Scully, Paul Richard;
(2021)
The Role of Occult Amyloid in the Elderly with Aortic Stenosis.
Doctoral thesis (Ph.D), UCL (University College London).
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Abstract
Aortic stenosis (AS) is common in the elderly. Transcatheter aortic valve implantation (TAVI) is increasingly being used to treat patients with symptomatic, severe AS. Another disease that is common in the elderly is cardiac amyloidosis, which can now be diagnosed non-invasively using bone scintigraphy. Cardiac computed tomography (CT) can also detect elevations in myocardial extracellular volume (ECV) associated with amyloid deposition. The prevalence and clinical impact of dual AS-amyloid pathology in the elderly TAVI population is not yet known. I aimed to confirm the prevalence of occult cardiac amyloidosis in patients referred for TAVI and the clinical impact it may have (procedural complications, symptom response and mortality). I also sought to explore the role of ECV quantification by CT (ECVCT), as well as quantification techniques for 99mTc-labelled-3,3-diphosphono1,2-propanodicarboxylic acid (DPD) scintigraphy. AS-amyloid was present in 1 in 8 elderly patients referred for TAVI. It was not associated with a higher periprocedural complication rate or mortality, although further larger studies are needed to verify these findings. Patients with AS-amyloid derived significant mortality benefit from TAVI compared to medical therapy, so patients should not be declined TAVI on the basis of dual pathology alone. ASamyloid is different from lone AS, however may also be distinct from isolated cardiac amyloidosis. Furthermore, there may be an interaction between the AS-primed myocardium and amyloid, which needs further exploration. ECVCT can be used to detect AS-amyloid and may offer a simple screening tool for co-existent cardiac amyloidosis in patients already undergoing CT. Importantly, this parameter also tracks mortality in patients with lone AS, which is the first time this has been demonstrated. Finally, I validated single photon emission tomography (SPECT)/CT quantification of bone scintigraphy as a means of quantifying amyloid burden and of improving diagnostic accuracy. For centres not performing SPECT/CT, heart/contralateral lung planar quantification is a viable alternative. These techniques may provide a means of monitoring response to novel amyloid-specific therapies.
| Type: | Thesis (Doctoral) |
|---|---|
| Qualification: | Ph.D |
| Title: | The Role of Occult Amyloid in the Elderly with Aortic Stenosis |
| Event: | UCL (University College London) |
| Open access status: | An open access version is available from UCL Discovery |
| Language: | English |
| Additional information: | Copyright © The Author 2021. Original content in this thesis is licensed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0) Licence (https://creativecommons.org/licenses/by-nc/4.0/). Any third-party copyright material present remains the property of its respective owner(s) and is licensed under its existing terms. Access may initially be restricted at the author’s request. |
| UCL classification: | UCL UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Population Health Sciences UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Population Health Sciences > Institute of Cardiovascular Science |
| URI: | https://discovery.ucl.ac.uk/id/eprint/10137074 |
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