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Concomitant Cardiac Amyloidosis in Severe Aortic Stenosis

2020; Elsevier BV; Volume: 77; Issue: 2 Linguagem: Inglês

10.1016/j.jacc.2020.11.007

1558-3597

Philippe Pîbarot, Patrizio Lancellotti, Jagat Narula,

Cardiovascular Function and Risk Factors

the Aeneid of Virgil, the Trojans were defeated after the Greeks left behind a huge wooden horse at the gates of Troy and pretended to sail back home after a 10-year siege.The wooden horse was filled with Greek warriors who invaded Troy after the Trojans brought the horse inside the city walls.Quite like the hidden warriors, cardiac amyloidosis (CA) is an insidious and often undetected process.Aortic stenosis (AS) and transthyretin (ATTR) amyloidosis are both more prevalent in elderly people, and may affect functional and clinical outcomes (1).However, there are, hitherto, few data pertaining to the exact prevalence and severity of CA and its impact on outcomes in patients with AS both before and after aortic valve replacement (AVR).In this issue of the Journal, Nitsche et al. (2) report results of a multicenter international registry of the prevalence, predictors, and outcomes in 408 consecutive severe AS patients with AS evaluated for transcatheter aortic valve replacement (TAVR) at 3 referral centers.Bone scintigraphy with 99m Tc-DPD was performed in all and assessed by a core laboratory using the Perugini grading system (grade 0, negative scan, and grades 1 to 3 for increasingly positive scans).ATTR-CA was diagnosed by a positive DPD result, and the absence of a clonal immunoglobulin and light-chain CA by a tissue biopsy. PREVALENCE, TYPE, AND SEVERITY OF CA IN SEVERE ASIn the study by Nitsche et al. (2), CA was detected in 48 (11.8%) patients, which is consistent with previous reports of prevalence between 9% and 16% (1,3-6).Of these 48 patients, one-third (n ¼ 16, 3.9% of the total population) had grade 1 and 7.9% had grade 2 or 3 DPD uptake.In this elderly population (age 83.4 AE 6.5 years) with severe AS, ATTR-CA was confirmed in all patients except 1 with light-chain CA.Compared to patients with lone AS, those with AS and CA were older and had worse functional status, worse cardiac remodeling, higher circulating N-terminal pro-brain natriuretic peptide and troponin levels, and more frequently exhibited a low-flow, low-gradient AS pattern. RED FLAGS FOR CONCOMITANT CA IN SEVERE ASThe study by Nitsche et al. (2) confirms that CA is frequent (1 out of 8 patients) in patients with severe AS referred for TAVR evaluation.However, systematic screening for CA using bone scintigraphy and light-chain analysis does not appear to be an optimal approach from logistic and economic standpoints.The challenge, in this context, is to differentiate a wooden horse (lone AS) from a Trojan horse (AS with CA).Hence, it is of paramount importance to develop and validate red flags for identification of AS patients