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Tian Y, Liu H. Advances and challenges in echocardiographic diagnosis and management of cardiac amyloidosis. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2025:10.1007/s10554-025-03362-5. [PMID: 40009119 DOI: 10.1007/s10554-025-03362-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2025] [Accepted: 02/13/2025] [Indexed: 02/27/2025]
Abstract
Cardiac amyloidosis is an infiltrative cardiomyopathy characterized by the abnormal accumulation of amyloid proteins within the heart muscle. It is recognized as a rare yet significant cardiac disease that is often overlooked as a potential cause of heart failure and cardiac arrhythmias, particularly in older individuals with rates escalating from 8 to 17 cases per 100,000 individuals. Cardiac amyloidosis primarily manifests as two predominant subtypes: light-chain and transthyretin amyloidosis, collectively accounting for over 95% of clinical cases. Early diagnosis of these conditions is often hindered by overlapping symptoms with other cardiac pathologies, resulting in diagnostic delays and suboptimal patient outcomes. Echocardiography, a non-invasive imaging technique, has become indispensable for diagnosing cardiac amyloidosis, uncovering crucial echocardiographic signs such as thickening of the left ventricular wall, diastolic dysfunction, and a granular appearance of the myocardium. Recent advancements in echocardiography have significantly enhanced the diagnostic accuracy of cardiac amyloidosis and improved patient management. Advanced echocardiographic techniques, including strain imaging, 3D echocardiography, and contrast echocardiography, have significantly enhanced diagnostic accuracy and prognostication. Future directions in echocardiography encompass the integration of artificial intelligence, the development of novel contrast agents, and the refinement of 4D echocardiography to further optimize patient care. This study explores the pivotal role of echocardiography in both diagnosing and managing cardiac amyloidosis, delving into the disease's underlying mechanisms, distinctive imaging characteristics, the significance of regular echocardiographic assessments, and discusses the challenges associated with differentiating between various types of amyloidosis without supplemental imaging or biopsy methods.
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Affiliation(s)
- Yun Tian
- Ultrasonic Department, Yantaishan Hospital, Yantaishan Hospital Affiliated to Binzhou Medical University, Yantai, 264003, China.
| | - Haibin Liu
- Emergency Department of North Campus, Yantaishan Hospital, Yantaishan Hospital Affiliated to Binzhou Medical University, Yantai, 264001, China
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Willixhofer R, Ermolaev N, Kronberger C, Eslami M, Vilsmeier J, Rettl R, Nitsche C, Kammerlander A, Bergler-Klein J, Kastner J, Niederseer D, Badr Eslam R. Prognostic Value of Submaximal Cardiopulmonary Exercise Testing in Patients With Cardiac Amyloidosis. Circ Rep 2025; 7:76-85. [PMID: 39931706 PMCID: PMC11807689 DOI: 10.1253/circrep.cr-24-0152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2024] [Accepted: 11/21/2024] [Indexed: 02/13/2025] Open
Abstract
Background This study assessed the prognostic value of submaximal cardiopulmonary exercise testing (CPET) in cardiac amyloidosis and explored CPET as an alternative to the 6-min walk test (6MWT). Methods and Results In this single-center prospective observational study, 160 patients with cardiac amyloidosis (87% male; mean age 78±7 years) were evaluated. A total of 145 performed maximum symptom limited CPET. The V̇E/V̇CO2 slope was 39±8, submaximal power output (SPO) was 24.75±11.50 W, and V̇O2 at anaerobic threshold (AT) was 8.13±2.29 mL/min/kg. During follow up, 34 (21.25%) patients died, and another 34 (21.25%) experienced heart failure (HF)-related hospitalization, with 15 (9.38%) patients experiencing both events. Univariate analysis showed that V̇E/V̇CO2 slope (hazard ratio [HR] 0.89; 95% confidence interval [CI] 0.86-0.93; P<0.001) and SPO (HR 0.91; 95% CI 0.87-0.96; P<0.001) were predictors of mortality. In multivariate analysis, V̇E/V̇CO2 slope remained a significant predictor (HR 0.92; 95% CI 0.88-0.97; P<0.001) for both all-cause mortality and HF-related hospitalization independently. A SPO cut-off of <28 W predicted a worse outcome for both measures independently. Moderate correlations for V̇E/V̇CO2 slope (-0.56 [CI -0.67, -0.42]) and SPO (0.55 [CI 0.42, 0.67]) with 6MWT distance have been found. Conclusions These findings highlight CPET parameters, particularly V̇E/V̇CO2 slope and SPO with a cut-off <28 W, as predictors of survival and HF-related hospitalization in cardiac amyloidosis.
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Affiliation(s)
- Robin Willixhofer
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna Vienna Austria
| | - Nikita Ermolaev
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna Vienna Austria
| | - Christina Kronberger
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna Vienna Austria
| | - Mahshid Eslami
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna Vienna Austria
| | - Johannes Vilsmeier
- Institute for Medical Statistics, Medical University of Vienna Vienna Austria
| | - René Rettl
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna Vienna Austria
| | - Christian Nitsche
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna Vienna Austria
| | - Andreas Kammerlander
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna Vienna Austria
| | - Jutta Bergler-Klein
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna Vienna Austria
| | - Johannes Kastner
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna Vienna Austria
| | - David Niederseer
- Hochgebirgsklinik Davos, Medicine Campus Davos Davos Switzerland
- Christine Kühne Center for Allergy Research and Education (CK-CARE), Medicine Campus Davos Davos Switzerland
- Department of Cardiology, Center of Translational and Experimental Cardiology (CTEC), University Heart Center Zurich, University Hospital Zurich, University of Zurich Zurich Switzerland
| | - Roza Badr Eslam
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna Vienna Austria
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Badwan O, Berglund F, Rosenzveig A, Persits I, Gharaibeh A, Kumar A, Agrawal A, Sul L, Chan N, Wang TKM, Hanna M, Klein AL. Pericardial Disease in Cardiac Amyloidosis: A Comprehensive Review. Am J Cardiol 2024; 223:100-108. [PMID: 38740164 DOI: 10.1016/j.amjcard.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 05/02/2024] [Accepted: 05/08/2024] [Indexed: 05/16/2024]
Abstract
In patients with cardiac amyloidosis, pericardial involvement is common, with up to half of patients presenting with pericardial effusions. The pathophysiological mechanisms of pericardial pathology in cardiac amyloidosis include chronic elevations in right-sided filling pressures, myocardial and pericardial inflammation due to cytotoxic effects of amyloid deposits, and renal involvement with subsequent uremia and hypoalbuminemia. The pericardial effusions are typically small; however, several cases of life-threatening cardiac tamponade with hemorrhagic effusions have been described as a presenting clinical scenario. Constrictive pericarditis can also occur due to amyloidosis and its identification presents a clinical challenge in patients with cardiac amyloidosis who concurrently manifest signs of restrictive cardiomyopathy. Multimodality imaging, including echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging, is useful in the evaluation and management of this patient population. The recognition of pericardial effusion is important in the risk stratification of patients with cardiac amyloidosis as its presence confers a poor prognosis. However, specific treatment aimed at the effusions themselves is seldom indicated. Cardiac tamponade and constrictive pericarditis may necessitate pericardiocentesis and pericardiectomy, respectively.
