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Deeb K, Korzhuk A. Cardiac Amyloidosis in the Setting of a Sarcomatous Pericardial Mass. Cureus 2023; 15:e40807. [PMID: 37485202 PMCID: PMC10362886 DOI: 10.7759/cureus.40807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 07/25/2023] Open
Abstract
Cardiac amyloidosis is a significantly underdiagnosed disease but should be suspected in anyone with restrictive heart physiology. Here, we present a case of a sarcomatous pericardial mass confounding the patient's progressive diastolic heart failure. Amyloidosis was eventually discovered by piecing together serial transthoracic echocardiogram, functional MRI, and technetium-99m (99mTc) pyrophosphate scintigraphy findings along with a negative lab workup. The presence of the sarcomatous pericardial mass raised the question of whether it played a role in the onset and progression of amyloidosis, but nonetheless, the presence of both diseases rendered multifaceted challenges regarding our patient's care. Anyone suspected to have amyloidosis should receive appropriate testing for a definitive diagnosis to catch the disease process and offer early treatment, as exciting research is emerging showing transthyretin stabilizers to have a reduction in all-cause mortality.
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Affiliation(s)
- Khaled Deeb
- Internal Medicine, West Palm Beach VA Medical Center, West Palm Beach, USA
| | - Anatoliy Korzhuk
- Internal Medicine, West Palm Beach VA Medical Center, West Palm Beach, USA
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2
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Chamova T, Gospodinova M, Asenov O, Todorov T, Pavlova Z, Kirov A, Cherninkova S, Kastreva K, Taneva A, Blagoeva S, Zhelyazkova S, Antimov P, Chobanov K, Todorova A, Tournev I. Seven Years of Selective Genetic Screening Program and Follow-Up of Asymptomatic Carriers With Hereditary Transthyretin Amyloidosis in Bulgaria. Front Neurol 2022; 13:844595. [PMID: 35463150 PMCID: PMC9024406 DOI: 10.3389/fneur.2022.844595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 02/28/2022] [Indexed: 11/28/2022] Open
Abstract
Hereditary transthyretin amyloidosis (ATTRv amyloidosis) is a rare, autosomal-dominant (AD) multisystem disorder resulting from the extracellular deposition of amyloid fibrils formed by a destabilized mutant form of transthyretin (TTR), a transport protein predominantly produced by the liver.
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Affiliation(s)
- Teodora Chamova
- Department of Neurology, Expert Centre for Hereditary Neurologic and Metabolic Disorders, University Hospital “Alexandrovska”, Medical University-Sofia, Sofia, Bulgaria
- *Correspondence: Teodora Chamova
| | - Mariana Gospodinova
- Expert Center for Transthyretin Cardiac Amyloidosis, University Hospital “St Ivan Rilski”, Sofia, Bulgaria
| | - Ognian Asenov
- Department of Neurology, Expert Centre for Hereditary Neurologic and Metabolic Disorders, University Hospital “Alexandrovska”, Medical University-Sofia, Sofia, Bulgaria
| | - Tihomir Todorov
- Independent Medico-Diagnostic Laboratory Genome Center “Bulgaria”, Sofia, Bulgaria
- Genetic Medico-Diagnostic Laboratory Genica, Sofia, Bulgaria
| | - Zornitsa Pavlova
- Independent Medico-Diagnostic Laboratory Genome Center “Bulgaria”, Sofia, Bulgaria
- Genetic Medico-Diagnostic Laboratory Genica, Sofia, Bulgaria
- Department of Medical Chemistry and Biochemistry, Medical University Sofia, Sofia, Bulgaria
| | - Andrey Kirov
- Independent Medico-Diagnostic Laboratory Genome Center “Bulgaria”, Sofia, Bulgaria
- Genetic Medico-Diagnostic Laboratory Genica, Sofia, Bulgaria
| | - Sylvia Cherninkova
- Department of Neurology, Expert Centre for Hereditary Neurologic and Metabolic Disorders, University Hospital “Alexandrovska”, Medical University-Sofia, Sofia, Bulgaria
| | - Kristina Kastreva
- Department of Neurology, Expert Centre for Hereditary Neurologic and Metabolic Disorders, University Hospital “Alexandrovska”, Medical University-Sofia, Sofia, Bulgaria
| | - Ani Taneva
- Department of Neurology, Expert Centre for Hereditary Neurologic and Metabolic Disorders, University Hospital “Alexandrovska”, Medical University-Sofia, Sofia, Bulgaria
| | - Stanislava Blagoeva
- Department of Neurology, Expert Centre for Hereditary Neurologic and Metabolic Disorders, University Hospital “Alexandrovska”, Medical University-Sofia, Sofia, Bulgaria
| | - Sashka Zhelyazkova
- Department of Neurology, Expert Centre for Hereditary Neurologic and Metabolic Disorders, University Hospital “Alexandrovska”, Medical University-Sofia, Sofia, Bulgaria
| | - Plamen Antimov
- Department of Neurology, Expert Centre for Hereditary Neurologic and Metabolic Disorders, University Hospital “Alexandrovska”, Medical University-Sofia, Sofia, Bulgaria
| | - Kaloian Chobanov
- Department of Neurology, Expert Centre for Hereditary Neurologic and Metabolic Disorders, University Hospital “Alexandrovska”, Medical University-Sofia, Sofia, Bulgaria
| | - Albena Todorova
- Independent Medico-Diagnostic Laboratory Genome Center “Bulgaria”, Sofia, Bulgaria
- Genetic Medico-Diagnostic Laboratory Genica, Sofia, Bulgaria
- Department of Medical Chemistry and Biochemistry, Medical University Sofia, Sofia, Bulgaria
| | - Ivailo Tournev
- Department of Neurology, Expert Centre for Hereditary Neurologic and Metabolic Disorders, University Hospital “Alexandrovska”, Medical University-Sofia, Sofia, Bulgaria
- Department of Cognitive Science and Psychology, New Bulgarian University, Sofia, Bulgaria
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3
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Amyloid Cardiomyopathy in Older Adults. CURRENT GERIATRICS REPORTS 2022. [DOI: 10.1007/s13670-022-00374-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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4
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Stone JR. Diseases of small and medium-sized blood vessels. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00020-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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5
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Teng C, Li P, Bae JY, Pan S, Dixon RAF, Liu Q. Diagnosis and treatment of transthyretin-related amyloidosis cardiomyopathy. Clin Cardiol 2020; 43:1223-1231. [PMID: 32725834 PMCID: PMC7661658 DOI: 10.1002/clc.23434] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/15/2020] [Accepted: 07/17/2020] [Indexed: 12/29/2022] Open
Abstract
Transthyretin-related amyloidosis (ATTR) is a subgroup of amyloidosis that results from extracellular misassembled and toxic amyloid deposits affecting multiple organ systems, and cardiac tissues in particular. Because ATTR often presents as heart failure with preserved ejection fraction (HFpEF), it has been largely underdiagnosed. Once considered incurable with a grave prognosis, ATTR cardiomyopathy has seen the development of promising alternatives for diagnosis and treatment, with early diagnosis and treatment of ATTR cardiomyopathy highly beneficial due to its high mortality rate. For instance, diagnosing ATTR cardiomyopathy previously required a cardiac biopsy, but new modalities, such as cardiac magnetic resonance imaging and radionuclide bone scans, show promise in accurately diagnosing ATTR cardiomyopathy. Ongoing research and clinical trials have focused on identifying new treatments which primarily target amyloid fiber formation by inhibiting TTR gene expression, stabilizing the TTR tetramer, preventing oligomer aggregation, or affecting degradation of amyloid fibers. In this review, we describe the advances made in the diagnosis and treatment of ATTR in order to increase awareness of the disease and encourage a lower threshold for ATTR workup. Our review also highlights the need for improving the screening, diagnosis, and treatment guidelines for ATTR cardiomyopathy.
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Affiliation(s)
- Catherine Teng
- Department of MedicineYale New Haven Health‐Greenwich HospitalGreenwichConnecticutUSA
| | - Pengyang Li
- Department of MedicineSaint Vincent HospitalWorcesterMassachusettsUSA
| | - Ju Young Bae
- Department of MedicineYale New Haven Health‐Greenwich HospitalGreenwichConnecticutUSA
| | - Su Pan
- Molecular Cardiology ResearchTexas Heart InstituteHoustonTexasUSA
| | | | - Qi Liu
- Molecular Cardiology ResearchTexas Heart InstituteHoustonTexasUSA
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6
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Gospodinova M, Sarafov S, Chamova T, Kirov A, Todorov T, Nakov R, Todorova A, Denchev S, Tournev I. Cardiac involvement, morbidity and mortality in hereditary transthyretin amyloidosis because of p.Glu89Gln mutation. J Cardiovasc Med (Hagerstown) 2020; 21:688-695. [PMID: 32740500 DOI: 10.2459/jcm.0000000000001036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Hereditary transthyretin amyloidosis is a systemic infiltrative disease, caused by a mutation in the transthyretin gene. p.Glu89Gln is the most common mutation in the Balkan countries. METHODS We evaluated the clinical manifestations, cardiac involvement, morbidity and mortality in 78 patients with p.Glu89Gln mutation, verified through a DNA analysis. Clinical assessment, electrocardiogram and echocardiography were performed at the time of diagnosis. The patients have been followed for 30 months. RESULTS All included patients were Caucasian, 39 (50%) - men, with median age at diagnosis of 56 years (42-73), median age at onset -- 53 years (35-69), starting significantly earlier in men (4.36, P = 0.004). Cardiac and neurological involvement was found in 74 (95%) patients. Pathological ECG was present in 65 (84%) patients, infarct pattern in 43 (56%), low voltage in 24 (31%). Echocardiography revealed an infiltrative cardiomyopathy with restrictive filling in 31 (40%) and ejection fraction less than 50% in 20 (27%) patients. Twenty-two patients (28%) died: 14 (64%) because of advanced heart failure, 6 (27%) died suddenly, 2 (9%) from an ischemic stroke. The median age at death was 58.5 years (52-72). No statistically significant sex difference in survival was observed; a significant difference in survival was found for the New York Heart Association class, familial amyloidotic polyneuropathy stage, ejection fraction, filling pattern and tafamidis treatment. CONCLUSION Cardiac involvement is common and has significant prognostic implications in the evaluated patients with p.Glu89Gln mutation. Heart failure and rhythm disturbances are the main causes of death. An earlier identification of the disease is crucial to improve prognosis.
