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Martín-Álvarez E, Larrañaga-Moreira JM, Crepo-Leiro MG, Barriales-Villa R. Diagnosing transthyretin amyloidosis in patients with known genetic cardiomyopathies - opportunities and open questions. Response. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:505-506. [PMID: 38237660 DOI: 10.1016/j.rec.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 12/21/2023] [Indexed: 03/01/2024]
Affiliation(s)
- Esteban Martín-Álvarez
- Servicio de Cardiología, Hospital Universitario de A Coruña, A Coruña, Spain; Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain.
| | - José María Larrañaga-Moreira
- Servicio de Cardiología, Hospital Universitario de A Coruña, A Coruña, Spain; Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
| | - María Generosa Crepo-Leiro
- Servicio de Cardiología, Hospital Universitario de A Coruña, A Coruña, Spain; Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Roberto Barriales-Villa
- Servicio de Cardiología, Hospital Universitario de A Coruña, A Coruña, Spain; Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
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Casian M, Jurcut R. Diagnosing transthyretin amyloidosis in patients with known genetic cardiomyopathies - opportunities and open questions. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:504-505. [PMID: 38056771 DOI: 10.1016/j.rec.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 11/23/2023] [Indexed: 12/08/2023]
Affiliation(s)
- Mihnea Casian
- Cardiology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania; Department of Cardiology, Expert Center for Rare Genetic Cardiovascular Diseases, Emergency Institute for Cardiovascular Diseases, Bucharest, Romania.
| | - Ruxandra Jurcut
- Cardiology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania; Department of Cardiology, Expert Center for Rare Genetic Cardiovascular Diseases, Emergency Institute for Cardiovascular Diseases, Bucharest, Romania
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Chang HC, Kuo L, Chung FP, Yu WC. Pitfalls for the non-invasive diagnosis of wild-type transthyretin amyloid cardiomyopathy in a young adult: a case report. Eur Heart J Case Rep 2023; 7:ytad308. [PMID: 37501713 PMCID: PMC10369205 DOI: 10.1093/ehjcr/ytad308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/16/2023] [Accepted: 07/10/2023] [Indexed: 07/29/2023]
Abstract
Background Using technetium (Tc)-labelled pyrophosphate (PYP) cardiac scintigraphy, a non-invasive diagnosis of transthyretin amyloid (ATTR) cardiomyopathy can be made without histopathological confirmation. In patients suspected of ATTR cardiomyopathy, however, atypical presentations may necessitate further investigation. Case summary A 30-year-old man with hypertension and end-stage renal disease on peritoneal dialysis presented with progressive exertional dyspnoea. Left ventricular hypertrophy (LVH) with a maximal end-diastolic wall thickness up to 16 mm was detected on echocardiography. Speckle-tracking analysis revealed a reduced longitudinal strain of left ventricle with a relative apical sparing pattern. Although the absence of monoclonal gammopathy, a grade 3 myocardial uptake in 99mTc-PYP cardiac scintigraphy, and negative TTR gene mutation inferred the diagnosis of wild-type ATTR, the relative youth of the patient still raised concerns regarding the diagnosis. Under clinical doubt, he underwent further testing. In non-contrast cardiac magnetic resonance (CMR) with native T1 mapping, the native T1 myocardial value was within the normal range. In endomyocardial biopsy (EMB), there was no evidence of amyloid deposition, negative Congo red staining, and no immunohistochemical evidence of transthyretin expression. These results excluded the diagnosis of ATTR cardiomyopathy and prevented subsequent unnecessary treatments. Discussion When patients with unexplained LVH meet the non-invasive diagnostic criteria for ATTR cardiomyopathy, an EMB should be considered in selected cases. Patients presenting at an atypical age for wild-type ATTR cardiomyopathy, absence of extracardiac symptoms/signs or classic electrocardiogram features for cardiac amyloidosis should be suspected of another diagnosis and require further CMR or EMB to confirm.