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Affiliation(s)
- Osamah Badwan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Felix Berglund
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Akiva Rosenzveig
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ian Persits
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ahmad Gharaibeh
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ashwin Kumar
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ankit Agrawal
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lidiya Sul
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicholas Chan
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Tom Kai Ming Wang
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mazen Hanna
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Ingebrigtsen A, Saeed S, Larsen TH, Reikvam H. Clinical and imaging characteristics of patients with cardiac amyloidosis- a single center observational study. Scand J Clin Lab Invest 2024; 84:193-201. [PMID: 38709651 DOI: 10.1080/00365513.2024.2346908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/19/2024] [Accepted: 04/21/2024] [Indexed: 05/08/2024]
Abstract
Amyloidosis is a disease characterized by the deposition of protein fibrils. Cardiac involvement is a significant factor in determining prognosis. This study aimed to examine the clinical profile, outcomes, and long-term mortality rates in patients with transthyretin (ATTR) and amyloid light-chain (AL) amyloidosis. The retrospective cohort study included 94 patients with amyloidosis (69 with AL and 25 with ATTR amyloidosis) diagnosed between 2010 and 2022. The study involved multimodality imaging (ECG, echocardiography and cardiac magnetic resonance (CMR) data and survival analyses. Patients with ATTR amyloidosis were older and had a higher proportion of males compared to those with AL amyloidosis. Cardiac involvement was more prevalent in the ATTR group, including atrial fibrillation (AF), while pleural and pericardial effusion were more frequent in the AL group. Biomarkers such as NT-proBNP and troponin T were significantly elevated in both groups and were associated with all-cause mortality only in univariate analyses. CMR data, especially typical late gadolinium enhancement (LGE) was not associated with increased mortality, while pleural effusion and left atrial dilatation on echocardiography were identified as powerful predictors of mortality. In conclusion, both AL and ATTR amyloidosis exhibited poor outcomes. Cardiac involvement, particularly dilated left atrium and pleural effusion on echocardiography were associated with an increased risk of mortality, while typical LGE on CMR was not.
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Affiliation(s)
- Andreas Ingebrigtsen
- Department of Clinical Science, K.G. Jebsen Center for Myeloid Blood Cancer, University of Bergen, Bergen, Norway
| | - Sahrai Saeed
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Terje Hjalmar Larsen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Håkon Reikvam
- Department of Clinical Science, K.G. Jebsen Center for Myeloid Blood Cancer, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Hussain B, Malik H, Mamas MA, Desai R, Aggarwal V, Kumar G, Alraies MC, Kalra A, Paul TK. Clinical Outcomes of Percutaneous Coronary Intervention in Amyloidosis, Sarcoidosis, and Hemochromatosis. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101267. [PMID: 39130172 PMCID: PMC11308414 DOI: 10.1016/j.jscai.2023.101267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/20/2023] [Accepted: 12/11/2023] [Indexed: 08/13/2024]
Abstract
Background Infiltrative diseases (IDs), including amyloidosis, sarcoidosis, and hemochromatosis, are characterized by abnormal cellular infiltration in multiple organs, including the heart. The prognosis of percutaneous coronary intervention (PCI) patients with underlying IDs has not been well-studied. We evaluated the prevalence of IDs in patients undergoing PCI and their association with post-PCI outcomes. Methods The National Inpatient Sample (NIS) 2016-2020 database was used to identify PCI patients with ICD-10 codes for a retrospective analysis. PCI patients were then divided into those with and without underlying IDs, which included amyloidosis, sarcoidosis, and hemochromatosis. Multivariable logistic regression was performed for composite post-PCI outcomes analyses. Results Among 2,360,860 patients admitted to undergo PCI, 7855 patients had underlying IDs. The highest prevalence was observed for sarcoidosis (0.2%) followed by hemochromatosis (0.07%) and amyloidosis (0.04%). Underlying amyloidosis was associated with worse composite post-PCI outcomes (odds ratio [OR], 1.6; 95% CI, 1.1-2.44; P = .02), including higher in-hospital mortality (OR, 1.9; 95% CI, 1.1-3.4; P = .04), higher risk of intra/post-PCI stroke (OR, 4.0; 95% CI, 1.1-16.0; P = .04), but not major bleeding (OR, 2.2; 95% CI, 0.97-5.03; P = .058). In contrast, underlying sarcoidosis (OR, 1.1; 95% CI, 0.87-1.41; P = .4), and hemochromatosis (OR, 1.18; 95% CI, 0.77-1.8; P = .44) were not associated with composite post-PCI outcomes. Amyloidosis patients undergoing PCI also had higher hospitalization charges ($212,123 vs $141,137; P = .03) and longer length of stay (8.2 vs 3.9 days; P < .001). Conclusions Underlying amyloidosis was associated with worse post-PCI outcomes including higher in-hospital mortality, intra/post-PCI stroke, and socioeconomic burden. A multidisciplinary approach and future studies are needed to investigate the screening and treatment strategies in these patients.
