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Ventricular tachyarrhythmias and sudden cardiac death in light‐chain amyloidosis: a clash of cardio‐toxicities?

2021; Wiley; Volume: 193; Issue: 4 Linguagem: Inglês

10.1111/bjh.17399

1365-2141

Mattia Zampieri, Marco Allinovi, Iacopo Olivotto, Elisabetta Antonioli, Martina Gabriele, Alessia Argirò, Carlo Fumagalli, Giulia Nardi, Carlo Di Mario, Alessandro M. Vannucchi, Federico Perfetto, Francesco Cappelli,

Takotsubo Cardiomyopathy and Associated Phenomena

Sudden cardiac death (SCD) is not uncommon in immunoglobulin light-chain amyloidosis (AL) and has been usually attributed to pulseless electrical activity (PEA) or agonal bradycardia occurring in the late stages of the cardiomyopathy.1, 2 In addition, the historically reported survival of 20 months in each. Successful resuscitation after defibrillator shock therapy resulted in a meaningful survival benefit, raising the possibility that ICD implantation may be appropriate in selected cases – an issue still controversial in AL amyloidosis.4, 5 Chemotherapy for AL amyloidosis is mainly based on regimens used for the treatment of myeloma and not specifically approved for AL cardiac involvement. Most of these drugs have established cardiotoxic potential, with increased risk of heart failure and arrhythmic events.7 Ventricular arrhythmogenesis in cardiac amyloidosis is not well understood. The widely accepted paradigm is that of a progressive cardiomyopathy in which myocardial infiltration leads to bradyarrhythmias and PEA in advanced stages;1 these are generally terminal events with limited if any therapeutic potential. However, our observation suggests that, at earlier stages, the synergistic toxicity of unrestrained circulating light chains8 and chemotherapy agents may rather trigger ventricular tachyarrhythmias. Our hypothesis requires further, large-scale validation. Nevertheless, these observations are potentially relevant for practice, raising important clinical questions. Should we implement specific surveillance strategies? Can we identify patients at greater risk? Can we define criteria and timing for ICD implantation in primary prevention? Should we consider a critical reappraisal of chemotherapy regimens in patients with moderate-to-severe cardiac involvement due to AL amyloidosis, in order to limit cardiotoxicity? As for many other neoplastic diseases, improvements in general outcomes must enhance our attention towards cardio-oncological issues in survivors; this is a testimony to the efficacy of current treatment, but equally represents a novel challenge to cardiologists. Mattia Zampieri, Francesco Cappelli and Federico Perfetto performed the research, designed the research study, contributed essential reagents or tools, analysed the data and wrote the paper. Marco Allinovi and Elisabetta Antonioli performed the research and contributed essential reagents or tools. Carlo Fumagalli, Martina Gabriele, Alessia Argirò, Giulia Nardi performed the research and analysed the data. Carlo di Mario, Iacopo Olivotto, Alessandro Maria Vannucchi designed the research study, contributed essential reagents or tools. None declared. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.