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Affiliation(s)
- Hao-Chih Chang
- Department of Medicine, Taipei Veterans General Hospital Taoyuan Branch, 100, Sec.3, Chenggong Road, Taoyuan District, Taoyuan 330023, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, 155, Sec. 2, Linong Street, Beitou District, Taipei 112304, Taiwan
- Department of Internal Medicine, College of Medicine, National Yang Ming Chiao Tung University, 201, Sec. 2, Shi-Pai Road, Beitou District, Taipei 112201, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, 155, Sec. 2, Linong Street, Beitou District, Taipei 112304, Taiwan
| | - Ling Kuo
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, 155, Sec. 2, Linong Street, Beitou District, Taipei 112304, Taiwan
- Department of Internal Medicine, College of Medicine, National Yang Ming Chiao Tung University, 201, Sec. 2, Shi-Pai Road, Beitou District, Taipei 112201, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, 201, Sec. 2, Shi-Pai Road, Beitou District, Taipei 112201, Taiwan
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, 155, Sec. 2, Linong Street, Beitou District, Taipei 112304, Taiwan
| | - Fa-Po Chung
- Corresponding authors. Tel: +886 2 2871-2121 ext. 3650, (F.-P.C.); Tel: +886 2 2871 2121 ext. 2997, Fax: +886 2 2877 1746, E-mail: (W.-C.Y.)
| | - Wen-Chung Yu
- Corresponding authors. Tel: +886 2 2871-2121 ext. 3650, (F.-P.C.); Tel: +886 2 2871 2121 ext. 2997, Fax: +886 2 2877 1746, E-mail: (W.-C.Y.)
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Iwaya T, Okada A, Tateishi E, Ohta Y, Morita Y, Ohta‐Ogo K, Izumi C. Multimodality assessments of wild‐type transthyretin cardiac amyloidosis with no ventricular hypertrophy. ESC Heart Fail 2022; 10:1412-1417. [PMID: 36335980 PMCID: PMC10053176 DOI: 10.1002/ehf2.14220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 09/15/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
While patients with transthyretin cardiac amyloidosis (ATTR-CA) typically present with concentric or asymmetric hypertrophy, a small percentage of ATTR-CA is known to present with 'atypical' cardiac morphologies such as eccentric hypertrophy or even no hypertrophy. However, detailed report of multimodality assessments of ATTR-CA with no ventricular hypertrophy is lacking. Herein, we report detailed multimodality assessments of an 81-year-old Japanese woman with heart failure and history of carpal tunnel syndrome and lumbar canal stenosis, presenting no ventricular hypertrophy and negative 99m technetium-pyrophosphate scintigraphy, who was eventually diagnosed as having wild-type ATTR-CA. Our case highlights the role of multimodality assessments for early diagnosis of ATTR-CA in patients with atypical cardiac morphologies and also emphasizes the limitations of bone scintigraphy and the importance of considering ATTR-CA in patients with non-cardiac manifestations of ATTR amyloidosis.
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Affiliation(s)
- Takuma Iwaya
- Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Osaka Japan
| | - Atsushi Okada
- Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Osaka Japan
| | - Emi Tateishi
- Department of Radiology National Cerebral and Cardiovascular Center Suita Osaka Japan
| | - Yasutoshi Ohta
- Department of Radiology National Cerebral and Cardiovascular Center Suita Osaka Japan
| | - Yoshiaki Morita
- Department of Radiology National Cerebral and Cardiovascular Center Suita Osaka Japan
| | - Keiko Ohta‐Ogo
- Department of Pathology National Cerebral and Cardiovascular Center Suita Osaka Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Osaka Japan
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Chaudhary AG, AlReefi FM, Abou Zahr RG, Elzeftawy HA, Alghamdi SS, Bushnag AA, Al-Maghrabi JA, Abumansour IS. Genotype-Phenotype Correlation of a Rare Transthyretin Variant Causing Amyloidosis. CJC Open 2022; 4:1031-1035. [PMID: 36562013 PMCID: PMC9764124 DOI: 10.1016/j.cjco.2022.09.005] [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: 06/18/2022] [Accepted: 09/14/2022] [Indexed: 11/05/2022] Open
Abstract
Left ventricular hypertrophy is a common entity with a broad differential diagnosis. We present a case of a middle-aged woman with left ventricular hypertrophy and neuropathy caused by a rare transthyretin variant in the absence of a family history or regional reports of hereditary transthyretin amyloidosis. This report outlines the diagnosis and management of patients with a mixed phenotype of hereditary transthyretin amyloidosis and enriches clinical data supporting the pathogenicity of a rare variant of transthyretin.