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Affiliation(s)
- Bilal Hussain
- Department of Internal Medicine, The Brooklyn Hospital Center, Brooklyn, New York
| | - Hamza Malik
- Department of Internal Medicine, Central Michigan University, Saginaw, Michigan
| | - Mamas A. Mamas
- Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom
| | - Rupak Desai
- Division of Cardiology, Atlanta VA Medical Center, Decatur, Georgia
| | - Vikas Aggarwal
- Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Gautam Kumar
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - M. Chadi Alraies
- Division of Cardiology, Wayne State University/Detroit Medical Center, Detroit, Michigan
| | - Ankur Kalra
- Division of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Timir K. Paul
- Division of Cardiology, University of Tennessee Health Sciences Center at Nashville, Ascension St. Thomas Hospital, Nashville, Tennessee
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Duca F, Rettl R, Kronberger C, Poledniczek M, Binder C, Dalos D, Koschutnik M, Donà C, Beitzke D, Loewe C, Nitsche C, Hengstenberg C, Badr-Eslam R, Kastner J, Bergler-Klein J, Kammerlander AA. Amyloid Burden Correlates with Electrocardiographic Findings in Patients with Cardiac Amyloidosis-Insights from Histology and Cardiac Magnetic Resonance Imaging. J Clin Med 2024; 13:368. [PMID: 38256502 PMCID: PMC10816127 DOI: 10.3390/jcm13020368] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 12/28/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Cardiac amyloidosis (CA) is associated with several distinct electrocardiographic (ECG) changes. However, the impact of amyloid depositions on ECG parameters is not well investigated. We therefore aimed to assess the correlation of amyloid burden with ECG and test the prognostic power of ECG findings on outcomes in patients with CA. Consecutive CA patients underwent ECG assessment and cardiac magnetic resonance imaging (CMR), including the quantification of extracellular volume (ECV) with T1 mapping. Moreover, seven patients underwent additional amyloid quantification using immunohistochemistry staining of endomyocardial biopsies. A total of 105 CA patients (wild-type transthyretin: 74.3%, variant transthyretin: 8.6%, light chain: 17.1%) were analyzed for this study. We detected correlations of total QRS voltage with histologically quantified amyloid burden (r = -0.780, p = 0.039) and ECV (r = -0.266, p = 0.006). In patients above the ECV median (43.9%), PR intervals were significantly longer (p = 0.016) and left anterior fascicular blocks were more prevalent (p = 0.025). In our survival analysis, neither Kaplan-Meier curves (p = 0.996) nor Cox regression analysis detected associations of QRS voltage with adverse patient outcomes (hazard ratio: 0.995, p = 0.265). The present study demonstrated that an increased amyloid burden is associated with lower voltages in CA patients. However, baseline ECG findings, including QRS voltage, were not associated with adverse outcomes.
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Affiliation(s)
- Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - René Rettl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Christina Kronberger
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Michael Poledniczek
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Christina Binder
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Daniel Dalos
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Matthias Koschutnik
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Carolina Donà
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Dietrich Beitzke
- Division of Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (D.B.); (C.L.)
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (D.B.); (C.L.)
| | - Christian Nitsche
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Roza Badr-Eslam
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Johannes Kastner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Jutta Bergler-Klein
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Andreas Anselm Kammerlander
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
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Javed N, Singh K, Shirah J, Vittorio TJ. Associations of Patients with Pericardial Effusion Secondary to Light-Chain or Transthyretin Amyloidosis- A Systematic Review. Curr Cardiol Rev 2024; 20:e080324227805. [PMID: 38465427 PMCID: PMC11327831 DOI: 10.2174/011573403x280737240221060630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/27/2024] [Accepted: 02/06/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND Pericardial effusion is associated with amyloidosis, specifically amyloid light chain (AL) and transthyretin (ATTR) subtypes. However, the patients might present with different clinical symptoms. OBJECTIVE To determine the characteristics and associations of patients with pericardial effusion owing to either AL or ATTR amyloidosis. METHODS This study reviewed 26 studies from databases such as PubMed, MEDLINE, Web of Science, Google Scholar and CINAHL databases after protocol registration. The data were analyzed in IBM SPSS 21. Many statistical tests, such as Student t- and the Mann-Whitney U tests, were used. Multivariate logistic regression analysis was also performed. A p-value< 0.05 was considered significant. RESULTS A total of 531 patients with pericardial effusion secondary to amyloidosis were included. The mean age was 58.4±24.5 years. Most of the patients were male (72.9%). Common co-morbid conditions included hypertension (16.8%) and active smoking (12.9%). The most common time from symptom onset to the clinical presentation was less than 1 week (45%). ATTR amyloidosis was more common in older patients (p<0.05). Abdominal and chest discomfort were commonly associated with AL and ATTR amyloidosis, respectively (p<0.05). Patients with AL amyloidosis had a higher association with interventricular septal thickening and increased posterior wall thickness (p<0.05). First-degree atrioventricular block, left bundle branch block (LBBB), and atrial fibrillation (AF) were more associated with ATTR amyloidosis (p<0.05). CONCLUSION Pericardial effusion in patients with AL amyloidosis was associated with hypertrophic remodeling, while conduction abnormalities were associated with ATTR amyloidosis.
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Affiliation(s)
- Nismat Javed
- Department of Internal Medicine, BronxCare Health System, Bronx, NY, 10457, USA
| | - Kirit Singh
- St. George’s University School of Medicine, University Centre Grenada, West Indies, Grenada
| | - Justin Shirah
- American University of the Caribbean School of Medicine, University Drive at Jordan Dr, Philipsburg, Cupecoy, Sint Maarten
| | - Timothy J. Vittorio
- Department of Internal Medicine, BronxCare Health System, Bronx, NY, 10457, USA
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Khan NA, Bhandari BS, Jyothula S, Ocazionez D, Buryanek J, Jani PP. Pulmonary manifestations of amyloidosis. Respir Med 2023; 219:107426. [PMID: 37839615 DOI: 10.1016/j.rmed.2023.107426] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/28/2023] [Accepted: 10/08/2023] [Indexed: 10/17/2023]
Abstract
Amyloidosis is caused by abnormal protein deposition in various tissues, including the lungs. Pulmonary manifestations of amyloidosis may be categorized by areas of involvement, such as parenchymal, large airway and pleural involvement. We describe four distinct manifestations of amyloidosis involving the lung and review their clinical, radiological and pathological features and summarize the evidence for treatment in each of these presentations. We describe alveolar-septal amyloidosis, cystic amyloid lung disease, endobronchial amyloidosis and pleural amyloidosis.
