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The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.

Surveillance for disease progression of transthyretin amyloidosis after heart transplantation in the era of novel disease modifying therapies

Published:October 25, 2021DOI:https://doi.org/10.1016/j.healun.2021.10.007

      Background

      Heart Transplantation (HT) is a rational therapy for advanced transthyretin cardiac amyloidosis (ATTR-CA), but the impact of ongoing amyloid deposition is not well defined. We evaluated a cohort of patients who underwent HT for ATTR-CA to determine the incidence of de novo or progression of post-HT ATTR deposition.

      Methods

      All patients who were followed post-HT for ATTR-CA at our center were included. Baseline demographics and post-HT manifestations of TTR deposition were collected. All patients completed the Composite Autonomic Symptom Score (COMPASS-31 quantifies autonomic symptoms, with a higher score [0-100] indicating more severe autonomic dysfunction) and Polyneuropathy Disability Score (PND, range from 0 [asymptomatic] to IV [confined to wheelchair/bed]) questionnaires.

      Results

      Twelve patients (5 wild-type, 7 variant [6 p.Val142Ile, 1 p.Thr80Ala]) were included. Mean age at HT was 64.6 (SD: 4.8) years, 83.3% male, and 50% Black. At a median of 4.0 years (IQR 2.4, 5.9) post-HT, 8 patients had symptoms of ATTR deposition (5 with gastrointestinal involvement, 4 orthopedic and 4 neurologic), with 4 patients having ≥2 body systems involved. There were no patients with recurrent cardiac involvement. Median COMPASS-31 score was 17.3 (IQR 11.3, 23.5) at 3.9 years (IQR 2.4, 5.9) post-HT. Four patients had a PND score of stage 1 (sensory disturbance), 1 patient was stage 2 (impaired walking) and 1 patient stage 3b (required a walking aid).

      Conclusions

      More than 50% of patients had evidence of progressive or de novo ATTR deposition post-HT, impairing quality of life despite a well-functioning cardiac allograft. These observations highlight an unmet need to establish the role of formal surveillance and treatment of TTR using TTR disease-modifying therapies, which may maintain or improve quality of life post-HT for ATTR-CA.

      KEYWORDS

      Abbreviations:

      ATTR-CA (transthyretin cardiac amyloidosis), COMPASS-31 (Composite Autonomic Symptom Score-31), FAP (familial amyloid polyneuropathy), GI (gastrointestinal), HT (heart transplantation), PND (Polyneuropathy Disability Score), PYP (99m-technetium pyrophosphate scintigraphy), UNOS (United Network of Organ Sharing)
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