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Packer M. The First Dedicated Comprehensive Heart Failure Program in the United States: The Division of Circulatory Physiology at Columbia Presbyterian (1992-2004). J Card Fail 2023; 29:1078-1090. [PMID: 37075940 DOI: 10.1016/j.cardfail.2023.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 04/21/2023]
Abstract
The first dedicated multidisciplinary heart failure program in the United States was founded as the Division of Circulatory Physiology at the Columbia University College of Physicians & Surgeons in 1992. The Division was administratively and financially independent of the Division of Cardiology and grew to 24 faculty members at its peak. Its administrative innovations included (1) a comprehensive full-integrated service line, with 2 differentiated clinical teams, one devoted to drug therapy and the other to heart transplantation and ventricular assist devices; (2) a nurse specialist/physician assistant-led clinical service; and (3) a financial structure independent of (and not supported by) other cardiovascular medical or surgical services. The division had 3 overarching missions: (1) to promote a unique career development path for each faculty member to be linked to recognition in a specific area of heart failure expertise; (2) to change the trajectory and enhance the richness of intellectual discourse in the discipline of heart failure, so as to foster an understanding of fundamental mechanisms and to develop new therapeutics; and (3) to provide optimal medical care to patients and to promote the ability of other physicians to provide optimal care. The major research achievements of the division included (1) the development of beta-blockers for heart failure, from initial hemodynamic assessments to proof-of-concept studies to large-scale international trials; (2) the development and definitive assessment of flosequinan, amlodipine, and endothelin antagonists; (3) initial clinical trials and concerns with nesiritide; (4) large-scale trials evaluating dosing of angiotensin converting-enzyme inhibitors and the efficacy and safety of neprilysin inhibition; (5) identification of key mechanisms in heart failure, including neurohormonal activation, microcirculatory endothelial dysfunction, deficiencies in peripheral vasodilator pathways, noncardiac factors in driving dyspnea, and the first identification of subphenotypes of heart failure and a preserved ejection fraction; (6) the development of a volumetric approach to the assessment of myocardial shortening; (7) conceptualization and early studies of cardiac contractility modulation as a treatment for heart failure; (8) novel approaches to the identification of cardiac allograft rejection and new therapeutics to prevent allograft vasculopathy; and (9) demonstration of the effect of left ventricular assist devices to induce reverse remodeling, and the first randomized trial showing a survival benefit with ventricular assist devices. Above all, the division served as an exceptional incubator for a generation of leaders in the field of heart failure.
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Affiliation(s)
- Milton Packer
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas, and Imperial College, London, UK.
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2
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Kittleson MM, Ruberg FL, Ambardekar AV, Brannagan TH, Cheng RK, Clarke JO, Dember LM, Frantz JG, Hershberger RE, Maurer MS, Nativi-Nicolau J, Sanchorawala V, Sheikh FH. 2023 ACC Expert Consensus Decision Pathway on Comprehensive Multidisciplinary Care for the Patient With Cardiac Amyloidosis: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2023; 81:1076-1126. [PMID: 36697326 DOI: 10.1016/j.jacc.2022.11.022] [Citation(s) in RCA: 78] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Witteles RM. Cardiac Transplantation and Mechanical Circulatory Support in Amyloidosis. JACC: CARDIOONCOLOGY 2021; 3:516-521. [PMID: 34729523 PMCID: PMC8543081 DOI: 10.1016/j.jaccao.2021.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/21/2021] [Accepted: 05/23/2021] [Indexed: 12/02/2022]
Abstract
Cardiac transplantation for amyloidosis was once considered contraindicated owing to unacceptably high morbidity/mortality rates. Increased therapeutic options for AL and ATTR amyloidosis and improved pre-transplantation screening practices have led to markedly improved transplant outcomes over the past 10-15 years. Mechanical circulatory support options remain limited but can be considered in selected patients, particularly for those with larger ventricular cavities. Transplant prioritization rules may need to be reconsidered for amyloidosis patients to adequately prioritize AL amyloidosis patients, who are at increased risk of pre-transplantation mortality.
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Affiliation(s)
- Ronald M Witteles
- Stanford Amyloid Center, Stanford University School of Medicine, Stanford, California, USA
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4
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Vaidya GN, Patel JK, Kittleson M, Chang DH, Kransdorf E, Geft D, Czer L, Vescio R, Esmailian F, Kobashigawa JA. Intermediate-term outcomes of heart transplantation for cardiac amyloidosis in the current era. Clin Transplant 2021; 35:e14308. [PMID: 33825224 DOI: 10.1111/ctr.14308] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 11/18/2020] [Accepted: 03/29/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Cardiac amyloidosis (CA) has been historically noted with poor outcomes after heart transplant (HTx). However, strict patient selection, appropriate multi-organ transplant, and aggressive post-transplant therapy can result in favorable outcomes. We present the experience in the largest single-center cohort of CA patients post-HTx in the recent era. METHODS Between January 2010 and December 2018, 51 CA patients underwent HTx-13 light-chain amyloidosis (AL) and 38 transthyretin amyloidosis (ATTR), 49 were included. Endpoints included 3-year survival, freedom from cardiac allograft vasculopathy (CAV), and freedom from non-fatal major adverse cardiac events (NF-MACE). RESULTS Overall 3-year survival was 81.6% (69.2% for AL and 86% for ATTR) and was comparable to survival for patients transplanted for non-amyloid restrictive cardiomyopathy (RCM) in the same period (89%, p = .46). Three-year freedom from CAV (84% vs. 89%, p = .98), NF-MACE (82% vs. 83%, p = .96), and any-treated rejection (95% vs. 89%, p = .54) were also comparable in both groups. No recurrence in amyloid was noted in endomyocardial biopsies. Six patients (46%) with AL amyloidosis underwent autologous stem cell transplant 1-year post-HTx, and two patients (8%) with variant ATTR-CA underwent combined heart-liver transplant due to cardiac cirrhosis. CONCLUSION In the current era, both AL and ATTR cardiac amyloidosis patients have acceptable outcomes after heart transplantation.
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Affiliation(s)
| | | | | | - David H Chang
- Smidt Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Evan Kransdorf
- Smidt Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Dael Geft
- Smidt Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Lawrence Czer
- Smidt Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Robert Vescio
- Department of Hematology/Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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5
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Di Nora C, Sponga S, Ferrara V, Patriarca F, Fanin R, Nalli C, Lechiancole A, Vendramin I, Livi U. Emerging therapy in light-chain and acquired transthyretin-related amyloidosis: an Italian single-centre experience in heart transplantation. J Cardiovasc Med (Hagerstown) 2021; 22:261-267. [PMID: 33633041 DOI: 10.2459/jcm.0000000000001094] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The prognosis for patients affected by light-chain cardiac amyloidosis and acquired transthyretin-related (TTR) amyloidosis is poor. Heart transplantation (HTx) could improve prognosis also enabling autologous stem cell transplantation (ASCT) in the first group. METHODS AND RESULTS A total of 36 patients affected by systemic amyloidosis have been referred to our centre from 2009 to 2019. Of these, nine had cardiac involvement: seven by light-chain amyloidosis and two by acquired TTR amyloidosis. None died while waiting for HTx. A specific internal protocol useful to select candidates and to monitor the organ involvement after HTx was developed. Median age at diagnosis was 54 years and 66% were male. The most common short-term complication after HTx was renal failure (44%), followed by acute cardiac rejection more than 2R (22%). ASCT was performed in six out of seven light-chain cardiac amyloidosis patients, with a median time of 6 months after HTx. Two patients affected by light-chain cardiac amyloidosis died due to amyloidosis relapse: one before undergoing ASCT. After a median follow-up of 31 (7-124) months, 1- and 5-year survival was 88 and 66% in the cardiac light-chain amyloidosis group. Conversely, 1- and 5-year survival was 100% in the acquired TTR amyloidosis group. CONCLUSION HTx may represent a valuable option in carefully selected patients. ASCT after HTx is an effective treatment that could decrease amyloidosis relapse in light-chain cardiac amyloidosis patients. A multidisciplinary approach is mandatory to select the best candidates and to obtain the most effective results with a specific surveillance follow-up protocol.
