedLVEF), the methods used to establish the diagnosis, as well as the therapeutic interventions.
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Affiliation(s)
- Jennaire Lewars
- Internal Medicine, Saint James School of Medicine, Chicago, USA
| | - Hersh Wazir
- Medicine, All Saints University College of Medicine, Toronto, CAN
| | | | - Uyi Faluyi
- Medicine, All Saints University School of Medicine, Toronto, CAN
| | - Yousry Girgis
- Internal Medicine, Holy Cross Hospital, Chicago, USA
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15
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Sher T, Velarde GP, Gertz MA. V122I Transthyretin Cardiomyopathy: An Opportunity to Build Trust and Resolve Disparities. J Am Coll Cardiol 2020; 76:93-95. [PMID: 32616166 DOI: 10.1016/j.jacc.2020.04.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 04/27/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Taimur Sher
- Department of Medicine, Mayo Clinic Florida, Jacksonville, Florida.
| | - Gladys P Velarde
- Department of Medicine, University of Florida at Jacksonville, Jacksonville, Florida
| | - Morie A Gertz
- Department of Medicine, Mayo Clinic Rochester, Rochester, Minnesota
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16
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Barrenechea IJ, Márquez L, Rojas HP, Nicola M, Dumont C. Awake C1-2 laminectomy, instrumentation, and fusion: case report. J Neurosurg Spine 2019; 32:554-558. [PMID: 31812136 DOI: 10.3171/2019.9.spine19961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 09/26/2019] [Indexed: 11/06/2022]
Abstract
Surgery of the cervical spine under conscious sedation has been rarely reported in the literature. The main indications are the lack of neurophysiological monitoring and surgery in patients with high cardiovascular risk. To date, no reports of awake C1-2 instrumentation have been published in the English-language literature. The authors present the case of a 76-year-old patient with multiple myeloma and severe cardiomyopathy associated with primary amyloidosis who experienced severe myelopathy from a C2 pseudotumor associated with an odontoid fracture. Due to his high cardiovascular risk, the patient underwent C1 decompression and C1-2 instrumentation and fusion via an awake technique. To accomplish this task, the authors performed multilayered muscular infiltration of local anesthetics and avoided manipulating the C2 root by anchoring C1 with a rod-claw system. The procedure did not last longer than that of general anesthetic approaches, and no complaints were reported by the patient during surgery, which he described as an overall "good experience." The patient was discharged on the 7th postoperative day and resumed his previous work 3 months later. Performing surgery under local anesthesia and conscious sedation reduces the risk of perioperative cardiovascular and respiratory complications in these high-risk patients by avoiding the use of drugs with cardiodepressant effects and endotracheal intubation.
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Affiliation(s)
| | | | | | | | - Carlos Dumont
- 3Cardiology, Hospital Privado de Rosario, Santa Fe, Argentina
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17
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Tret'yakov AY, Zakharchenko SP, Tret'yakova VA, Ermilov OV, Shekhovtsov SA, Khabibulin RR, Aleinikova KS, Dan VS, Leshcheva NA. Clinical observation of a combination of diffuse alveolar-septal pulmonary lesion and amyloid cardiomyopathy in systemic AL-amyloidosis in the elderly. TERAPEVT ARKH 2019; 90:96-100. [PMID: 30701840 DOI: 10.26442/00403660.2018.12.000016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A rare observation of systemic AL-amyloidosis with a debut in old age, accompanied by diffuse alveolar-septal lesion of the lungs and mediastinal lymphadenopathy in combination with amyloid cardiomyopathy in the absence of pathology of kidney and liver function.
