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Recent Cases
Supravalvular aortic stenosis
Walid Gharzuddine - 2016-04-27

Cardiac amyloidosis, sequel
Dr. Ahmad Al Ayouby Dr. Hassan Kazma - 2016-04-27

Retro-cardiac mass,diagnosis
Walid Gharzuddine - 2016-03-16

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Cardiac amyloidosis, sequel
Published on 2016-04-27 by Dr. Ahmad Al Ayouby Dr. Hassan Kazma
History and Findings

Although cardiac amyloidosis has been discussed more than once on this website, we present a case contributed to us by Cardiology fellow Dr. Ahmad Ayyoubi working with Dr. Hassan Kazma. The reason being that a new diagnostic tool is presented which I find very interesting and worth being disseminated to colleagues who perform Echocardiography.

Below is a case of suspected cardiac amyloidosis in a patient under treatment for multiple myeloma. Video shows  parasternal long axis view with the characteristic ground glass echo texture.

video 1

Figure 1. shows the bull’s eye pattern of  global longitudinal strain with the typical pattern of a decreasing gradient of strain from apex to base or what is termed apical sparing. In a study by Phelan et al. (ref.) the bull’s eye map of longitudinal strain was divided into three rings: the basal, mid-ventricular and apical rings. A relative apical longitudinal strain was calculated as follows:

Relative apical LS =  (average  apical LS/ (average basal LS + mid-LS)


I55 consecutive patients with cardiac amyloidosis (CA) were compared with 30 control patients with LV hypertrophy  (n=15 with hypertrophic  cardiomyopathy, n=15 with aortic stenosis).

A value relative apical (LS) of >1.0 was sensitive (93%) and specific (82%) in differentiating CA from controls (area under the curve 0.94).

 In a logistic regression multivariate analysis, relative apical LS was the only parameter predictive of CA (p=0.004). Only relative apical LS was found to be significantly predictive of CA (p<0.004) using multivariable logistic regression analysis with the diagnosis of CA as the outcome variable and the following as predictors: age, gender, New York Heart Association grade, a history of hypertension or diabetes, EF, E/e’, E/A, DT, global LS, peak gradient across the aortic valve, low voltage on ECG and relative apical LS.

In the above case performing the above calculation on the GLS values in the bull’s eye map above, would yield a ratio of 1.22 which is highly in favor of cardiac amyloidosis.



Dermot Phelan, Patrick Collier, Paaladinesh Thavendiranathan, Zoran B Popovic,  Mazen Hanna, Juan Carlos Plana, Thomas H Marwick, James D Thomas

Relative apical sparing of longitudinal strain using two-dimensional speckle-tracking echocardiography is both sensitive and specific for the diagnosis of cardiac amyloidosis

 Heart 2012;98:1442e1448.

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