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Affiliation(s)
- Concetta Di Nora
- Department of Cardiothoracic Science, Azienda Sanitaria Universitaria Integrata di Udine
| | - Sandro Sponga
- Department of Cardiothoracic Science, Azienda Sanitaria Universitaria Integrata di Udine
| | - Veronica Ferrara
- Department of Cardiothoracic Science, Azienda Sanitaria Universitaria Integrata di Udine
| | | | - Renato Fanin
- Haematology Department, Azienda sanitaria Universitaria Integrata, DAME
| | - Chiara Nalli
- Department of Cardiothoracic Science, Azienda Sanitaria Universitaria Integrata di Udine
| | - Andrea Lechiancole
- Department of Cardiothoracic Science, Azienda Sanitaria Universitaria Integrata di Udine
| | - Igor Vendramin
- Department of Cardiothoracic Science, Azienda Sanitaria Universitaria Integrata di Udine
| | - Ugolino Livi
- Department of Cardiothoracic Science
- Department of Medical Area DAME, University of Udine, Udine, Italy
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6
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Abstract
Please add expansion for AL. Hematologic disease control combined with solid organ transplantation can result in long-term survival in selected patients with light chain (AL) amyloidosis and limited other organ involvement. Restoration of critical cardiac function with organ transplantation can render patients eligible for effective disease-directed therapies, including high-dose therapy and autologous stem cell transplantation. Access to directed-donor organs, exchange programs for renal transplantation, and extended-donor organs for cardiac transplantation improves the availability of organs for patients with AL amyloidosis. Disease recurrence in the graft and progression in other organs remain concerns but often can be managed with a variety of effective plasma cell-directed therapies.
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Griffin JM, Chiu L, Axsom KM, Bijou R, Clerkin KJ, Colombo P, Cuomo MO, De Los Santos J, Fried JA, Goldsmith J, Habal M, Haythe J, Helmke S, Horn EM, Latif F, Hi Lee S, Lin EF, Naka Y, Raikhelkar J, Restaino S, Sayer GT, Takayama H, Takeda K, Teruya S, Topkara V, Tsai EJ, Uriel N, Yuzefpolskaya M, Farr MA, Maurer MS. United network for organ sharing outcomes after heart transplantation for al compared to ATTR cardiac amyloidosis. Clin Transplant 2020; 34:e14028. [PMID: 32623785 DOI: 10.1111/ctr.14028] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/20/2020] [Accepted: 06/25/2020] [Indexed: 12/17/2022]
Abstract
Light-chain (AL) cardiac amyloidosis (CA) has a worse prognosis than transthyretin (ATTR) CA. In this single-center study, we compared post-heart transplant (OHT, orthotopic heart transplantation) survival for AL and ATTR amyloidosis, hypothesizing that these differences would persist post-OHT. Thirty-nine patients with CA (AL, n = 18; ATTR, n = 21) and 1023 non-amyloidosis subjects undergoing OHT were included. Cox proportional hazards modeling was used to evaluate the impact of amyloid subtype and era (early era: from 2001 to 2007; late era: from 2008 to 2018) on survival post-OHT. Survival for non-amyloid patients was greater than ATTR (P = .034) and AL (P < .001) patients in the early era. One, 3-, and 5-year survival rates were higher for ATTR patients than AL patients in the early era (100% vs 75%, 67% vs 50%, and 67% vs 33%, respectively, for ATTR and AL patients). Survival in the non-amyloid cohort was 87% at 1 year, 81% at 3 years, and 76% at 5 years post-OHT. In the late era, AL and ATTR patients had unadjusted 1-year, 3-year, and 5-year survival rates of 100%, which was comparable to non-amyloid patients (90% vs 84% vs 81%). Overall, these findings demonstrate that in the current era, differences in post-OHT survival for AL compared to ATTR are diminishing; OHT outcomes for selected patients with CA do not differ from non-amyloidosis patients.
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Affiliation(s)
- Jan M Griffin
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Leonard Chiu
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Kelly M Axsom
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Rachel Bijou
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Kevin J Clerkin
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Paolo Colombo
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Margaret O Cuomo
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Jeffeny De Los Santos
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Justin A Fried
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | | | - Marlena Habal
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Jennifer Haythe
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Stephen Helmke
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Evelyn M Horn
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA.,Division of Cardiology, Department of Medicine, Weill-Cornell Medical School, New York, NY, USA
| | - Farhana Latif
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Sun Hi Lee
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Edward F Lin
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Jayant Raikhelkar
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Susan Restaino
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Gabriel T Sayer
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Sergio Teruya
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Veli Topkara
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Emily J Tsai
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Nir Uriel
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Melana Yuzefpolskaya
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Maryjane A Farr
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
| | - Mathew S Maurer
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA
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8
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Heart transplantation in cardiac storage diseases: data on Fabry disease and cardiac amyloidosis. Curr Opin Organ Transplant 2020; 25:211-217. [DOI: 10.1097/mot.0000000000000756] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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9
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Rosenblum H, Castano A, Alvarez J, Goldsmith J, Helmke S, Maurer MS. TTR (Transthyretin) Stabilizers Are Associated With Improved Survival in Patients With TTR Cardiac Amyloidosis. Circ Heart Fail 2019; 11:e004769. [PMID: 29615436 DOI: 10.1161/circheartfailure.117.004769] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/01/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND TTR (transthyretin) cardiac amyloidosis is caused by dissociation of TTR into monomers, which misassemble into amyloid fibrils. TTR stabilizers act at the dimer-dimer interface to prevent dissociation. We investigated differences in survival among patients with TTR cardiac amyloidosis on stabilizer medications compared with those not on stabilizers. METHODS AND RESULTS A retrospective study of patients with TTR cardiac amyloidosis presenting to a single center was conducted. Baseline characteristics were compared between those treated with stabilizers and those not treated with stabilizers. Cox proportional hazards modeling assessed for univariate predictors of the composite outcome of death or orthotopic heart transplant (OHT). Multivariable Cox proportional hazards assessed whether stabilizer treatment was independently associated with improved death or OHT after controlling for significant univariate predictors. One hundred twenty patients (mean age, 75±8, 88% male) were included: 29 patients who received stabilizers and 91 patients who did not. Stabilizer use was associated with a lower risk of the combined end point of death or OHT (hazard ratio, 0.32; 95% confidence interval, 0.18-0.58; P<0.0001). Subjects treated with stabilizers were more likely to be of White race (93% versus 55%; P<0.001), classified as New York Heart Association classes I and II (79% versus 38%; P=0.002), less likely to have a mutation (10% versus 36%; P=0.010), have lower troponin I (median 0.06 versus 0.12 ng/mL; P=0.002), and higher left ventricular ejection fraction (49% versus 40%; P=0.011), suggesting earlier stage of disease. In multivariable Cox analysis, the association between stabilizer and death or OHT persisted when adjusted for all noncollinear univariate predictors with P<0.05 (hazard ratio, 0.37; 95% confidence interval, 0.19-0.75; P=0.003). CONCLUSIONS TTR stabilizers are associated with decreased death and OHT in TTR cardiac amyloidosis. These results need to be confirmed by ongoing randomized clinical trials.
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Affiliation(s)
- Hannah Rosenblum
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital
| | - Adam Castano
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital
| | - Julissa Alvarez
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital
| | - Jeff Goldsmith
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital
| | - Stephen Helmke
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital
| | - Mathew S Maurer
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital.