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Affiliation(s)
- Nauman A Khan
- Department of Pulmonary, Critical Care and Sleep Medicine, McGovern School of Medicine, University of Texas McGovern Medical School, Houston, TX, USA.
| | - Bharat S Bhandari
- Department of Pulmonary, Critical Care and Sleep Medicine, McGovern School of Medicine, University of Texas McGovern Medical School, Houston, TX, USA
| | - Soma Jyothula
- Department of Pulmonary Medicine and Lung Transplant at Methodist Hospital, South Texas Medical Center, San Antonio, TX, USA
| | - Daniel Ocazionez
- Department of Diagnostic and Interventional Imaging, The University of Texas McGovern Medical School at Houston, Houston, TX, USA
| | - Jamie Buryanek
- Department of Pathology and Laboratory Medicine, The University of Texas McGovern Medical School, Houston, TX, USA, USA
| | - Pushan P Jani
- Department of Pulmonary, Critical Care and Sleep Medicine, McGovern School of Medicine, University of Texas McGovern Medical School, Houston, TX, USA
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Abstract
Cardiac amyloidosis (CA) occurs when the insoluble fibrils formed by misfolded precursor proteins deposit in cardiac tissues. The early clinical manifestations of CA are not evident, but it is easy to progress to refractory heart failure with an inferior prognosis. Echocardiography is the most commonly adopted non-invasive modality of imaging to visualize cardiac structures and functions, and the preferred modality in the evaluation of patients with cardiac symptoms and suspected CA, which plays a vital role in the diagnosis, prognosis, and long-term management of CA. The present review summarizes the echocardiographic manifestations of CA, new echocardiographic techniques, and the application of multi-parametric echocardiographic models in CA diagnosis.
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Affiliation(s)
- Shichu Liang
- Department of Cardiology, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, China
| | - Zhiyue Liu
- Department of Cardiology, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, China
| | - Qian Li
- Department of Cardiology, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, China
| | - Wenfeng He
- Department of Cardiology, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, China
| | - He Huang
- Department of Cardiology, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, China.
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10
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Peters AE, Solomon N, Chiswell K, Fonarow GC, Khouri MG, Baylor L, Alvir J, Bruno M, Huda A, Allen LA, Sharma K, DeVore AD, Greene SJ. Transthyretin amyloid cardiomyopathy among patients hospitalized for heart failure and performance of an adapted wild-type ATTR-CM machine learning model: Findings from GWTG-HF. Am Heart J 2023; 265:22-30. [PMID: 37400049 DOI: 10.1016/j.ahj.2023.06.013] [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] [Received: 06/27/2023] [Accepted: 06/27/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND An 11-factor random forest model has been developed among ambulatory heart failure (HF) patients for identifying potential wild-type amyloidogenic TTR cardiomyopathy (wtATTR-CM). The model has not been evaluated in a large sample of patients hospitalized for HF. METHODS This study included Medicare beneficiaries aged ≥65 years hospitalized for HF in the Get With The Guidelines-HF® Registry from 2008-2019. Patients with and without a diagnosis of ATTR-CM were compared, as defined by inpatient and outpatient claims data within 6 months pre- or post-index hospitalization. Within a cohort matched 1:1 by age and sex, univariable logistic regression was used to evaluate relationships between ATTR-CM and each of the 11 factors of the established model. Discrimination and calibration of the 11-factor model were assessed. RESULTS Among 205,545 patients (median age 81 years) hospitalized for HF across 608 hospitals, 627 patients (0.31%) had a diagnosis code for ATTR-CM. Univariable analysis within the 1:1 matched cohort of each of the 11-factors in the ATTR-CM model found pericardial effusion, carpal tunnel syndrome, lumbar spinal stenosis, and elevated serum enzymes (e.g., troponin elevation) to be strongly associated with ATTR-CM. The 11-factor model showed modest discrimination (c-statistic 0.65) and good calibration within the matched cohort. CONCLUSIONS Among US patients hospitalized for HF, the number of patients with ATTR-CM defined by diagnosis codes on an inpatient/outpatient claim within 6 months of admission was low. Most factors within the prior 11-factor model were associated with greater odds of ATTR-CM diagnosis. In this population, the ATTR-CM model demonstrated modest discrimination.
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Affiliation(s)
- Anthony E Peters
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | | | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, CA
| | - Michel G Khouri
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | | | | | | | | | - Larry A Allen
- Division of Cardiology & Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora, CO
| | - Kavita Sharma
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Adam D DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC.
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11
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Moody WE, Turvey-Haigh L, Knight D, Coats CJ, Cooper RM, Schofield R, Robinson S, Harkness A, Oxborough DL, Gillmore JD, Whelan C, Augustine DX, Fontana M, Steeds RP. British Society of Echocardiography guideline for the transthoracic echocardiographic assessment of cardiac amyloidosis. Echo Res Pract 2023; 10:13. [PMID: 37653443 PMCID: PMC10468878 DOI: 10.1186/s44156-023-00028-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023] Open
Abstract
These guidelines form an update of the BSE guideline protocol for the assessment of restrictive cardiomyopathy (Knight et al. in Echo Res Prac, 2013). Since the original recommendations were conceived in 2013, there has been an exponential rise in the diagnosis of cardiac amyloidosis fuelled by increased clinician awareness, improvements in cardiovascular imaging as well as the availability of new and effective disease modifying therapies. The initial diagnosis of cardiac amyloidosis can be challenging and is often not clear-cut on the basis of echocardiography, which for most patients presenting with heart failure symptoms remains the first-line imaging test. The role of a specialist echocardiographer will be to raise the suspicion of cardiac amyloidosis when appropriate, but the formal diagnosis of amyloid sub-type invariably requires further downstream testing. This document seeks to provide a focused review of the literature on echocardiography in cardiac amyloidosis highlighting its important role in the diagnosis, prognosis and screening of at risk individuals, before concluding with a suggested minimum data set, for use as an aide memoire when reporting.
