Introduction Cardiac amyloidosis should be considered in patients with recurrent exacerbations of congestive heart failure. We report the importance of tissue Doppler imaging (TDI) in the diagnosis of restrictive cardiomyopathy in a patient with a history of multiple myeloma and recurrent CHF, suspected to have secondary amyloidosis and in whom cardiac biopsy was not feasible.
Case Presentation A 66-year-old obese Caucasian female was hospitalized several times because of CHF exacerbation with syncope, increasing exertional dyspnea, and recurrent pleural effusions. The patient had a past history of multiple myeloma, congestive heart failure, hypothyroidism, hyperlipidemia, peptic ulcer disease, and depression. An echocardiogram showed ejection fraction of 60%, severe diastolic dysfunction without left ventricular dilatation, and enlarged atria. TDI findings were consistent with restrictive cardiomyopathy. The patient declined further intervention and biopsy and expired from complications of her end-stage CHF.
Discussion TDI is a noninvasive imaging, which allows measurement of motion patterns and velocities of cardiac structures and is increasingly used for the assessment of diastolic function. Taking into consideration the patient's history of multiple myeloma and echocardiogram findings, secondary amyloidosis was the most likely explanation for her recurrent CHF exacerbation. The echocardiographic impression of cardiac amyloidosis was reinforced by the TDI, which demonstrated a characteristic low intramyocardial velocity pattern in addition to the “sparkling” pattern (patchy echoes within the myocardium) and severe diastolic dysfunction seen in the two-dimensional echocardiogram. Digitalis, calcium channel blockers, and β-blockers are contraindicated in amyloid-associated cardiomyopathy because they bind easily to amyloid fibrils, causing toxicity at apparently therapeutic levels. In secondary amyloidosis, aggressive treatment of the underlying infection, inflammatory or neoplastic disease can improve symptoms and slow the progression of the disease. Recognition of cardiac amyloidosis is critical in the management of CHF in a patient with multiple myeloma. TDI may facilitate the diagnosis.
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