Real-life experience with inotersen at CEPARM, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro / Experiência de vida-real com inotersena no CEPARM, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro

Abstract Background Hereditary transthyretin amyloidosis (ATTRv) is an inherited, progressive, and fatal disease still largely underdiagnosed. Mutations in the transthyretin (TTR) gene cause the TTR protein to destabilize, misfold, aggregate, and deposit in body tissues, which makes ATTRv a disease with heterogeneous clinical phenotype. Objective To describe the long-term efficacy and safety of inotersen therapy in patients with ATTRv peripheral neuropathy (ATTRv-PN). Methods Patients who completed the NEURO-TTR pivotal study and the NEURO-TTR OLE open-label extension study migrated to the present study and were followed-up for at least 18 more months to an average of 67 months and up to 76 months since day 1 of the inotersen therapy (D1-first dose of inotersen). Disease progression was evaluated by standard measures. Results Ten ATTRv-PN patients with Val30Met mutation were included. The mean disease duration on D1 was of 3 years, and the mean age of the patients was of 46.8 years. During an additional 18-month follow up, neurological function, based on the Neuropathy Impairment Score and the Polyneuropathy Disability Score, functionality aspects (Karnofsky Performance Status), and nutritional and cardiac aspects were maintained. No new safety signs have been noted. Conclusion The treatment with inotersen was effective and well tolerated for the average of 67 months and up to 76 months. Our results are consistent with those of larger phase-III trials.

Resumo Antecedentes Amiloidose hereditária por transtirretina (ATTRv) é uma doença hereditária, progressiva e fatal ainda largamente subdiagnosticada. Mutações no gene transtirretina (TTR) promovem desestabilização, desdobramento, agregação e depósito da proteína TTR em tecidos do corpo, o que faz da ATTRv uma doença de fenótipo clínico heterogêneo. Objetivo Descrever a eficácia e segurança da terapia com inotersena no longo prazo em pacientes com neuropatia periférica ATTRv (ATTRv-PN). Métodos Pacientes que completaram o estudo pivotal NEURO-TTR e o estudo de extensão aberta NEURO-TTR OLE migraram para este estudo e foram acompanhados por no mínimo 18 meses adicionais, em média por 67 meses, e por até 76 meses, desde o dia 1 da terapia com inotersena (D1-primeira dose de inotersena). A progressão da doença foi avaliada por medidas padronizadas. Resultados Dez pacientes com ATTRv-PN com mutação Val30Met foram incluídos. A duração média da doença no D1 era de 3 anos, e a média de idade dos pacientes era de 46,8 anos. Durante o período de acompanhamento adicional de 18 meses, a função neurológica, baseada no Neuropathy Impairment Score e no Polyneuropathy Disability Score, os aspectos de funcionalidade (Karnofsky Performance Status), nutricional e cardíacos estavam mantidos. Não se observou nenhum novo sinal de segurança. Conclusão O tratamento com inotersena foi eficaz e bem tolerado por 67 meses em média, e por até 76 meses. Nossos resultados são consistentes com os de estudos maiores de fase III.

Advancements in pharmacological therapy for transthyretin cardiac amyloidosis and its comorbidities / 中国药房

Transthyretin cardiac amyloidosis myocardiopathy （ATTR-CM） is an infiltrative cardiomyopathy characterized by the deposition of amyloidogenic material in the myocardial interstitium due to the misfolding of monomers following the dissociation of unstable transthyretin （TTR） tetramers. Previous treatments for ATTR-CM lacked specificity，primarily targeting symptomatic management of heart failure and arrhythmias. In recent years，researchers have developed two major classes of drugs addressing the pathogenesis of ATTR-CM. The first class stabilizes TTR tetramer structure （such as tafamidis and acoramidis）， while the second class interferes with TTR synthesis （such as patisiran）. Among these，tafamidis has been confirmed as the only currently effective treatment for ATTR-CM，while other drugs are still in clinical trial stages with limited clinical evidence. Concerning the management of comorbidities in ATTR-CM，treatment mainly focuses on common cardiac comorbidities （such as heart failure and arrhythmias）. Traditional drugs used to improve heart failure prognosis （such as β-blockers and renin-angiotensin- receptor blocker），have not demonstrated prognosis improvement in ATTR-CM patients and may even lead to adverse reactions. For ATTR-CM patients with concurrent atrial fibrillation，anticoagulation therapy is recommended to prevent thrombus formation，and amiodarone can be used for rhythm control. Despite significant advancements in pharmaceutical treatments for ATTR-CM，the overall prognosis remains poor，necessitating further research into the pathogenesis and target development to enhance the prognosis of ATTR-CM patients.

