Prognostic Significance of Strain Imaging in Amyloidosis
Piercarlo Ballo, MD*,
Sergio Mondillo, MD,
Alfredo Zuppiroli, MD
In the interesting article in a recent issue of iJACC by Koyama et al. (1), tissue Doppler (TD) longitudinal strain measured at the left ventricular (LV) base was reported to be an independent predictor of outcome in patients with cardiac amyloid light-chain (AL) amyloidosis. These findings point out an interesting potential clinical application of strain imaging for risk stratification in these subjects. However, caution is needed in accepting the independent prognostic role of basal strain, as a number of established prognostic factors, such as LV ejection fraction, New York Heart Association functional class, natriuretic peptide plasma concentration, cardiac troponins, indexed left atrial volume, the ratio of mitral peak velocity of early filling to early diastolic mitral annular velocity, right ventricular dysfunction, and renal failure, were not considered in survival analyses. Several evidences confirmed a major impact of these factors on clinical outcome in patients with cardiac AL amyloidosis (2). This may be of particular importance because nearly 70% of cardiovascular events (15 of 22) occurred in group 3 (cardiac amyloidosis with clinical evidence of heart failure), where the relative contribution of these variables to clinical outcome is expected to be relevant. Even if a subgroup analysis showed a borderline significant association of basal strain with outcome among patients with no clinical evidence of heart failure, it should be considered that most of these variables are important determinants of outcome in the pre-clinical stages of heart failure as well (3).
In addition, we believe that the evaluation of strain imaging as a prognosticator in cardiac AL amyloidosis should not be limited to the assessment of baseline deformation values. We recently reported an early improvement in both average longitudinal strain and systolic dyssynchrony after treatment with melphalan and dexamethasone, an aspect that was not detectable by color TD (4). Because response to therapy is an important predictor of survival in these patients, the prognostic meaning of changes in strain pattern after therapy might be an intriguing issue to investigate. The clinical impact of myocardial dyssynchrony—a controversial question in cardiac amyloidosis, for which, to date, 3-dimensional echocardiography and color TD have yielded conflicting results, ranging from increased dyssynchrony to abnormal hypersynchronization—may also represent an interesting application of strain imaging. Lastly, the promising role of speckle tracking imaging should be pointed out. Very recent preliminary data suggest that longitudinal strain measured by speckle tracking may be a powerful independent predictor of mortality in patients with primary amyloidosis and normal LV ejection fraction (5).
* Department of Cardiology, S. Maria Annunziata Hospital, via dell'Antella 58, Florence, 50012, Italy (Email: pcballo{at}tin.it).
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REFERENCES
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- Koyama J, Falk RH. Prognostic significance of strain Doppler imaging in light-chain amyloidosis J Am Coll Cardiol Img 2010;3:333-342.[Abstract/Free Full Text]
- Kristen AV, Perz JB, Schonland SO, et al. Non-invasive predictors of survival in cardiac amyloidosis Eur J Heart Fail 2007;9:617-624.[Abstract/Free Full Text]
- Dini FL, Whalley G, Poppe K, et al. Plasma N-terminal protype-B natriuretic peptide and restrictive mitral flow to risk-stratify patients with stage B heart failure Clin Cardiol 2009;32:711-717.[CrossRef][Web of Science][Medline]
- Ballo P, Motto A, Corsini F, Orlandini F, Mondillo S. Early improvement in cardiac function detected by tissue Doppler and strain imaging after melphalan-dexamethasone therapy in a 51-year old subject with severe cardiac amyloidosis Int J Cardiol 2008;130:278-282.[CrossRef][Web of Science][Medline]
- Saleh HK, Villarraga HR, Bellavia D, et al. Can strain by speckle tracking imaging predict mortality in primary amyloid patients with normal left ventricle ejection fraction?(abstr) J Am Coll Cardiol 2010;55(Suppl A):A137.[CrossRef]
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REFERENCES