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Ungericht M, Wanschitz J, Kroiss AS, Röcken C, Schuetz T, Messner M, Zaruba MM, Loescher WN, Poelzl G. Amyloid myopathy: expanding the clinical spectrum of transthyretin amyloidosis-case report and literature review. J Nucl Cardiol 2023; 30:1420-1426. [PMID: 35581484 PMCID: PMC10371878 DOI: 10.1007/s12350-022-02990-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/09/2022] [Indexed: 11/29/2022]
Abstract
We identified two patients with transthyretin (ATTR) amyloid myopathy (one ATTR variant amyloidosis, ATTRv; one wild-type ATTR amyloidosis, ATTRwt). Myopathy was the initial manifestation in ATTRwt, whereas it followed neuropathy and cardiomyopathy in ATTRv. The ATTRwt patient showed muscular tracer uptake on 99mTc-DPD planar scintigraphy at the time of initial diagnosis, consistent with ATTR amyloid myopathy. The ATTRv patient underwent heart transplantation because of progressive heart failure. Within the next two years, progressive myopathic symptoms and extracardiac tracer uptake on 99mTc-DPD planar scintigraphy were documented, attributable to ATTR amyloid myopathy. Interstitial amyloid deposits were confirmed by muscle biopsy in both patients, with a particularly high amyloid burden in the adipose tissue. This case report highlights the frequent concomitant presence of cardiac ATTR amyloidosis and ATTR amyloid myopathy. ATTR amyloid myopathy may precede cardiac manifestation in ATTRwt or occur after heart transplantation in ATTRv. Due to the high diagnostic accuracy of 99mTc-DPD scintigraphy for detecting ATTR amyloid myopathy and the emergence of novel therapeutics, it is important to increase the awareness of its presence.
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Affiliation(s)
- Maria Ungericht
- Department of Internal Medicine III, Cardiology & Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Julia Wanschitz
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alexander S Kroiss
- Department of Nuclear Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Röcken
- Department of Pathology, Christian-Albrechts-University, Kiel, Germany
| | - Thomas Schuetz
- Department of Internal Medicine III, Cardiology & Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Moritz Messner
- Department of Internal Medicine III, Cardiology & Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Marc-Michael Zaruba
- Department of Internal Medicine III, Cardiology & Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Wolfgang N Loescher
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gerhard Poelzl
- Department of Internal Medicine III, Cardiology & Angiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
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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] [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: 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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Quarta CC, Zheng J, Hutt D, Grigore SF, Manwani R, Sachchithanantham S, Mahmood SA, Whelan CJ, Fontana M, Martinez-Naharro A, Chacko L, Lachmann HJ, Gillmore JD, Rapezzi C, Hawkins PN, Wechalekar AD. 99mTc-DPD scintigraphy in immunoglobulin light chain (AL) cardiac amyloidosis. Eur Heart J Cardiovasc Imaging 2021; 22:1304-1311. [PMID: 34254119 PMCID: PMC8527328 DOI: 10.1093/ehjci/jeab095] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 06/21/2021] [Indexed: 12/14/2022] Open
Abstract
Aims Technetium-99m-labelled 3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD scintigraphy) is recognized as highly accurate for the non-invasive diagnosis of transthyretin (ATTR) cardiac amyloidosis (CA). A proportion of patients with immunoglobulin light chain (AL) CA have also been reported to show cardiac 99mTc-DPD uptake. Herein, we assessed the frequency and degree of cardiac 99mTc-DPD uptake and its clinical significance among patients with AL CA. Methods and results Between 2010 and 2017, 292 consecutive patients with AL CA underwent 99mTc-DPD scintigraphy and were included in this study: 114 (39%) had cardiac 99mTc-DPD uptake: grade 1 in 75%, grade 2 in 17%, and grade 3 in 8% of cases. Patients with cardiac 99mTc-DPD uptake had poorer cardiac systolic function and higher N-terminal pro-brain natriuretic peptide. No differences were noted in cardiac magnetic resonance parameters between patients with and without cardiac 99mTc-DPD uptake (N = 19 and 42, respectively). Patients with cardiac 99mTc-DPD uptake showed a trend to worse survival than those with no uptake (log-rank P = 0.056). Among 22 patients who underwent serial 99mTc-DPD scintigraphy, 5 (23%) showed reduction in the grade of cardiac uptake. Conclusions In this large cohort of patients with AL CA, 99mTc-DPD scintigraphy ∼40% of cases showed cardiac uptake, including grade 2–3 in 10% of all patients (25% of those with cardiac 99mTc-DPD uptake). Cardiac 99mTc-DPD uptake was associated with poorer cardiac function and outcomes. These data highlight the critical importance of ruling out AL amyloidosis in all patients with cardiac 99mTc-DPD uptake to ensure such patients are not assumed to have ATTR CA.