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Affiliation(s)
- William E Moody
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2TH, UK.
- Institute of Cardiovascular Science, College of Medical and Dental Science, University of Birmingham, Birmingham, UK.
| | - Lauren Turvey-Haigh
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2TH, UK
| | - Daniel Knight
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | | | - Robert M Cooper
- Liverpool Heart and Chest Hospital, Liverpool, UK
- Liverpool John Moores University, Liverpool, UK
| | | | | | - Allan Harkness
- East Suffolk and North Essex NHS Foundation Trust, Essex, UK
| | - David L Oxborough
- Sports and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Julian D Gillmore
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Carol Whelan
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Daniel X Augustine
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Department For Health, University of Bath, Bath, UK
| | - Marianna Fontana
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Richard P Steeds
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2TH, UK
- Institute of Cardiovascular Science, College of Medical and Dental Science, University of Birmingham, Birmingham, UK
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12
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Pou C, Ferreiro L, Suárez-Antelo J, Golpe A, Álvarez-Dobaño JM, Toubes ME, Lama A, Rodríguez-Núñez N, Ricoy J, Rábade C, Lourido T, Valdés L. Characteristics of pleural effusion due to amyloidosis. Ann Thorac Med 2023; 18:53-60. [PMID: 37323369 PMCID: PMC10263077 DOI: 10.4103/atm.atm_433_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/01/2023] [Indexed: 06/17/2023] Open
Abstract
The characteristics of patients with pleural amyloidosis (PA) are poorly known. A systematic review was performed of studies reporting clinical findings, pleural fluid (PF) characteristics, and the most effective treatment of PA. Case descriptions and retrospective studies were included. The review included 95 studies with a total sample of 196 patients. The mean age was 63 years, male/female ratio was 1.6:1, and 91.9% of patients were >50 years. The most common symptom was dyspnea (88 patients). PF was generally serious (63%), predominantly lymphocytic, and with the biochemical characteristics of transudates (43.4%) or exudates (42.6%). Pleural effusion was generally bilateral (55%) and <1/3 of the hemithorax (50%), although in 21% pleural effusion (PE) exceeded 2/3. Pleural biopsy was performed in 67 patients (yield: 83.6%; 56/67) and was positive in 54% of exudates and 62.5% of unilateral effusions. Of the 251 treatments prescribed, only 31 were effective (12.4%). The combination of chemotherapy and corticosteroids was effective in 29.6% of cases, whereas talc pleurodesis was effective in 21.4% and indwelling pleural catheter in 75% of patients (only four patients). PA is more frequent in adults from 50 years of age. PF is usually bilateral, serous, and indistinctly a transudate or exudate. A pleural biopsy can aid in diagnosis if effusion is unilateral or an exudate. Treatments are rarely effective and there may be definitive therapeutic options for PE in these patients.
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Affiliation(s)
- Cristina Pou
- Department of Pulmonology, Álvaro Cunqueiro University Teaching Hospital, Vigo, Spain
| | - Lucía Ferreiro
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
- Interdisciplinary Research Group in Pulmonology, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Juan Suárez-Antelo
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Antonio Golpe
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
- Interdisciplinary Research Group in Pulmonology, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - José M. Álvarez-Dobaño
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
- Interdisciplinary Research Group in Pulmonology, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - María Elena Toubes
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Adriana Lama
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Nuria Rodríguez-Núñez
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Jorge Ricoy
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Carlos Rábade
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Tamara Lourido
- Department of Pulmonology, Álvaro Cunqueiro University Teaching Hospital, Vigo, Spain
| | - Luis Valdés
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
- Interdisciplinary Research Group in Pulmonology, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
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13
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Deep Learning to Classify AL versus ATTR Cardiac Amyloidosis MR Images. Biomedicines 2023; 11:biomedicines11010193. [PMID: 36672702 PMCID: PMC9855341 DOI: 10.3390/biomedicines11010193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/18/2022] [Accepted: 01/11/2023] [Indexed: 01/13/2023] Open
Abstract
The aim of this work was to compare the classification of cardiac MR-images of AL versus ATTR amyloidosis by neural networks and by experienced human readers. Cine-MR images and late gadolinium enhancement (LGE) images of 120 patients were studied (70 AL and 50 TTR). A VGG16 convolutional neural network (CNN) was trained with a 5-fold cross validation process, taking care to strictly distribute images of a given patient in either the training group or the test group. The analysis was performed at the patient level by averaging the predictions obtained for each image. The classification accuracy obtained between AL and ATTR amyloidosis was 0.750 for cine-CNN, 0.611 for Gado-CNN and between 0.617 and 0.675 for human readers. The corresponding AUC of the ROC curve was 0.839 for cine-CNN, 0.679 for gado-CNN (p < 0.004 vs. cine) and 0.714 for the best human reader (p < 0.007 vs. cine). Logistic regression with cine-CNN and gado-CNN, as well as analysis focused on the specific orientation plane, did not change the overall results. We conclude that cine-CNN leads to significantly better discrimination between AL and ATTR amyloidosis as compared to gado-CNN or human readers, but with lower performance than reported in studies where visual diagnosis is easy, and is currently suboptimal for clinical practice.