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Affiliation(s)
| | | | - V A Tret'yakova
- People's Friendship University of Russia (RUDN University), Moscow, Russia
| | - O V Ermilov
- Belgorod National Research University, Belgorod, Russia
| | - S A Shekhovtsov
- Belgorod Regional Clinical Hospital of St. Joasaph, Belgorod, Russia
| | - R R Khabibulin
- People's Friendship University of Russia (RUDN University), Moscow, Russia
| | | | - V S Dan
- Belgorod National Research University, Belgorod, Russia
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18
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Abstract
BACKGROUND Cardiac amyloidosis is an underdiagnosed cause of restrictive cardiomyopathy resulting from the infiltration of the myocardium by amyloid proteins. CASE REPORT We report the case of an 83-year-old woman who presented with increasing dyspnea and lower-extremity swelling. She reported a medical history of unspecified heart failure. Evaluation in the Emergency Department (ED) revealed evidence of heart failure on physical examination, low-voltage electrocardiogram, chest x-ray study with mild pulmonary edema, and laboratory evaluation with elevated brain natriuretic peptide and troponin. Bedside cardiac ultrasound illustrated severe concentric ventricular hypertrophy and interventricular septal wall thickening with "sparkling" hyperechoic appearance of the myocardium, mildly reduced left ventricular ejection fraction, and small pericardial effusion. Inpatient comprehensive echocardiogram and follow-up nuclear medicine cardiac amyloid pyrophosphate study were suggestive of cardiac amyloidosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians commonly treat acute on chronic systolic heart failure with diuresis and reductions in preload and afterload with nitrates. Identifying amyloid cardiomyopathy in the ED is of clinical significance because treatment should include loop diuretics but should avoid β-blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers, and digoxin. Atrioventricular nodal blocking agents may have detrimental effects in cardiac amyloidosis because the cardiac output in this patient population is dependent on heart rate due to a significantly reduced stroke volume from the concentric hypertrophy minimizing diastolic filling. Also, caution should be taken when initiating nitrates in amyloid cardiomyopathy because further reducing preload in an already preload-depleted state can result in hypotension.
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Affiliation(s)
- Mauricio Baca
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, Florida
| | - Mark Newberry
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, Florida; Emergency Department Ultrasonography, Mount Sinai Medical Center, Miami Beach, Florida
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19
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Kopishinskaya SV. [Transthyretin familial amyloid polyneuropathy]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 118:82-89. [PMID: 30499502 DOI: 10.17116/jnevro201811810182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Transthyretin family amyloid polyneuropathy (TTR-FAP) is a progressive, ultimately fatal disease. It manifests itself primarily with sensory, motor and autonomic polyneuropathy and/or cardiomyopathy and is caused by extracellular deposition of insoluble amyloid fibrils in the endoneurium. The cause of TTR-FAP is the mutation in the gene encoding transthyretin, more than 100 types of mutations are known. Given the phenotypic diversity of TTR-FAP, it is difficult for clinicians to make this diagnosis. An erroneous diagnosis is a frequent occurrence, risking the onset of an organ pathology. The paper addresses the issues of the pathogenesis, diagnosis and treatment of TTR-FAP.
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Affiliation(s)
- S V Kopishinskaya
- Federal State Budget Educational Establishment of Higher Education Nizhny Novgorod State Medical Academy of the Ministry of Public Health of the Russian Federation, Nizhny Novgorod, Russia
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20
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Abstract
BACKGROUND The extent of right ventricular (RV) involvement in transthyretin amyloidosis (ATTR) is unknown. OBJECTIVES This study sought to establish the degree of RV involvement in ATTR amyloidosis, and compare findings with RV involvement in hypertrophic cardiomyopathy (HCM). METHODS Forty-two patients with ATTR amyloidosis and echocardiographic evidence of cardiac amyloidosis (cardiac ATTR), 19 ATTR patients with normal left ventricular (LV) wall thickness (non-cardiac ATTR), 25 patients with diagnosed HCM and 30 healthy controls were included in this study. Echocardiographic measurements for conventional parameters, as well as RV global and segmental strain, were recorded. RESULTS When comparing RV structure and function between cardiac ATTR amyloidosis and HCM patients, only segmental strain differed between the two groups. In cardiac ATTR amyloidosis, we found an RV apex-to-base strain gradient with highest deformation in the apex. This pattern was reversed in patients with HCM. CONCLUSIONS RV involvement is common in cardiac ATTR patients. The present study also detected an RV apical sparing pattern in patients with ATTR cardiomyopathy, similar to what has previously been described for the left ventricle in these patients. This pattern was not seen in HCM patients. Further studies are needed to assess the clinical importance of these findings.
