CARDIAC AMYLOIDOSIS IMAGING ERIC MARTIN MD

Transcription

1 CARDIAC AMYLOIDOSIS IMAGING ERIC MARTIN MD

2 DISCLOSURES Bayer Dalcor Pharma UK LTD Harvard Clinical Research Institute Heartflow Inc. NIH Vascular Dynamics Employee-Iowa Heart Center/Mercy-Des Moines

3 BACKGROUND Amyloidosis is a heterogeneous group of diseases Localized or systemic deposition of insoluble extracellular fibrillary proteins in organs and tissues Clinical manifestation is based on organ involved and type of precursor protein (AL or ATTR) Systemic involvement usually fatal (1 per 1,000 deaths) 3,000 new US cases annually

4 AMYLOID SUBTYPES AA- rarely affects the heart AL ATTR 1) Familial (mutant, ATTRm) 2) Senile (wild-type, ATTRw) Aβ2M- also rarely affects the heart

5 AL Amyloidosis ~ 1in 100,000 Cardiac involvement in ~ 50% 25% shows CHF AF and conduction abnormalities are common Cardiac involvement has poor prognosis Median survival of 6-12 months

6 ATTRw Amyloidosis- Wild Type Genetically normal Senile Non-hereditary Most commonly in males >70 y/o

7 ATTRm Amyloidosis- Mutant Genetically Abnormal Familial (Autosomal Dominant) Seen in all ages >100 mutations 3-4% of US African-Americans have Val122Ile mutation

8 European Cardiology Review, 2015; 10 (2):113 7

9 European Cardiology Review, 2015; 10 (2):113 7

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11 Rodney H. Falk et al. JACC 2016;68: American College of Cardiology Foundation

12 AL Amyloidosis Rodney H. Falk et al. JACC 2016;68: American College of Cardiology Foundation

13 Rodney H. Falk et al. JACC 2016;68: American College of Cardiology Foundation

14 American College of Cardiology Foundation Rodney H. Falk et al. JACC 2016;68:

15 American College of Cardiology Foundation Rodney H. Falk et al. JACC 2016;68:

16 Rodney H. Falk et al. JACC 2016;68: American College of Cardiology Foundation

17 Rodney H. Falk et al. JACC 2016;68: American College of Cardiology Foundation

18 American College of Cardiology Foundation Rodney H. Falk et al. JACC 2016;68:

19 USUAL SUSPECTS CHF with LVH and at least Gr II diastolic dysfunction Typical CMR findings on CMR - Diffuse Late Gadolinium Enhancement - ECV expansion - Characteristic T-1 relaxation time

20 99m Tc-PYP IMAGING Ability to specifically identify ATTR cardiac amyloidosis non-invasively

21 PATIENT SELECTION CHF and unexplained LVH African-americans >60y/o w/ CHF and LVH (>12mm) >60y/o HFpEF Individuals, especially elderly males, w/ CHF and unexplained neuropathy, bilateral CTS, atrial arrhythmias in the absence of usual risk factors Individuals with known or suspected Familial Amyloidosis

22 PATIENT SELECTION Dx Cardiac ATTR in individuals w/ CMR or Echo consistent with cardiac amyloidosis Patients w/ suspected ATTR and contraindications to CMR such as renal insufficiency or cardiac devices

23 DOSIMETRY 99M Tc-PYP 15mCi Total Body Effective Dose= 3.2mSv

24 IMAGING PROCEDURE SPECT and Planar images are obtained 1 hr after 99mTc-PYP injection PLANAR IMAGING: - useful for visual interpretation - quantification of heart to lung ratio

25 IMAGING PROCEDURE SPECT IMAGING: - Avoid overlap of bone uptake - Distinguish blood pool from myocardial activity - Assess distribution of myocardial uptake especially in interventricular septum. - Quantify degree of myocardial uptake by comparison to rib uptake

26 IMAGE INTERPRETATION Anterior and lateral planar images and reconstructed SPECT images are reviewed Quantitative: Heart to Lung ratio in 1 hour Semi-quantitative: Visual comparison to rib uptake in 3 hours

27 QUANTITATIVE

28 QUANTITATIVE H/L RATIO =/> 1.5 (POSITIVE) H/L RATIO <1.5 (NEGATIVE)

29 Mean heart-to-contralateral ratio according to amyloid subtype. Sabahat Bokhari et al. Circ Cardiovasc Imaging. 2013;6: Copyright American Heart Association, Inc. All rights reserved.

30 SEMI-QUANTITATIVE

31 SEMI-QUANTITATIVE GRADE Grade 0 Grade 1 Grade 2 Grade 3 MYOCARDIAL 99MTc-PYP UPTAKE No uptake or Normal Bone uptake Uptake less than rib uptake Uptake equal to rib uptake Uptake greater than rib uptake with mild or absent rib uptake Visual score of =/> 2 are considered ATTR positive

32 INTERPRETATION CAVEATS Focal tracer uptake could represent rib fracture or recent MI Recent MI can remain positive for 7 days and rarely thereafter Any degree of uptake can be seen in AL amyloidosis and as such a complete evaluation is warranted

33 TREATMENTS Often unresponsive to diuretics at normal dosages No data on prognostic benefit of ACEI CCB and Digoxin are potentially toxic Best to avoid BB due to high incidence of CHB

34 AL Suppress immunoglobulin light chain production CVD (Cyclophosphamide, Velcade, Dexamethasone)

35 TTR Hepatic TTR Production Inhibition TTR Stabilization -Tafamadis (Vyndaquel) -Diflunisal Increase TTR Clearance -Doxycycline