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Affiliation(s)
| | - Stayko Sarafov
- Clinic of Neurology, Aleksandrovska University Hospital, Medical University Sofia
| | - Teodora Chamova
- Clinic of Neurology, Aleksandrovska University Hospital, Medical University Sofia
| | - Andrey Kirov
- Genetic Medico-Diagnostic Laboratory 'Genica'.,Department of Medical Chemistry and Biochemistry, Medical University Sofia
| | | | - Radislav Nakov
- Clinic of Gastroenterology, Tsaritsa Yoanna University Hospital Sofia
| | - Albena Todorova
- Genetic Medico-Diagnostic Laboratory 'Genica'.,Department of Medical Chemistry and Biochemistry, Medical University Sofia
| | - Stefan Denchev
- Clinic of Cardiology, Medical Institute, Ministry of Interior Sofia
| | - Ivailo Tournev
- Clinic of Neurology, Aleksandrovska University Hospital, Medical University Sofia.,Department of Cognitive Science and Psychology, New Bulgarian University, Sofia, Bulgaria
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7
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Schwartzlow C, Kazamel M. Hereditary Transthyretin Amyloidosis: Clinical Presentation and Management Updates. J Clin Neuromuscul Dis 2020; 21:144-156. [PMID: 32073460 DOI: 10.1097/cnd.0000000000000270] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Hereditary transthyretin amyloidosis, once a rare progressive neuropathy and/or cardiomyopathy, is now recognized with increasing worldwide frequency, various phenotypes, and over 130 gene mutations identified to date. This inherited disorder develops as a result of mutated transthyretin amyloid aggregation and systematic deposition throughout the body. With increasing knowledge about the pathophysiology of this disease, new disease-modifying therapies are being developed. In addition to slowing progression, these new agents were found to improve quality of life and reduce the severity of neuropathic symptoms. Two new gene-modifying therapies recently received Food and Drug Administration approval following the positive results from phase III trials. These include an antisense oligonucleotide, inotersen, and small interfering RNA, patisiran, which were reported to reduce the production of transthyretin and had promising safety profiles. Additional novel therapies are being explored with hopes to prolong survival. Therefore, early diagnosis of this treatable disorder has become increasingly important in clinical practice.
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Affiliation(s)
- Coreen Schwartzlow
- Department of Neurology, The University of Alabama at Birmingham, Birmingham, AL
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8
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Di Giovanni B, Gustafson D, Adamson MB, Delgado DH. Hiding in Plain Sight: Cardiac Amyloidosis, an Emerging Epidemic. Can J Cardiol 2019; 36:373-383. [PMID: 32145865 DOI: 10.1016/j.cjca.2019.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/09/2019] [Accepted: 12/09/2019] [Indexed: 12/13/2022] Open
Abstract
Amyloidosis is a term used to describe a group of rare heterogeneous diseases that ultimately result in the deposition and accumulation of misfolded proteins. These misfolded proteins, known as amyloids, are associated with a variety of precursor proteins that have amyloidogenic potential. Ultimately, the specific type of amyloidosis is dependent on multiple factors including genetic variability of precursor proteins and the tissue or organ in which the amyloid accumulates. Several types of amyloid have a predilection for the heart and thus contribute to cardiac amyloidosis, a major cause of restrictive cardiomyopathy. Individuals with cardiac amyloidosis present clinically with heart failure with preserved ejection fraction. Although improved diagnostics and increased awareness of cardiac amyloidosis have led to a relative increase in diagnosis, cardiac amyloidosis remains an underrecognized and underdiagnosed cause of heart failure with preserved ejection fraction. It is essential to properly identify cases of cardiac amyloidosis and determine the pathology responsible for the formation of amyloid to appropriately provide management. This review aims to encourage physician awareness of cardiac amyloidosis by focusing on clinical presentation and the distinctions between types. Furthermore, epidemiology is central to understanding the affected demographics and sometimes hereditary nature of the disease. Improved understanding of cardiac amyloidosis will ideally lead to earlier diagnosis and interventions to improve patient outcomes.
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Affiliation(s)
- Bennett Di Giovanni
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
| | - Dakota Gustafson
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Mitchell B Adamson
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Diego H Delgado
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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9
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Kirov A, Sarafov S, Pavlova Z, Todorov T, Chamova T, Gospodinova M, Tournev I, Mitev V, Todorova A. Founder effect of the Glu89Gln TTR mutation in the Bulgarian population. Amyloid 2019; 26:181-185. [PMID: 31353960 DOI: 10.1080/13506129.2019.1634539] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Hereditary transthyretin amyloidosis is an autosomal dominant genetic disorder caused by missense mutations in the TTR gene resulting in amyloid formation of the transthyretin protein. Depending on the system affection, the manifestations may be different and high heterogeneity in the penetrance is observed. An endemic region in Bulgaria exists where the TTR mutation Glu89Gln is found with high frequency. This is a rare mutation and was probably introduced in the population by a common ancestor. This phenomenon, called "founder effect" was proved in carrier families by haplotype analysis of microsatellite markers showing linkage disequilibrium. Allele frequencies were analyzed and haplotype reconstruction was done with Arlequin v.3.01 software. The common ancestry of the carriers was demonstrated using additional data for their genealogies and microsatellite data from a control group of non-affected individuals. The results show that the mutation Glu89Gln is linked to one haplotype, called "hypothetical founder haplotype" which was compared to published haplotype data from other European patients and no similarity was found. Further population genetics studies of carriers of the Glu89Gln mutation from other endemic regions are required in order to clarify the geographical distribution of the mutation.
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Affiliation(s)
- Andrey Kirov
- Genetic Medico-Diagnostic Laboratory Genica , Sofia , Bulgaria
| | - Stayko Sarafov
- Clinic of Nervous Diseases, UMBAL Aleksandrovska , Sofia , Bulgaria.,Department of Neurology, Medical University Sofia , Sofia , Bulgaria
| | - Zornitza Pavlova
- Genetic Medico-Diagnostic Laboratory Genica , Sofia , Bulgaria.,Genome Center "Bulgaria" , Sofia , Bulgaria.,Department of Medical Chemistry and Biochemistry, Medical University Sofia , Sofia , Bulgaria
| | - Tihomir Todorov
- Genetic Medico-Diagnostic Laboratory Genica , Sofia , Bulgaria.,Genome Center "Bulgaria" , Sofia , Bulgaria
| | - Teodora Chamova
- Clinic of Nervous Diseases, UMBAL Aleksandrovska , Sofia , Bulgaria
| | | | - Ivailo Tournev
- Clinic of Nervous Diseases, UMBAL Aleksandrovska , Sofia , Bulgaria.,Department for Cognitive Science and Psychology, New Bulgarian University , Sofia , Bulgaria
| | - Vanyo Mitev
- Department of Medical Chemistry and Biochemistry, Medical University Sofia , Sofia , Bulgaria
| | - Albena Todorova
- Genetic Medico-Diagnostic Laboratory Genica , Sofia , Bulgaria.,Genome Center "Bulgaria" , Sofia , Bulgaria.,Department of Medical Chemistry and Biochemistry, Medical University Sofia , Sofia , Bulgaria
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10
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Prevalence of cardiac amyloidosis among adult patients referred to tertiary centres with an initial diagnosis of hypertrophic cardiomyopathy. Int J Cardiol 2019; 300:191-195. [PMID: 31371117 DOI: 10.1016/j.ijcard.2019.07.051] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/15/2019] [Accepted: 07/15/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Differential diagnosis of genetic causes of left ventricular hypertrophy (LVH) is crucial for disease-specific therapy. We aim to describe the prevalence of Cardiac Amyloidosis (CA) among patients ≥40 years with an initial diagnosis of HCM referred for second opinion to national cardiomyopathy centres. METHODS Consecutive patients aged ≥40 years referred with a tentative HCM diagnosis in the period 2014-2017 underwent clinical evaluation and genetic testing for HCM (including trans-thyretin-TTR). Patients with at least one red flag for CA underwent blood/urine tests, abdominal fat biopsy and/or bone-scintigraphy tracing and eventually ApoAI sequencing. RESULTS Out of 343 patients (age 60 ± 13 years), 251 (73%) carried a likely/pathogenic gene variant, including 12 (3.5%) in the CA-associated genes TTR (n = 11) and ApoAI (n = 1). Furthermore, 6 (2%) patients had a mutation in GLA. Among the remaining, mutation-negative patients, 26 with ≥1 CA red-flag were investigated further: 3 AL-CA and 17 wild-type-TTR-CA were identified. Ultimately, 32(9%) patients were diagnosed with CA. Prevalence of CA increased with age: 1/75 (1%) at age 40-49, 2/86 (2%) at age 50-59, 8/84 (9%) at age 60-69, 13/61 (21%) at age 70-79, 8/31 (26%) at age ≥80 (p for trend <0.01). CONCLUSIONS Among patients referred with and initial diagnosis of HCM, CA was the most common unrecognized mimic (9% prevalence) and increased with age (from 1% at ages 40-49 years to 26% >80 years). Age at diagnosis should be considered one of the most relevant red flags for CA in patients with HCM phenotypes; however, there is no clear age cut-off mandating scintigraphy and other second level investigations in the absence of other features suggestive of CA.