Clinical, genetic characteristics and follow-up in 14 patients with transthyretin familial amyloid polyneuropathy / 中华神经科杂志

Objective:To summarize the clinical and genetic characteristics in patients with transthyretin familial amyloid polyneuropathy (TTR-FAP).Methods:Fourteen unrelated TTR-FAP patients diagnosed at Xuanwu Hospital, Capital Medical University from September 2014 to February 2022 were retrospectively reviewed. The clinical manifestation, electrophysiology, cardiac function, biopsy and gene mutation were analyzed.Results:In the 14 patients (13 males, 1 female) diagnosed as TTR-FAP, the mean age at onset was 53.9 years (range: 33.0-71.0 years), with a mean course from symptom-onset to diagnosis of 4.1 years. The late-onset type occurred in 9 cases. Seven patients had a family history of TTR-FAP. Distal paresthesia of lower limbs was the commonest initial symptom (8 cases), with sensorimotor neuropathy and autonomic dysfunction seen initially in 4 and 2 cases, respectively. Cardiac involvement occurred in 6/8 of the patients. Nerve conduction studies indicated extremely axonal impairment with demyelinating features. Sural nerve biopsies showed moderate to severe axonal loss of myelinated fibers and the positive rate of Congo red staining was 8/14. Of 8 different TTR mutations detected, V50M was the most common (appearing in 5 cases). No obvious neuropathy progression was seen in the 5 patients who received tafamidis and 2 patients died of dyscrasia. Conclusions:TTR-FAP is more common in males, with sensorimotor axonal polyneuropathy, autonomic dysfunction and cardiac subclinical damage as the predominant symptoms. V50M is the commonest mutation. Tafamidis can delay the progression of disability.

Correlation analysis of serum TTR, RBP4 expressions and gestational metabolic syndrome / 中华内分泌外科杂志

Objective:To investigate the relationship between the expressions of serum trans thyroxine protein (TTR) , retinol binding protein 4 (RBP4) and metabolic syndrome of pregnancy (GMS) .Methods:A total of 103 patients with GMS from May. 2017 to Dec. 2019 were selected as the observation group, in addition, 100 healthy pregnant women with single pregnancy and no complications were selected as control group. Before pregnancy, the height and weight were detected. After the diagnosis of GMS, serum markers and blood pressure were detected. The levels of total cholesterol (TC) , triglyceride (TG) , low density lipoprotein cholesterol (LDL-C) , high density lipoprotein cholesterol (HDL-C) and fasting blood glucose (FBG) were detected by Hitachi 7600 automatic biochemical analyzer, and the expression levels of TTR and RBP4 in serum were detected by enzyme-linked immunosorbent assay (ELISA) . Receiver operating characteristic (ROC) curve was drawn to evaluate the diagnostic value of TTR and RBP4 in GMS. Multivariate Logistic regression model was used to analyze the influencing factors of GMS in pregnant women.Results:There was no significant difference in age or gestational weeks between the two groups ( P>0.05) . Compared with those in the control group, the levels of BMI, TC, TG, LDL-C, FBG, systolic blood pressure, diastolic blood pressure, serum TTR and RBP4 expression levels were higher in the observation group before pregnancy ( P<0.05) , while HDL-C was lower ( P<0.05) . The area under the curve (AUC) of TTR and RBP4 alone or combination in the diagnosis of GMS was 0.797, 0.816 and 0.898, respectively. The cut-off value of TTR was 284.91 mg/L, and the sensitivity and specificity were 63.10% and 89.00%, respectively. The cut-off value of RBP4 was 17.89 mg/L, and the sensitivity and specificity were 69.90% and 87.00%, respectively. The sensitivity and specificity of the combined diagnosis were 83.50% and 84.00% respectively. Multivariate Logistic regression analysis showed that high level of TTR and high level of RBP4 were independent risk factors of GMS in pregnant women ( P<0.05) . Conclusions:The expression levels of serum TTR and RBP4 in GMS patients are high, and they have certain diagnostic value for GMS. They are independent risk factors of GMS in pregnant women, which may provide new ideas for the early diagnosis and prevention of GMS.

