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J Am Coll Cardiol, 2008; 51:2445, doi:10.1016/j.jacc.2008.03.033
© 2008 by the American College of Cardiology Foundation
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CORRESPONDENCE: LETTER TO THE EDITOR

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Grace Casaclang-Verzosa, MD, FPCC, Marion E. Barnes, MS and Teresa S.M. Tsang, MD, FACC*

* Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905 (Email: tsang.teresa{at}mayo.edu).

We thank Dr. Leone and colleagues for their interest in our recently published article (1) and for their comments regarding atrial amyloid deposition being a potential mechanism for atrial remodeling and atrial fibrillation (AF). They cited 2 studies in support of this theory. The study by Röcken et al. (2) found that 40 of 245 patients (16.3%) who underwent cardiac surgery had amyloid in the right atrial appendages, and of this group of 40, 14 (35%) had AF. The study by Dr. Leone and colleagues consisted of 72 patients with AF undergoing valvular surgery; 33 (46%) had evidence of atrial amyloid, whereas only 6 of 52 (12%) patients in sinus rhythm with heart failure (serving as control subjects) had atrial amyloid (3). Both of these cross-sectional studies suggested a link between atrial amyloid and AF.

In contrast, Steiner and Hajkova (4) autopsied 100 hearts and examined the relationship between amyloid deposition and AF. Their study did not show a statistical difference in either prevalence or severity of atrial amyloid between patients who had AF and those who did not.

The data from all 3 series are interesting and valuable, but limited by: 1) their cross-sectional nature and, therefore, difficulty with interpretation of cause and effect; 2) the relatively small study populations; and 3) the fact that isolated atrial amyloid is exceedingly common in older people and nearly universal in advanced ages (86% in ages 81 to 90 years) (5). The aggregate data could neither prove nor refute the theory of amyloid as an important substrate for atrial remodeling and AF development.

Furthermore, it is peculiar to note that the prevalence of AF in amyloid patients has not yet been shown to be of an inordinately high magnitude. One would surmise that if atrial amyloid is a potent AF substrate, patients with cardiac amyloid should have a very high prevalence of AF, especially as they almost invariably have large atria, and many also have restrictive diastolic physiology. Earlier publications on cardiac amyloid patients have not provided adequate data regarding AF prevalence, because they either were very small series (6–10) or did not specifically evaluate the prevalence of AF (11–14). Our group has begun to review our own amyloid series regarding the prevalence/incidence of AF, and the data will be reported in the near future.

Indeed, the clinical impact of isolated atrial amyloid is uncertain. The relationship of atrial amyloid to age and its role in left atrial remodeling and AF remain intriguing and warrant further investigations.


   References
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 References
 

  1. Casaclang-Verzosa G, Gersh BJ, Tsang TS. Structural and functional remodeling of the left atrium: clinical and therapeutic implications for atrial fibrillation J Am Coll Cardiol 2008;51:1-11.[Abstract/Free Full Text]
  2. Röcken C, Peters B, Juenemann G, et al. Atrial amyloidosis: an arrhythmogenic substrate for persistent atrial fibrillation Circulation 2002;106:2091-2097.[Abstract/Free Full Text]
  3. Leone O, Boriani G, Chiappini B, et al. Amyloid deposition as a cause of atrial remodelling in persistent valvular atrial fibrillation Eur Heart J 2004;25:1237-1241.[Abstract/Free Full Text]
  4. Steiner I, Hajkova P. Patterns of isolated atrial amyloid: a study of 100 hearts on autopsy Cardiovasc Pathol 2006;15:287-290.[CrossRef][ISI][Medline]
  5. Steiner I. The prevalence of isolated atrial amyloid J Pathol 1987;153:395-398.[CrossRef][ISI][Medline]
  6. Murtagh B, Hammill SC, Gertz MA, Kyle RA, Tajik AJ, Grogan M. Electrocardiographic findings in primary systemic amyloidosis and biopsy-proven cardiac involvement Am J Cardiol 2005;95:535-537.[CrossRef][ISI][Medline]
  7. Kyle RA, Spittell PC, Gertz MA, et al. The premortem recognition of systemic senile amyloidosis with cardiac involvement Am J Med 1996;101:395-400.[CrossRef][ISI][Medline]
  8. Kyle RA, Linos A, Beard CM, et al. Incidence and natural history of primary systemic amyloidosis in Olmsted County, Minnesota, 1950 through 1989 Blood 1992;79:1817-1822[see comments].[Abstract/Free Full Text]
  9. Falk RH, Rubinow A, Cohen AS. Cardiac arrhythmias in systemic amyloidosis: correlation with echocardiographic abnormalities J Am Coll Cardiol 1984;3:107-113.[Abstract]
  10. Roberts WC, Waller BF. Cardiac amyloidosis causing cardiac dysfunction: analysis of 54 necropsy patients Am J Cardiol 1983;52:137-146.[CrossRef][ISI][Medline]
  11. Kyle RA, Gertz MA, Greipp PR, et al. Long-term survival (10 years or more) in 30 patients with primary amyloidosis Blood 1999;93:1062-1066.[Abstract/Free Full Text]
  12. Kyle RA, Gertz MA. Primary systemic amyloidosis: clinical and laboratory features in 474 cases Semin Hematol 1995;32:45-59.[ISI][Medline]
  13. Kyle RA, Greipp PR. Amyloidosis (AL). Clinical and laboratory features in 229 cases. Mayo Clin Proc 1983;58:665-683.[ISI][Medline]
  14. Kyle RA, Bayrd ED. Amyloidosis: review of 236 cases Medicine (Baltimore) 1975;54:271-299.[Medline]

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Local Amyloidosis as a Possible Component of the Atrial Remodeling Accompanying Trial
Ornella Leone, Giuseppe Boriani, Giuseppe Marinelli, and Claudio Rapezzi
J. Am. Coll. Cardiol. 2008 51: 2444-2445. [Full Text] [PDF]




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