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10
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Abstract
BACKGROUND The true prevalence of heart failure due to wild type transthyretin amyloidosis (ATTRwt) is likely underestimated. There is a paucity of data with regard to the management of ATTRwt-related advanced heart failure and the natural history of extracardiac ATTRwt. METHODS We conducted a retrospective cohort study of patients undergoing cardiac transplant (HTx) for ATTRwt at a single institution. Comprehensive clinical data, including baseline hemodynamic and echocardiographic characteristics, and posttransplant outcomes, were obtained. RESULTS Seven patients with ATTRwt underwent HTx between 2007 and 2015. All patients were male with a mean age of 66 ± 9. Patients had a reduced ejection fraction (mean, 37 ± 14%) and elevated filling pressures pre-HTx (mean pulmonary capillary wedge pressure 22 ± 7 mm Hg) before HTx. Three-year survival was 100%; 1 patient died of pancreatic cancer 45 months post-HTx (1 death per 30.8 patient-years). Oxygen consumption (Δ +6.8 ± 4.9 mL·kg·min) and 6-minute walk distances (Δ +189 ± 60 m) improved. Symptomatic gastrointestinal involvement (n = 2) and peripheral nerve involvement (n = 4) by ATTRwt developed late. CONCLUSIONS This is the first report of a series of ATTRwt patients receiving HTx in which excellent outcomes are demonstrated. Although cardiac death is averted, systemic manifestations of ATTRwt may develop posttransplantation.
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11
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Abstract
"Cardiac amyloidosis" is the term commonly used to reflect the deposition of abnormal protein amyloid in the heart. This process can result from several different forms, most commonly from light-chain (AL) amyloidosis and transthyretin (ATTR) amyloidosis, which in turn can represent wild-type (ATTRwt) or genetic form. Regardless of the origin, cardiac involvement is usually associated with poor prognosis, especially in AL amyloidosis. Although several treatment options, including chemotherapy, exist for different forms of the disease, cardiac transplantation is increasingly considered. However, high mortality on the transplantation list, typical for patients with amyloidosis, and suboptimal post-transplant outcomes are major issues. We are reviewing the literature and summarizing pros and cons of listing patients with amyloidosis for cardiac or combine organ transplant, appropriate work-up, and intermediate and long-term outcomes. Both AL and ATTR amyloidosis are included in this review.
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Maurer MS, Elliott P, Comenzo R, Semigran M, Rapezzi C. Addressing Common Questions Encountered in the Diagnosis and Management of Cardiac Amyloidosis. Circulation 2017; 135:1357-1377. [PMID: 28373528 PMCID: PMC5392416 DOI: 10.1161/circulationaha.116.024438] [Citation(s) in RCA: 274] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Advances in cardiac imaging have resulted in greater recognition of cardiac amyloidosis in everyday clinical practice, but the diagnosis continues to be made in patients with late-stage disease, suggesting that more needs to be done to improve awareness of its clinical manifestations and the potential of therapeutic intervention to improve prognosis. Light chain cardiac amyloidosis, in particular, if recognized early and treated with targeted plasma cell therapy, can be managed very effectively. For patients with transthyretin amyloidosis, there are numerous therapies that are currently in late-phase clinical trials. In this review, we address common questions encountered in clinical practice regarding etiology, clinical presentation, diagnosis, and management of cardiac amyloidosis, focusing on recent important developments in cardiac imaging and biochemical diagnosis. The aim is to show how a systematic approach to the evaluation of suspected cardiac amyloidosis can impact the prognosis of patients in the modern era.
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Affiliation(s)
- Mathew S Maurer
- From Columbia University Medical Center, New York, NY (M.S.M.); University College London and St. Bartholomew's Hospital, UK (P.E.); Tufts Medical Center, Boston, MA (R.C.); Massachusetts General Hospital, Harvard University, Boston (M.S.); and Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Italy (C.R.).
| | - Perry Elliott
- From Columbia University Medical Center, New York, NY (M.S.M.); University College London and St. Bartholomew's Hospital, UK (P.E.); Tufts Medical Center, Boston, MA (R.C.); Massachusetts General Hospital, Harvard University, Boston (M.S.); and Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Italy (C.R.)
| | - Raymond Comenzo
- From Columbia University Medical Center, New York, NY (M.S.M.); University College London and St. Bartholomew's Hospital, UK (P.E.); Tufts Medical Center, Boston, MA (R.C.); Massachusetts General Hospital, Harvard University, Boston (M.S.); and Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Italy (C.R.)
| | - Marc Semigran
- From Columbia University Medical Center, New York, NY (M.S.M.); University College London and St. Bartholomew's Hospital, UK (P.E.); Tufts Medical Center, Boston, MA (R.C.); Massachusetts General Hospital, Harvard University, Boston (M.S.); and Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Italy (C.R.)
| | - Claudio Rapezzi
- From Columbia University Medical Center, New York, NY (M.S.M.); University College London and St. Bartholomew's Hospital, UK (P.E.); Tufts Medical Center, Boston, MA (R.C.); Massachusetts General Hospital, Harvard University, Boston (M.S.); and Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Italy (C.R.)
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Bozkurt B, Colvin M, Cook J, Cooper LT, Deswal A, Fonarow GC, Francis GS, Lenihan D, Lewis EF, McNamara DM, Pahl E, Vasan RS, Ramasubbu K, Rasmusson K, Towbin JA, Yancy C. Current Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart Association. Circulation 2016; 134:e579-e646. [PMID: 27832612 DOI: 10.1161/cir.0000000000000455] [Citation(s) in RCA: 427] [Impact Index Per Article: 53.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Perlini S, Mussinelli R, Salinaro F. New and Evolving Concepts Regarding the Prognosis and Treatment of Cardiac Amyloidosis. Curr Heart Fail Rep 2016; 13:267-272. [PMID: 27900617 DOI: 10.1007/s11897-016-0311-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Systemic amyloidoses are rare and proteiform diseases, caused by extracellular accumulation of insoluble misfolded fibrillar proteins. Prognosis is dictated by cardiac involvement, which is especially frequent in light chain (AL) and in transthyretin variants (ATTR, both mutated, (ATTRm), and wild-type, (ATTRwt)). Recently, ATTRwt has emerged as a potentially relevant cause of a heart failure with preserved ejection fraction (HFpEF). Cardiac amyloidosis is an archetypal example of restrictive cardiomyopathy, with signs and symptoms of global heart failure and diastolic dysfunction. Independent of the aetiology, cardiac amyloidosis is associated with left ventricular concentric "hypertrophy" (i.e. increased wall thickness), preserved (or mildly depressed) ejection fraction, reduced midwall fractional shortening and global longitudinal function, as well as evident diastolic dysfunction, up to an overly restrictive pattern of the left ventricular filling. Cardiac biomarkers such as troponins and natriuretic peptides are very robust and widely accepted diagnostic as well as prognostic tools. Owing to its dismal prognosis, accurate and early diagnosis is mandatory and potentially life-saving. Although pathogenesis is still not completely understood, direct cardiomyocyte toxicity of the amyloidogenic precursor proteins and/or oligomer aggregates adds on tissue architecture disruption caused by amyloid deposition. The clarification of mechanisms of cardiac damage is offering new potential therapeutic targets, and several treatment options with a relevant impact on prognosis are now available.
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Affiliation(s)
- Stefano Perlini
- Clinica Medica II, Department of Internal Medicine, University of Pavia, P. le Golgi 19, 27100, Pavia, Italy.
