Cardiac amyloidosis presenting as refractory heart failure: Role of GLS in diagnosis and on follow up.

Figures

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  Figure 1.. Standard -lead electrocardiogram demonstrating normal sinus rhythm with left axis deviation and left bundle branch block. Pathological Q waves are noted in the inferior leads (II, III, and aVF). Features suggestive of left ventricular hypertrophy with associated repolarization abnormality (strain pattern) are also evident.

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  Figure 2.. Two-dimensional transthoracic echocardiographic demonstrating concentric left ventricular hypertrophy.

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  Figure 3.. Pulsed wave Doppler recording across the mitral valve demonstrating peak early (E) diastolic velocity of 121 cm/s and late (A) diastolic velocity of 82.5 cm/s, yielding an E/A ratio of 1.5. This pseudonormalized filling pattern reflects elevated left ventricular filling pressures despite relatively preserved E and A velocities, a common finding in cardiac amyloidosis.

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  Figure 4.. Tissue Doppler imaging (TDI) of the lateral mitral annulus demonstrating an early diastolic velocity (E’) of 5.98 cm/s, indicative of impaired myocardial relaxation.

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  Figure 5.. Tissue Doppler imaging (TDI) of the septal mitral annulus demonstrating an early diastolic velocity (E’) of 4.03 cm/s, yielding an elevated E/E’ ratio (>14 when combined with mitral inflow E 121 cm/s). This indicates markedly impaired myocardial relaxation and high left ventricular filling pressures, strongly supportive of grade III diastolic dysfunction in cardiac amyloidosis.

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  Figure 6.. Speckle-tracking echocardiographic global longitudinal strain (GLS) bull’s-eye plot demonstrating severely reduced myocardial strain with a calculated GLS of −9.7%. The segmental strain map shows marked reduction in basal and mid-ventricular longitudinal deformation with relative preservation of apical strain, producing the characteristic apical sparing (“cherry-on-top”) pattern that is highly suggestive of cardiac amyloidosis in the appropriate clinical setting.

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  Figure 7.. Follow-up speckle-tracking transthoracic echocardiographic global longitudinal strain (GLS) bull’s-eye plot demonstrating severely impaired myocardial strain with a calculated GLS of −1.9%. The segmental strain map shows diffuse reduction in longitudinal deformation with loss of the previously observed apical sparing pattern, consistent with interval progression of myocardial involvement compared with the baseline study.