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14
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Markousis-Mavrogenis G, Giannakopoulou A, Belegrinos A, Pons MR, Bonou M, Vartela V, Papavasiliou A, Christidi A, Kourtidou S, Kolovou G, Bacopoulou F, Chrousos GP, Mavrogeni SI. Cardiovascular Magnetic Resonance Imaging Patterns in Rare Cardiovascular Diseases. J Clin Med 2022; 11:6403. [PMID: 36362632 PMCID: PMC9657782 DOI: 10.3390/jcm11216403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 08/27/2023] Open
Abstract
Rare cardiovascular diseases (RCDs) have low incidence but major clinical impact. RCDs' classification includes Class I-systemic circulation, Class II-pulmonary circulation, Class III-cardiomyopathies, Class IV-congenital cardiovascular diseases (CVD), Class V-cardiac tumors and CVD in malignancy, Class VI-cardiac arrhythmogenic disorders, Class VII-CVD in pregnancy, Class VIII-unclassified rare CVD. Cardiovascular Magnetic Resonance (CMR) is useful in the diagnosis/management of RCDs, as it performs angiography, function, perfusion, and tissue characterization in the same examination. Edema expressed as a high signal in STIRT2 or increased T2 mapping is common in acute/active inflammatory states. Diffuse subendocardial fibrosis, expressed as diffuse late gadolinium enhancement (LGE), is characteristic of microvascular disease as in systemic sclerosis, small vessel vasculitis, cardiac amyloidosis, and metabolic disorders. Replacement fibrosis, expressed as LGE, in the inferolateral wall of the left ventricle (LV) is typical of neuromuscular disorders. Patchy LGE with concurrent edema is typical of myocarditis, irrespective of the cause. Cardiac hypertrophy is characteristic in hypertrophic cardiomyopathy (HCM), cardiac amyloidosis (CA) and Anderson-Fabry Disease (AFD), but LGE is located in the IVS, subendocardium and lateral wall in HCM, CA and AFD, respectively. Native T1 mapping is increased in HCM and CA and reduced in AFD. Magnetic resonance angiography provides information on aortopathies, such as Marfan, Turner syndrome and Takayasu vasculitis. LGE in the right ventricle is the typical finding of ARVC, but it may involve LV, leading to the diagnosis of arrhythmogenic cardiomyopathy. Tissue changes in RCDs may be detected only through parametric imaging indices.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Flora Bacopoulou
- University Research Institute for Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Center for Adolescent Medicine and UNESCO Chair on Adolescent Health Care, First Department of Pediatrics, “Agia Sophia” Children’s Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - George P. Chrousos
- University Research Institute for Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Center for Adolescent Medicine and UNESCO Chair on Adolescent Health Care, First Department of Pediatrics, “Agia Sophia” Children’s Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Sophie I. Mavrogeni
- Onassis Cardiac Surgery Center, 17674 Athens, Greece
- University Research Institute for Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Center for Adolescent Medicine and UNESCO Chair on Adolescent Health Care, First Department of Pediatrics, “Agia Sophia” Children’s Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
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15
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Characteristics and prognostic value of pleural effusion in secondary hemophagocytic lymphohistiocytosis. Int J Hematol 2022; 116:102-109. [PMID: 35338447 PMCID: PMC8956144 DOI: 10.1007/s12185-022-03333-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 03/10/2022] [Accepted: 03/10/2022] [Indexed: 12/04/2022]
Abstract
The clinical features of patients with secondary hemophagocytic lymphohistiocytosis (sHLH) complicated with pleural effusion have rarely been evaluated. We retrospectively analyzed 203 patients newly diagnosed with sHLH from July 2015 to July 2019 according to the HLH-2004 protocol. Baseline characteristics, laboratory results, and imaging were reviewed. Pleural effusion was found in 58.6% of the studied sHLH population, and characteristic imaging findings were minimal volume and bilaterality. Patients with pleural effusion had lower PLT counts, HB levels and ALB levels as well as higher sCD25 levels than those without pleural effusion (all p values < 0.05). Multivariate analyses showed that lg(sCD25) and PLT ≤ 65 × 109/L were significant risk factors for developing pleural effusion in sHLH. Regarding prognostic value, survival analysis showed a lower survival probability for patients with pleural effusion than for those without pleural effusion (median OS, 90 vs. 164 days, p = 0.028). In multivariate analysis, pleural effusion was an independent prognostic factor for overall survival (OS) (HR 2.68; 95% CI 1.18–6.11, p = 0.019). Pleural effusion is frequently found in patients with sHLH and is associated with greater inflammation and worse outcomes.
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16
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Scheel PJ, Mukherjee M, Hays AG, Vaishnav J. Multimodality Imaging in the Evaluation and Prognostication of Cardiac Amyloidosis. Front Cardiovasc Med 2022; 9:787618. [PMID: 35402557 PMCID: PMC8989413 DOI: 10.3389/fcvm.2022.787618] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy resulting from deposition of misfolded immunoglobulin light chains (AL-CA) or transthyretin (ATTR-CA) proteins in the myocardium. Survival varies between the different subtypes of amyloidosis and degree of cardiac involvement, but accurate diagnosis is essential to ensure initiation of therapeutic interventions that may slow or potentially prevent morbidity and mortality in these patients. As there are now effective treatment options for CA, identifying underlying disease pathogenesis is crucial and can be guided by multimodality imaging techniques such as echocardiography, magnetic resonance imaging, and nuclear scanning modalities. However, as use of cardiac imaging is becoming more widespread, understanding optimal applications and potential shortcomings is increasingly important. Additionally, certain imaging modalities can provide prognostic information and may affect treatment planning. In patients whom imaging remains non-diagnostic, tissue biopsy, specifically endomyocardial biopsy, continues to play an essential role and can facilitate accurate and timely diagnosis such that appropriate treatment can be started. In this review, we examine the multimodality imaging approach to the diagnosis of CA with particular emphasis on the prognostic utility and limitations of each imaging modality. We also discuss how imaging can guide the decision to pursue tissue biopsy for timely diagnosis of CA.
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17
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Baker KR. Light Chain Amyloidosis: Epidemiology, Staging, and Prognostication. Methodist Debakey Cardiovasc J 2022; 18:27-35. [PMID: 35414848 PMCID: PMC8932379 DOI: 10.14797/mdcvj.1070] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/02/2022] [Indexed: 12/19/2022] Open
Abstract
Amyloidosis is a disorder of protein misfolding and metabolism in which insoluble fibrils are deposited in various tissues, causing organ dysfunction and eventually death. Out of the 60-plus heterogeneous amyloidogenic proteins that have been identified, approximately 30 are associated with human disease. The unifying feature of these proteins is their tendency to form beta-pleated sheets aligned in an antiparallel fashion. These sheets then form rigid, nonbranching fibrils that resist proteolysis, causing mechanical disruption and local oxidative stress in affected organs such as the heart, liver, kidneys, nervous system, and gastrointestinal tract. Here we review the epidemiology of light chain amyloidosis, the staging, and the concomitant prognostication that is critical in determining the appropriate treatment.