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11
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Gastl M, Peereboom SM, Gotschy A, Fuetterer M, von Deuster C, Boenner F, Kelm M, Schwotzer R, Flammer AJ, Manka R, Kozerke S. Myocardial triglycerides in cardiac amyloidosis assessed by proton cardiovascular magnetic resonance spectroscopy. J Cardiovasc Magn Reson 2019; 21:10. [PMID: 30700314 PMCID: PMC6354424 DOI: 10.1186/s12968-019-0519-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/04/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cardiac involvement of amyloidosis leads to left-ventricular (LV) wall thickening with progressive heart failure requiring rehospitalization. Cardiovascular magnetic resonance (CMR) is a valuable tool to non-invasively assess myocardial thickening as well as structural changes. Proton CMR spectroscopy (1H-CMRS) additionally allows assessing metabolites including triglycerides (TG) and total creatine (CR). However, opposing results exist regarding utilization of these metabolites in LV hypertrophy or thickening. Therefore, the aim of this study was to measure metabolic alterations using 1H-CMRS in a group of patients with thickened myocardium caused by cardiac amyloidosis. METHODS 1H-CMRS was performed on a 1.5 T system (Achieva, Philips Healthcare, Best, The Netherlands) using a 5-channel receive coil in 11 patients with cardiac amyloidosis (60.5 ± 11.4 years, 8 males) and 11 age- and gender-matched controls (63.2 ± 8.9 years, 8 males). After cardiac morphology and function assessment, proton spectra from the interventricular septum (IVS) were acquired using a double-triggered PRESS sequence. Post-processing was performed using a customized reconstruction pipeline based on ReconFrame (GyroTools LLC, Zurich, Switzerland). Spectra were fitted in jMRUI/AMARES and the ratios of triglyceride-to-water (TG/W) and total creatine-to-water (CR/W) were calculated. RESULTS Besides an increased LV mass and a thickened IVS concomitant to the disease characteristics, patients with cardiac amyloidosis presented with decreased global longitudinal (GLS) and circumferential (GCS) strain. LV ejection fraction was preserved relative to controls (60.0 ± 13.2 vs. 66.1 ± 4.3%, p = 0.17). Myocardial TG/W ratios were significantly decreased compared to controls (0.53 ± 0.23 vs. 0.80 ± 0.26%, p = 0.015). CR/W ratios did not show a difference between both groups, but a higher standard deviation in patients with cardiac amyloidosis was observed. Pearson correlation revealed a negative association between elevated LV mass and TG/W (R = - 0.59, p = 0.004) as well as GCS (R = - 0.48, p = 0.025). CONCLUSIONS A decrease in myocardial TG/W can be detected in patients with cardiac amyloidosis alongside impaired cardiac function with an association to the degree of myocardial thickening. Accordingly, 1H-CMRS may provide an additional diagnostic tool to gauge progression of cardiac amyloidosis along with standard imaging sequences. TRIAL REGISTRATION EK 2013-0132.
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Affiliation(s)
- Mareike Gastl
- Institute for Biomedical Engineering, University and ETH Zurich, Gloriastrasse 35, 8092 Zurich, Switzerland
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
- Department Cardiology, Pneumology and Angiology, Heinrich Heine University, Düsseldorf, Germany
| | - Sophie M. Peereboom
- Institute for Biomedical Engineering, University and ETH Zurich, Gloriastrasse 35, 8092 Zurich, Switzerland
| | - Alexander Gotschy
- Institute for Biomedical Engineering, University and ETH Zurich, Gloriastrasse 35, 8092 Zurich, Switzerland
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Maximilian Fuetterer
- Institute for Biomedical Engineering, University and ETH Zurich, Gloriastrasse 35, 8092 Zurich, Switzerland
| | - Constantin von Deuster
- Institute for Biomedical Engineering, University and ETH Zurich, Gloriastrasse 35, 8092 Zurich, Switzerland
| | - Florian Boenner
- Department Cardiology, Pneumology and Angiology, Heinrich Heine University, Düsseldorf, Germany
| | - Malte Kelm
- Department Cardiology, Pneumology and Angiology, Heinrich Heine University, Düsseldorf, Germany
| | - Rahel Schwotzer
- Comprehensive Cancer Center Zürich, University Hospital Zurich, Zurich, Switzerland
| | - Andreas J. Flammer
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Robert Manka
- Institute for Biomedical Engineering, University and ETH Zurich, Gloriastrasse 35, 8092 Zurich, Switzerland
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Sebastian Kozerke
- Institute for Biomedical Engineering, University and ETH Zurich, Gloriastrasse 35, 8092 Zurich, Switzerland
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12
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Daño cardiaco en una cohorte de pacientes con amiloidosis por transtiretina por la mutación Val30Met. Rev Esp Cardiol 2019. [DOI: 10.1016/j.recesp.2017.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Ripoll-Vera T, Buades J, Cisneros E, Gómez Y, Núñez J, Raya M. Cardiac Involvement in a Patient Cohort With Val30Met Mutation Transthyretin Amyloidosis. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2019; 72:92-94. [PMID: 29223374 DOI: 10.1016/j.rec.2017.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 09/18/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Tomás Ripoll-Vera
- Servicio de Cardiología, Hospital Universitario Son Llàtzer, Palma de Mallorca, Balearic Islands, Spain; Instituto de Investigación Sanitaria de Baleares (IdISBa), Palma de Mallorca, Balearic Islands, Spain; CiberOBN, Instituto de Salud Carlos III, Madrid, Spain.
| | - Juan Buades
- Instituto de Investigación Sanitaria de Baleares (IdISBa), Palma de Mallorca, Balearic Islands, Spain; Servicio de Medicina Interna, Hospital Universitario Son Llàtzer, Palma de Mallorca, Balearic Islands, Spain
| | - Eugenia Cisneros
- Instituto de Investigación Sanitaria de Baleares (IdISBa), Palma de Mallorca, Balearic Islands, Spain; Servicio de Medicina Interna, Hospital Universitario Son Llàtzer, Palma de Mallorca, Balearic Islands, Spain
| | - Yolanda Gómez
- Servicio de Cardiología, Hospital Universitario Son Llàtzer, Palma de Mallorca, Balearic Islands, Spain; Instituto de Investigación Sanitaria de Baleares (IdISBa), Palma de Mallorca, Balearic Islands, Spain
| | - Juana Núñez
- Servicio de Cardiología, Hospital Universitario Son Llàtzer, Palma de Mallorca, Balearic Islands, Spain; Instituto de Investigación Sanitaria de Baleares (IdISBa), Palma de Mallorca, Balearic Islands, Spain
| | - Manuel Raya
- Instituto de Investigación Sanitaria de Baleares (IdISBa), Palma de Mallorca, Balearic Islands, Spain; Servicio de Medicina Interna, Hospital Universitario Son Llàtzer, Palma de Mallorca, Balearic Islands, Spain
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14
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Suhr OB, Lundgren E, Westermark P. One mutation, two distinct disease variants: unravelling the impact of transthyretin amyloid fibril composition. J Intern Med 2017; 281:337-347. [PMID: 28093848 DOI: 10.1111/joim.12585] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although hereditary transthyretin (h-ATTR) amyloidosis is a monogenetic disease, a large variation in its phenotype has been observed. The common hypothesis of amyloid fibril formation involves dissociation of the transthyretin (TTR) tetramer into monomers that after misfolding reassemble into amyloid fibrils. This notion is partly challenged by the finding of two distinct types of amyloid fibrils. One of these, type A, consists of C-terminal ATTR fragments and full-length TTR, whereas the other, type B, consists only of full-length TTR. All organs of an individual patient contain ATTR deposits of either type A or type B fibrils, and the composition in each individual remains unchanged over time. The finding of two distinct types of ATTR fibrils suggests that there are at least two different pathways in operation for ATTR fibril formation. For the most common European mutation, TTR Val30Met, ATTR fibril composition is related to the outcome of liver transplantation, which is the first successful treatment for the disease, and the penetrance of the trait. In addition, the presence of C-terminal ATTR fragments has an impact on the affinity for various tracers used for noninvasive imaging of amyloid depositions such as 99 m-technetium-diphosphono-propanodicarboxylic acid scintigraphy and positron emission tomography utilizing Pittsburgh component B, and even for the gold standard diagnostic procedure, tissue biopsy stained by Congo red and examined under polarized light. The importance of amyloid fibril composition needs to be taken into consideration when designing clinical trials of treatment modalities, and also in the evaluation of diagnostic methods such as imaging techniques.
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Affiliation(s)
- O B Suhr
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - E Lundgren
- Department of Molecular Biology, Umeå University, Umeå, Sweden
| | - P Westermark
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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First European consensus for diagnosis, management, and treatment of transthyretin familial amyloid polyneuropathy. Curr Opin Neurol 2016; 29 Suppl 1:S14-26. [PMID: 26734952 PMCID: PMC4739312 DOI: 10.1097/wco.0000000000000289] [Citation(s) in RCA: 153] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose of review Early and accurate diagnosis of transthyretin familial amyloid polyneuropathy (TTR-FAP) represents one of the major challenges faced by physicians when caring for patients with idiopathic progressive neuropathy. There is little consensus in diagnostic and management approaches across Europe. Recent findings The low prevalence of TTR-FAP across Europe and the high variation in both genotype and phenotypic expression of the disease means that recognizing symptoms can be difficult outside of a specialized diagnostic environment. The resulting delay in diagnosis and the possibility of misdiagnosis can misguide clinical decision-making and negatively impact subsequent treatment approaches and outcomes. Summary This review summarizes the findings from two meetings of the European Network for TTR-FAP (ATTReuNET). This is an emerging group comprising representatives from 10 European countries with expertise in the diagnosis and management of TTR-FAP, including nine National Reference Centres. The current review presents management strategies and a consensus on the gold standard for diagnosis of TTR-FAP as well as a structured approach to ongoing multidisciplinary care for the patient. Greater communication, not just between members of an individual patient's treatment team, but also between regional and national centres of expertise, is the key to the effective management of TTR-FAP.
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Sixty years of transthyretin familial amyloid polyneuropathy (TTR-FAP) in Europe: where are we now? A European network approach to defining the epidemiology and management patterns for TTR-FAP. Curr Opin Neurol 2016; 29 Suppl 1:S3-S13. [PMID: 26734951 PMCID: PMC4739317 DOI: 10.1097/wco.0000000000000288] [Citation(s) in RCA: 152] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Purpose of review Transthyretin familial amyloid polyneuropathy (TTR-FAP) is a highly disabling, life-threatening disease characterized by progressive sensorimotor and autonomic neuropathy. The profile of the disease across Europe is inadequately understood at present. Recent findings The incidence and clinical presentation of TTR-FAP varies widely within Europe, with early and late-onset disease subtypes. In those regions in which the disease is endemic (Portugal, Sweden, Cyprus, and Majorca), a Val30Met substitution in the TTR gene is the predominant genetic cause, whereas in the rest of Europe, cases of TTR-FAP are mainly sporadic with genetic heterogeneity. Current management strategies lack cohesion and patients can experience years of misdiagnosis and suboptimal treatment. Summary The article aims to disseminate the findings and recommendations from two recent meetings of the European Network for TTR-FAP (ATTReuNET), a panel comprising representatives from 10 European countries (Bulgaria, Cyprus, France, Germany, Italy, the Netherlands, Portugal, Spain, Sweden, and Turkey) with expertise in the diagnosis and management of TTR-FAP. We explore the epidemiology and genetic mark of TTR-FAP across Europe and assess current management strategies, with a view to developing an alternative framework – a networked approach to disease management with an emphasis on collaboration and sharing of best practice.
