Acta med. scand. Vol. 198, pp. 525-528, 1975

Diagnosis of Cardiac Amyloidosis by Myocardial Biopsy Pavo Hedner, AlfRausing, Karin Steen and Alf Torp From the Department of'lnternal Medicine A , University Hospital, Lund, and the Departments qf Pathology and Internal Medicine, Malmii Generul Hospital, Malmci, Sweden

ABSTRACT. A case of cardiac amyloidosis with Severe heart failure is presented. The diagnosis was confirmed by myocardial biopsy. The microscopical and ultrastructural changes in this biopsy are described in detail. The Clinical appearance of cardiac amyioidosis is usually non-specific, as are the results o f t h e clinical investigation. Descriptions of the pathological findings in cardiac amyloidosis ( 1 1) are based on post mortem examinations,where au tolyticchanges can interfere to a certain degree. Biopsies from the liver, kidney and rectal mucosa may provide indirect evidence for the occurrence of the disease (8). Cardiac biopsy must, however, be considered the best method of making the diagnosis of cardiac amyloidosis. This has recently been Pointed out (3), but the findings of such a biopsy have, a s far as we know, not yet been published. CASE REPORT The patient was a man, 38 years old, previously in good health. He was referred to hospital because of dyspnoea when exerted, swelling of the ankles, diarrhoea and weight reduction. Upon admission, slight ankle oedema was noted as well as dyspnoea upon slight physical effort. Physical examination of the heart revealed no abnormal findings. BP was llO/S5 mmHg. Routine laboratory investigations revealed an ESR of 7 mm/h, a Hb concentration of 13.6 g/lOO ml and WBC of 6700. The values for serum electrolytes, albumin, creatinine. protein-bound iodine and glucose were normal. ECG showed sinus rhythm with a P-R interval of 18 msec. Apart from a conspicuously low voltage (sum of the total R-S wave voltage in leads I , 11 and I11 < l . 5 mV) no definite pathological pattern could be recognized (Fig. I ) . X-ray examination of the chest showed general enlargement of the heart with a total heart volume of 1090 ml, cor-

responding to 630 mI/m2 BSA. Because of the history of diarrhoea and weight reduction, radiological and bacteriological investigations of the intestine were performed with negative results. In view of the otherwise unexplained clinical picture of right heart failure and the changes in the ECG, cardiac amyloidosis was suspected. There were no signs of any infectious or malignant disease that might cause a secondary amyloidosis, ~ ~ breaction ~ was ~ positive, ~ ~i n smears from the sternal mamow, 1&13 % of plasma cells were found with nuclear inclusion bodies, staining slightly blue with Wright's stain, but apart from this the picture was normal. N o skeletal destructions were found. The concentrations of IgG and IgA in serum were normal. A Serum immunoelectrophoresis revealed a small monoclonal component of free lambda light chains (determined by Dr G. Husby, Rikshospitalet, Oslo, Norway). BenceJones protein could not be demonstrated in the urine. A biopsy from the rectal mucosa showed staining properties characteristicfor amyloid, To further evaluate the cardiac function the oatient underwent complete right and left heart catheterization as well as an endomyocardial biopsy from the right ventricle. Via a vein in the right arm a double lumen catheter no. 9 was placed in the pulmonary artery wedge position with its side hole recording the pressure in the pulmonary artery. A short polyethylene catheter was inserted percutaneously in the left brachial artery. Finally, a red Odman-Ledin catheter was inserted percutaneously in the right femoral artery and via retrograde approach, the left ventricle was reached. Cardiac function was evaluated at rest using routine techniques. The condition of the patient did not permit any measurements during exercise. The results showed signs of severe left and especially right heart failure with pulmonary artery wedge and right atrial mean pressures of almost 20 mmHg. Correspondingly, the end-diastolic pressures in the left and right ventricles were of the same magnitude. The pressure curve from the right ventricle was highly pathological, with an early diastolic dip that was extreme, followed by a late diastolic plateau. This configuration of the curve was transmitted far beyond the tricuspid valves. Thus the pressure curve from the superior vena cava showed an extreme ventricularization. The values for cardiac index and stroke index were Acta med. scand. 198

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526 P . Hedner et ul.