- Amyloidosis Research and Treatment Center, Fondazione Policlinico IRCCS San Matteo, University of Pavia, P. le Golgi 19, 27100, Pavia, Italy.
| | - Roberta Mussinelli
- Clinica Medica II, Department of Internal Medicine, University of Pavia, P. le Golgi 19, 27100, Pavia, Italy
| | - Francesco Salinaro
- Clinica Medica II, Department of Internal Medicine, University of Pavia, P. le Golgi 19, 27100, Pavia, Italy
- Experimental Medicine PhD Program, University of Pavia, Pavia, Italy
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15
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Abstract
The natural history of immunoglobulin light chain associated amyloidosis (AL) is determined by the extent of cardiac involvement. Patients with cardiac AL and symptomatic heart failure have a median survival of approximately six months without successful treatment of the underlying plasma cell disorder The outcome in cardiac AL is determined by both the severity of cardiac involvement and the response to treatment. Staging systems using cardiac biomarkers, including NT- proBNP and troponin, have been found to be powerful predictors of prognosis and are used to guide treatment. Arrhythmias are common in cardiac AL and may lead to acute hemodynamic compromise. Sudden cardiac death, often due to pulseless electrical activity, is an important cause of early mortality. Supportive therapy for heart failure is usually limited to diuretics. Beta-blockers, ACE-inhibitors, and angiotensin receptor blockers are poorly tolerated in cardiac AL and should be avoided. Cardiac transplantation is controversial and reserved for highly selected patients with limited extracardiac involvement. The primary target of treatment in cardiac AL is obliteration of the plasma cell clone, using chemotherapy alone or combined with autologous stem cell transplantation. Despite the risk of early mortality, overall survival has improved with advances in disease modifying therapy. Earlier diagnosis and treatment of cardiac AL is crucial to improving survival.
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Affiliation(s)
- Martha Grogan
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, MN, USA,
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16
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Palladini G, Milani P, Merlini G. Novel strategies for the diagnosis and treatment of cardiac amyloidosis. Expert Rev Cardiovasc Ther 2015; 13:1195-211. [PMID: 26496239 DOI: 10.1586/14779072.2015.1093936] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Systemic amyloidoses are rare, complex diseases caused by misfolding of autologous protein. The presence of heart involvement is the most important prognostic determinant. The diagnosis of amyloid cardiac involvement relies on echocardiography and magnetic resonance imaging, while scintigraphy with bone tracers is helpful in differentiating light chain amyloidosis from other types of amyloidosis involving the heart. Although these diseases are fatal, effective treatments exist that can alter their natural history, provided that they are started before irreversible cardiac damage has occurred. Refined diagnostic techniques, accurate patients' stratification based on biomarkers of cardiac dysfunction, the availability of novel, more powerful drugs, and ultimately, the unveiling of the cellular mechanisms of cardiac damage created a favorable environment for a dramatic improvement in the treatment of this disease that we expect in the next few years.
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Affiliation(s)
- Giovanni Palladini
- a Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Paolo Milani
- a Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Giampaolo Merlini
- a Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo and Department of Molecular Medicine, University of Pavia, Pavia, Italy
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17
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Bejar D, Colombo PC, Latif F, Yuzefpolskaya M. Infiltrative Cardiomyopathies. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2015; 9:29-38. [PMID: 26244036 PMCID: PMC4498662 DOI: 10.4137/cmc.s19706] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 03/05/2015] [Accepted: 03/18/2015] [Indexed: 12/15/2022]
Abstract
Infiltrative cardiomyopathies can result from a wide spectrum of both inherited and acquired conditions with varying systemic manifestations. They portend an adverse prognosis, with only a few exceptions (ie, glycogen storage disease), where early diagnosis can result in potentially curative treatment. The extent of cardiac abnormalities varies based on the degree of infiltration and results in increased ventricular wall thickness, chamber dilatation, and disruption of the conduction system. These changes often lead to the development of heart failure, atrioventricular (AV) block, and ventricular arrhythmia. Because these diseases are relatively rare, a high degree of clinical suspicion is important for diagnosis. Electrocardiography and echocardiography are helpful, but advanced techniques including cardiac magnetic resonance (CMR) and nuclear imaging are increasingly preferred. Treatment is dependent on the etiology and extent of the disease and involves medications, device therapy, and, in some cases, organ transplantation. Cardiac amyloid is the archetype of the infiltrative cardiomyopathies and is discussed in great detail in this review.
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Affiliation(s)
- David Bejar
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Paolo C Colombo
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Farhana Latif
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
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18
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Maurer MS, Grogan DR, Judge DP, Mundayat R, Packman J, Lombardo I, Quyyumi AA, Aarts J, Falk RH. Tafamidis in Transthyretin Amyloid Cardiomyopathy. Circ Heart Fail 2015; 8:519-26. [DOI: 10.1161/circheartfailure.113.000890] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 03/26/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Mathew S. Maurer
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
| | - Donna R. Grogan
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
| | - Daniel P. Judge
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
| | - Rajiv Mundayat
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
| | - Jeff Packman
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
| | - Ilise Lombardo
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
| | - Arshed A. Quyyumi
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
| | - Janske Aarts
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
| | - Rodney H. Falk
- From the Clinical Cardiovascular Research Laboratory for the Elderly (CCRLE), Columbia University Medical Center, New York Presbyterian Hospital (M.S.M.); Drug Development Department, FoldRx Pharmaceuticals/Pfizer Inc, Cambridge, MA (D.R.G., J.P.); Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University, Baltimore, MD (D.P.J.); Global Medicines Development (GMD) (J.A., I.L.) and Global Innovative Pharma – Statistics (R.M.), Pfizer Inc, New York, NY; Department
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19
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Davis MK, Kale P, Liedtke M, Schrier S, Arai S, Wheeler M, Lafayette R, Coakley T, Witteles RM. Outcomes after heart transplantation for amyloid cardiomyopathy in the modern era. Am J Transplant 2015; 15:650-8. [PMID: 25648766 DOI: 10.1111/ajt.13025] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 09/10/2014] [Accepted: 09/12/2014] [Indexed: 01/25/2023]
Abstract
We conducted a review of patients undergoing heart transplantation (HT) at our institution for amyloid cardiomyopathy (ACM) between 2008 and 2013. Complete follow-up was available for all patients. Nineteen patients with ACM underwent HT during the study period, accounting for 9.4% of all HT performed at our institution during this period. Amyloid subtype was light chain (AL) in 9 patients and transthyretin (ATTR) in 10 (2 wild-type, 7 familial, 1 unknown). Eight of nine patients with AL amyloidosis began chemotherapy prior to HT, six have resumed chemotherapy since HT, and five have undergone autologous stem cell transplantation. Most recent free light chain levels in AL patients decreased by a median of 85% from peak values. Only one patient developed recurrent graft amyloidosis, occurring at 3.5 years post-HT and asymptomatic. After a median follow-up of 380 days, 17 (89.5%) patients are alive. To our knowledge, this is the largest single-center series reported of ACM patients undergoing HT in the modern era. Our results suggest that acceptable outcomes following HT can be achieved in the short-to-intermediate term and that this is a feasible option for end-stage ACM with careful patient selection and aggressive control of amyloidogenic light chains in AL patients.
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Affiliation(s)
- M K Davis
- Division of Cardiovascular Medicine and Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA
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20
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Kinkhabwala MP, Mancini D. Patient selection for cardiac transplant in 2012. Expert Rev Cardiovasc Ther 2014; 11:179-91. [DOI: 10.1586/erc.12.186] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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21
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Halwani O, Delgado DH. Cardiac amyloidosis: an approach to diagnosis and management. Expert Rev Cardiovasc Ther 2014; 8:1007-13. [DOI: 10.1586/erc.10.41] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Abstract
Systemic amyloidoses are rare, complex diseases caused by misfolding of autologous proteins. Although these diseases are fatal, effective treatments exist that can alter their natural history, provided that they are started before irreversible organ damage has occurred. The cornerstones of the management of systemic amyloidoses are early diagnosis, accurate typing, appropriate risk-adapted therapy, tight follow-up, and effective supportive treatment. Internists play a key role in suspecting the disease, thus allowing early diagnosis, starting the diagnostic workup and selecting patients that should be referred to specialized centers, judiciously titrating supportive measures, and following patients throughout the course of the disease. Here we review the pathogenesis, diagnosis and treatment of the most common forms of systemic amyloidoses.