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Damy T, Jaccard A, Guellich A, Lavergne D, Galat A, Deux JF, Hittinger L, Dupuis J, Frenkel V, Rigaud C, Plante-Bordeneuve V, Bodez D, Mohty D. Identification of prognostic markers in transthyretin and AL cardiac amyloidosis. Amyloid 2016; 23:194-202. [PMID: 27647161 DOI: 10.1080/13506129.2016.1221815] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The prognosis of amyloidosis is known to depend heavily on cardiac function and may be improved by identifying patients at highest risk for adverse cardiac events. AIMS Identify predictors of mortality in patients with cardiac light-chain amyloidosis (AL), hereditary transthyretin amyloidosis (m-TTR), or wild-type transthyretin amyloidosis (WT-TTR) to prompt physician to refer these patients to dedicated centers. METHODS AND RESULTS Observational study. About 266 patients referred for suspected cardiac amyloidosis (CA) in two French university centers were included. About 198 patients had CA (AL = 118, m-TTR = 57, and WT-TTR = 23). Their median (25th-75th percentile) age, NT-proBNP left ventricular ejection fraction were, respectively, 68 years (59-76), 2339 pg mL-1 (424-5974), and 60% (48-66). About 31% were in NYHA class III-IV. Interventricular septal thickness was greater in the m-TTR and WT-TTR groups than in the AL group (p < 0.0001). Median follow-up in survivor was 26 months (15-44) and 87 (44%) patients died. By multivariate analysis, independent predictors of mortality for AL amyloidosis were the following: age, cardiac output and NT-proBNP; for TTR amyloidosis was: NT-proBNP. When all amyloidosis were combined NT-proBNP, low cardiac output and pericardial effusion were independently associated with mortality. CONCLUSION NT-proBNP is a strong prognosticator in the three types of cardiac amyloidosis. High NT-proBNP, low cardiac output, and pericardial effusion at the time of screening should prompt physician to refer the patients to amyloidosis referral center.
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Affiliation(s)
- Thibaud Damy
- a Department of Cardiology , AP-HP, Henri Mondor Teaching Hospital , Créteil , France.,b University Paris-East (UPEC) School of Medicine , Créteil , France.,c GRC Amyloid Research Institute, IMRB INSERM U955 , Créteil , France.,d Mondor Amyloidosis Network, Henri Mondor Teaching Hospital , Créteil , France.,e AP-HP, INSERM, Clinical Investigations Center 1430, Henri Mondor Teaching Hospital , Créteil , France.,f Department of Clinical Research and Public Health , Clinical Investigations Center 006, Henri Mondor Teaching Hospital , Créteil , France
| | - Arnaud Jaccard
- g Department of Cardiology , Dupuytren Teaching Hospital , Limoges , France.,h Dupuytren Teaching Hospital, AL Amyloidosis Referral Center , Limoges , France
| | - Aziz Guellich
- a Department of Cardiology , AP-HP, Henri Mondor Teaching Hospital , Créteil , France.,b University Paris-East (UPEC) School of Medicine , Créteil , France.,c GRC Amyloid Research Institute, IMRB INSERM U955 , Créteil , France.,d Mondor Amyloidosis Network, Henri Mondor Teaching Hospital , Créteil , France
| | - David Lavergne
- g Department of Cardiology , Dupuytren Teaching Hospital , Limoges , France.,h Dupuytren Teaching Hospital, AL Amyloidosis Referral Center , Limoges , France
| | - Arnault Galat
- a Department of Cardiology , AP-HP, Henri Mondor Teaching Hospital , Créteil , France.,b University Paris-East (UPEC) School of Medicine , Créteil , France.,c GRC Amyloid Research Institute, IMRB INSERM U955 , Créteil , France.,d Mondor Amyloidosis Network, Henri Mondor Teaching Hospital , Créteil , France
| | - Jean-François Deux
- a Department of Cardiology , AP-HP, Henri Mondor Teaching Hospital , Créteil , France.,b University Paris-East (UPEC) School of Medicine , Créteil , France.,c GRC Amyloid Research Institute, IMRB INSERM U955 , Créteil , France.,i Department of Radiology , AP-HP, Henri Mondor Teaching Hospital , Créteil , France
| | - Luc Hittinger
- a Department of Cardiology , AP-HP, Henri Mondor Teaching Hospital , Créteil , France.,b University Paris-East (UPEC) School of Medicine , Créteil , France.,c GRC Amyloid Research Institute, IMRB INSERM U955 , Créteil , France.,d Mondor Amyloidosis Network, Henri Mondor Teaching Hospital , Créteil , France
| | - Jehan Dupuis
- b University Paris-East (UPEC) School of Medicine , Créteil , France.,d Mondor Amyloidosis Network, Henri Mondor Teaching Hospital , Créteil , France.,e AP-HP, INSERM, Clinical Investigations Center 1430, Henri Mondor Teaching Hospital , Créteil , France.,j Department of Hematology , AP-HP, Henri Mondor Teaching Hospital , Créteil , France
| | - Valérie Frenkel
- b University Paris-East (UPEC) School of Medicine , Créteil , France.,c GRC Amyloid Research Institute, IMRB INSERM U955 , Créteil , France.,l Department of Immunohematolgy , AP-HP, Henri Mondor Teaching Hospital , Créteil , France
| | - Charlotte Rigaud
- g Department of Cardiology , Dupuytren Teaching Hospital , Limoges , France.,h Dupuytren Teaching Hospital, AL Amyloidosis Referral Center , Limoges , France
| | - Violaine Plante-Bordeneuve
- b University Paris-East (UPEC) School of Medicine , Créteil , France.,c GRC Amyloid Research Institute, IMRB INSERM U955 , Créteil , France.,d Mondor Amyloidosis Network, Henri Mondor Teaching Hospital , Créteil , France.,e AP-HP, INSERM, Clinical Investigations Center 1430, Henri Mondor Teaching Hospital , Créteil , France.,f Department of Clinical Research and Public Health , Clinical Investigations Center 006, Henri Mondor Teaching Hospital , Créteil , France.,k Department of Neurology , AP-HP, Henri Mondor Teaching Hospital , Créteil , France , and
| | - Diane Bodez
- a Department of Cardiology , AP-HP, Henri Mondor Teaching Hospital , Créteil , France.,b University Paris-East (UPEC) School of Medicine , Créteil , France.,c GRC Amyloid Research Institute, IMRB INSERM U955 , Créteil , France.,d Mondor Amyloidosis Network, Henri Mondor Teaching Hospital , Créteil , France
| | - Dania Mohty
- g Department of Cardiology , Dupuytren Teaching Hospital , Limoges , France.,h Dupuytren Teaching Hospital, AL Amyloidosis Referral Center , Limoges , France
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Survival After Transplantation in Patients With Mutations Other Than Val30Met: Extracts From the FAP World Transplant Registry. Transplantation 2016; 100:373-81. [PMID: 26656838 PMCID: PMC4732012 DOI: 10.1097/tp.0000000000001021] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Liver transplantation (LTx) has been performed for hereditary transthyretin amyloidosis (ATTR) since 1990. Outcomes for a relatively large series of LTx ATTR patients with the Val30Met (mutation are available, but for non-Val30Met patients, only a few reports with a small number of patients exist. Here, we present outcomes for non-Val30Met ATTR patients after LTx, as reported to the Familial Amyloid Polyneuropathy World Transplant Registry (FAPWTR). Methods Data regarding outcome were extracted for all non-Val30Met patients reported to the registry. Survival rates were analyzed by the Kaplan-Meier method and log-rank test. Results The total number of patients with a non-Val30Met mutation in the registry was 264 (174 men and 90 women), representing 57 mutations. The 10-year survival varied markedly for the 9 most common mutations, ranging from 21% for Ser50Arg to 85% for Val71Ala. Poor survival was noted for all mutations with leptomeningeal complications except for those with the Tyr114Cys mutation. Conclusions Large differences in survival were observed relative to different mutations and between mutations with similar phenotypes. Excellent survival was noted for mutations, such as Leu111Met, Val71Ala, and Leu58His. Patients with mutations other than Val30Met are not a homogeneous group, and the term non-Val30Met should be used with caution or avoided. Moreover, for several mutations, data are too limited to allow evaluation of the efficacy of LTx, and continuous international collaboration is important for obtaining treatment guidance.
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Coelho T, Merlini G, Bulawa CE, Fleming JA, Judge DP, Kelly JW, Maurer MS, Planté-Bordeneuve V, Labaudinière R, Mundayat R, Riley S, Lombardo I, Huertas P. Mechanism of Action and Clinical Application of Tafamidis in Hereditary Transthyretin Amyloidosis. Neurol Ther 2016; 5:1-25. [PMID: 26894299 PMCID: PMC4919130 DOI: 10.1007/s40120-016-0040-x] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Indexed: 11/24/2022] Open
Abstract
Transthyretin (TTR) transports the retinol-binding protein-vitamin A complex and is a minor transporter of thyroxine in blood. Its tetrameric structure undergoes rate-limiting dissociation and monomer misfolding, enabling TTR to aggregate or to become amyloidogenic. Mutations in the TTR gene generally destabilize the tetramer and/or accelerate tetramer dissociation, promoting amyloidogenesis. TTR-related amyloidoses are rare, fatal, protein-misfolding disorders, characterized by formation of soluble aggregates of variable structure and tissue deposition of amyloid. The TTR amyloidoses present with a spectrum of manifestations, encompassing progressive neuropathy and/or cardiomyopathy. Until recently, the only accepted treatment to halt progression of hereditary TTR amyloidosis was liver transplantation, which replaces the hepatic source of mutant TTR with the less amyloidogenic wild-type TTR. Tafamidis meglumine is a rationally designed, non-NSAID benzoxazole derivative that binds with high affinity and selectivity to TTR and kinetically stabilizes the tetramer, slowing monomer formation, misfolding, and amyloidogenesis. Tafamidis is the first pharmacotherapy approved to slow the progression of peripheral neurologic impairment in TTR familial amyloid polyneuropathy. Here we describe the mechanism of action of tafamidis and review the clinical data, demonstrating that tafamidis treatment slows neurologic deterioration and preserves nutritional status, as well as quality of life in patients with early-stage Val30Met amyloidosis.
