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The incidence of atrial fibrillation among patients with AL amyloidosis undergoing high-dose melphalan and stem cell transplantation: experience at a single institution

Bone Marrow Transplantation volume 52, pages 1349–1351 (2017)Cite this article

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High-dose melphalan and autologous stem cell transplantation (HDM/SCT) can induce hematologic responses and prolong survival in selected patients with Immunoglobulin light chain (AL) amyloidosis.1 Complications related to cardiac events surrounding HDM/SCT remain an ongoing concern in patients with Immunoglobulin light chain (AL) amyloidosis. Prior studies have shown that atrial fibrillation (AF) can complicate SCT in up to 22% of cases,2, 3, 4, 5, 6, 7 and that pre-existing cardiac involvement may lead to a further increase in the risk of AF during SCT.2 Factors that may predispose patients with amyloid cardiomyopathy to develop AF include advanced age, heart failure, a low left ventricular ejection fraction, an enlarged left atrial diameter and a high-mean right atrial pressure; however, these risk factors are independent of SCT.8 Other studies have suggested that although AF can be successfully treated in these patients, the presence of AF can lead to more complicated hospital admissions with greater lengths of stay and increased mortality.2, 3 Although AF has been described in general as a complication of SCT, the factors specifically predisposing patients with AL amyloidosis to develop AF in the period surrounding SCT have yet to be established. This is the first report to describe the incidence, risk factors and outcomes related to AF in patients with AL amyloidosis undergoing SCT.

We retrospectively analyzed the medical records of 91 consecutive patients with AL amyloidosis undergoing HDM/SCT between January 2011 and June 2016 at Boston Medical Center (BMC). Eligibility criteria to undergo HDM/SCT at BMC were: age >18 years, ECOG performance status ⩽2, New York Heart Association Class ⩽2, left ventricular ejection fraction >40%, the absence of pleural effusions, room air oxygen saturation >95%, lung diffusion capacity >50% and supine systolic blood pressure >90 mm Hg. The peri-transplant period was defined as the first day of stem cell mobilization with G-CSF until time of neutrophil engraftment (absolute neutrophil count >500 for two consecutive days) after HDM/SCT and discharge from the outpatient SCT program. In this study, the Modified Mayo Clinic Cardiac Biomarker Staging System was utilized and defined by a B type natriuretic peptide (BNP) >100 pg/mL and a troponin I >0.1 ng/mL, with stage I having no elevated biomarkers, stage II having either elevated and stage III having both elevated.9

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Acknowledgements

A summary of the results of this study was presented at the XV International Symposium on Amyloidosis in July 7, 2016 in Uppsala, Sweden. We gratefully acknowledge the numerous colleagues in the Amyloidosis Center, Cancer Clinical Trials Office, and Center for Cancer and Blood Disorders at Boston Medical Center who assisted with the multidisciplinary evaluation and treatment of the patients with AL amyloidosis.

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Authors and Affiliations

  1. Department of Internal Medicine, Boston Medical Center, Boston, MA, USA

    M Arun

  2. Department of Medicine, Section of Hematology and Medical Oncology, Boston Medical Center, Boston, MA, USA

    D Brauneis, A C Shelton, J M Sloan, K Quillen, V Sanchorawala & C Varga

  3. Amyloidosis Center, Boston University School of Medicine, Boston, MA, USA

    D Brauneis, G Doros, A C Shelton, J M Sloan, K Quillen, F L Ruberg, V Sanchorawala & C Varga

  4. Department of Medicine, Section of Cardiovascular Medicine, Boston Medical Center, Boston, MA, USA

    F L Ruberg

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  1. M Arun
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Correspondence to V Sanchorawala.

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Arun, M., Brauneis, D., Doros, G. et al. The incidence of atrial fibrillation among patients with AL amyloidosis undergoing high-dose melphalan and stem cell transplantation: experience at a single institution. Bone Marrow Transplant 52, 1349–1351 (2017). https://doi.org/10.1038/bmt.2017.148

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