The Interpretation and Update of the Diagnosis Pathway of Chinese Expert Consensus on the Diagnosis and Treatment of Transthyretin Cardiac Amyoidosis / 罕见病研究

Transthyretin cardiac amyloidosis (ATTR-CA) is caused by the deposition of transthyretin(TTR) in the myocardial interstitium. Its clinical manifestations are mainly heart failure and arrhythmia, leading to poor life quality and low survival rate. Diagnosis is often delayed or missed due to the lack of disease awareness, the non-specific clinical symptom presentation of the disease, and inadequacy of non-invasive diagnostic methods and medications in the past. The recent availability of effective treatments makes the early recognition and diagnosis especially critical, because treatment is likely more effective earlier in the disease course. Therefore, it is crucial to establish a diagnosis and treatment strategy to facilitate the rapid and accurate identification of the disease. Based on the advances in research and experiences gained ATTR-CA, our team has developed a consensus on diagnosis and treatment for the disease. In this article, we interpret the key points and present the update of diagnostic process, providing clinicians with an overview of key aspects of ATTR-CA in China.

Progress in New Therapies Targeting the Pathogenesis of Cardiomyopathywith Hypertrophic Phenotype / 罕见病研究

Hypertrophic cardiomyopathy (HCM) is cardiomyopathy with a clinical phenotype of cardiac hypertrophy. The etiology includes genetically defective encoding sarcomeres, congenital metabolic diseases such as lysosomal storage diseases, systemic amyloidosis such as transthyretin amyloidosis(ATTR), and Fabry disease. Previous therapies did not target the etiology and pathogenesis and therefore were less effective. In recent years, treatments targeting different mechanisms of myocardial hypertrophy have achieved good results. Mavacamten can reduce myocardial contractility by inhibiting ATP activity, thereby significantly improving left ventricular outflow tract(LVOT) obstruction, cardiac contractility, ventricular tension, and limitting myocardial damage. By inhibiting the dissociation of transthyretin(TTR) and subsequent formation and deposition of the amyloid fibril, tafamidis can reduce the mortality and morbidity of patients with transthyretin cardiac amyloidosis(ATTR-CA). Gene silencing and gene editing technology can reduce abnormal TTR levels. Synthesis of α-galactosidase A by gene recombination technology in vitro can effectively reduce left ventricular mass index(LVMi), improve cardiac function, reduce angina attacks and decrease mortality of Fabry disease.

Homage to Paula Coutinho ­ a pioneer in portuguese and worldwide neurogenetics / Homenagem a Paula Coutinho ­ uma pioneira da neurogenética portuguesa e mundial

This is a tribute to an outstanding Portuguese neurologist and researcher, Paula Coutinho (1941-2022), who specialized in the care and study of people with familial amyloidotic polyneuropathy and Machado-Joseph disease which she helped define. As a result, she collaborated with the inauguration of the Centro de Estudos de Paramiloidose Antônio Rodrigues de Mello (CEPARM) founded in 1984 at the University Hospital of the Federal University of Rio de Janeiro. Since then, we admire her commitment to science and patients.

Esta é uma homenagem a uma notável neurologista e pesquisadora portuguesa, Paula Coutinho (1941-2022), que se especializou no cuidado e estudo de pessoas com polineuropatia amiloidótica familiar e doença Machado-Joseph, que ela ajudou a definir. Como resultado, colaborou com a inauguração do Centro de Estudos de Paramiloidose Antônio Rodrigues de Mello (CEPARM) fundado em 1984 no Hospital Universitário da Universidade Federal do Rio de Janeiro. Desde então, admiramos o seu compromisso com a ciência e os pacientes.

Suspecting and diagnosing transthyretin amyloid cardiomyopathy (ATTR-CM) in India: An Indian expert consensus

Transthyretin cardiac amyloidosis (ATTR-CM) is a rare and under-recognized disorder characterized by the aggregation of transthyretin-derived insoluble amyloid fibrils in the myocardium. Heterogeneity of symptoms at presentation, makes its diagnosis often delayed. An expert panel gathered on a virtual platform across India to conduct a meeting for developing a guiding tool for ATTR-CM diagnosis. The panel recommended younger age (40 years) for suspecting ATTR-CM and thick-walled non-dilated hypokinetic ventricle was considered as one of the important red flags. Electrocardiogram (ECG) and echocardiography (ECHO) findings were recommended as primary tests to raise the suspicion while nuclear scintigraphy and hematological tests were recommended to confirm the diagnosis and rule out amyloid light-chain (AL) amyloidosis. Cardiac magnetic resonance (CMR) and biopsy were recommended in case of ambiguity in the presence of red flags. Considering the lack of expert guidelines in the Indian scenario, a standardized diagnostic algorithm was also proposed.