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Affiliation(s)
- Sandra Arvidsson
- a Department of Clinical Physiology , Heart Centre, Umeå University , Umeå , Sweden
| | - Michael Y Henein
- b Department of Public Health and Clinical Medicine , Umeå University , Umeå , Sweden
| | - Gerhard Wikström
- c Department of Medical Sciences , Cardiology, Uppsala University , Uppsala , Sweden
| | - Ole B Suhr
- b Department of Public Health and Clinical Medicine , Umeå University , Umeå , Sweden
| | - Per Lindqvist
- a Department of Clinical Physiology , Heart Centre, Umeå University , Umeå , Sweden.,d Department of Surgical and Perioperative Sciences , Umeå University , Umeå , Sweden
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21
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Abstract
OBJECTIVE Transthyretin (ATTR) amyloidosis is an under-recognized, progressive disease manifesting as cardiomyopathy and/or polyneuropathy. Diflunisal, a nonsteroidal anti-inflammatory drug (NSAID), has demonstrated transthyretin stabilization in vitro and slowing of polyneuropathy progression in the hereditary ATTR subtype (ATTRm). However, the use of diflunisal has only been described in a small cohort of patients with ATTR cardiac amyloidosis (CA). We hypothesized that selected patients with ATTR-CA, both hereditary and wild-type (ATTRwt), would tolerate diflunisal with limited adverse events. MATERIALS AND METHODS This is a retrospective, longitudinal study of 23 patients with ATTR-CA (10 ATTRm and 13 ATTRwt) diagnosed at the Cleveland Clinic from May 2007 to August 2017 who were treated with diflunisal. Patients were prescribed diflunisal, fully informed of the risks of side effects. Patient characteristics and subsequent adverse events were recorded. RESULTS The duration of diflunisal therapy ranged from 1-89 months (median 15 months). Average eGFR at diflunisal initiation was 61.9 ± 15.4 mL/min/m2. Only one patient had a transient rise in Cr of 0.31 mg/dL. There were no clinically significant bleeding events, despite most of the patients being on anticoagulants or antiplatelet agents. Three of 23 patients (13%) withdrew treatment due to drug side effects (erosive gastritis, epigastric pain and decreased appetite). No patients died or were hospitalized for heart failure. CONCLUSION Diflunisal was well-tolerated in both the ATTRm- and ATTRwt-CA populations. Withdrawal due to side effects was related to gastrointestinal complaints, but most patients had no adverse events. Diflunisal can be safely used in a selected group of ATTR-CA patients with appropriate clinical, renal and hematologic monitoring.
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Affiliation(s)
- Asad Ikram
- a Department of Cardiovascular Medicine , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Joseph P Donnelly
- a Department of Cardiovascular Medicine , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Brett W Sperry
- a Department of Cardiovascular Medicine , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Christy Samaras
- b Department of Hematology and Medical Oncology , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Jason Valent
- b Department of Hematology and Medical Oncology , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Mazen Hanna
- a Department of Cardiovascular Medicine , Cleveland Clinic Foundation , Cleveland , OH , USA
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22
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Phull P, Sanchorawala V, Connors LH, Doros G, Ruberg FL, Berk JL, Sarosiek S. Monoclonal gammopathy of undetermined significance in systemic transthyretin amyloidosis (ATTR). Amyloid 2018; 25:62-67. [PMID: 29424556 PMCID: PMC6157907 DOI: 10.1080/13506129.2018.1436048] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To identify the prevalence of monoclonal gammopathy of undetermined significance (MGUS) in patients with transthyretin (ATTR) amyloidosis. PATIENTS AND METHODS We performed a retrospective analysis of patients with biopsy-proven ATTRwt (wild-type transthyretin amyloid protein) and genopositive ATTR V122I (valine-to-isoleucine substitution at position 122 of the TTR gene) amyloidosis evaluated at the Amyloidosis Center at Boston University and Boston Medical Center between 1 January 2003 and 31 December 2016. RESULTS There were a total of 226 patients with ATTRwt and ATTR V122I amyloidosis evaluated during the specified time frame with 155 and 71 patients in each cohort, respectively. Those with complete medical records, 140 patients with ATTRwt and 57 V1221 ATTRm subjects, were included in the analyses. Fifty-five patients (39%) in the ATTRwt cohort and 28 patients (49%) in the ATTR V122I cohort had an MGUS, as indicated by an abnormality in the serum-free light-chain ratio and/or serum immunofixation electrophoresis. CONCLUSION These data confirm the high prevalence of coexistent MGUS with ATTR amyloidosis in this patient population, with an MGUS rate that is higher than the general population. These findings also highlight the importance of a thorough diagnostic evaluation in patients with amyloidosis to determine the precursor protein, as the clinical course and treatment of AL (light-chain amyloid protein) and ATTR amyloidosis are distinct.
