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Cardiac transplantation in transthyretin amyloid cardiomyopathy: outcomes from three decades of tertiary centre experience. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Transthyretin cardiac amyloidosis (ATTR-CM) is a progressive and fatal cardiomyopathy. Treatment options in patients with advanced heart failure are limited to cardiac transplantation (CT). Despite small case series demonstrating comparable outcomes with CT between patients with ATTR-CM and non-amyloid cardiomyopathies, ATTR-CM is considered to be an absolute contraindication to CT in some centres. This is in part due to a perceived risk of amyloid recurrence in the cardiac allograft. We report outcomes of patients with ATTR-CM assessed at our centre whom underwent CT over the past thirty years.
Methods
We retrospectively evaluated all ATTR-CM patients assessed at the UK National Amyloidosis Centre between 1990 and 2020 who underwent CT. Pre-transplantation disease and patient characteristics were determined and outcomes were compared with our large cohort of non-transplanted ATTR-CM patients. Censor date was 11th January 2022.
Results
Eleven (9 male, 2 female) patients with ATTR-CM underwent CT including 8 with wild-type ATTR-CM and 3 with variant ATTR-CM (ATTRv). Median age at CT was 60.3 years and median follow up post-CT was 65.7 months. Median (range) NT-proBNP concentration pre-transplant was 4478ng/L (1057–8778ng/L), median (range) left ventricular ejection fraction (LVEF) was 39% (27–56%) and mean (IQR) interventricular septal (IVSD) was 18 mm (15.9–20.1 mm). 8 patients were NYHA functional class III, the 3 remaining patients were class II.
One, three, and five-year survival was 100%, 89% and 86%, respectively and the longest surviving patient was censored >19 years post CT. Survival is at least comparable to UK and US CT outcome registry data for all non-amyloid patients undergoing CT. No patients had recurrence of amyloid in the cardiac allograft as assessed by endomyocardial biopsy and/or Tc-DPD scintigraphy. Two patients were commenced on Patisiran for amyloid polyneuropathy at 211 and 5 months post-CT. Graft rejection requiring treatment was observed in 2 patients, and successfully treated with intravenous steroids. Renal impairment was common, with 6 patients being left with chronic kidney disease.
Three patients died, including one with ATTRv-CM from complications of leptomeningeal amyloidosis. Survival among the cohort of patients who underwent CT was significantly longer than UK patients with ATTR-CM generally (P≤0.006), regardless of NAC ATTR disease stage and including those diagnosed under 65 years of age (P=0.028). (Figure 1) All surviving patients were NYHA functional class I at time of censor.
Conclusion
Our data indicates that cardiac transplantation is well tolerated, restores functional capacity, and prolongs survival in ATTR-CM with little risk of recurrence of amyloid in the cardiac allograft. We believe that our data argues strongly for ATTR-CM to be routinely included in the list of indications for cardiac transplantation.
Funding Acknowledgement
Type of funding sources: None.
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A multi-modality, multi-parametric phenotyping study of transthyretin amyloid cardiomyopathy associated with the p.V142I TTR variant. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly recognised cause of heart failure. 3–4% of individuals of African descent carry a transthyretin gene mutation encoding the p.V142I variant, a powerful risk factor for development of variant ATTR-CM. This equates to 1.6 million potential carriers in the USA alone. We report findings from a multi-parametric, multi-modality phenotyping study of p.V142I ATTR-CM.
Hypothesis
The phenotype of p.V142I variant ATTR-CM is an aggressive form of ATTR CM.
Methods
A retrospective phenotyping study of 395 patients with p.V142I-ATTR-CM at our national referral centre was conducted. Patients underwent evaluation at the centre at time of diagnosis, including clinical and functional assessment, echocardiography, biomarker analysis; a subgroup had cardiac magnetic resonance imaging. 395 wild type ATTR-CM patients matched for independent predictors of prognosis (NAC Disease Stage, age, decade of first presentation) were used as a comparator group.
Results
Average age of pV142I ATTR-CM patients was 75.8 years. There was significant functional impairment (38.2% of cases NHYA ≥ III, mean 6 minute walk test distance 272m). Significant impairment of echocardiographic parameters was seen; mean LVEF 43%, global longitudinal strain −9.1%, TAPSE 14.2mm, E/E prime 17.4, E/A ratio 2.47 with high frequency of at least moderate mitral (44%) and tricuspid regurgitation (51%). Median NT-proBNP was 3165 ng/L (IQR 4224). Arrhythmias were common with 17.4% of patients having a bradyarrhythmia, 26.1% having atrial fibrillation/flutter, and 5.6% having a pacemaker at presentation. Uni and multivariate cox regression analysis identified serum troponin, tricuspid regurgitation, LVEF, TAPSE and lower systolic blood pressure as independent predictors of prognosis. Prognostic parameters were statistically significantly worse and five year survival by Kaplan Meier analysis was significantly reduced when compared to matched WT ATTR-CM patients (p<0.05) (Figure 1).
Mean serum high sensitivity troponin T and extracellular volume (ECV) by cardiac magnetic resonance (CMR) was higher in p.V142I ATTR-CM than WT ATTR-CM cases (94 ng/L vs 74.2 ng/L, p<0.05, 58% vs 55%, p<0.05). Interventricular wall thickness however was lower in p.V142I ATTR-CM than matched WT cases (17.2 mm vs 16.8 mm).
Conclusion
p.V142I ATTR-CM is an aggressive phenotype, with significant functional impairment, burden of regurgitant valvular disease and systolic impairment resulting in poor survival.
Patients with p.V142I ATTR-CM had a higher burden of amyloid infiltration as measured as shown by ECV measurements on CMR, higher serum troponin and lower wall thickness when compared to a matched cohort of WT ATTR-CM patients. This novel observation suggests a unique disease mechanism that is more cardiotoxic which results in myocyte loss and myocardial thinning as opposed to myocyte hypertrophy.
Funding Acknowledgement
Type of funding sources: None.
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