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Affiliation(s)
- Teresa Coelho
- Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal.
| | - Giampaolo Merlini
- Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | | | | | - Daniel P Judge
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Mathew S Maurer
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | | | | | | | | | | | - Pedro Huertas
- Massachusetts General and McLean Hospitals, Harvard Medical School, Boston, MA, USA
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Pıhtılı A, Bingol Z, Durmuş H, Parman Y, Kıyan E. Vocal Cord Paralysis and Hypercapnic Respiratory Failure in a Patient with Familial Amyloidotic Polyneuropathy. Intern Med 2016; 55:1783-6. [PMID: 27374684 DOI: 10.2169/internalmedicine.55.5564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report a patient case with familial amyloidotic polyneuropathy (FAP) who presented with vocal cord paralysis (VCP). A 60-year-old man with FAP (Gly89Gln) presented with hoarseness and snoring for the previous two years. A chest X-ray demonstrated cardiomegaly and bilateral diaphragmatic elevation. The findings of a restrictive pattern on spirometry and daytime hypercapnia were consistent with respiratory muscle weakness related to neuropathy [forced expiratory volume (FEV1): 38%, forced vital capacity (FVC): 39%, FEV1/FVC: 77, partial pressure of arterial oxygen (PaO2): 80 mmHg, partial pressure of carbon dioxide in arterial blood (PaCO2): 52 mmHg]. An ear-nose-throat examination showed VCP. Polysomnography revealed severe obstructive sleep apnea (OSA). FAP may cause OSA by VCP and hypercapnic respiratory failure by respiratory muscle weakness. Therefore, an ear-nose-throat examination, spirometry, arterial blood gases analysis and polysomnography are important for these patients.
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Affiliation(s)
- Aylin Pıhtılı
- Haydarpaşa Numune Training and Research Hospital, Turkey
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22
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Hawkins PN, Ando Y, Dispenzeri A, Gonzalez-Duarte A, Adams D, Suhr OB. Evolving landscape in the management of transthyretin amyloidosis. Ann Med 2015; 47:625-38. [PMID: 26611723 PMCID: PMC4720049 DOI: 10.3109/07853890.2015.1068949] [Citation(s) in RCA: 159] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 06/30/2015] [Indexed: 12/12/2022] Open
Abstract
Transthyretin (TTR) amyloidosis (ATTR amyloidosis) is a multisystemic, multigenotypic disease resulting from deposition of insoluble ATTR amyloid fibrils in various organs and tissues. Although considered rare, the prevalence of this serious disease is likely underestimated because symptoms can be non-specific and diagnosis largely relies on amyloid detection in tissue biopsies. Treatment is guided by which tissues/organs are involved, although therapeutic options are limited for patients with late-stage disease. Indeed, enthusiasm for liver transplantation for familial ATTR amyloidosis with polyneuropathy was dampened by poor outcomes among patients with significant neurological deficits or cardiac involvement. Hence, there remains an unmet medical need for new therapies. The TTR stabilizers tafamidis and diflunisal slow disease progression in some patients with ATTR amyloidosis with polyneuropathy, and the postulated synergistic effect of doxycycline and tauroursodeoxycholic acid on dissolution of amyloid is under investigation. Another therapeutic approach is to reduce production of the amyloidogenic protein, TTR. Plasma TTR concentration can be significantly reduced with ISIS-TTR(Rx), an investigational antisense oligonucleotide-based drug, or with patisiran and revusiran, which are investigational RNA interference-based therapeutics that target the liver. The evolving treatment landscape for ATTR amyloidosis brings hope for further improvements in clinical outcomes for patients with this debilitating disease.
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Affiliation(s)
- Philip N. Hawkins
- National Amyloidosis Centre, Royal Free Hospital, University College London, London, UK
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences Kumamoto University, Kumamoto, Japan
| | | | | | - David Adams
- National Reference Centre for FAP, APHP, CHU Bicêtre, Université Paris-Sud, INSERM U788, Paris, France
| | - Ole B. Suhr
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Queiroz MCDC, Pedrosa RC, Berensztejn AC, Pereira BDB, Nascimento EMD, Duarte MMT, Pereira-Junior PP, Cruz MW. Frequency of Cardiovascular Involvement in Familial Amyloidotic Polyneuropathy in Brazilian Patients. Arq Bras Cardiol 2015; 105:503-9. [PMID: 26351985 PMCID: PMC4651409 DOI: 10.5935/abc.20150112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 05/26/2015] [Indexed: 11/20/2022] Open
Abstract
Background Familial amyloidotic polyneuropathy (FAP) is a rare disease diagnosed in Brazil
and worldwide. The frequency of cardiovascular involvement in Brazilian FAP
patients is unknown. Objective Detect the frequency of cardiovascular involvement and correlate the
cardiovascular findings with the modified polyneuropathy disability (PND)
score. Methods In a national reference center, 51 patients were evaluated with clinical
examination, electrocardiography (ECG), echocardiography (ECHO), and 24-hour
Holter. Patients were classified according to the modified PND score and divided
into groups: PND 0, PND I, PND II, and PND > II (which included PND IIIa, IIIb,
and IV). We chose the classification tree as the statistical method to analyze the
association between findings in cardiac tests with the neurological classification
(PND). Results ECG abnormalities were present in almost 2/3 of the FAP patients, whereas ECHO
abnormalities occurred in around 1/3 of them. All patients with abnormal ECHO also
had abnormal ECG, but the opposite did not apply. The classification tree
identified ECG and ECHO as relevant variables (p < 0.001 and p = 0.08,
respectively). The probability of a patient to be allocated to the PND 0 group
when having a normal ECG was over 80%. When both ECG and ECHO were abnormal, this
probability was null. Conclusions Brazilian patients with FAP have frequent ECG abnormalities. ECG is an appropriate
test to discriminate asymptomatic carriers of the mutation from those who develop
the disease, whereas ECHO contributes to this discrimination.
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Affiliation(s)
| | - Roberto Coury Pedrosa
- Instituto do Coração Edson Saad, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | | | - Emília Matos do Nascimento
- Instituto Alberto Luiz Coimbra de Pós-Graduação e Pesquisa em Engenharia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | | | - Marcia Waddington Cruz
- Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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García-Pavía P, Muñoz-Beamud F, Casasnovas C. Recomendaciones para el diagnóstico y tratamiento de la polineuropatía amiloidótica familiar por transtiretina. Med Clin (Barc) 2015; 145:211-7. [DOI: 10.1016/j.medcli.2015.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 02/04/2015] [Accepted: 02/05/2015] [Indexed: 10/23/2022]
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Damy T, Judge DP, Kristen AV, Berthet K, Li H, Aarts J. Cardiac findings and events observed in an open-label clinical trial of tafamidis in patients with non-Val30Met and non-Val122Ile hereditary transthyretin amyloidosis. J Cardiovasc Transl Res 2015; 8:117-27. [PMID: 25743445 PMCID: PMC4382536 DOI: 10.1007/s12265-015-9613-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 02/03/2015] [Indexed: 01/09/2023]
Abstract
A phase 2, open-label study in 21 patients with non-Val30Met and non-Val122Ile hereditary transthyretin amyloidosis showed that tafamidis (20 mg daily for 12 months) stabilized these transthyretin variants. We assessed cardiac amyloid infiltration and cardiac abnormalities in this same study population. At baseline, median age was 64.3 years, 11 patients were in NYHA class II, 13 had conduction abnormalities, 14 N-terminal pro-hormone brain natriuretic peptide concentrations >300 pg/ml, and 17 interventricular septal thickness >12 mm. Mean (SD) left ventricular ejection fraction was 60.3 % (9.96). Patients with normal heart rate variability increased from 4/19 at baseline to 8/19 at month 12 (p < 0.05). Cardiac biomarkers remained stable. Although four patients had increases in interventricular septal thickness ≥2 mm, the remainder had stable septal wall thickness. There were no clinically relevant changes in mean echocardiographic/electrocardiographic variables and no safety concerns.
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Affiliation(s)
- Thibaud Damy
- Department of Cardiology, University Hospital Henri Mondor, Amyloidosis Mondor Network, DHU ATVB, Créteil, France,
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Jang MA, Lee GY, Kim K, Kim SJ, Kim JS, Lee SY, Kim HJ, Jeon ES. Asp58Ala is the predominant mutation of the TTR gene in Korean patients with hereditary transthyretin-related amyloidosis. Ann Hum Genet 2015; 79:99-107. [PMID: 25644864 DOI: 10.1111/ahg.12101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 12/05/2014] [Indexed: 11/29/2022]
Abstract
Hereditary transthyretin (TTR)-related amyloidosis (ATTR) seems to be a rare autosomal-dominant inherited form of systemic amyloidosis. Studies indicate considerable heterogeneity in the disease's presentation and genotype; however, there is little data from Korea, where the prevalence of hereditary ATTR is very low. In this study, we investigated the phenotypic and genotypic spectra of hereditary ATTR in Korea. Direct sequencing analysis was performed to detect TTR gene mutations in amyloidosis patients whose results of TTR immunohistochemical staining were positive or equivocal. Clinical presentation was categorized as exclusively cardiac, exclusively neurologic, or mixed phenotype. Of 12 genetic tests performed, seven were positive for TTR mutations. D58A (c.173A>C) was the most common mutation in this study (57%, 4/7). The majority of those patients with hereditary ATTR had the mixed phenotype (86%, 6/7). The patients with D58A mutation had older ages of disease onset (median, 61 years vs. 42 years; P = 0.08), and a higher incidence of gastrointestinal involvement (75% vs. 0%; P = 0.03) than those with other identified TTR mutations. A significant male predominance was also noted in this study (P = 0.01).