Fig. I . ECG and pressure

tracings from right and left heart catheterization. Upper left tracing=ECG lead V,. RV=right ventric@,RA= right atrium, LV=left ventricle. Paper speed 25 mm/ sec. Right: ECG (limb leads), paper speed 50 mmlsec.

extremely low, 1.2 I/min and 15 ml/beat/m2BSA, respectively, consistent with a severely impaired cardiac function. At the end of the investigation, endomyocardial biopsy was performed from the right ventricle, using the same technique as described elsewhere (12). When performing the biopsy, it was obvious that the myocardium was very soft. Only a very slight touch of the biopsy instrument against the myocardial wall gave a biopsy specimen of adequate size. At the moment of the biopsy no extrasystoles or other arrhythmias could be detected on the continuous ECG recording. Microscopic cxarnina fion Two biopsies from the right ventricle were taken for light microscopy. They were fixed in 10% neutral formalin, embedded in paraffin and stained with hematoxylin and eosin. Congo red, PAS, van Gieson, periodic acid silver

Fig. 2. Cross sectioned muscle cells surrounded by amy-

loid mantles. Note empty amyloid rings. Hematoxylrn and eosin. ~ 2 9 2 . Actn med. s c a d . 198

method, and methyl violet. Serial sections were prepared. One biopsy from the right ventricle was prepared for electron microscopic examination. The fixation took place in 2 . 5 % glutaraldehyde in a chilled phosphate buffer at pH 7 . 3 for two hours, followed by 1 % osmium tetroxide in a phosphate buffer at pH 7 . 3 for one hour. The dehydration was performed in an ethanol series and the tissue was contrasted with phosphotungstic acid, passed through styrene and embedded in Vestopal. Sections were stained with lead citrate and uranyl acetate. In light microscopy all sections had a similar appearance and showed heavy infiltration with amyloid. staining orange with Congo red. Examination in polarized light of Congo red stained sections gave greenish birefringence of the amyloid. There was no metachromasia in methyl violet stained sections, and PAS reaction was negative. The amyloid surrounded the single muscle cells like a mantle, closely following the surface (Fig. 2). In the contracted cells there was an accordion-like contour of the amyloid band, seemingly indicating that it followed the movement of the cell membrane. In the silver irnpregnation it was possible to see the brownish amyloid between the reticular fibers and the cell surface. In many places there were rings of amyloid without recognizable muscle structures centrally, giving the impression of rnyolysis (Fig. 2). I n longitudinally oriented cells it was possible to observe an intermingling of myofibnls and amyloid. There was a moderate amyloid infiltration of vascular walls, staining in the same manner as the parenchymal amyloid. Electron microscopic examination of the cardiac biopsy disclosed the amyloid as a band of fibrillar material of even thickness surrounding all muscle cells. On the outer side of this band, collagen fibrils were often seen. Amyloid was also seen surrounding even the smallest vessels. Ir. many places there were no visible plasma membranes of the muscle cells and the amyloid seemed to be directly juxtaposed to intracellular structures (Fig. 3).

Fig. 3 . Amyloid mass in contact with intracellular myofibril (right). Note abrupt end of cell embedded in amyloid. Approximately x 18200.

The endpoints of muscle cells were often embedded in amyloid. In some places there was an elongation of sarcomeres with prominent I-banding, giving the impression of stretching of the myofibrils over amyloid masses (Fig. 4). In high magnification the amyloid was seen a s fibrils of about 90 A thickness with random orientation, in good accordance to the findings of Roberts and Ferrans (11). The patient returned home t w o weeks after the investigation. His condition deteriorated slowly. About four

months after the investigation he died of cardiac failure. Autopsy was not performed.

DISCUSSION T h e absence of a n y infectious inflammatory d i s e a s e t o g e t h e r with t h e o c c u r r e n c e of a m y l o i d in t h e h e a r t a n d in t h e intestine as well s u g g e s t e d t h a t t h e patient suffered from p r i m a r y a m y l o i d o s i s . This

Fig. 4. Cell with peripheral myofibril showing lengthened sarcomeres. Approximately x6800. Actu med. srund. 198