Ophthalmological manifestations of hereditary transthyretin amyloidosis / Manifestações oftalmológicas da amiloidose hereditária por transtirretina

ABSTRACT Transthyretin familial amyloidosis is the most common form of inherited systemic amyloidosis worldwide. The condition develops secondary to more than 100 different point mutations in the transthyretin gene (18q12.1). The mutations lead to abnormal amyloid deposits, mainly in the heart and peripheral nerves. Leptomeningeal and mainly ocular involvement is common. Although there are several different types of treatment available, ocular involvement, which occurs also in liver transplant recipients, remains a major challenge, progressing even in liver transplant recipients. Patients with ocular involvement require efficient ophthalmological follow-up to prevent vision loss. In this review, different forms of ocular involvement characterizing the subtypes of transthyretin mutations were described, and the effects of different treatments were summarized. Further research is necessary to fully elucidate these issues.

RESUMO A amiloidose familiar por transtirretina é a forma mais comum de amiloidose sistêmica hereditária mundialmente. A condição é secundária a mais de 100 mutações ponto diferentes no gene da transtirretina (18q12.1). Mutações levam a depósitos anormais de amilóide principalmente no coração e nos nervos periféricos. O envolvimento leptomeníngeo, e principalmente ocular também é comum. Apesar do advento de várias formas diferentes de tratamento, o envolvimento ocular ainda é um grande problema, progredindo mesmo em pacientes submetidos à transplante hepático. Nesta revisão, avaliamos as diferentes formas de envolvimento ocular presentes entre os subtipos de mutações da transtirretina e os efeitos dos diferentes tratamentos disponíveis. O envolvimento ocular é desafiador na amiloidose familiar por transtirretina, exigindo acompanhamento oftalmológico eficiente para mitigar a perda de visão. Mais pesquisas são necessárias para auxiliar na resolução dessas questões.

Polineuropatía por amiloidosis por transtiretina de inicio tardío. Caso clínico / Late-onset hereditary transthyretin amyloidosis with polyneuropathy. Report of one case

Hereditary transthyretin amyloidosis is a multisystemic autosomal dominant genetic disorder characterized by progressive distal sensory-motor polyneuropathy or restrictive cardiomyopathy, secondary to amyloid deposits. Its pathogenesis lies in the TTR gene mutation, and the Val50Met mutation is the most frequent. Patients have significant differences in the onset and severity of clinical presentation according to their country of origin. The diagnosis of this pathology is complex, even more in countries where it is not considered endemic. However, early suspicion and management are essential to improve survival and avoid unnecessary diagnostic and therapeutic strategies. We report a 69-year-old woman who presented a sensory-motor polyneuropathy, predominantly sensory, associated with distal neuropathic pain and bilateral vitritis. The history of her Italian father with polyneuropathy of unspecified etiology stood out. A vitreous biopsy identified amyloid substance deposits (congo red positive). These were also confirmed on a superficial peroneal nerve biopsy. During the etiological study of her polyneuropathy, an increased Kappa/Lambda index of 2.55 mg/L stood out. Therefore, light chain amyloidosis was suspected, and chemotherapy treatment was indicated without favorable response. After 10 years of progressive neurological and ophthalmological involvement, a genetic study confirmed the first case of late-onset hereditary transthyretin amyloidosis Val50Met with polyneuropathy in Chile.

Diagnóstico de amiloidosis sistémica: bases hematológicas útiles para el cardiólogo clínico / Diagnosis in systemic amiloydosis: useful hematological bases for the clinical cardiologist / Diagnóstico de amiloidose sistémica: bases hematológicas úteis para o cardiologista clínico

Las amiloidosis son un grupo heterogéneo de patologías caracterizado por el depósito extracelular de proteínas fibrilares anormalmente plegadas que se depositan en los tejidos y ocasionan su disfunción. La calidad y expectativa de vida depende del órgano afectado y del grado de compromiso, la afectación cardíaca es la principal determinante de la sobrevida y calidad de vida. El diagnóstico requiere la biopsia tisular y tipificación de la proteína. Su detección tardía se asocia a inferior pronóstico y sobrevida. La forma más común de amiloidosis es la causada por depósito de cadenas livianas monoclonales (AL), para la cual nuevos agentes de inmuno y quimioterapia dirigidas a suprimir la clona de células plasmáticas han demostrado mejorar la sobrevida. Para la amiloidosis por transtiretina (ATTR), segunda en frecuencia, existen terapias estabilizadoras de la proteína y terapias dirigidas a detener su síntesis a través del silenciamiento genético. Esta revisión se dirige a describir las bases hematológicas útiles para el cardiólogo clínico.

