Clinical Outcomes and Prognosis
Asmi K. Multani
Student Researcher
Libin Cardiovascular Institute of Alberta, University of Calgary
Red Deer, Alberta, Canada
James White, MD
Professor of Cardiology
Stephenson Cardiac Imaging Centre
Calgary, Alberta, Canada
Fereshteh Hasanzadeh, MSc
Master Student in Cardiovascular and Respiratory Science
Cumming School of Medicine, University of Calgary
Calgary, Alberta, Canada
Dina Labib, MD, PhD, FSCMR
PhD student
Libin Cardiovascular Institute of Alberta, University of Calgary
Calgary, Alberta, Canada
Steven Dykstra, MSc, BSc
PhD Student
Libin Cardiovascular Institute of Alberta, University of Calgary
Calgary, Alberta, Canada
Easter Prosia, MD
Core Lab Technician
University of Calgary, Canada
Rylan Marianchuk
Intern
University of Calgary, Canada
Sandra Rivest, RN
Research nurse
Libin Cardiovascular Institute of Alberta, University of Calgary
Calgary, Alberta, Canada
Rosa Sandonato, RN
General Associate AHS Research/Clinical Admin
University of Calgary
Calgary, Alberta, Canada
Jacqueline Flewitt, MSc
Research Collaborations Coordinator
Libin Cardiovascular Institute of Alberta, University of Calgary
Calgary, Alberta, Canada
Andrew G. Howarth, MD, PhD
Clinical Co-director
Libin Cardiovascular Institute of Alberta, University of Calgary
Calgary, Alberta, Canada
Carmen P. Lydell, MD
Clinical Co-director
Libin Cardiovascular Institute of Alberta, University of Calgary
Calgary, Alberta, Canada
Robert J. Miller, MD
Associate professor of Cardiology
University of Calgary, Canada
Nowell M. Fine, MD
Associate professor of cardiology
Libin Cardiovascular Institute
Calgary, Alberta, Canada
Bradley Sarak, MD
Cardiovascular Magnetic Resonance Imaging fellow
Libin Cardiovascular Institute of Alberta, University of Calgary, Canada
Cardiac Amyloidosis (CA) is a cardiomyopathy characterized by the deposition of amyloid protein in all myocardial tissues, including the right ventricle (RV). This chamber may also be impacted by elevated hemodynamic demands from elevated pulmonary arterial pressures in patients with advanced disease. Accordingly, the contractile health of the RV has been postulated to provide important and incremental prognostic value in patients with CA. Cardiac magnetic resonance (CMR) provides highly reproducible evaluations of RV volumes and contractile performance. In a prospectively recruited population of CA patients undergoing CMR imaging we aimed to study the association of RV volumes and ejection fraction (EF) with the incident risk of death or heart failure hospitalization.
Methods:
A total of 120 patients with CA were identified from the Cardiovascular Imaging Registry of Calgary (CIROC). Patients were required to have confirmation of disease using objective criteria, including abnormal technetium pyrophosphate imaging or cardiac biopsy in ATTR-CA, and abnormal CMR plus extracardiac tissue biopsy in AL-CA. All patients underwent baseline health questionnaires prior to CMR imaging using a standardized imaging protocol. CMR images were analyzed without knowledge of clinical outcomes to obtain multi-chamber volumes at end diastole and systole. Patients were followed for all-cause death or heart failure hospitalization. Univariable and multivariable analyses were performed to identify associations between CMR-derived RV parameters and time to first event, measured from date of CMR.
Results:
A total of 120 patients were studied, 73 (61%) with ATTR-CA, and 44 (37%) with AL-CA. Three patients remained unclassified by sub-type at time of analysis. Baseline characteristics, health profiles and cardiac MRI characteristics shown in Table 1. At a median follow-up of 696 days (IQR 123.6-272.5), 82 subjects (68%) experienced a primary composite outcome with 41 (34%) patients dying and 72 (60%) experiencing a heart failure hospitalization. Patients experiencing a primary composite outcome had higher indexed LV mass (95 vs 83 g/m2, p=0.016), lower LVEF (51 vs 56%, p=0.025), and a non-significant trend toward higher indexed LA volumes (55 vs 49 ml/m2, p=0.054). RVEF was significantly lower in event positive patients (47 vs 56%, p=0.001) with a reduced RVEF below 45% being present in 38% of patients experiencing an event compared to 13% in patients without an event (p=0.002). Following adjustment for age, sex, GFR, LVEF, indexed LV mass and indexed LA volume, RVEF < 45% remained independently associated with the primary outcome of death or heart failure hospitalization (aHR 2.23, p=0.004). There was no interaction with amyloid sub-type (p=0.90).
Conclusion:
In patients with CA, right ventricular function assessed by CMR is a powerful and independent predictor of future death or heart failure hospitalization.