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Affiliation(s)
- Giovanni Palladini
- Amyloidosis Research and Treatment Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy
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23
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Potena L, Quarta CC, Grigioni F, Rapezzi C. Prognostic stratification and treatment of cardiac light chain amyloidosis: a narrow path in the jungle. J Heart Lung Transplant 2013; 33:136-8. [PMID: 24480447 DOI: 10.1016/j.healun.2013.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 11/12/2013] [Indexed: 01/04/2023] Open
Affiliation(s)
- Luciano Potena
- Heart Failure and Heart Transplant Program, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Italy
| | - Candida Cristina Quarta
- Heart Failure and Heart Transplant Program, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Italy
| | - Francesco Grigioni
- Heart Failure and Heart Transplant Program, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Italy
| | - Claudio Rapezzi
- Heart Failure and Heart Transplant Program, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Italy
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24
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Gray Gilstrap L, Niehaus E, Malhotra R, Ton VK, Watts J, Seldin DC, Madsen JC, Semigran MJ. Predictors of survival to orthotopic heart transplant in patients with light chain amyloidosis. J Heart Lung Transplant 2013; 33:149-56. [PMID: 24200511 DOI: 10.1016/j.healun.2013.09.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 08/23/2013] [Accepted: 09/10/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Orthotopic heart transplant (OHT), followed by myeloablative chemotherapy and autologous stem cell transplant (ASCT), has been successful in the treatment of amyloid light-chain (AL) cardiac amyloidosis. The purpose of this study was to identify predictors of survival to OHT in patients with end-stage heart failure due to AL amyloidosis and compare post-OHT survival of cardiac amyloid patients with survival of other cardiomyopathy patients undergoing OHT. METHODS From January 2000 to June 2011, 31 patients with end-stage heart failure secondary to AL amyloidosis were listed for OHT at Massachusetts General Hospital. Univariate and multivariate regression analyses identified predictors of survival to OHT. Kaplan-Meier analysis compared survival between the Massachusetts General Hospital amyloidosis patients and non-amyloid cardiomyopathy patients from the Scientific Registry of Transplant Recipients (SRTR). RESULTS Low body mass index was the only predictor of survival to OHT in patients with end-stage heart failure caused by cardiac amyloidosis. Survival of cardiac amyloid patients who died before receiving a donor heart was only 63 ± 45 days after listing. Patients who survived to OHT received a donor organ at 53 ± 48 days after listing. Survival of AL amyloidosis patients on the waiting list was less than patients on the waiting list for all other non-amyloid diagnoses. The long-term survival of amyloid patients who underwent OHT was no different than the survival of non-amyloid, restrictive (p = 0.34), non-amyloid dilated (p = 0.34), or all non-amyloid cardiomyopathy patients (p = 0.22) in the SRTR database. CONCLUSIONS Amyloid patients who survive to OHT, followed by ASCT, have a survival rate similar to other cardiomyopathy patients undergoing OHT; however, 35% of the patients died awaiting OHT. The only predictor of survival to OHT in AL amyloidosis patients was a low body mass index, which correlated with a shorter time on the waiting list. To optimize the survival of these patients, access to donor organs must be improved.
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Affiliation(s)
- Lauren Gray Gilstrap
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily Niehaus
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rajeev Malhotra
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Van-Khue Ton
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutes, Baltimore, Maryland
| | - James Watts
- Cardiology Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - David C Seldin
- Section of Hematology and Oncology, Amyloidosis Center, Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Joren C Madsen
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Marc J Semigran
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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25
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Honek T, Krejčí J, Špinarová L, Hude P, Němec P, Adam Z, Sirotková A, Žampachová V, Vítovec J. Heart transplantation for cardiac light chain amyloidosis with subsequent autologous stem cell transplantation. COR ET VASA 2013. [DOI: 10.1016/j.crvasa.2012.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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26
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Abstract
Amyloid is an abnormal extracellular fibrillar protein deposit in the tissues. In humans, more than 25 different proteins can adopt a fibrillar conformation in vivo that results in the pathognomonic tinctorial property of amyloid (that is, green birefringence when an affected tissue specimen is stained with Congo red dye and viewed by microscopy under cross-polarized light). Amyloid deposition is associated with disturbance of organ function and causes a wide variety of clinical syndromes that are classified according to the respective fibril protein precursor. Systemic amyloidosis, in which amyloid deposits are widespread and typically accumulate gradually, continues to be fatal and is responsible for about one in 1,500 deaths per year in the UK. Advances in our understanding of the pathogenesis of systemic amyloidosis have resulted in the identification of new therapeutic targets, and several drugs with novel mechanisms of action are currently under development. Meanwhile, an increased awareness of amyloidosis coupled with enhancements to existing diagnostic techniques and therapeutic strategies have already resulted in better outcomes for patients with the disease.
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28
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29
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Esplin BL, Gertz MA. Current Trends in Diagnosis and Management of Cardiac Amyloidosis. Curr Probl Cardiol 2013; 38:53-96. [DOI: 10.1016/j.cpcardiol.2012.11.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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30
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Affiliation(s)
- Moshe E. Gatt
- Department of Haematology; Hadassah Hebrew University Medical Centre; Jerusalem; Israel
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31
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DePasquale EC, Nasir K, Jacoby DL. Outcomes of adults with restrictive cardiomyopathy after heart transplantation. J Heart Lung Transplant 2012; 31:1269-75. [PMID: 23079066 DOI: 10.1016/j.healun.2012.09.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 08/28/2012] [Accepted: 09/14/2012] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Restrictive cardiomyopathy (RCM) represents a spectrum of disorders with a common physiology but divergent etiologies. RCM commonly leads to progressive heart failure and the need for heart transplantation (HTx). Pediatric RCM is a more homogeneous disorder with post-HTx outcomes comparable to those for non-RCM patients. However, post-HTx outcomes in adult RCM patients have not been studied to date. METHODS Demographic, clinical and survival outcomes of 38,190 adult HTx-only recipients from 1987 to 2010 were acquired from the registry of the United Network of Organ Sharing. The study population included 544 RCM patients (1.4%) and 37,646 non-RCM patients (98.6%). RCM diagnoses included idiopathic (n = 227, 42%), amyloid (n = 142, 26%), sarcoid (n = 81, 15%), radiation/chemotherapy (XRT) (n = 35, 6%) and other (n = 59, 11%). RESULTS Follow-up began at the time of HTx (74±64 months). During the follow-up period, 224 (41%) patients in the RCM group died, whereas 18,791 (50%) in the non-RCM group died. Crude 1-, 5- and 10-year survival for RCM patients was 84%, 66% and 45%, and for non-RCM patients was 85%, 70% and 50%, respectively. The overall unadjusted hazard ratio of RCM vs non-RCM for all-cause mortality was 1.07 (confidence interval [CI] 0.93 to 1.22). Multivariate Cox proportional hazards regression analysis yielded a hazard ratio of 1.06 (CI 0.91 to 1.25). RCM subgroup analysis showed decreased survival at 1, 5 and 10 years in the XRT (71%, 47% and 32%) and amyloid (79%, 47% and 28%) patient groups. The unadjusted hazard ratio for the XRT and amyloid subgroups vs RCM for all-cause mortality was 1.81 (p = 0.002) and 1.85 (p = 0.0004), respectively. CONCLUSIONS Outcomes for RCM patients post-HTx are comparable to those of non-RCM patients. However, RCM subgroup analysis suggests increased mortality for XRT and amyloid subgroups. Further analysis is warranted to understand the contributing factors.
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Affiliation(s)
- Eugene C DePasquale
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles
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32
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Abstract
PURPOSE OF REVIEW We review the clinical and pathological features of the various types of amyloid that involve the heart, the diagnostic utility of endomyocardial biopsy, and the experience of patient survival and disease recurrence following cardiac transplant for amyloidosis. RECENT FINDINGS Patient outcome is dependent on arresting the cause of amyloid as well as controlling the accumulated damage, which may involve multiple organs. As such, the stratification of patient suitability for cardiac transplant must be considered in conjunction with concurrent treatments, which may include autologous stem cell, liver or kidney transplant, and chemotherapy. SUMMARY As the efficacy of these therapies changes, the indications for cardiac transplantation need to be re-evaluated.