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18
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Karpathiou G, Péoc’h M, Sundaralingam A, Rahman N, Froudarakis ME. Inflammation of the Pleural Cavity: A Review on Pathogenesis, Diagnosis and Implications in Tumor Pathophysiology. Cancers (Basel) 2022; 14:1415. [PMID: 35326567 PMCID: PMC8946533 DOI: 10.3390/cancers14061415] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/08/2022] [Accepted: 03/08/2022] [Indexed: 12/12/2022] Open
Abstract
Pleural effusions are a common respiratory condition with many etiologies. Nonmalignant etiologies explain most pleural effusions and despite being nonmalignant, they can be associated with poor survival; thus, it is important to understand their pathophysiology. Furthermore, diagnosing a benign pleural pathology always harbors the uncertainty of a false-negative diagnosis for physicians and pathologists, especially for the group of non-specific pleuritis. This review aims to present the role of the inflammation in the development of benign pleural effusions, with a special interest in their pathophysiology and their association with malignancy.
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Affiliation(s)
- Georgia Karpathiou
- Pathology Department, University Hospital of Saint-Etienne, 42055 Saint-Etienne, France;
| | - Michel Péoc’h
- Pathology Department, University Hospital of Saint-Etienne, 42055 Saint-Etienne, France;
| | - Anand Sundaralingam
- Oxford Centre for Respiratory Medicine, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7LE, UK; (A.S.); (N.R.)
| | - Najib Rahman
- Oxford Centre for Respiratory Medicine, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7LE, UK; (A.S.); (N.R.)
| | - Marios E. Froudarakis
- Pneumonology and Thoracic Oncology Department, University Hospital of Saint-Etienne, 42055 Saint-Etienne, France;
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19
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Wu Y, Pu C, Zhu W, He C, Fei J, Hu H. A Risk Score to Diagnose Cardiac Involvement and Provide Prognosis Information in Patients at Risk of Cardiac Light-Chain Amyloidosis. Front Cardiovasc Med 2022; 9:817456. [PMID: 35355963 PMCID: PMC8959494 DOI: 10.3389/fcvm.2022.817456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/14/2022] [Indexed: 12/14/2022] Open
Abstract
Background Cardiac light-chain amyloidosis (AL CA) portends poor prognosis. Contrast cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE) imaging is an important tool in recognizing AL CA. But contraindications to contrast CMR would significantly restrict its clinical application value. Our study aims to construct a convenient risk score to help identify cardiac involvement in patients at risk of AL CA. Moreover, we also investigate whether this risk score could provide prognosis information. Materials and Methods Sixty-three patients at risk of AL CA were retrospectively included in our study. Basic clinical characters, lab results, 12-lead electrocardiogram data, and cardiac magnetic resonance image data were collected. AL CA was diagnosed according to typical CA LGE pattern. Logistic analysis was used to figure out predictive parameters of AL CA and their β coefficients, further constructing the risk score. Receiver operating characteristics (ROC) curve was used to find the cut-off point best distinguishing AL CA+ from AL CA–patients. Bootstrapping was used for internal validation. All patients were divided into high-risk and low-risk group according to the diagnostic cut-off point, and followed up for survival information. Kaplan-Meier plots and log-rank test were performed to analyze if this score had prognostic value. Results The risk score finally consisted of 4 parameters: pericardial effusion (PE) (1 point), low electrocardiographic QRS voltages (LQRSV) (1 point), CMR-derived impaired global radial strain (GRS) (<15.14%) (1 point) and increased left ventricular maximum wall thickness (LVMWT) (>13 mm) (2 points). Total score ranged from 0 to 5 points. A cut-off point of 1.5 showed highest accuracy in diagnosing AL CA with an AUC of 0.961 (95% CI: 0.924–0.997, sensitivity: 90.6%, specificity: 83.9%). Kaplan-Meier plots and log-rank test showed that the high-risk group had significantly poor overall survival rates. Conclusion In patients at risk of AL CA, a risk score incorporating the presence of PE, LQRSV, and CMR-derived impaired GRS and increased LVMWT is predictive of a diagnosis of AL CA by LGE criteria. This risk score may be helpful especially when contrast CMR is not available or contraindicated, and further studies should be considered to validate this score.
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Affiliation(s)
- Yan Wu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Cailing Pu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wenchao Zhu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chengbin He
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingle Fei
- Department of Radiology, Lishui Central Hospital, Lishui, China
| | - Hongjie Hu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Hongjie Hu
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20
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Jung MH, Chang S, Han EJ, Youn JC. Multimodal Imaging and Biomarkers in Cardiac Amyloidosis. Diagnostics (Basel) 2022; 12:627. [PMID: 35328180 PMCID: PMC8946926 DOI: 10.3390/diagnostics12030627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/12/2022] [Accepted: 01/28/2022] [Indexed: 01/15/2023] Open
Abstract
Amyloidosis is a progressive infiltrative disease instigated by the extracellular deposition of amyloid fibrils in various organs such as the heart, kidney, and peripheral nerves. Cardiac amyloid deposits cause restrictive cardiomyopathy, leading to a poor prognosis in systemic amyloidosis. The most common etiologies of cardiac amyloidosis (CA) are immunoglobulin light chain deposits (AL-CA) and misfolded transthyretin deposits (ATTR-CA). In recent years, many developments have been accomplished in the field of diagnosis and treatment of CA. At present, ATTR-CA can be noninvasively diagnosed if the following two conditions are fulfilled in the setting of typical echocardiographic/cardiac MRI findings: (1) grade 2 or 3 myocardial uptake in bone scintigraphy confirmed by SPECT and (2) absence of monoclonal protein confirmed by serum-free light chain assay, and serum/urine protein electrophoresis with immunofixation test. Effective therapies are evolving in both types of CA (tafamidis for ATTR-CA and immunologic treatments for AL-CA). Thus, early suspicion and prompt diagnosis are crucial for achieving better outcomes. In this review, we have summarized the role of multimodal imaging (e.g., echocardiography, cardiac MRI, and bone scintigraphy) and biomarkers (e.g., troponin, BNP) in the diagnosis, risk stratification, and treatment monitoring of CA.