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Affiliation(s)
- Pooja Phull
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA
| | - Vaishali Sanchorawala
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA.,b Section of Hematology and Oncology , Boston Medical Center , Boston , MA , USA
| | - Lawreen H Connors
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA.,d Department of Biostatistics , Boston University School of Public Health , Boston , MA , USA
| | - Gheorghe Doros
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA.,c Department of Pathology and Laboratory Medicine , Boston Medical Center , Boston , MA , USA
| | - Frederick L Ruberg
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA.,e Section of Cardiovascular Medicine , Boston Medical Center , Boston , MA , USA
| | - John L Berk
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA.,f Section of Pulmonary Medicine , Boston Medical Center , Boston , MA , USA
| | - Shayna Sarosiek
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA.,b Section of Hematology and Oncology , Boston Medical Center , Boston , MA , USA
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Affiliation(s)
- Marios Arvanitis
- a Department of Medicine , Boston University School of Medicine/Boston Medical Center , Boston , MA , USA
| | - Gloria G Chan
- b Amyloidosis Center , Boston University School of Medicine/Boston Medical Center , Boston , MA , USA
| | - Daniel R Jacobson
- a Department of Medicine , Boston University School of Medicine/Boston Medical Center , Boston , MA , USA.,b Amyloidosis Center , Boston University School of Medicine/Boston Medical Center , Boston , MA , USA.,c Section of Hematology/Oncology, Medical Service , VA Boston Healthcare System , Boston , MA , USA
| | - John L Berk
- a Department of Medicine , Boston University School of Medicine/Boston Medical Center , Boston , MA , USA.,b Amyloidosis Center , Boston University School of Medicine/Boston Medical Center , Boston , MA , USA
| | - Lawreen H Connors
- b Amyloidosis Center , Boston University School of Medicine/Boston Medical Center , Boston , MA , USA.,d Department of Pathology and Laboratory Medicine , Boston University School of Medicine/Boston Medical Center , Boston , MA , USA
| | - Frederick L Ruberg
- b Amyloidosis Center , Boston University School of Medicine/Boston Medical Center , Boston , MA , USA.,e Section of Cardiovascular Medicine, Department of Medicine , Boston University School of Medicine/Boston Medical Center , Boston , MA , USA
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Tabet R, Zaidan J, Karam B, Saouma S, Ghavami F. A Plasma Cell Dyscrasia Presenting as Amyloid Cardiomyopathy and Autonomic Dysfunction in a Healthy Patient. Cureus 2017; 9:e1409. [PMID: 28861330 PMCID: PMC5576963 DOI: 10.7759/cureus.1409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Systemic amyloidosis is a rare multisystem disease caused by incorrectly folded proteins that deposit pathologically in different tissues and organs of the human body. It has a very wide spectrum of clinical presentations according to the affected organ(s), and its diagnosis is commonly delayed. Cardiac involvement is the leading cause of morbidity and mortality and carries a poor prognosis, especially in primary light chain amyloidosis. Therefore any delay in the diagnosis can result in devastating outcomes for the patient. We report the case of a 65-year-old man who presented with dizziness and lightheadedness. He was found to have orthostatic hypotension and further investigations revealed the diagnosis of amyloid cardiomyopathy complicating a plasma cell dyscrasia. What is worth noting, in this case, is that the patient had cardiac amyloidosis presenting primarily as autonomic dysfunction and orthostatic hypotension, without any cardiac-specific symptoms such as heart failure or angina. This is a very unusual presentation of advanced-stage cardiac amyloidosis. This article highlights the variety of clinical presentations of cardiac amyloidosis, and focuses on the recent progress such as novel diagnostic and surveillance approaches using imaging, biomarkers, and new histological typing techniques. Current and future promising treatment options are also discussed, including methods directly targeting the amyloid deposits.
