Challenges in the approach to a patient with aortic stenosis and cardiac amyloidosis with ATTR mutation associated with negative scintigraphy - A case report

Abstract

Introduction: Cardiac amyloidosis (CA) poses significant diagnostic and therapeutic challenges. In this case report, we detail a patient with CA due to a rare transthyretin (CA-TTR) mutation, manifesting with negative myocardial scintigraphy and requiring genetic testing for diagnosis. The patient also had severe aortic stenosis (AS), necessitating discussion with a heart team to determine the optimal treatment strategy.

Case report: A 70-year-old male with a family history of sudden death was previously diagnosed with third-degree atrioventricular block and treated with a pacemaker. He presented with worsening exertional dyspnoea, and examination revealed a third heart sound, a systolic murmur indicative of AS and bilateral muscular atrophy in the thenar region. Transthoracic echocardiography indicated severe AS and moderate left ventricular dysfunction, with images suggesting infiltrative disease. Pyrophosphate scintigraphy revealed no abnormal cardiac tracer uptake. Cardiac magnetic resonance imaging (MRI) revealed extensive, heterogeneous, subendocardial late gadolinium enhancement in both the atria and ventricles, which was consistent with CA. Genetic testing identified the Phe84Leu mutation in the TTR gene. Following heart team discussions, the patient underwent successful transcatheter aortic valve implantation (TAVI) and remained asymptomatic in follow-up, being monitored at an outpatient clinic specializing in CA and using tafamidis.

Discussion: CA-TTR can be an autosomal dominant disease with variable penetrance involving abnormal amyloid protein deposition in tissues and can often be diagnosed noninvasively via myocardial scintigraphy. However, some TTR mutations do not affect scintigraphy results, necessitating genetic testing when clinical suspicion is high, potentially avoiding endomyocardial biopsy. Moreover, AS occurs in up to 16 % of TTR amyloidosis patients, with the conditions mutually exacerbating each other. Recent consensus suggests that TAVI reduces mortality in patients with severe AS and amyloidosis.

Conclusions: Various diagnostic algorithms emphasize the use of myocardial scintigraphy for suspected CA-TTR. Genetic testing is crucial when scintigraphy results are negative, but clinical suspicion remains high, potentially circumventing invasive procedures. Compared with medical management alone, TAVI has been shown to improve quality of life and survival in patients with concurrent severe AS and CA.

Keywords: ATTR mutation; Aortic stenosis; Cardiac amyloidosis; Case report; Genetic test; TAVI.

Fig. 1

Chest X-ray showing cardiomegaly and pleural effusion.

Fig. 2

TTE with aortic valve exhibited significant calcification.

Fig. 3

TTE depicting enlargement of both atrial. The LV walls, especially the interventricular septum, show increased thickness and echogenicity, known as “myocardial sparkling”, indicative of infiltrative disease.

Fig. 4

Planar scintigraphy did not reveal abnormal tracer uptake.

Fig. 5

Myocardial scintigraphy with 99 m technetium pyrophosphate illustrating the absence of abnormal tracer uptake with the presence of a blood pool inside the cardiac cavities visible in the SPECT images.

Figs. 6 and 7

Cardiac magnetic resonance imaging (MRI) revealing extensive and heterogeneous late gadolinium enhancement within the myocardium in both ventricles and both atria. The enhancement pattern is a hallmark feature of infiltrative conditions, such as amyloidosis.

Fig. 8

CT revealing significant aortic calcification.