The amyloidoses are a heterogeneous group of diseases caused by the extracellular deposition of abnormally folded fibrillar proteins in organs and tissues, causing their dysfunction. The quality and life expectancy depend on the affected organ, with cardiac involvement being the main determinant of survival and quality of life. Diagnosis requires tissue biopsy and protein typing. Its late detection is associated with a lower prognosis and survival. The most common form of amyloidosis is caused by monoclonal light chain (AL) deposition, for which new immunological agents and chemotherapy aimed at suppressing plasma cell cloning have been shown to improve survival. For transthyretin amyloidosis (ATTR), the second in frequency, there are protein-stabilizing therapies and therapies aimed at stopping its synthesis through genetic silencing. This review focuses on the hematological bases for the clinical cardiologist.

As amiloidoses são um grupo heterogêneo de patologias caracterizadas pela deposição extracelular de proteínas fibrilares anormalmente dobradas, que se depositam nos tecidos, causando sua disfunção. A qualidade e expectativa de vida dependem do órgão afetado e do grau de comprometimento, sendo o acometimento cardíaco o principal determinante da sobrevida e qualidade de vida. O diagnóstico requer biópsia tecidual e tipagem de proteínas. Sua detecção tardia está associada a um menor prognóstico e sobrevida. A forma mais comum de amiloidose é causada pela deposição monoclonal de cadeia leve (AL), para a qual novos agentes imuno e quimioterápicos destinados a suprimir a clonagem de plasmócitos demonstraram melhorar a sobrevida. Para a amiloidose por transtirretina (ATTR), segunda em frequência, existem terapias estabilizadoras de proteínas e terapias destinadas a interromper sua síntese por meio do silenciamento genético. Esta revisão enfoca a amiloidose sistêmica, com foco em bases hematológicas úteis para o cardiologista clínico.

Primer uso de tafamidis en amiloidosis cardíaca TTR en Uruguay / First use of tafamidis in cardiac amyloidosis TTR in Uruguay / Primeiro uso de tafamidis em amiloidose cardíaca TTR no Uruguai

La amiloidosis cardíaca es una entidad con creciente reconocimiento, la variedad por transtiretina es la que más se diagnostica en la tercera edad de la vida. Hay reciente disponibilidad de fármacos que mejoran el pronóstico y la calidad de vida de los pacientes. Presentamos un caso de amiloidosis por transtiretina donde se usó por primera vez en nuestro país el fármaco tafamidis aprobado para el tratamiento de esta enfermedad.

Cardiac amyloidosis is an entity on increasing recognition, transthyretin variety is the most diagnosed in the third age. There is a recent availability of drugs that can improve the prognosis and quality of life of these patients. We present a case of transthyretin amyloidosis and the first use of tafamidis in our country.

A amiloidose cardíaca é uma entidade em crescente reconhecimento, a variedade transtiretina é a mais diagnosticada em idosos. Há disponibilidade recente de medicamentos que melhoram o prognóstico e a qualidade de vida dos pacientes. Apresentamos um caso de amiloidosis transteretina onde o medicamento tafamidis aprovado para esta doença foi utilizado pela primeira vez em nosso país.

Consensus to 99mTechnetium-Pyrophosphate Scintigraphy in the Diagnosis of Transthyretin-related Cardiac Amyloidosis / 罕见病研究

Transthyretin-related amyloid cardiomyopathy (ATTR-CM) is a disease caused by the depo-sition of insoluble amyloid fibers formed by the misfolding of transthyretin precursor protein in the intercellular space of cardiomyocytes. This lesion may lead to myocardial dysfunction, cogestive heart failure, and death.When diagnosed earlier, the patient can be treated with drugs as soon as possible to intervene in the progress of the disease, so as to effectively improve the patient's prognosis.99mtechnetium-pyrophosphate (99Tcm-PYP)single-photon emission computed tomography (SPECT) has been widely used in the imaging examination of cardiac amyloidosis (CA) in recent years. While achieving early non-invasive diagnosis, accurate pathological classification can be obtained through Perugini visual score analysis, semi-quantitative analysis of heart to contralateral lung (H/CL) ratio, and SPECT image analysis. This article presents the application, methods, and the precautions of 99Tcm-PYPSPECT in the diagnosis of ATTR-CM, aiming to provide clinical reference for the application of this technology.