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33
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Abstract
Amyloid diseases in man are caused by as many as 23 different pre-cursor proteins already described. Cardiologists predominantly encounter three main types of amyloidosis that affect the heart: light chain (AL) amyloidosis, senile systemic amyloidosis (SSA) and hereditary amyloidosis, most commonly caused by a mutant form of transthyretin. In the third world, secondary amyloid (AA) is more prevalent, due to chronic infections and inadequately treated inflammatory conditions. Much less common, are the non-transthyretin variants, including mutations of fibrinogen, the apolipoproteins apoA1 and apoA2 and gelsolin. These rarer types do not usually cause significant cardiac compromise. Occurring worldwide, later in life and of less clinical significance, isolated atrial amyloid (IAA) also involves the heart. Heart involvement by amyloid often has devastating consequences. Clinical outcome depends on amyloid type, the extent of systemic involvement and the treatment options available. An exact determination of amyloid type is critical to appropriate therapy. In this review we describe the different approaches required to treat this spectrum of amyloid cardiomyopathies.
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Affiliation(s)
- S W Dubrey
- Department of Cardiology, Hillingdon Hospital, Pield Heath Road, Uxbridge, Middlesex, UB8 3NN, UK.
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34
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Dharmarajan K, Maurer MS. Transthyretin cardiac amyloidoses in older North Americans. J Am Geriatr Soc 2012; 60:765-74. [PMID: 22329529 DOI: 10.1111/j.1532-5415.2011.03868.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The amyloidoses are a group of hereditary or acquired disorders caused by the extracellular deposition of insoluble protein fibrils that impair tissue structure and function. All amyloidoses result from protein misfolding, a common mechanism for disorders in older persons, including Alzheimer's disease and Parkinson's disease. Abnormalities in the protein transthyretin (TTR), a serum transporter of thyroxine and retinol, is the most common cause of cardiac amyloidoses in elderly adults. Mutations in TTR can result in familial amyloidotic cardiomyopathy, and wild-type TTR can result in senile cardiac amyloidosis. These underdiagnosed disorders are much more common than previously thought. The resulting restrictive cardiomyopathy can cause congestive heart failure, arrhythmias, and advanced conduction system disease. Although historically difficult to make, the diagnosis of TTR cardiac amyloidosis has become easier in recent years with advances in cardiac imaging and more widespread use of genetic analysis. Although therapy has largely involved supportive medical care, avoidance of potentially toxic agents, and rarely organ transplantation, the near future brings the possibility of targeted pharmacotherapies designed to prevent TTR misfolding and amyloid deposition. Because these disease-modifying agents are designed to prevent disease progression, it has become increasingly important that older persons with TTR amyloidosis be expeditiously identified and considered for enrollment in clinical registries and trials.
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Affiliation(s)
- Kumar Dharmarajan
- Division of Cardiology, Columbia University Medical Center, New York, New York 10034, USA
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35
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Abstract
The cardiac involvement and associated mortality that occur in systemic AL amyloidosis remain among the most challenging aspects of the systemic amyloid-related diseases. Monoclonal immunoglobulin light chains produced by a clone of plasma cells are usually the cause of symptoms and organ dysfunction via both poorly understood toxic effects of misfolded species and accumulation of interstitial amyloid fibrils in key viscera. Treatment is aimed at eliminating the clonal cells in order to eliminate toxic light chain production. Recent advances in therapy have helped many patients with AL achieve complete hematologic responses and significant reversal of organ damage but these benefits do not extend to that 10-15 % who present with advanced cardiac involvement. Even with cardiac transplant followed by effective therapy such as stem cell transplant, outcomes for these patients remain promising at best.
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Affiliation(s)
- Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation "IRCCS Policlinico San Matteo", and Department of Molecular Medicine, University of Pavia, Viale Golgi 19, 27100, Pavia, Italy,
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36
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Varr BC, Liedtke M, Arai S, Lafayette RA, Schrier SL, Witteles RM. Heart transplantation and cardiac amyloidosis: approach to screening and novel management strategies. J Heart Lung Transplant 2011; 31:325-31. [PMID: 22051505 DOI: 10.1016/j.healun.2011.09.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Revised: 09/03/2011] [Accepted: 09/28/2011] [Indexed: 11/17/2022] Open
Abstract
Limited data exist regarding screening methods and outcomes for orthotopic heart transplantation (OHT) in cardiac amyloidosis. As a result, uncertainty exists over the best approach to OHT for cardiac amyloidosis and for the timing of critical post-transplant therapies. This article reviews 6 patients who underwent OHT for cardiac amyloidosis at the Stanford University Amyloid Center from 2008 to present. All patients with light-chain amyloidosis received chemotherapy in the interval between OHT and autologous hematopoietic stem cell transplant. Five patients remain alive up to 25 months after OHT, without evidence of recurrent cardiac amyloid deposition. A novel strategy of OHT, followed by light-chain suppressive chemotherapy before autologous hematopoietic stem cell transplant, is feasible for patients with light-chain amyloidosis.
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Affiliation(s)
- Brandon C Varr
- Department of Internal Medicine, Stanford University School of Medicine, Stanford, CA, USA
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37
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Kapoor P, Thenappan T, Singh E, Kumar S, Greipp PR. Cardiac amyloidosis: a practical approach to diagnosis and management. Am J Med 2011; 124:1006-15. [PMID: 22017778 DOI: 10.1016/j.amjmed.2011.04.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 04/05/2011] [Accepted: 04/06/2011] [Indexed: 10/16/2022]
Abstract
Cardiac amyloidosis, the primary determinant of prognosis in systemic amyloidoses, is characterized by infiltration of myocardium by amyloid protein resulting in cardiomyopathy and conduction disturbances. Cardiac involvement is primarily encountered in immunoglobulin (AL) and transthyretin-associated (hereditary/familial and senile) amyloidoses. Although the latter variants could be indolent, untreated AL amyloidosis with clinical cardiac involvement is a rapidly fatal disease. The management decisions of cardiac amyloidosis are based on the underlying cause. Although treatment of senile systemic amyloidosis is largely supportive, the therapeutic approaches for AL amyloidosis include chemotherapy, autologous stem cell transplantation, and, rarely, cardiac transplantation. The familial variant is potentially curable with a liver ± cardiac transplantation. This narrative review outlines a practical approach to these challenging diagnoses in the face of rapidly evolving management strategies.
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Desport E, Moumas E, Abraham J, Delbès S, Lacotte-Thierry L, Touchard G, Fermand JP, Bridoux F, Jaccard A. [Current treatment of AL amyloidosis]. Nephrol Ther 2011; 7:467-73. [PMID: 21497573 DOI: 10.1016/j.nephro.2011.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 02/09/2011] [Indexed: 10/28/2022]
Abstract
Systemic AL amyloidosis is a rare complication of monoclonal gammopathies. Renal manifestations are frequent, mostly characterized by heavy proteinuria, with nephrotic syndrome and renal failure in more than half of the patients at diagnosis. Without treatment, median survival does not exceed 12 months. Amyloid heart disease and diffusion of amyloid deposits are associated with reduced survival. Treatment of systemic AL amyloidosis has been profoundly modified with the introduction of international criteria for the definition of organ involvement and hematologic response, and with the use of sensitive tests for the measurement of serum-free light chain levels. Melphalan plus dexamethasone is now established as the gold standard for first line treatment of systemic AL, with similar efficacy and reduced treatment-related mortality compared to high-dose therapy. Modern chemotherapy regimens, based on the use of novel agents such as bortezomib and lenalidomide, might further improve patient survival.