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Affiliation(s)
- Candida Cristina Quarta
- National Amyloidosis Centre, University College London (Royal Free Campus), Rowland Hill Street, London NW3 2PF, UK.,Alexion Pharmaceutical LTD, Stockley Park, 3 Furzeground Way, Hayes, Uxbridge, London UB11 1EZ, UK
| | - Jiexin Zheng
- Cardiovascular Center, University Hospital of Ferrara, Ferrara, Italy
| | - David Hutt
- National Amyloidosis Centre, University College London (Royal Free Campus), Rowland Hill Street, London NW3 2PF, UK
| | - Simona F Grigore
- National Amyloidosis Centre, University College London (Royal Free Campus), Rowland Hill Street, London NW3 2PF, UK
| | - Richa Manwani
- National Amyloidosis Centre, University College London (Royal Free Campus), Rowland Hill Street, London NW3 2PF, UK
| | - Sajitha Sachchithanantham
- National Amyloidosis Centre, University College London (Royal Free Campus), Rowland Hill Street, London NW3 2PF, UK
| | - Shameem A Mahmood
- National Amyloidosis Centre, University College London (Royal Free Campus), Rowland Hill Street, London NW3 2PF, UK
| | - Carol J Whelan
- National Amyloidosis Centre, University College London (Royal Free Campus), Rowland Hill Street, London NW3 2PF, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London (Royal Free Campus), Rowland Hill Street, London NW3 2PF, UK
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, University College London (Royal Free Campus), Rowland Hill Street, London NW3 2PF, UK
| | - Liza Chacko
- National Amyloidosis Centre, University College London (Royal Free Campus), Rowland Hill Street, London NW3 2PF, UK
| | - Helen J Lachmann
- National Amyloidosis Centre, University College London (Royal Free Campus), Rowland Hill Street, London NW3 2PF, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London (Royal Free Campus), Rowland Hill Street, London NW3 2PF, UK
| | - Claudio Rapezzi
- Cardiovascular Center, University Hospital of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, RA, Italy
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London (Royal Free Campus), Rowland Hill Street, London NW3 2PF, UK
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, University College London (Royal Free Campus), Rowland Hill Street, London NW3 2PF, UK
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Löfbacka V, Axelsson J, Pilebro B, Suhr OB, Lindqvist P, Sundström T. Cardiac transthyretin amyloidosis 99mTc-DPD SPECT correlates with strain echocardiography and biomarkers. Eur J Nucl Med Mol Imaging 2020; 48:1822-1832. [PMID: 33367948 PMCID: PMC8113207 DOI: 10.1007/s00259-020-05144-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 09/09/2020] [Accepted: 12/01/2020] [Indexed: 11/29/2022]
Abstract
Purpose Hereditary transthyretin-amyloid amyloidosis (ATTRv) is an underdiagnosed condition commonly manifesting as congestive heart failure. Recently, scintigraphy utilizing DPD as a tracer was shown to identify ATTRv and wild-type ATTR cardiomyopathy. The aim of this study was to determine the value of quantified scintigraphy utilizing 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) single-photon emission computed tomography (SPECT)/CT, and to correlate its uptake with well-established cardiac functional parameters. Methods Forty-eight patients with genetically verified ATTRv type-A fibril composition, positive 99mTc-DPD SPECT/CT, were retrospectively analyzed. Manual mapping of volumes of interest (VOIs) on DPD SPECT/CT examinations was used to quantify heart uptake. DPD mean and maximum uptake together with a calculated DPD-based amyloid burden (DPDload) was correlated with echocardiographic strain values and cardiac biomarkers. Results Statistically significant correlations were seen in VOIs between DPD uptakes and the corresponding echocardiographic strain values. Furthermore, DPDload had a strong correlation with echocardiographic strain parameters and also correlated with biomarkers troponin T and logarithmic NT-ProBNP. Conclusions In patients with ATTRv cardiomyopathy, DPD SPECT/CT measures the amyloid distribution and provides information on cardiac amyloid load. DPD amyloid load correlates with functional cardiac parameters.