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Affiliation(s)
- Mi-Ae Jang
- Department of Laboratory Medicine and Genetics, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Iorio A, De Angelis F, Di Girolamo M, Luigetti M, Pradotto L, Mauro A, Manfellotto D, Fuciarelli M, Polimanti R. Most recent common ancestor of TTR Val30Met mutation in Italian population and its potential role in genotype-phenotype correlation. Amyloid 2015; 22:73-8. [PMID: 25510352 DOI: 10.3109/13506129.2014.994597] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Transthyretin (TTR)-related amyloidosis is characterized by autosomal transmission of amyloidogenic mutated TTR. Val30Met is one of the most common amyloidogenic TTR mutations, showing a worldwide distribution with phenotypic heterogeneity among human populations. Multiple founder mutations for Val30Met foci have been hypothesized and the different origins may explain the phenotypic variability. The aim of our study is to determine the origin of Italian Val30Met and to analyze the genetic relationship of other Val30Met foci. METHODS We analyzed the origin of Italian Val30Met through 11 microsatellite markers around the TTR gene in 29 patients and 34 healthy controls. RESULTS Our genetic analysis showed an estimated age of origin of 34-36 generations ago for the Italian Val30Met. Comparing Italian Val30Met haplotypes with those from Sweden and Portugal highlights relevant differences that seem to be consistent with an independent origin of Italian Val30Met mutation. This genetic evidence agrees with the disease phenotypic variation in these populations. DISCUSSION AND CONCLUSIONS Italian Val30Met mutation should have originated before the Portuguese and Swedish Val30Met ones (which arose through independent mutational events). This indicates a genetic diversity in the surrounding regions of three different Val30Met mutations, supporting the hypothesis that TTR non-coding regions may contribute to phenotypic heterogeneity.
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Affiliation(s)
- Andrea Iorio
- Department of Biology, University of Rome "Tor Vergata" , Rome , Italy
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Glaudemans AWJM, van Rheenen RWJ, van den Berg MP, Noordzij W, Koole M, Blokzijl H, Dierckx RAJO, Slart RHJA, Hazenberg BPC. Bone scintigraphy with (99m)technetium-hydroxymethylene diphosphonate allows early diagnosis of cardiac involvement in patients with transthyretin-derived systemic amyloidosis. Amyloid 2014; 21:35-44. [PMID: 24455993 DOI: 10.3109/13506129.2013.871250] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess the usefulness of bone scintigraphy with (99m)Technetium-hydroxymethylene diphosphonate ((99m)Tc-HDP) for the detection of cardiac involvement in a group of patients with ATTR amyloidosis in different phases of disease, to relate the findings to echocardiography, ECG and cardiac biomarkers, and to evaluate different bone scintigraphic techniques and calculation methods for quantification of the cardiac uptake and for correlation with echocardiographic features and cardiac biomarkers. METHODS Forty-one patients underwent clinical examinations, echocardiography, ECG, measurement of cardiac biomarkers and bone scintigraphy (planar imaging and SPECT-CT) and were subsequently subdivided into three groups: (1) carriers of an amyloidogenic TTR mutation, n = 11, (2) proven ATTR amyloidosis without echocardiographically-defined (mean wall thickness >12 mm) cardiac amyloidosis (AC), n = 19, and (3) ATTR amyloidosis with echocardiographically-defined cardiac amyloidosis, n = 11. Planar and SPECT-CT images were analyzed visually according to a routine scoring system (grade 0-3) and semi-quantitatively by heart-to-whole body (H/WB) and heart-to-skull (H/S) ratio on planar images and by a left ventricle-blood pool ratio on SPECT-CT images. RESULTS All patients with ATTR and echocardiographically-defined AC and none of the carriers showed high cardiac uptake on bone scintigraphy. Furthermore, 8 out of 19 patients with ATTR without echocardiographically-defined AC showed high cardiac uptake. Highest correlations were found between H/S ratio on planar bone scintigraphy with troponin T (r = 0.76, p < 0.0001) and H/WB ratio with left ventricular mass index (r = 0.73, p < 0.0001). CONCLUSIONS Bone scintigraphy with (99m)Tc-HDP may detect cardiac involvement in patients with ATTR amyloidosis prior to echocardiographic evidence of cardiac involvement. Cardiac uptake on bone scintigraphy correlates with severity of cardiac involvement using echocardiography, ECG and cardiac biomarkers. Visual grading and calculation of H/S ratio on planar imaging are the preferred methods to assess cardiac uptake.
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Lladó L, Fabregat J, Ramos E, Baliellas C, Roca J, Casasnovas C. Trasplante cardiaco y hepático secuencial por polineuropatía amiloidótica familiar. Med Clin (Barc) 2014; 142:211-4. [DOI: 10.1016/j.medcli.2013.10.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 10/24/2013] [Accepted: 10/24/2013] [Indexed: 10/25/2022]
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Arruda-Olson AM, Zeldenrust SR, Dispenzieri A, Gertz MA, Miller FA, Bielinski SJ, Klarich KW, Scott CG, Grogan M. Genotype, echocardiography, and survival in familial transthyretin amyloidosis. Amyloid 2013; 20:263-8. [PMID: 24131106 DOI: 10.3109/13506129.2013.845745] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND More than 100 transthyretin (TTR) variants have been identified which cause familial systemic amyloidosis. It has been increasingly recognized that TTR variants of familial systemic amyloidosis contribute to clinical characteristics, including age at diagnosis, cardiac phenotype and survival. METHODS Two hundred and eighty-two patients who underwent genotyping for TTR variants were identified. This study focused on 116 patients representing the three most common TTR variants; T60A (n = 58), V30M (n = 37) and V122I (n = 21). The remaining subjects (n = 61) were distributed amongst 33 different genotypes and excluded from analysis. RESULTS Age at diagnosis was similar by genotype. Septal, posterior wall thickness, right ventricular systolic pressure and left ventricular mass index were greater and LVEF lower in the V122I subgroup. At mean follow up of 3.0 ± 2.6 years there were 62 deaths. V30M patients had the best survival. Survival was similar between V122I and T60A patients. The association of genotype with mortality persisted after adjustments for clinical variables. CONCLUSIONS For familial TTR amyloidosis cardiac involvement is frequent and mortality high for T60A, V122I and V30M genotypes. Specific genotype predicted severity of phenotypic expression as measured by echocardiography and survival.
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Ihse E, Rapezzi C, Merlini G, Benson MD, Ando Y, Suhr OB, Ikeda SI, Lavatelli F, Obici L, Quarta CC, Leone O, Jono H, Ueda M, Lorenzini M, Liepnieks J, Ohshima T, Tasaki M, Yamashita T, Westermark P. Amyloid fibrils containing fragmented ATTR may be the standard fibril composition in ATTR amyloidosis. Amyloid 2013; 20:142-50. [PMID: 23713495 DOI: 10.3109/13506129.2013.797890] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract The clinical phenotype of familial ATTR amyloidosis depends to some extent on the particular mutation, but differences exist also within mutations. We have previously described that two types of amyloid fibril compositions exist among Swedish ATTRV30M amyloidosis patients, one consisting of a mixture of intact and fragmented ATTR (type A) and one consisting of mainly intact ATTR (type B). The fibril types are correlated to phenotypic differences. Patients with ATTR fragments have a late onset and develop cardiomyopathy, while patients without fragments have an early onset and less myocardial involvement. The present study aimed to determine whether this correlation between fibril type and phenotype is valid for familial ATTR amyloidosis in general. Cardiac or adipose tissues from 63 patients carrying 29 different TTR non-V30M mutations as well as 13 Japanese ATTRV30M patients were examined. Fibril type was determined by western blotting and compared to the patients' age of onset and degree of cardiomyopathy. All ATTR non-V30M patients had a fibril composition with ATTR fragments, except two ATTRY114C patients. No clear conclusions could be drawn about a phenotype to fibril type correlation among ATTR non-V30M patients. In contrast, Japanese ATTRV30M patients showed a similar correlation as previously described for Swedish ATTRV30M patients. This study shows that a fibril composition with fragmented ATTR is very common in ATTR amyloidosis, and suggests that fibrils composed of only full-length ATTR is an exception found only in a subset of patients.
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Affiliation(s)
- Elisabet Ihse
- Department of Immunology, Genetics and Pathology, Uppsala University, Sweden
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Perfetto F, Cappelli F, Bergesio F, Ciuti G, Porciani MC, Padeletti L, Moggi Pignone A. Cardiac amyloidosis: the heart of the matter. Intern Emerg Med 2013; 8:191-203. [PMID: 21739229 DOI: 10.1007/s11739-011-0647-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 06/14/2011] [Indexed: 01/01/2023]
Abstract
Amyloidosis comprises a unique group of diseases that share in common the extracellular deposition of insoluble fibrillar proteins in organs and tissue including the heart. Cardiac amyloidosis could be primary a part of systemic acquired amyloidosis, or a result of heredofamilial amyloidosis. Although the infiltration of the heart from different types of amyloid results in restrictive cardiomyopathy that manifests with refractory congestive heart failure and conduction abnormalities, unequivocal identification of the deposited amyloidogenic protein is mandatory in order to avoid misdiagnosis and inappropriate treatment. Recent developments in imaging techniques and extracardiac tissue biopsy have minimized the need for invasive endomyocardial biopsy for amyloidosis. Despite advances in treatment, the prognosis of a patient with amyloidosis is still poor and depends upon the underlying disease, and the type and degree of dysfunction of the involved organs. Thus, early diagnosis is mandatory because patients with advanced disease are usually too ill for intensive therapy. This review outlines current approaches to diagnosis, assessment of disease severity, and treatment of cardiac amyloidosis.