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Affiliation(s)
- Ammar G. Chaudhary
- Cardiovascular Diseases Department, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
- Corresponding Author: Dr Ammar G. Chaudhary, Cardiovascular Diseases Department, King Faisal Specialist Hospital and Research Centre, P.O. Box 40047, Jeddah 21499, Saudi Arabia. Tel.: +966 12 667 7777 x41406; fax: +966 12 667 7777 x65822.
| | - Fadi M. AlReefi
- Department of Adult Cardiology, Almoosa Specialist Hospital, Alhasa, Saudi Arabia
| | - Riad G. Abou Zahr
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Hossam A. Elzeftawy
- Radiology Department, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Saleh S. Alghamdi
- Cardiovascular Diseases Department, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Areej A. Bushnag
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Jaudah A. Al-Maghrabi
- Department of Pathology, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
- Department of Pathology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Iman S. Abumansour
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
- Department of Medical Genetics, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
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Lin W, Chattranukulchai P, Lee AP, Lin YH, Yu WC, Liew HB, Oomman A. Clinical recommendations to diagnose and monitor patients with transthyretin amyloid cardiomyopathy in Asia. Clin Cardiol 2022; 45:898-907. [PMID: 35795903 PMCID: PMC9451661 DOI: 10.1002/clc.23882] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/10/2022] [Accepted: 06/15/2022] [Indexed: 11/11/2022] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR‐CM) is a debilitating and life‐threatening condition with a heterogeneous clinical presentation. Recent guidelines from the United States and Europe have been published to guide clinical practice and to facilitate management conformity by covering current diagnostic and treatment strategies for patients with ATTR‐CM. These guidelines highlight the importance of an early diagnosis to optimize therapeutic outcomes, specifying the use of tests and imaging techniques to allow accurate, noninvasive diagnosis of ATTR‐CM. However, as regional practice variations across Asia may limit access to healthcare, availability of specific tests, and expertise in assessing diagnostic images, there is an ongoing need to provide an Asian perspective on these clinical guidelines. This review article provides practical recommendations for the diagnosis and monitoring of patients with ATTR‐CM in Asia, highlighting the need for additional guidelines to support a broad and diverse population, consider differing healthcare systems and diagnostic testing availability, and provide a flexible yet robust algorithm.
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Affiliation(s)
- Weiqin Lin
- Department of Cardiology, National University Heart Centre, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Pairoj Chattranukulchai
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Alex Pw Lee
- Division of Cardiology, Department of Medicine and Therapeutics, Li Ka Shing Institutes of Health Science, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, Republic of China
| | - Wen-Chung Yu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China.,Department of Internal Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Houng-Bang Liew
- Department of Cardiology, Clinical Research Centre, Queen Elizabeth Hospital II, Kota Kinabalu, Malaysia
| | - Abraham Oomman
- Department of Cardiology, Apollo Hospitals, Chennai, India
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Takano R, Ueda N, Okada A, Matsumoto M, Ikeda Y, Hatakeyama K, Izumi C, Kusano K. Fat Biopsy from a Pocket of Cardiac Implantable Electronic Device: An Alternative Diagnostic Option for Cardiac Amyloidosis. HeartRhythm Case Rep 2022; 8:554-557. [PMID: 35996711 PMCID: PMC9391401 DOI: 10.1016/j.hrcr.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ryo Takano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Nobuhiko Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
- Address reprint requests and correspondence: Dr Nobuhiko Ueda, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565, Japan.