Neurosonographic characteristics of peripheral nerve in transthyretin familial amyloid polyneuropathy / 中华神经科杂志

Objective:To study peripheral nerve morphology in patients with transthyretin familial amyloid polyneuropathy (TTR-FAP) using high-frequency ultrasonography (HFUS), and to evaluate the value of HFUS in diagnosis of TTR-FAP.Methods:Thirty-eight patients with TTR-FAP diagnosed by gene detection and 23 normal controls from June 2015 to June 2021 in Peking University First Hospital were enrolled in this study. Consecutive ultrasonography scanning was performed in 6 pairs of nerves of bilateral limbs with 30 sites. The cross sectional area (CSA), CSA variability and inter-nerve CSA variability data of the two groups were retrospectively calculated and compared.Results:Compared with the normal controls, TTR-FAP patients showed larger CSA values at most nerve sites of both upper and lower limbs, and there were statistically significant differences at M1(median nerve) [8.55 (6.90, 9.40) mm 2vs 10.05 (9.10, 14.10) mm 2, Z=5.58, P<0.001], M3 (median nerve) [(6.98±1.66) mm 2vs (9.29±2.30) mm 2, t=6.28, P<0.001], M5 (median nerve) [(8.91±1.81) mm 2vs (14.33±4.20) mm 2, t=9.84, P<0.001], U5 (ulnar nerve) [(6.20±1.93) mm 2vs (9.34±2.85) mm 2, t=7.31, P<0.001], Sci1 (sciatic nerve) [(53.50±17.24) mm 2vs (79.74±20.75) mm 2, t=7.57, P<0.001], Sci2 (sciatic nerve) [(53.66±14.21) mm 2vs (73.98±19.21) mm 2, t=6.82, P<0.001] and Tib (tibial nerve) [(31.05±8.43) mm 2vs (46.29±13.14) mm 2, t=7.84, P<0.001] sites. There was no statistically significant difference in CSA at each site among the different subtypes and disease severity of TTR-FAP patients ( P>0.05). There was no statistically significant difference in CSA-variability of the median and ulnar nerves between the patients with TTR-FAP and the normal controls ( P>0.05). The side-to-side difference ratio of intra-nerve CSA variability of the ulnar nerve in the patients with TTR-FAP was smaller than that of the normal controls (1.15±0.10 vs 1.46±0.43, t=3.43, P=0.002), whereas no statistically significant difference of that in the median nerve was found between the two groups ( P>0.05). Conclusions:The most pronounced peripheral nerve thickening in the proximal limb segments with no signs of asymmetric distribution or lateralization is confirmed by HFUS in TTR-FAP patients and should be regarded as a marker of TTR-FAP. HFUS has clinical value in diagnosis of peripheral neuropathy in TTR-FAP patients.

An Autopsy Case of Transthyretin-Related Cardiac Amyloidosis (TTR-CA), Which Fell into Low-Output Syndrome after Cardiac Surgery / 日本心臓血管外科学会雑誌

We present the case of 83-year-old male patient. He was under observation as an outpatient with mild to moderate aortic stenosis and regurgitation since 75 years old. He underwent surgery because of repeated hospitalization by heart failure due to progressive aortic valve stenosis and regurgitation, mitral valve stenosis and regurgitation, and tricuspid regurgitation. Elective aortic valve replacement, mitral valve replacement and tricuspid valve repair was performed. Even though his condition after surgery was stable, suddenly feature like low output syndrome appeared on day 6, and led to a mortality on day 8 after operation. Ejection fraction was kept above 50 percent before and after surgery, which indicated to Heart Failure with preserved Ejection Fraction (HFpEF). After autopsy examination, by immunohistochemical staining identified transthyretin, we demonstrated previously undiagnosed transthyretin-related cardiac amyloidosis (TTR-CA).

Familial amyloid polyneuropathy: a proposal for an epidemiological study through the creation of a virtual platform / Polineuropatia amiloidótica familiar: uma proposta de estudo epidemiológico por meio da criação de uma plataforma virtual