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Affiliation(s)
- Mi-Hyang Jung
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Suyon Chang
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Eun Ji Han
- Division of Nuclear Medicine, Department of Radiology, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Jong-Chan Youn
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
- Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
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21
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Germain P, Vardazaryan A, Padoy N, Labani A, Roy C, Schindler TH, El Ghannudi S. Deep Learning Supplants Visual Analysis by Experienced Operators for the Diagnosis of Cardiac Amyloidosis by Cine-CMR. Diagnostics (Basel) 2021; 12:diagnostics12010069. [PMID: 35054236 PMCID: PMC8774777 DOI: 10.3390/diagnostics12010069] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/24/2021] [Accepted: 12/27/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Diagnosing cardiac amyloidosis (CA) from cine-CMR (cardiac magnetic resonance) alone is not reliable. In this study, we tested if a convolutional neural network (CNN) could outperform the visual diagnosis of experienced operators. Method: 119 patients with cardiac amyloidosis and 122 patients with left ventricular hypertrophy (LVH) of other origins were retrospectively selected. Diastolic and systolic cine-CMR images were preprocessed and labeled. A dual-input visual geometry group (VGG ) model was used for binary image classification. All images belonging to the same patient were distributed in the same set. Accuracy and area under the curve (AUC) were calculated per frame and per patient from a 40% held-out test set. Results were compared to a visual analysis assessed by three experienced operators. Results: frame-based comparisons between humans and a CNN provided an accuracy of 0.605 vs. 0.746 (p < 0.0008) and an AUC of 0.630 vs. 0.824 (p < 0.0001). Patient-based comparisons provided an accuracy of 0.660 vs. 0.825 (p < 0.008) and an AUC of 0.727 vs. 0.895 (p < 0.002). Conclusion: based on cine-CMR images alone, a CNN is able to discriminate cardiac amyloidosis from LVH of other origins better than experienced human operators (15 to 20 points more in absolute value for accuracy and AUC), demonstrating a unique capability to identify what the eyes cannot see through classical radiological analysis.
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Affiliation(s)
- Philippe Germain
- Department of Radiology, Nouvel Hopital Civil, University Hospital, 67000 Strasbourg, France; (A.L.); (C.R.); (S.E.G.)
- Correspondence:
| | - Armine Vardazaryan
- ICube, University of Strasbourg, CNRS, 67000 Strasbourg, France; (A.V.); (N.P.)
- IHU (Institut Hopitalo-Universitaire), 67000 Strasbourg, France
| | - Nicolas Padoy
- ICube, University of Strasbourg, CNRS, 67000 Strasbourg, France; (A.V.); (N.P.)
- IHU (Institut Hopitalo-Universitaire), 67000 Strasbourg, France
| | - Aissam Labani
- Department of Radiology, Nouvel Hopital Civil, University Hospital, 67000 Strasbourg, France; (A.L.); (C.R.); (S.E.G.)
| | - Catherine Roy
- Department of Radiology, Nouvel Hopital Civil, University Hospital, 67000 Strasbourg, France; (A.L.); (C.R.); (S.E.G.)
| | - Thomas Hellmut Schindler
- Mallinckrodt Institute of Radiology, Division of Nuclear Medicine, Washington University School of Medicine, Saint Louis, MO 63110, USA;
| | - Soraya El Ghannudi
- Department of Radiology, Nouvel Hopital Civil, University Hospital, 67000 Strasbourg, France; (A.L.); (C.R.); (S.E.G.)
- Department of Nuclear Medicine, Nouvel Hopital Civil, University Hospital, 67000 Strasbourg, France
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22
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[Cardiac amyloidosis and aortic valve stenosis]. Herz 2021; 46:485-496. [PMID: 34487196 DOI: 10.1007/s00059-021-05054-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 10/20/2022]
Abstract
Aortic valve stenosis in old age has become a topic of interest for cardiology and cardiac surgery after the development of transvascular and transluminal minimally invasive techniques for aortic valve implantation. The observation of amyloid deposits in surgically excised valvular material led to the diagnostics of amyloidosis of the myocardium, which was discovered in up to 20% of the patients who underwent valve implantation. Clinical signs of cardiac amyloidosis, such as carpal tunnel syndrome and ruptured distal biceps tendon should be taken into account. In addition to the electrocardiogram (ECG), echocardiogram and magnetic resonance imaging, 99mtechnetium bone scintigraphy plays a key diagnostic role. The simultaneous occurrence of severe aortic valve stenosis and amyloidosis explains the special hemodynamic situation of a low gradient with low blood flow in high-grade valve stenosis. The interventional or surgical valve implantation improves the prognosis for these patients, similarly to aortic valve stenosis alone, followed by a specific pharmaceutical treatment depending on the type of amyloidosis.
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23
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Abstract
Cardiac amyloidosis, a form of infiltrative cardiomyopathy, is associated with poor prognosis in untreated patients. Early diagnosis is important for timely initiation of effective therapies. Despite advances in diagnostic modalities, it remains a challenging diagnosis, requiring high index of clinical suspicion. Echocardiography represents the first-line cardiac imaging modality for evaluation of heart failure and suspected cardiac amyloidosis. In this review, we discuss echocardiographic findings in cardiac amyloidosis.
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24
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Tumoral Phenocopies of Hypertrophic Cardiomyopathy: The Role of Cardiac Magnetic Resonance. J Clin Med 2021; 10:jcm10081683. [PMID: 33919877 PMCID: PMC8070813 DOI: 10.3390/jcm10081683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/01/2021] [Accepted: 04/09/2021] [Indexed: 12/04/2022] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is a genetic cardiac disease that presents with cardiac hypertrophy. HCM phenocopies are clinical conditions that are phenotypically undistinguishable from HCM, but with a different underlying etiology. Cardiac tumors are rare entities that can sometimes mimic HCM in their echocardiographic appearance, thus representing an example of HCM phenocopy. At present, only case reports of tumoral HCM phenocopies can be found in literature. In this systematic review, we analyzed all the published cases in which a cardiac tumor mimicked HCM to the point of misleading the diagnosis, providing a structured overview of the currently available evidence on this topic.
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