528 P . Hedner et al. type and distribution of amyloid in younger patients may appear without any obvious etiology, or associated with multiple myeloma o r macroglobulinaemia (6). Our patient presented no signs of macroglobulinaemia or classical multiple myeloma. On the other hand, the percentage of plasma cells in the bone marrow was elevated, and free monoclonal A-chains were detected in serum in low concentration. A search for A-chains in serum and urine in patients with primary amyloidosis may reveal many patients with circulating free A-chains. This strengthens the connection between amyloidosis and immunopathy, a s suggested by Osserman et al. (10) and Franklin (5). The haemodynamic findings although suggesting cardiac amyloidosis, are not pathognomonic (7). In one of the cases described by Buja et al. ( 2 ) , and in a case reported by Crockett et al. (4),thoracotomy was considered necessary to exclude constrictive pericarditis. Together with the clinical picture, and the haemodynamic findings, the diagnosis in our patient was established by the typical histological appearance in the myocardial biopsy, where the amyloid showed positive staining and characteristic birefringence with Congo red. Absence of meiachromasia does not exclude amyloidosis, and more than one staining method is always to be recommended in cases of suspected primary amyloidosis. The ultrastructural appearance was also typical. The position of the amyloid between the connective tissue fibrils and the cell surface is remarkable. It conveys an impression of the amyloid being formed in close connection with the plasma membrane. The intermingling of amyloid and intracellular structures could possibly be taken as a sign of intracellular formation of amyloid, but we prefer to believe that the plasma membrane has been destroyed secondarily by degenerative changes, e.g. by nutritional disturbance due to the amyloid surrounding the cell. The strict adherence of the amyloid mantle to the cell surface seems to indicate that it contracted with the cell at the moment of biopsy. The stretching of some sarcomeres indicates that the amyloid may be a mechanical hindrance in some positions.

Acto med. scand. 198

The soft consistency of the myocardium which was noted during the investigation is interesting, in contrast to the rubber-like consistency felt at autopsy. We presume that amyloid at body temperature is much softer than in the dead and chilled body. The present case illustrates the usefulness of cardiac biopsy when suspecting cardiac amyloidosis, especially as the method is reliable and easy to perform ( I , 9, 12), and gives in vivo morphological information from the organ of primary interest.

REFERENCES 1. Ah, N., Ferrans, V . J., Roberts, W. C. & Massumi, R.

A.: Clinical evaluation of transvenous catheter technique for endomyocardial biopsy. Chest 63: 399, 1973. 2. Buja, L. M . , Khoi, N. B. & Roberts, W. C.: Clinically significant cardiac amyloidosis. Amer. J . Cardiol. 26: 394, 1970. 3 . Case Records of Massachusetts General Hospital. New Engl. J . Med. 290: 1474, 1974. 4. Crockett, L. K . , Thompson, M. & Dekker, A.: A review of cardiac amyloidosis. Report of a case presenting as constructive pericarditis. Amer. J. med. Sci. 264: 149, 1972. 5. Franklin. E. C.: The complexity of amyloid. New Engl. J . Med. 290: 512, 1974. 6. Franklin, E. C. & Zucker-Franklin, D.: Current concepts of amyloid. Advanc. Immunol. 15: 249, 1972. 7 . Goodwin, J. F., Gordon, H . , Hollman, A . & Bishop, M. B.: Clinical aspects of cardiomyopathy. Brit. med. J. 1:69, 1961. 8. Kyle, R. A., Spencer, R. J. & DaNin, D. C.: Value of rectal biopsy in the diagnosis of primary systemic amyloidosis. Amer. J. med. Sci. 251:501, 1966. 9. Olsen, E. G . J.: Diagnostic value of the endomyocardial bioptome. Lancet I : 658, 1974. 10. Osserman, E. F., Takatsuki, K. & Tala], N.: The pathogenesis of “amyloidosis”: Studies on the role of abnormal gamma globulins and gamma globulin fragments of the Bence-Jones (I-polypeptide) type in the pathogenesis of “primary” and “secondary amyloidosis” and the “amyloidosis” associated with plasma cell myeloma. Semin. Hematol. I : 3. 1964. 1 1 . Roberts, W. C. & Ferrans, V. J.: Pathological aspects of certain cardiomyopathies. Circulat. Res., Suppl. 2: 128, 1974. 12. Torp, A . : Endomyocardial biopsy. Scand. J. thorac. cardiovasc. Surg. 7: 253, 1973.

Diagnosis of cardiac amyloidosis by myocardial biopsy.

A case of cardiac amyloidosis with severe heart failure is presented. The diagnosis was confirmed by myocardial biopsy. The microscopical and ultrastr...
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