Amyloidosis are characterized by mutations in the gene coding for transthyretin (TTR), located on chromosome 18. TTR is a set of four 127-aminoacid polypeptides structured as homotetrameric protein of 56 kDa with a secondary ß sheet structure. It plays the role of thyroxin (T4) carrier, and has a binding domain for retinol (vitamin A). It is synthesized in the liver, although a small quantity is also produced by the choroid plexus, and retinal cells. Mutations of this gene result in loss of tetramer stability. Insoluble amyloid fibrils (AF) are formed and deposited in tissues and organs. The abnormal aggregation of TTR protein trigger several syndromes, such as familial amyloid polyneuropathy (FAP-TTR), cardiomyopathies (CMP), and senile systemic amyloidosis (SSA). It is estimated there are 5,000 to 10,000 cases of FAP-TTR globally. OBJECTIVE: The study intends to develop an online platform for the diagnosis of FAP-TTR. The aim is to facilitate the diagnosis process and promote a tool for epidemiological study. METHODS: The project was based on a literature review featuring clinical and epidemiological evidence for the development of a practical platform (applied research). RESULTS: It was elaborated a platform containing a questionnaire to allow a more dynamic, cheaper, and efficient operation, mediated by a better characterization of the disease to enable its early diagnosis. CONCLUSION: The platform might become a valuable resource for the characterization, diagnosis, and future epidemiological study of FAP-TTR

As amiloidoses se caracterizam por mutações no gene codificante da transtirretina (TTR) no cromossomo 18. A proteína TTR compõe-se de uma corrente de polipeptídios de 127 resíduos, que constituem uma proteína homotetramérica de 56kDa com estrutura secundária de folha ß, que serve como proteína de deslocamento para a tiroxina (T4), e uma proteína de ligação ao retinol (vitamina A). O principal local de produção dessa proteína é o fígado, embora uma pequena quantidade seja produzida pelo plexo coroide e pelas células retinianas. O gene codificante da TTR (18q11.2-12) é pequeno (7 kb) e contém quatro éxons. As mutações convertem-se em perda do equilíbrio do tetrâmero proteico. Surgem assim, fibrilas amiloides (FA) em cadeias não ramificadas de 10 a 12 nm de diâmetro e fibrilas indissolúveis, que se condensam nos tecidos e órgãos. As síndromes concernentes ao acúmulo da proteína TTR são: polineuropatia amiloidótica familiar (PAFTTR), miocardiopatias (MCP) e amiloidose sistêmica senil (ASS). Estimativa recente relatou a existência de 5.000 a 10.000 casos de PAFTTR no mundo. OBJETIVO: O estudo objetiva elaborar uma plataforma de diagnóstico PAFTTR on-line para auxiliar como ferramenta de contribuição para o estudo da epidemiologia e facilitar o diagnóstico. MÉTODOS: O projeto baseou-se em uma pesquisa bibliográfica capaz de levantar evidências clínicas e epidemiológicas na elaboração de uma plataforma facilitadora (pesquisa aplicada). RESULTADOS: O resultado alcançado foi a elaboração da plataforma contendo um questionário, que tornará o trabalho dos profissionais mais dinâmico, barato e eficiente, caracterizando melhor a doença e promovendo um diagnóstico precoce. CONCLUSÃO: A plataforma poderá tornar-se recurso valioso para caracterização, diagnóstico e futuro estudo epidemiológico da PAF-TTR

Cardiomiopatía amiloídea por transtiretina: diagnóstico y manejo en la actualidad / Transthyretin amyloid cardiomyopathy: a review

RESUMEN: La cardiomiopatía amiloide por transtiretina (CATTR) es una enfermedad caracterizada por depósito extracelular de fibrillas amiloides en el miocardio, a partir de transtiretina mal plegada, generando una miocardiopatía restrictiva. Esta proteína mal plegada puede tener origen hereditario o adquirido, siendo más frecuente en adultos mayores. La CA-TTR ha surgido como una causa subdiagnosticada de insuficiencia cardíaca con fracción de eyección preservada (IC FEp). El pilar fundamental para su diagnóstico es la alta sospecha clínica, basada en diversas banderas de alerta ya que la sintomatología que provoca suele ser inespecífica. Como veremos en esta revisión, el diagnóstico puede sustentarse con la cintigrafía ósea, reservando para situaciones particulares la toma de biopsia. Con el advenimiento de nuevas terapias que impactan en la sobrevida de esta enfermedad, el tiempo para realizar el diagnóstico certero y la diferenciación de otras causas de amiloidosis cardíaca como la de cadenas livianas, se ha tornado crucial.

ABSTRACT: Transthyretin amyloid cardiomyopathy (AT-TR-CM) is a disease characterized by extracellular deposition of amyloid fibrils in the myocardium, from misfolded transthyretin, generating a restrictive cardiomyopathy. This misfolded protein may be inherited or acquired, and is more prevalent in elderly patients. ATTR-CM has emerged as an underdiagnosed cause of heart failure with preserved ejection fraction (HF-PEF). The fundamental pillarfor its diagnosis is high clinical suspicion since the symptoms are usually nonspecific. The diagnosis can be made from bone scintigraphy, reserving myocardial biopsy for particular situations. With the advent of new therapies that affect the survival of these patients, a timely diagnosis has become crucial.