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Ando Y, Coelho T, Berk JL, Cruz MW, Ericzon BG, Ikeda SI, Lewis WD, Obici L, Planté-Bordeneuve V, Rapezzi C, Said G, Salvi F. Guideline of transthyretin-related hereditary amyloidosis for clinicians. Orphanet J Rare Dis 2013; 8:31. [PMID: 23425518 PMCID: PMC3584981 DOI: 10.1186/1750-1172-8-31] [Citation(s) in RCA: 476] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 01/01/2013] [Indexed: 02/07/2023] Open
Abstract
Transthyretin amyloidosis is a progressive and eventually fatal disease primarily characterized by sensory, motor, and autonomic neuropathy and/or cardiomyopathy. Given its phenotypic unpredictability and variability, transthyretin amyloidosis can be difficult to recognize and manage. Misdiagnosis is common, and patients may wait several years before accurate diagnosis, risking additional significant irreversible deterioration. This article aims to help physicians better understand transthyretin amyloidosis—and, specifically, familial amyloidotic polyneuropathy—so they can recognize and manage the disease more easily and discuss it with their patients. We provide guidance on making a definitive diagnosis, explain methods for disease staging and evaluation of disease progression, and discuss symptom mitigation and treatment strategies, including liver transplant and several pharmacotherapies that have shown promise in clinical trials.
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Affiliation(s)
- Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.
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Planté-Bordeneuve V, Kerschen P. Transthyretin familial amyloid polyneuropathy. HANDBOOK OF CLINICAL NEUROLOGY 2013; 115:643-58. [PMID: 23931808 DOI: 10.1016/b978-0-444-52902-2.00038-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
TTR FAP is characterized by phenotypic and genotypic heterogeneity. The severity of polyneuropathy along with autonomic dysfunction and heart involvement makes it a life-threatening disease. This protein is mainly produced by the liver. Molecular genetic testing is essential in the diagnostic strategy. TTR-Val30Met is the most frequent substitution, resulting in a guanine to cytosine mutation in exon 2 of the gene. It is virtually the only variant detected in Portugal, Brazil, and Sweden. By contrast, as many as 30 different TTR variants are reported in Japan and in other European countries. A less severe phenotype with late onset has been reported. Diagnosis should be performed as early as possible since upcoming pharmacological therapeutic approaches are now available, in addition to liver transplantation.
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Affiliation(s)
- V Planté-Bordeneuve
- Department of Neurology, CHU Henri Mondor, Créteil, France; Inserm 1016, Université Paris-Descartes, Institut Cochin, Paris, France.
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Coelho T, Maurer MS, Suhr OB. THAOS - The Transthyretin Amyloidosis Outcomes Survey: initial report on clinical manifestations in patients with hereditary and wild-type transthyretin amyloidosis. Curr Med Res Opin 2013. [PMID: 23193944 DOI: 10.1185/03007995.2012.754348] [Citation(s) in RCA: 221] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Transthyretin (TTR) amyloidosis is a rare, life-threatening, systemic, autosomal dominant condition occurring in adults, with two main forms: hereditary (associated with TTR gene mutations) and wild-type. Studies indicate considerable heterogeneity in disease presentation, with predominantly polyneuropathic, predominantly cardiac, or mixed phenotypes. METHODS THAOS - the Transthyretin Amyloidosis Outcomes Survey - is the first global, multicenter, longitudinal, observational survey that collects data on the natural history of TTR amyloidosis (ClinicalTrials.gov: NCT00628745). This paper presents data on signs and symptoms, neurological and cardiac assessments, biomarkers and quality of life in the patients enrolled in THAOS from its inception in December 2007 to September 2011. RESULTS At the time of this analysis, data were available from 611 symptomatic patients with hereditary TTR amyloidosis, 67 symptomatic patients with wild-type TTR amyloidosis, and 274 currently asymptomatic individuals with a TTR mutation. Nineteen countries were participating in the registry. The largest patient groups came from Portugal (n = 453), the USA (n = 129), Italy (n = 70), and Japan (n = 68). Predominant symptom presentation in patients with hereditary TTR amyloidosis differed according to the underlying disease-causing mutation (polyneuropathy for Val30Met, cardiomyopathy for Val122Ile and Leu111Met, and mixed for Glu89Gln). However, each mutation was associated with clear multisystem involvement. Similarly, although cardiomyopathy was predominant in patients with wild-type TTR amyloidosis, many also showed symptoms consistent with neuropathy. Quality of life in patients with hereditary TTR amyloidosis, but not asymptomatic carriers of disease-causing mutations, was severely impaired relative to that of the age-matched general US population. CONCLUSIONS This preliminary analysis highlights the considerable phenotypic heterogeneity for neurological and cardiac manifestations in patients with hereditary and wild-type TTR amyloidosis and the necessity of providing multidisciplinary care. THAOS registry data will help better characterize the diverse presentation and course of TTR amyloidosis worldwide and aid in improving and standardizing diagnosis and treatment.
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Affiliation(s)
- Teresa Coelho
- Centre for the Study of Amyloidoses, Hospital Santo António, Porto, Portugal
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Cho HJ, Yoon JY, Bae MH, Lee JH, Yang DH, Park HS, Cho Y, Chae SC, Jun JE. Familial Transthyretin Amyloidosis with Variant Asp38Ala Presenting with Orthostatic Hypotension and Chronic Diarrhea. J Cardiovasc Ultrasound 2012; 20:209-12. [PMID: 23346293 PMCID: PMC3542517 DOI: 10.4250/jcu.2012.20.4.209] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 10/04/2012] [Accepted: 11/21/2012] [Indexed: 11/22/2022] Open
Abstract
A 53-year-old man complained of orthostatic, non-rotating dizziness, and chronic watery diarrhea of several years duration. His nerve-conduction velocity test revealed peripheral sensory-motor polyneuropathy and he showed an autonomic function abnormality. Echocardiographic examination showed ventricular and atrial wall thickening with a granular "sparkling" appearance. Left ventricular systolic function was preserved but pseudonormal diastolic dysfunction was present. Coronary angiography showed normal coronary arteries and an endomyocardial biopsy revealed lesions consistent with cardiac amyloidosis. Colonoscopic biopsy also revealed the deposition of amyloid fibrils. Gene analysis found the transthyretin variant Asp38Ala. His son had same mutation, but three daughters did not. In conclusion, we report a case of familial transthyretin amyloidosis with Asp38Ala.
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Affiliation(s)
- Hyun Jun Cho
- Division of Cardiology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
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Rapezzi C, Longhi S, Milandri A, Lorenzini M, Gagliardi C, Gallelli I, Leone O, Quarta CC. Cardiac involvement in hereditary-transthyretin related amyloidosis. Amyloid 2012; 19 Suppl 1:16-21. [PMID: 22494034 DOI: 10.3109/13506129.2012.673185] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Hereditary transthyretin-related amyloidosis remains a widely underdiagnosed condition, owing to its extreme phenotypic variability: the clinical spectrum of the disease ranges from an almost exclusive neurologic involvement to strictly cardiac manifestations. This heterogeneity is linked to several factors including specific transthyretin mutations, geographic distribution and endemic vs. non-endemic aggregation type. The existence of exclusively or predominantly cardiac phenotypes makes the recognition of the disease very challenging since it can mimic other more common causes of left ventricular "hypertrophy". Assessment of such patients should include an active search for possible red flags that can indicate the correct final diagnosis.
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Affiliation(s)
- Claudio Rapezzi
- Institute of Cardiology, University of Bologna and S.Orsola-Malpighi Hospital, Bologna, Italy.
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Salvi F, Pastorelli F, Plasmati R, Bartolomei I, Dall'Osso D, Rapezzi C. Genotypic and phenotypic correlation in an Italian population of hereditary amyloidosis TTR-related (HA-TTR): clinical and neurophysiological aids to diagnosis and some reflections on misdiagnosis. Amyloid 2012; 19 Suppl 1:58-60. [PMID: 22620967 DOI: 10.3109/13506129.2012.682187] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
131 HA-TTR patients from a single referral centre presented at onset five major clinical syndromes: (1) the typical "Portuguese variant" axonal polyneuropathy with dissociated (syringomyelic like) sensory loss and autonomic dysfunction; (2) bilateral carpal tunnel syndrome; (3) restless leg syndrome with impotence and unexplained loss of weight; (4) pure motor neuropathy without autonomic abnormalities; (5) recurrent small brain or spinal cord ischemia or haemorrhages with leptomeningeal amyloid deposition (and late superficial siderosis of the central nervous system) and vitreous deposits. Some patients in our population presented a "pseudodemyelinating" onset of the somatic neuropathy, as well as atypical motor neuropathy simulating lower motor neuron disease. The five syndromes can overlap in advanced stages of the disease. Genetic screening of HA-TTR could be worthwhile in any idiopathic progressive axonal peripheral neuropathy, as well as in drug resistant demyelinating sensory-motor neuropathy or in pure motor neuropathy, when multi-organ involvement is present.
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Affiliation(s)
- Fabrizio Salvi
- IRCCS Istituto delle Scienze Neurologiche, UOC Neurologia, Centro Il Bene, Bellaria Hospital, Bologna, Italy.
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Kerschen P, Planté-Bordeneuve V. Neuropatie amiloidi familiari. Neurologia 2012. [DOI: 10.1016/s1634-7072(12)60703-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Rapezzi C, Quarta CC, Guidalotti PL, Pettinato C, Fanti S, Leone O, Ferlini A, Longhi S, Lorenzini M, Reggiani LB, Gagliardi C, Gallo P, Villani C, Salvi F. Role of (99m)Tc-DPD scintigraphy in diagnosis and prognosis of hereditary transthyretin-related cardiac amyloidosis. JACC Cardiovasc Imaging 2012; 4:659-70. [PMID: 21679902 DOI: 10.1016/j.jcmg.2011.03.016] [Citation(s) in RCA: 231] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 03/28/2011] [Indexed: 12/14/2022]
Abstract
OBJECTIVES In a cohort of patients with hereditary transthyretin-related amyloidosis (ATTR), we aimed to assess the role of (99m)Tc-3,3-diphosphono-1,2-propanodicarboxylic acid ((99m)Tc-DPD) in detecting myocardial amyloid infiltration across a wide spectrum of cardiac involvement and in predicting major adverse cardiac events (MACE). BACKGROUND Hereditary transthyretin-related amyloidosis is a challenging and underdiagnosed condition where both early diagnosis and prognosis remain problematic. METHODS We evaluated 63 patients with ATTR: 40 with and 23 without echocardiographically diagnosed amyloidotic cardiomyopathy (AC). Myocardial uptake of (99m)Tc-DPD scintigraphy was semiquantitatively and visually assessed at 5 min and 3 h. RESULTS All patients with AC showed moderate-to-severe myocardial tracer uptake (i.e., visual score ≥2). Within the subgroup without AC, only 4 patients (with Ala36Pro, Gly47Ala, Thr49Ala, and Glu89Gln transthyretin mutations) showed myocardial tracer uptake and abnormal heart/whole body retention (H/WB) values: in all these cases endomyocardial biopsies showed amyloidotic infiltration. The H/WB was positively correlated with left ventricular (LV) mean wall thickness (Pearson's r=0.695, p<0.001) and negatively with LV ejection fraction (r=-0.368, p=0.004). The H/WB was an unfavorable predictor of MACE-free survival at Cox univariate analysis and contributed to the multivariate model. Notably, LV wall thickness >12 mm in combination with H/WB >7.5 was associated with the highest event rate. CONCLUSIONS In ATTR, (99m)Tc-DPD scintigraphy can identify myocardial infiltration across a wide spectrum of morphologic/functional cardiac involvement, allowing an early diagnosis of the disease (even before the appearance of echocardiographic abnormalities). The (99m)Tc-DPD myocardial uptake is a prognostic determinant of "cardiac" outcome in ATTR, either alone or in combination with LV wall thickness.