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Affiliation(s)
- Viktor Löfbacka
- Heart Centre, Clinical Physiology, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Jan Axelsson
- Radiation Physics, Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Björn Pilebro
- Heart Centre, Cardiology, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Ole B Suhr
- Heart Centre, Cardiology, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Per Lindqvist
- Heart Centre, Clinical Physiology, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Torbjörn Sundström
- Diagnostic Radiology, Department of Radiation Sciences, Umeå University, Umeå, Sweden.
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González-López E, Gallego-Delgado M, Guzzo-Merello G, de Haro-Del Moral FJ, Cobo-Marcos M, Robles C, Bornstein B, Salas C, Lara-Pezzi E, Alonso-Pulpon L, Garcia-Pavia P. Wild-type transthyretin amyloidosis as a cause of heart failure with preserved ejection fraction. Eur Heart J 2015. [PMID: 26224076 DOI: 10.1093/eurheartj/ehv338] [Citation(s) in RCA: 696] [Impact Index Per Article: 77.3] [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: 12/12/2022] Open
Abstract
AIMS Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous clinical syndrome with multiple underlying causes. Wild-type transthyretin (TTR) amyloidosis (ATTRwt) is an underdiagnosed cause of HFpEF that might benefit from new specific treatments. ATTRwt can be diagnosed non-invasively by (99m)Tc-3,3-diphosphono-1,2-propanodicarboxylic acid ((99m)Tc-DPD) scintigraphy. We sought to determine the prevalence of ATTRwt among elderly patients admitted due to HFpEF. METHODS AND RESULTS We prospectively screened all consecutive patients ≥60 years old admitted due to HFpEF [left ventricular (LV) ejection fraction ≥50%] with LV hypertrophy (≥12 mm). All eligible patients were offered a (99m)Tc-DPD scintigraphy. The study included 120 HFpEF patients (59% women, 82 ± 8 years). A total of 16 patients (13.3%; 95% confidence interval: 7.2-19.5) showed a moderate-to-severe uptake on the (99m)Tc-DPD scintigraphy. All patients with a positive scan underwent genetic testing of the TTR gene, and no mutations were found. An endomyocardial biopsy was performed in four patients, confirming ATTRwt in all cases. There were no differences in age, gender, hypertension, diabetes, coronary artery disease, or atrial fibrillation between ATTRwt patients and patients with other HFpEF forms. Although patients with ATTRwt exhibited higher median N-terminal pro-brain natriuretic peptide (6467 vs. 3173 pg/L; P = 0.019), median troponin I (0.135 vs. 0.025 µg/L; P < 0.001), mean LV maximal wall thickness (17 ± 3.4 vs. 14 ± 2.5 mm; P = 0.001), rate of pericardial effusion (44 vs. 19%; P = 0.047), and rate of pacemakers (44 vs. 12%; P = 0.004), clinical overlap between ATTRwt and other HFpEF forms was high. CONCLUSION ATTRwt is an underdiagnosed disease that accounts for a significant number (13%) of HFpEF cases. The effect of emerging TTR-modifying drugs should be evaluated in these patients.
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Affiliation(s)
- Esther González-López
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 2, Majadahonda, Madrid 28222, Spain
| | - Maria Gallego-Delgado
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 2, Majadahonda, Madrid 28222, Spain
| | - Gonzalo Guzzo-Merello
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 2, Majadahonda, Madrid 28222, Spain
| | | | - Marta Cobo-Marcos
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 2, Majadahonda, Madrid 28222, Spain
| | - Carolina Robles
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 2, Majadahonda, Madrid 28222, Spain
| | - Belén Bornstein
- Department of Biochemistry, Hospital Universitario Puerta de Hierro, Madrid, Spain Department of Biochemistry, Biomedical Research Institute 'Alberto Sols', Medicine UAM-CSIC, Madrid, Spain Rare Diseases Biomedical Research Centre (CIBERER), Madrid, Spain
| | - Clara Salas
- Department of Pathology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Enrique Lara-Pezzi
- Myocardial Biology Programme, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Luis Alonso-Pulpon
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 2, Majadahonda, Madrid 28222, Spain
| | - Pablo Garcia-Pavia
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla, 2, Majadahonda, Madrid 28222, Spain Myocardial Biology Programme, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
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