Familial amyloid polyneuropathy caused by transthyretin Ala117Ser mutation: a case report and literature review / 中华神经科杂志

Objective:To investigate the clinical manifestations of familial amyloid multiple neuropathy (FAP) caused by Ala117Ser mutation, and to improve the clinical recognition of FAP.Methods:The clinical manifestations, electrophysiological examination, pathology and gene mutation characteristics of a case of FAP, who admitted to Fujian Medical University Union Hospital on November 25, 2014, were analyzed, and the literatures on the FAP cases caused by Ala117Ser mutation were reviewed and summarized.Results:The patient was a 59-year-old male from Fujian province. The first symptom was numbness in the extremities, followed by obvious autonomic nerve symptoms and motor disorder, and fatal cardiac dysfunction occurred in the later stage of the disease. The skin biopsy showed amyloidosis, and transthyretin gene analysis indicated the mutation of c.349G>T p.Ala117Ser. The clinical manifestations of FAP caused by Ala117Ser mutation reported in literatures are consistent with this case. And the reported FAP cases in China are concentrated in southern regions such as Fujian Province and Guangdong Province.Conclusions:Ala117Ser mutation in FAP patients is usually late onset and clinically manifested as multiple sensorimotor peripheral neuropathy, accompanied by prominent autonomic symptoms. The distribution of the patients has significant regional characteristics. Histopathological and genetic tests for the clinical diagnosis are of great significance.

Clinical characteristics and genetic mutation analysis in a family with familial vitreous amyloidosis / 中华实验眼科杂志

Objective:To analyze the clinical characteristics and transthyretin ( TTR) gene mutation of a family with familial vitreous amyloidosis (FVA). Methods:A pedigree investigation was performed.The clinical data of 20 family members of a Han family with FVA treated in the Affiliated Hospital of Guizhou Medical University from May 2005 to March 2019 were collected, including demographic data and ophthalmic examination results.Nine eyes of five patients underwent vitrectomy successively, and vitreous samples collected during operation were sent for pathological examination by Congo red staining.The best corrected visual acuity (BCVA) and intraocular pressure (IOP) were measured, and the anterior segment as well as fundus was observed under the slit lamp microscope at 1 week and 6 months after surgery.Peripheral venous blood (4 ml) was collected from 20 members in this family and DNA was extracted.The next-generation sequencing technology was used for gene detection of proband, and Sanger sequencing was performed in 20 family members including the proband.The pathogenicity of the mutation sites was analyzed according to ACMG guidelines.This study adhered to the Declaration of Helsinki.The study protocol was approved by an Ethics Committee of Affiliated Hospital of Guizhou Medical University (No.2019-296). Written informed consent was obtained from each subject.Results:The preoperative BCVA of the nine eyes (5 patients) remained 0.1 to 0.2 in 6 eyes, and counting fingers to 50 cm in 3 eyes, and the mean value of preoperative IOP was (15.18±1.32) mmHg (1 mmHg=0.133 kPa). Cotton-wool like opacity in the vitreous and white pedal disc punctate granule on the posterior lens capsule were seen in the 9 eyes under the slit lamp microscope.Vitreous specimens of patients were Congo red stain positive.The BCVA remained 0.8 in 8 eyes and 0.6 in 1 eye at 1 week after vitrectomy, and remained 0.8 in 6 eyes, 0.6 in 2 eyes and light perception in 1 eye at 6 months after surgery.Mean values of postoperative IOP were (15.32±2.11) mmHg and (16.13±1.25) mmHg at 1 week and 6 months after surgery, respectively.Secondary glaucoma occurred in 8 eyes at 3 to 14 years postoperatively.Mean BCVA of the 13 phenotypic normal family members (26 eyes) remained 0.8 to 1.0, and the mean value of IOP was (15.52±1.15) mmHg, and abnormalities were not found in anterior segment or fundus.Additionally, two members (4 eyes) failed to take examinations.Genetic testing revealed heterozygous mutation in p. Gly103Arg of TTR gene in 15 family members.According to ACMG guidelines, the variation score was PS1+ PM2+ PP3, and it was likely pathogenic. Conclusions:The secondary glaucoma is of relatively high incidence in patients with FVA after vitrectomy.The heterozygous mutation of TTR gene (p.Gly103Arg) might be the variation site of the family with vitreous amyloidosis.