| | - Atsushi Okada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Manabu Matsumoto
- Department of Pathology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshihiko Ikeda
- Department of Pathology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kinta Hatakeyama
- Department of Pathology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
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Falk RH, Dorbala S, Cuddy SAM. Letter by Falk et al Regarding Article, "False-Positive 99mTechnetium-Pyrophosphate Scintigraphy in Two Patients With Hypertrophic Cardiomyopathy". Circ Heart Fail 2022; 15:e008636. [PMID: 35378985 DOI: 10.1161/circheartfailure.121.008636] [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: 11/16/2022]
Affiliation(s)
- Rodney H Falk
- Amyloidosis Program, Division of Cardiology, Department of Medicine (R.H.F., S.D., S.A.M.C.), Brigham and Women's Hospital, Boston, MA
| | - Sharmila Dorbala
- Amyloidosis Program, Division of Cardiology, Department of Medicine (R.H.F., S.D., S.A.M.C.), Brigham and Women's Hospital, Boston, MA.,CV Imaging Program, Cardiovascular Division, Department of Radiology (S.D., S.A.M.C.), Brigham and Women's Hospital, Boston, MA
| | - Sarah A M Cuddy
- Amyloidosis Program, Division of Cardiology, Department of Medicine (R.H.F., S.D., S.A.M.C.), Brigham and Women's Hospital, Boston, MA.,CV Imaging Program, Cardiovascular Division, Department of Radiology (S.D., S.A.M.C.), Brigham and Women's Hospital, Boston, MA
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Shah KB, Rao K, Trankle CR. Response by Shah et al to Letter Regarding Article, "False-Positive 99mTechnetium-Pyrophosphate Scintigraphy in Two Patients With Hypertrophic Cardiomyopathy". Circ Heart Fail 2022; 15:e008697. [PMID: 35378983 DOI: 10.1161/circheartfailure.121.008697] [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: 11/16/2022]
Affiliation(s)
- Keyur B Shah
- Pauley Heart Center, Department of Medicine, Virginia Commonwealth University, Richmond
| | - Krishnasree Rao
- Pauley Heart Center, Department of Medicine, Virginia Commonwealth University, Richmond
| | - Cory R Trankle
- Pauley Heart Center, Department of Medicine, Virginia Commonwealth University, Richmond
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Affiliation(s)
| | - James R Stone
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Tahara N, Lairez O, Endo J, Okada A, Ueda M, Ishii T, Kitano Y, Lee HE, Russo E, Kubo T. 99m Technetium-pyrophosphate scintigraphy: a practical guide for early diagnosis of transthyretin amyloid cardiomyopathy. ESC Heart Fail 2021; 9:251-262. [PMID: 34841715 PMCID: PMC8788016 DOI: 10.1002/ehf2.13693] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/16/2021] [Accepted: 10/25/2021] [Indexed: 01/15/2023] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR‐CM) is caused by the cardiac deposition of insoluble amyloid fibrils formed by misfolded transthyretin proteins and is associated with various cardiac symptoms, such as progressive heart failure, conduction disturbance, and arrhythmia. The implementation of 99mtechnetium (99mTc)‐labelled bone radiotracer scintigraphy for diagnosing ATTR‐CM has enabled accurate diagnosis of the disease with high sensitivity and specificity and positioned this diagnostic modality as an integral part of disease diagnostic algorithms. In 2020, 99mTc‐pyrophosphate scintigraphy received exceptional approval for Japanese national health insurance reimbursement as a diagnostic method of ATTR‐CM. Nevertheless, the utility of 99mTc‐labelled bone radiotracer scintigraphy and the importance of an early diagnosis of suspected ATTR‐CM using this technique have yet to be internalized as common practice by general cardiologists, and guidance on daily clinical scenarios to consider this technique for a diagnosis of suspected ATTR‐CM is warranted. In this review, we discuss the utility of 99mTc‐labelled bone radiotracer scintigraphy for the early diagnosis of ATTR‐CM based on published literature and the outcomes of an advisory board meeting. This review also discusses clinical scenarios that could support early diagnosis of suspected ATTR‐CM as well as common pitfalls, correct implementation, and future perspectives of 99mTc‐labelled bone radiotracer scintigraphy in daily clinical practice. The clinical scenarios to consider 99mTc‐labelled bone radiotracer scintigraphy in daily practice may include, but are not limited to, patients with a family history of the hereditary type of disease; elderly patients (aged ≥60 years) with unexplained cardiac findings (e.g. cardiac hypertrophy associated with abnormalities on an electrocardiogram, heart failure with preserved ejection fraction associated with unexplained left ventricular hypertrophy, and heart failure with reduced ejection fraction associated with atrial fibrillation and left ventricular hypertrophy); and patients with cardiac hypertrophy associated with diastolic dysfunction, right ventricular/interatrial septum/valve thickness, left ventricular sparkling, or apical sparing. Cardiac hypertrophy and persistent elevation in cardiac troponin in elderly patients are also suggestive of ATTR‐CM. 99mTc‐labelled bone radiotracer scintigraphy is also recommended in patients with characteristic cardiac magnetic resonance findings (e.g. diffuse subendocardial late gadolinium enhancement patterns, native T1 increase, and increase in extracellular volume) or patients with cardiac hypertrophy and bilateral carpal tunnel syndrome.
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Affiliation(s)
- Nobuhiro Tahara
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0001, Japan
| | - Olivier Lairez
- Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Jin Endo
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Atsushi Okada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | | | | | | | | | - Toru Kubo
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University, Kochi, Japan
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