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Affiliation(s)
- Estelle Desport
- Service de néphrologie et transplantation rénale, hôpital Jean-Bernard, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
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Infiltrative Cardiovascular Diseases. J Am Coll Cardiol 2010; 55:1769-79. [DOI: 10.1016/j.jacc.2009.12.040] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Revised: 12/07/2009] [Accepted: 12/07/2009] [Indexed: 01/20/2023]
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Abstract
Amyloidosis is a clinical disorder caused by the extracellular deposition of misfolded, insoluble aggregated protein with a characteristic ss pleated sheet configuration that produces apple-green birefringence under polarized light when stained with Congo red dye. The spectrum of organ involvement can include the kidneys, heart, blood vessels, central and peripheral nervous systems, liver, intestines, lungs, eyes, skin, and bones. Cardiovascular amyloidosis can be primary, a part of systemic amyloidosis, or the result of chronic systemic disease elsewhere in the body. The most common presentations are congestive heart failure because of restrictive cardiomyopathy and conduction abnormalities. Recent developments in imaging techniques and extracardiac tissue sampling have minimized the need for invasive endomyocardial biopsy for amyloidosis. Cardiac amyloidosis management will vary depending on the subtype but consists of supportive treatment of cardiac related symptoms and reducing the amyloid fibrils formation attacking the underlying disease. Despite advances in treatment, the prognosis for patients with amyloidosis is still poor and depends on the underlying disease type. Early diagnosis of cardiac amyloidosis may improve outcomes but requires heightened suspicion and a systematic clinical approach to evaluation. Delays in diagnosis, uncertainties about the relative merits of available therapies, and difficulties in mounting large-scale clinical trials in rare disorders combine to keep cardiac amyloidosis a challenging problem. This review outlines current approaches to diagnosis, assessment of disease severity, and treatment of cardiac amyloidosis.
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Affiliation(s)
- Simon W Dubrey
- Department of Cardiology, Hillingdon Hospital, Uxbridge Middlesex, UB8 3NN
| | - Rodney H Falk
- Brigham and Women's Hospital Cardiac Amyloidosis Program, Harvard Vanguard Medical Associates, Boston, MA, USA
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Abstract
Amyloidosis is an uncommon disorder in which proteins change conformation, aggregate, and form fibrils that infiltrate tissues, leading to organ failure and death. The most frequent types are light-chain (AL) derived from monoclonal B-cell disorders producing amyloidogenic immunoglobulin light chains, and the hereditary and "senile systemic" (ATTR) variants from mutant and wild-type transthyretin (TTR). Diagnosis requires tissue biopsy. AL is more frequent and causes more organ disease than ATTR. Although both can cause cardiomyopathy and heart failure, AL progresses more quickly, so survival depends on timely diagnosis. Typing is usually based on clinical and laboratory findings with monoclonal gammopathy evaluation and, if indicated, TTR gene testing. Direct tissue typing is required when one patient has 2 potential amyloid-forming proteins. In coming years, widespread use of definitive proteomics will improve typing. New therapies are in testing for ATTR, whereas those for AL have followed multiple myeloma, leading to improved survival. Challenges of diagnosing and caring for patients with amyloidosis include determination of type, counseling, and delivery of prompt therapy often while managing multisystem disease. Recent advances grew from clinical research and advocacy in many countries, and global husbandry of such efforts will reap future benefits for families and patients with amyloidosis.
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Rubinshtein R, Glockner JF, Feng D, Araoz PA, Kirsch J, Syed IS, Oh JK. Comparison of magnetic resonance imaging versus Doppler echocardiography for the evaluation of left ventricular diastolic function in patients with cardiac amyloidosis. Am J Cardiol 2009; 103:718-23. [PMID: 19231340 DOI: 10.1016/j.amjcard.2008.10.039] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Revised: 10/24/2008] [Accepted: 10/24/2008] [Indexed: 11/29/2022]
Abstract
To assess the role of magnetic resonance imaging (MRI) in the assessment of diastolic function, diastolic mitral inflow parameters using MRI and transthoracic Doppler echocardiography (echocardiography) were compared in patients with cardiac amyloidosis. Thirty-eight patients (age 60 +/- 12 years; 32% women) in sinus rhythm with cardiac amyloidosis (biopsy-proven systemic amyloidosis and positive echocardiographic and contrast-enhanced cardiac MRI findings) were evaluated. Cine phase-contrast MRI images of mitral inflow were obtained in the left ventricle to quantify diastolic blood flow. MRI measurements of diastolic parameters were compared (Spearman's rank correlation) with echocardiographic diastolic mitral inflow velocity parameters. Additional analysis was performed comparing MRI findings in patients with a restrictive echocardiographic diastolic filling pattern (n = 23) versus those without (n = 15). For the 38 patients, early diastolic (E) peak velocity was 61 +/- 26 cm/s using MRI versus 79 +/- 21 using echocardiography (Spearman's rank correlation 0.55, p = 0.0004), and late diastolic (A) peak velocity was 46 +/- 22 cm/s using MRI versus 47 +/- 22 cm/s using echocardiography (Spearman's rank correlation 0.54, p = 0.0005). E/A ratio was 1.55 +/- 0.9 using MRI and 2.25 +/- 1.4 using echocardiography (Spearman's rank correlation 0.75, p <0.0001). Deceleration times in both modalities showed good correlation (MRI, 180 +/- 44 ms vs echocardiography, 179 +/- 49; Spearman's rank correlation 0.61, p = 0.0001). MRI E/A ratio for peak velocities was significantly higher in patients with restrictive echocardiographic patterns (1.95 +/- 1.0) versus those without (0.93 +/- 0.3; p = 0.0003). Two of 23 patients with a restrictive echocardiographic pattern had an MRI E/A ratio <1. In conclusion, mitral inflow peak velocities, deceleration times, and E/A ratios detected using phase-contrast MRI in patients with cardiac amyloidosis showed moderately good correlation with echocardiography and identified most patients with restrictive echocardiographic patterns.
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Affiliation(s)
- Ronen Rubinshtein
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.
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Audard V, Matignon M, Weiss L, Remy P, Pardon A, Haioun C, Belhadj K, Salomon L, Hillon ML, Sahali D, Vermes E, Lang P, Grimbert P. Successful long-term outcome of the first combined heart and kidney transplant in a patient with systemic Al amyloidosis. Am J Transplant 2009; 9:236-40. [PMID: 19067666 PMCID: PMC2810314 DOI: 10.1111/j.1600-6143.2008.02469.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Simultaneous cardiac and renal involvement is associated with a particularly poor prognosis in patients with AL amyloidosis (AL-A). We report the first case of a successful long-term outcome of combined heart and kidney transplantation not followed by autologous stem cell transplantation in a patient with systemic AL-A. The recipient was a 46-year-old man with end-stage renal failure associated with serious cardiac involvement in the context of AL-A. Before transplantation, two courses of oral melphalan plus prednisone induced partial hematologic remission, as shown by the decrease in circulating free light chain with no improvement of renal or heart function. The patient underwent combined heart and kidney transplantation as a rescue treatment. During the follow-up period (36 months), plasma cell dyscrasia remains in complete remission, with normal free lambda light chain levels and no recurrence of amyloid deposition on heart and kidney grafts. This case report demonstrates that combined heart and kidney transplantation not systematically associated with stem cell transplantation may be considered an additional therapeutic option in AL-A patients with severe organ dysfunction and partial hematologic remission.