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Affiliation(s)
- Rabih Tabet
- Internal Medicine, Staten Island University Hospital, Northwell Health
| | - Julie Zaidan
- Internal Medicine, Staten Island University Hospital, Northwell Health
| | - Boutros Karam
- Internal Medicine, Staten Island University Hospital, Northwell Health
| | - Samer Saouma
- Internal Medicine, Staten Island University Hospital, Northwell Health
| | - Foad Ghavami
- Cardiology, Staten Island University Hospital, Northwell Health
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Karafiatova L, Pika T. Amyloid cardiomyopathy. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2017; 161:117-127. [PMID: 28145535 DOI: 10.5507/bp.2017.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 01/09/2017] [Indexed: 11/23/2022] Open
Abstract
Amyloidosis is a heterogeneous group of diseases characterized by the deposition of amyloid. It is caused by extracellular deposition of insoluble fibrils with beta-pleated sheet configuration. The protein misfolding abnormalities result in amyloid fibrils and may manifest as primary, secondary, or familial amyloidosis. Amyloid deposition can occur in multiple organs (eg, heart, liver, kidney, skin, eyes, lungs, nervous system) resulting in a variety of clinical manifestations. Cardiac involvement can occur as part of a systemic disease or as a localized phenomenon. Cardiac involvement in all types of amyloidosis represents a major negative prognostic factor. Early diagnosis, multi-disciplinary cooperation and proper therapy are key aspects of care for patients with amyloid cardiomyopathy. Early diagnosis is crucial, especially in AL amyloidosis, as patients with advanced heart disease are unsuitable candidates for modern, effective hematological treatment including autologous stem cell transplantation. Despite signal development in diagnostics and therapy, the prognosis for patients with advanced cardiac involvement remains poor. This article is an overview of amyloidosis, providing information about the characteristics of cardiac amyloidosis, and present a structured approach to diagnosis, treatment and prognosis of this condition.
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Affiliation(s)
- Lucie Karafiatova
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - Tomas Pika
- Department of Hemato-Oncology, University Hospital Olomouc, Czech Republic
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Abstract
INTRODUCTION More than ten distinct forms of amyloidoses that can involve the heart have been described, classified according to which protein originates the deposits. Cardiac amyloid infiltration translates into progressive and often life-threatening cardiomyopathy, but disease severity, prognosis and treatment drastically differ according to the amyloidosis type. The notion that protein misfolding and aggregation play a more general role in human cardiomyopathies has further raised attention towards the definition of the proteotoxicity mechanisms. Areas covered: Mass spectrometry-based proteomics plays an important role as a diagnostic tool and for understanding the molecular bases of amyloid cardiomyopathies. The landscape of applications of proteomics to the study of cardiac amyloidoses and amyloid-related cardiotoxicity is summarized, with a critical synthesis of the major achievements. Expert commentary: Current strengths and limitations of proteomics in the clinical setting and in translational research on amyloid cardiomyopathy are discussed, with the foreseen potential future directions in the field.