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Affiliation(s)
- Claudio Rapezzi
- Institute of Cardiology, University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy.
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Abstract
A nonhereditary form of systemic amyloidosis associated with wild-type transthyretin causes heart involvement predominantly in elderly men (systemic senile amyloidosis, or SSA). However, hereditary transthyretin-related amyloidosis (ATTR) is the most frequent form of familial systemic amyloidosis, a group of severe diseases with variable neurological and organ involvement. ATTR remains a challenging and widely underdiagnosed condition, owing to its extreme phenotypic variability: the clinical spectrum of the disease ranges from an almost exclusive neurologic involvement to a strictly cardiac presentation. Such heterogeneity principally results from differential effects of the various reported transthyretin mutations, the geographic region the patient is from and, in the case of the most common mutation, Val30Met, whether or not large foci of cases occur (endemic versus nonendemic aggregation). Genetic or environmental factors (such as age, sex, and amyloid fibril composition) also contribute to the heterogeneity of ATTR, albeit to a lesser extent. The existence of exclusively or predominantly cardiac phenotypes should lead clinicians to consider the possibility of ATTR in all patients who present with an unexplained increase in left ventricular wall thickness at echocardiography. Assessment of such patients should include an active search for possible red flags that can point to the correct final diagnosis.
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Barreiros AP, Post F, Hoppe-Lotichius M, Linke RP, Vahl CF, Schäfers HJ, Galle PR, Otto G. Liver transplantation and combined liver-heart transplantation in patients with familial amyloid polyneuropathy: a single-center experience. Liver Transpl 2010; 16:314-23. [PMID: 20209591 DOI: 10.1002/lt.21996] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Liver transplantation (LT) is the only curative option for patients with familial amyloid polyneuropathy (FAP) at present. Twenty patients with FAP underwent LT between May 1998 and June 2007. Transthyretin mutations included predominantly the Val30Met mutation but also 10 other mutations. Seven patients received a pacemaker prior to LT, and because of impairment of mechanical cardiac function, 4 combined heart-liver transplants were performed, 1 simultaneously and 3 sequentially. The first patient, who underwent simultaneous transplantation, died. Seven patients died after LT, with 5 dying within the first year after transplantation. The causes of death were cardiac complications (4 patients), infections (2 patients), and malnutrition (1 patient). One-year survival was 75.0%, and 5-year survival was 64.2%. Gly47Glu and Leu12Pro mutations showed an aggressive clinical manifestation: 2 patients with the Gly47Glu mutation, the youngest patients of all the non-Val30Met patients, suffered from severe cardiac symptoms leading to death despite LT. Two siblings with the Leu12Pro mutation, who presented only with grand mal seizures, died after LT because of sepsis. In conclusion, the clinical course in patients with FAP is very variable. Cardiac symptoms occurred predominantly in patients with non-Val30Met mutations and prompted combined heart-liver transplantation in 4 patients. Although early LT in Val30Met is indicated in order to halt the typical symptoms of polyneuropathy, additional complications occurring predominantly with other mutations may prevail and lead to life-threatening complications or a fatal outcome. Combined heart-liver transplantation should be considered in patients with restrictive cardiomyopathy.
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Affiliation(s)
- Ana-Paula Barreiros
- Department of Internal Medicine I, Johannes Gutenberg University, Langenbeckstrasse 1, 55101 Mainz, Germany.
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Rapezzi C, Merlini G, Quarta CC, Riva L, Longhi S, Leone O, Salvi F, Ciliberti P, Pastorelli F, Biagini E, Coccolo F, Cooke RMT, Bacchi-Reggiani L, Sangiorgi D, Ferlini A, Cavo M, Zamagni E, Fonte ML, Palladini G, Salinaro F, Musca F, Obici L, Branzi A, Perlini S. Systemic cardiac amyloidoses: disease profiles and clinical courses of the 3 main types. Circulation 2009; 120:1203-12. [PMID: 19752327 DOI: 10.1161/circulationaha.108.843334] [Citation(s) in RCA: 540] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Most studies of amyloidotic cardiomyopathy consider as a single entity the 3 main systemic cardiac amyloidoses: acquired monoclonal immunoglobulin light-chain (AL); hereditary, mutated transthyretin-related (ATTRm); and wild-type transthyretin-related (ATTRwt). In this study, we compared the diagnostic/clinical profiles of these 3 types of systemic cardiac amyloidosis. METHODS AND RESULTS We conducted a longitudinal study of 233 patients with clear-cut diagnosis by type of cardiac amyloidosis (AL, n=157; ATTRm, n=61; ATTRwt, n=15) at 2 large Italian centers providing coordinated amyloidosis diagnosis/management facilities since 1990. Average age at diagnosis was higher in AL than in ATTRm patients; all ATTRwt patients except 1 were elderly men. At diagnosis, mean left ventricular wall thickness was higher in ATTRwt than in ATTRm and AL. Left ventricular ejection fraction was moderately depressed in ATTRwt but not in AL or ATTRm. ATTRm patients less often displayed low QRS voltage (25% versus 60% in AL; P<0.0001) or low voltage-to-mass ratio (1.1+/-0.5 versus 0.9+/-0.5; P<0.0001). AL patients appeared to have greater hemodynamic impairment. On multivariate analysis, ATTRm was a strongly favorable predictor of survival, and ATTRwt predicted freedom from major cardiac events. CONCLUSIONS AL, ATTRm, and ATTRwt should be considered 3 different cardiac diseases, probably characterized by different pathophysiological substrates and courses. Awareness of the diversity underlying the cardiac amyloidosis label is important on several levels, ranging from disease classification to diagnosis and clinical management.
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Affiliation(s)
- Claudio Rapezzi
- Istituto di Cardiologia, Policlinico S. Orsola-Malpighi, Via Massarenti n 9, 40125 Bologna, Italy.
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Collins AB, Smith RN, Stone JR. Classification of amyloid deposits in diagnostic cardiac specimens by immunofluorescence. Cardiovasc Pathol 2009; 18:205-16. [DOI: 10.1016/j.carpath.2008.05.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Revised: 04/25/2008] [Accepted: 05/29/2008] [Indexed: 10/21/2022] Open
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Noto Y, Tokuda T, Shiga K, Tsuchiya A, Yazaki M, Matoba S, Nakagawa M. Cardiomyopathy in a Japanese family with the Glu61Lys transthyretin variant: a new phenotype. Amyloid 2009; 16:99-102. [PMID: 20536403 DOI: 10.1080/13506120902879335] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We report a Japanese family with transthyretin (TTR) amyloidosis caused by ATTRGlu61Lys that was associated with progressive cardiomyopathy, peripheral neuropathy, and bilateral carpal tunnel syndrome. Amyloidotic polyneuropathy in association with ATTRGlu61Lys was previously described in a Japanese family by Shiomi et al., (Biochem Biophys Res Commun 1993;194:1090-1096), and the main clinical features of that family were late-onset sensorimotor polyneuropathy and severe autonomic disturbance. However, there have been no descriptions of either cardiac involvement or carpal tunnel syndrome. The Japanese family, we present here, had severe cardiomyopathy as a cardinal symptom, which is a new phenotype of the TTR amyloidosis with ATTRGlu61Lys. This report, alongwith a previous one, demonstrates the clinical variety of TTR amyloidosis caused by ATTRGlu61Lys.
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Affiliation(s)
- Yuichi Noto
- Department of Molecular Neurology and Gerontology, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
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Rapezzi C, Riva L, Quarta CC, Perugini E, Salvi F, Longhi S, Ciliberti P, Pastorelli F, Biagini E, Leone O, Cooke RMT, Bacchi-Reggiani L, Ferlini A, Cavo M, Merlini G, Perlini S, Pasquali S, Branzi A. Gender-related risk of myocardial involvement in systemic amyloidosis. Amyloid 2008; 15:40-8. [PMID: 18266120 DOI: 10.1080/13506120701815373] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
To investigate associations between gender and myocardial involvement in systemic amyloidosis, we reviewed all patients presenting between 1994 and September 2006 in our institutional network (100 AL and 98 familial transthyretin-related amyloidosis (ATTR) patients, plus 12 elderly men with senile systemic amyloidosis). We focused on echocardiographic descriptors of myocardial involvement (height-indexed mean left ventricular (LV) wall thickness, LV mass index), and baseline LV function. Among familial ATTR patients, female prevalence was lower within the highest tertile of either echocardiographic indicator of myocardial involvement. Gender was independently associated with height-indexed mean LV wall thickness (as were gene mutations). Female prevalence appeared rather similar across the different neurological stages. Within the subgroup of familial ATTR patients with amyloidotic cardiomyopathy, women tended to display a considerably less severe morphological and functional echocardiographic profile. We explored the possible role of female sex hormones by considering menopausal status: women in the highest tertile of mean LV wall thickness index were more often postmenopausal than those in the other two tertiles and had a much higher ( approximately 15 years) mean age; analogous age-related associations were not observable for men. In conclusion, these findings raise the hypothesis that some biological characteristic associated with female gender protects against myocardial involvement in familial ATTR.
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Affiliation(s)
- Claudio Rapezzi
- Institute of Cardiology, University of Bologna, Bologna, Italy.
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