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Affiliation(s)
- Vincent Audard
- Service de néphrologie et transplantation
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, 94010 Créteil,FR,* Correspondence should be adressed to: Vincent Audard
| | - Marie Matignon
- Service de néphrologie et transplantation
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, 94010 Créteil,FR
| | - Lise Weiss
- Service de néphrologie et transplantation
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, 94010 Créteil,FR
| | - Philippe Remy
- Service de néphrologie et transplantation
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, 94010 Créteil,FR
| | - Agathe Pardon
- Service de néphrologie et transplantation
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, 94010 Créteil,FR
| | - Corinne Haioun
- Service d'Hématologie Biologique
AP-HPHôpital Henri MondorUniversité Paris XIICréteil,FR
| | - Karim Belhadj
- Service d'Hématologie Biologique
AP-HPHôpital Henri MondorUniversité Paris XIICréteil,FR
| | - Laurent Salomon
- Service d'urologie
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, Créteil,FR
| | - Marie Line Hillon
- Service de chirurgie thoracique et cardio-vasculaire
AP-HPHôpital Henri MondorUniversité Paris XII Val de MarneCréteil,FR
| | - Dil Sahali
- Service de néphrologie et transplantation
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, 94010 Créteil,FR
| | - Emanuelle Vermes
- Service de chirurgie thoracique et cardio-vasculaire
AP-HPHôpital Henri MondorUniversité Paris XII Val de MarneCréteil,FR
| | - Philippe Lang
- Service de néphrologie et transplantation
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, 94010 Créteil,FR
| | - Philippe Grimbert
- Service de néphrologie et transplantation
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, 94010 Créteil,FR
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Maceira AM, Prasad SK, Hawkins PN, Roughton M, Pennell DJ. Cardiovascular magnetic resonance and prognosis in cardiac amyloidosis. J Cardiovasc Magn Reson 2008; 10:54. [PMID: 19032744 PMCID: PMC2605441 DOI: 10.1186/1532-429x-10-54] [Citation(s) in RCA: 185] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Accepted: 11/25/2008] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Cardiac involvement is common in amyloidosis and associated with a variably adverse outcome. We have previously shown that cardiovascular magnetic resonance (CMR) can assess deposition of amyloid protein in the myocardial interstitium. In this study we assessed the prognostic value of late gadolinium enhancement (LGE) and gadolinium kinetics in cardiac amyloidosis in a prospective longitudinal study. MATERIALS AND METHODS The pre-defined study end point was all-cause mortality. We prospectively followed a cohort of 29 patients with proven cardiac amyloidosis. All patients underwent biopsy, 2D-echocardiography and Doppler studies, 123I-SAP scintigraphy, serum NT pro BNP assay, and CMR with a T1 mapping method and late gadolinium enhancement (LGE). RESULTS Patients with were followed for a median of 623 days (IQ range 221, 1436), during which 17 (58%) patients died. The presence of myocardial LGE by itself was not a significant predictor of mortality. However, death was predicted by gadolinium kinetics, with the 2 minute post-gadolinium intramyocardial T1 difference between subepicardium and subendocardium predicting mortality with 85% accuracy at a threshold value of 23 ms (the lower the difference the worse the prognosis). Intramyocardial T1 gradient was a better predictor of survival than FLC response to chemotherapy (Kaplan Meier analysis P = 0.049) or diastolic function (Kaplan-Meier analysis P = 0.205). CONCLUSION In cardiac amyloidosis, CMR provides unique information relating to risk of mortality based on gadolinium kinetics which reflects the severity of the cardiac amyloid burden.
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Affiliation(s)
- Alicia M Maceira
- Cardiac Imaging Unit – ERESA. Hospital Arnau de Vilanova, Valencia, Spain
| | - Sanjay K Prasad
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK
| | | | - Michael Roughton
- Medical Statistics Department, Royal Brompton Hospital, London, UK
| | - Dudley J Pennell
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK
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Mignot A, Varnous S, Redonnet M, Jaccard A, Epailly E, Vermes E, Boissonnat P, Gandjbakhch I, Herpin D, Touchard G, Bridoux F. Heart transplantation in systemic (AL) amyloidosis: a retrospective study of eight French patients. Arch Cardiovasc Dis 2008; 101:523-32. [PMID: 19041836 DOI: 10.1016/j.acvd.2008.06.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 06/16/2008] [Accepted: 06/19/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND Immunoglobulinic (AL) amyloidosis is a complication of plasma cell dyscrasia, characterized by widespread deposition of amyloid fibrils derived from monoclonal light chains. Cardiac amyloid is the main prognostic factor, with a median survival of six months. Cardiac transplantation in AL amyloidosis is associated with high mortality, due to disease recurrence in the allograft and systemic progression. Suppression of light chain (LC) production with chemotherapy by melphalan plus dexamethasone (MD) or high dose melphalan followed by autologous stem cell transplantation (HDM/ASCT) improves survival. However, both the indications and results of chemotherapy in patients transplanted for cardiac AL amyloidosis remain unclear. AIMS To assess the outcome of cardiac transplantation and haematological therapy in patients with cardiac AL amyloidosis. METHODS Eight French patients, who underwent heart transplantation for cardiac AL amyloidosis between 2001 and 2006 were studied retrospectively. RESULTS Before transplantation, six patients received MD (n=5) or HDM/ASCT (n=1). Haematological remission was obtained in three patients treated with MD. In the three remaining patients, postoperative HDM/ASCT (n=2) or allogeneic bone marrow transplantation (n=1) resulted in haematological remission in one patient. In 2 patients not treated before transplantation, post-operative treatment with MD resulted in complete hematological remission in one. After a median follow-up of 26 months from cardiac transplantation, six patients were alive and four had sustained haematological remission, as indicated by normal serum free LC levels. CONCLUSION Appropriate haematological therapy, including MD, may result in a survival benefit in AL amyloidosis patients with advanced heart failure requiring transplantation.
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Affiliation(s)
- Aude Mignot
- Department of Cardiology, CHU of Poitiers, University of Poitiers, Poitiers, France
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Hosch W, Kristen AV, Libicher M, Dengler TJ, Aulmann S, Heye T, Schnabel PA, Schirmacher P, Katus HA, Kauczor HU, Longerich T. Late enhancement in cardiac amyloidosis: correlation of MRI enhancement pattern with histopathological findings. Amyloid 2008; 15:196-204. [PMID: 18925458 DOI: 10.1080/13506120802193233] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Late enhancement (LE) in cardiac magnetic resonance imaging (MRI) is a characteristic finding in patients with cardiac amyloidosis (CA) but the histomorphological explanation has not been clarified yet. Five patients with CA were evaluated by MRI prior to heart transplantation. This consisted of morphological, volumetric, and functional data, including LE analysis. For LE analysis, left ventricular (LV) short-axis sections from basal, midventricular, and apical positions were divided into 12 segments resulting in a 36-segment model. Each segment was differentiated by subendocardial, midmural, and subepicardial localization. Histological amyloid and collagenous fiber deposition was correlated with LE in corresponding MRI slides. LE was visualized in 103/180 (57.2%) predominantly subendocardial segments. Histological analysis of amyloid deposition was (peri-)vascular (n = 5), diffuse interstitial (n = 3) and/or nodular (n = 4). Extent of fibrosis was moderate to severe. Cytoplasmatic vacuolization and decline of myofibrils was seen in all patients. Fibrosis was significantly associated with LE in subendocardial and midmural localizations (p<0.05), whereas the extent of amyloid deposition was not associated with LE findings in any region. LE seems to be associated with fibrosis due to ischemia of cardiomyocytes by small vessel amyloid deposition rather than with amyloid deposition in CA, suggesting that amyloid deposition might be present prior to LE detection.
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Affiliation(s)
- Waldemar Hosch
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, Heidelberg, Germany.
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Lebovic D, Hoffman J, Levine BM, Hassoun H, Landau H, Goldsmith Y, Maurer MS, Steingart RM, Cohen AD, Comenzo RL. Predictors of survival in patients with systemic light-chain amyloidosis and cardiac involvement initially ineligible for stem cell transplantation and treated with oral melphalan and dexamethasone. Br J Haematol 2008; 143:369-73. [PMID: 18691169 DOI: 10.1111/j.1365-2141.2008.07327.x] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The treatment of systemic light-chain (AL) amyloidosis with symptomatic cardiac involvement at diagnosis remains a challenge. We report the results of 40 consecutive newly diagnosed AL cardiac patients who were not candidates for stem cell transplant and therefore received monthly oral melphalan and dexamethasone. Median survival was 10.5 months and baseline predictors of survival included gender, troponin I and interventricular septal thickness. The most significant predictor of survival was response to therapy. The haematological response rate was 58% (23/40) with 13% (5/40) complete responses; most responses were noted in <3 cycles. Achievement of a rapid response to therapy extends survival.
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Affiliation(s)
- D Lebovic
- Department of Medicine, Weill-Cornell School of Medicine, New York Hospital, NY, USA
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