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Affiliation(s)
- Francesca Lavatelli
- a Amyloidosis Research and Treatment Center , Fondazione IRCCS Policlinico San Matteo, and University of Pavia , Pavia , Italy
| | - Giampaolo Merlini
- a Amyloidosis Research and Treatment Center , Fondazione IRCCS Policlinico San Matteo, and University of Pavia , Pavia , Italy
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Arahata M, Shimadoi S, Yamatani S, Hayashi SI, Miwa S, Asakura H, Nakao S. Three cases of systemic amyloidosis successfully diagnosed by subcutaneous fat tissue biopsy of the hip. Clin Interv Aging 2016; 11:1061-6. [PMID: 27540285 PMCID: PMC4981157 DOI: 10.2147/cia.s110636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Fine-needle aspiration biopsy of the abdominal fat pad is considered to be a minimally invasive procedure for diagnosing systemic amyloidosis. However, this procedure is sometimes difficult and can be dangerous for elderly patients whose abdominal fat layer is thin because of malnutrition. In such cases, alternative diagnostic methods are required. We report three elderly patients with heart failure complicated by malnutrition. In all cases, electrocardiogram showed low voltage in the limb leads and a pseudoinfarct pattern in the chest leads, and echocardiography showed left ventricular wall thickening with granular sparkling appearance. These patients were suspected of having amyloid cardiomyopathy but could not undergo myocardial biopsies because of their poor conditions. After failed attempts at biopsy of the abdominal fat pad or the other organs, subcutaneous fat tissue biopsy over the hip led to the diagnosis of systemic amyloidosis with cardiomyopathy. The resultant diagnosis guided us to choose the appropriate treatment for the patients. This article illustrates that subcutaneous fat tissue biopsy of the hip could be a useful procedure for diagnosing systemic amyloidosis in elderly patients, particularly when a fat tissue biopsy of the abdomen is associated with a high risk of complications because of malnutrition.
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Affiliation(s)
- Masahisa Arahata
- Department of Internal Medicine, Nanto Municipal Hospital, Nanto
| | - Shigeru Shimadoi
- Department of Internal Medicine, Nanto Municipal Hospital, Nanto
| | - Satosi Yamatani
- Department of Internal Medicine, Nanto Municipal Hospital, Nanto
| | - Shin-ichi Hayashi
- Department of Diagnostic Pathology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama
| | - Shigeharu Miwa
- Department of Diagnostic Pathology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama
| | | | - Shinji Nakao
- Department of Cellular Transplantation Biology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
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28
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Abstract
Aims In transthyretin amyloid (ATTR) amyloidosis various principal phenotypes have been described: cardiac, neuropathic, or a mixed cardiac and neuropathic. In addition, two different types of amyloid fibrils have been identified (type A and type B). Type B fibrils have thus far only been found in predominantly early-onset V30M and in patients carrying the Y114C mutation, whereas type A is noted in all other mutations currently examined as well as in wild-type ATTR amyloidosis. The fibril type is a determinant of the ATTR V30M disease phenotype. (99m)Tc-DPD scintigraphy is a highly sensitive method for diagnosing heart involvement in ATTR amyloidosis. The objective of this study was to determine the relationship between ATTR fibril composition and (99m)Tc-DPD scintigraphy outcome in patients with biopsy-proven ATTR amyloidosis. Methods Altogether 55 patients with biopsy-proven diagnosis of ATTR amyloidosis and amyloid fibril composition determined were examined by (99m)Tc-DPD scintigraphy. The patients were grouped and compared according to their type of amyloid fibrils. Cardiovascular evaluation included ECG, echocardiography, and cardiac biomarkers. The medical records were scrutinized to identify subjects with hypertension or other diseases that have an impact on cardiac dimensions. Results A total of 97% with type A and none of the patients with type B fibrils displayed (99m)Tc-DPD uptake at scintigraphy (p < 0.001). Findings from analyses of cardiac biomarkers, ECG, and echocardiography, though significantly different, could not differentiate between type A and B fibrils in individual patients. Conclusion In ATTR amyloidosis, the outcome of (99m)Tc-DPD scintigraphy is strongly related to the patients' transthyretin amyloid fibril composition.
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Affiliation(s)
- Björn Pilebro
- Heart Centre, Cardiology, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- CONTACT Björn Pilebro, MD Heart Centre, Cardiology, Department of Public Health and Clinical Medicine, Umeå University Hospital, SE 901 85 Umeå, Sweden
| | - Ole B. Suhr
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Ulf Näslund
- Heart Centre, Cardiology, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Per Westermark
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Per Lindqvist
- Heart Centre, Department of Surgical and Perioperative Sciences, Clinical Physiology, Umeå University, Umeå, Sweden
| | - Torbjörn Sundström
- Department of Radiation Sciences, Diagnostic Radiology, Umeå University, Umeå, Sweden
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Abstract
BACKGROUND Transthyretin (TTR) V122I (rs76992529) is one of 111 variants caused by point mutations in the coding sequence of the human TTR gene that are associated with systemic amyloidosis. It results from a G to A transition at a CG dinucleotide in codon 142(122 of the mature protein) of the gene and has been described almost exclusively in people of African descent. Several series have reported allele frequencies from 0.015 to 0.020 in African-Americans. OBJECTIVE To define more accurately the frequency of the TTR V122I variant allele in the African-American population. METHODS DNA isolated from blood spots from 1688 New York State African-American newborns was genotyped for the TTR V122I allele. We also compiled new data from the Jackson Heart Study and previously unpublished data from the Dallas Heart Study, plus data from a San Diego "wellness study", providing 15 650 additional allelotypes to those already reported. RESULTS Among the New York newborns, the TTR V122I allele was present in 65/3376 alleles (allele prevalence 0.0193). The combined available data from all the non-selected African-American cohorts showed the TTR variant allele to be present in 451/26 062 alleles (allele prevalence of 0.0173), slightly but not significantly lower than our previously published estimates. CONCLUSIONS The allele prevalence for TTR V122I in African-Americans is 0.0173. Of African-Americans under age 65, 3.43% carry at least one copy of the variant amyloidogenic allele.
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Seethala S, Jain S, Ohori NP, Monaco S, Lacomis J, Crock F, Nemec J. Focal monomorphic ventricular tachycardia as the first manifestation of amyloid cardiomyopathy. Indian Pacing Electrophysiol J 2010; 10:143-7. [PMID: 20234811 PMCID: PMC2833238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
52-year-old patient presented with palpitation and well tolerated monomorphic ventricular tachycardia. He had normal echocardiogram and coronary angiogram 3 months prior to presentation. Surface EKG revealed regular wide-complex tachycardia with right bundle branch block morphology and right inferior axis. In conjunction with recent negative cardiac evaluation, this suggested idiopathic focal ventricular tachycardia from anterolateral basal left ventricle. CARTO based activation mapping confirmed the presence of VT focus in that area. Radiofrequency ablation at the site of perfect pacemap resulted in a partial suppression of the focus. Echocardiogram was subsequently performed because of progressive dyspnea. It revealed asymmetrical thickening of posterolateral left ventricle, with delayed enhancement on contrast magnetic resonance imaging. Fine needle aspiration of abdominal fat stained with Congo red confirmed the diagnosis of systemic AL amyloidosis due to IgG lambda-light chain deposition. Consequently, the patient underwent placement of implantable defibrillator and hematopoetic stem cell transplantation. He remains in excellent functional status 18 months after presentation.
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Affiliation(s)
- Srikanth Seethala
- Department of Internal Medicine, University of Pittsburgh, 200 Lothrop St, Pittsburgh PA 15213
| | - Sandeep Jain
- Cardiovascular Institute, University of Pittsburgh, 200 Lothrop St, Pittsburgh PA 15213
| | - N. Paul Ohori
- Department of Pathology, University of Pittsburgh, 200 Lothrop St, Pittsburgh PA 15213
| | - Sara Monaco
- Department of Pathology, University of Pittsburgh, 200 Lothrop St, Pittsburgh PA 15213
| | - Joan Lacomis
- Department of Radiology, University of Pittsburgh, 200 Lothrop St, Pittsburgh PA 15213
| | - Frederick Crock
- Cardiovascular Institute, University of Pittsburgh, 200 Lothrop St, Pittsburgh PA 15213
| | - Jan Nemec
- Cardiovascular Institute, University of Pittsburgh, 200 Lothrop St, Pittsburgh PA 15213
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