Unmasking Right Heart Involvement in Transthyretin Amyloidosis by Cardiac Magnetic Resonance

Saturday, February 7, 2026

10:50 AM - 10:57 AM

Location: Galapagos / Aruba / Ilhabela (2nd Lower Level)

Presenting Author(s)

Aylen Perez Barreda, MD, MSc

Cardiologist specialist
Cardiovascular Institute Havana
Havana, La Habana, Cuba

Primary Author(s)

Aylen Perez Barreda, MD, MSc

Cardiologist specialist
Cardiovascular Institute Havana
Havana, La Habana, Cuba

Co-Author(s)

JM

Jessica M. Mirella, MD

Staff
Hospital Nacional Rosales
Lourdes Colón, La Libertad, El Salvador

Co-Author(s)

LA

Lilian Abreu Mendiola, MD

Fellow
Institute of Cardiology and Cardiovascular Surgery, Cuba
YM

Yamile Marcos Gutierrez, MD, MSc

Cardiovascular Institute Havana
Havana, Cuba
LB

Llimia Bencomo Rodriguez, MD

Cardiovascular Institute Havana, Cuba
AM

Aniley Martinez Gonzalez, MD, MSc

Cardiovascular Institute Havana, Cuba
MP

Maidelis Prieto Guerra, MD, MSc

Cardiologist
Hospital Hermanos Ameijeiras, Cuba
LC

Lázaro Omar Cabrera Rodríguez, MD, MSc

Cardiologist
Institute of Cardiology and Cardiovascular Surgery, Cuba
CO

Carlos Oro Cortina

Cardiovascular Institute Havana, Cuba
KP

Kenia Padron Garcia, MD

Cardiovascular Institute Havana
Havana, Cuba
Katia Menacho Medina, PhD

Academic Lecturer and Senior Cardiac Imaging Fellow and
University College London
UCL
London, England, United Kingdom
AP

Amalia Peix Gonzalez, MD, PhD

Cardiovascular Institute Havana
Havana, Cuba

Background: Transthyretin cardiac amyloidosis (ATTR-CA) is an underdiagnosed infiltrative cardiomyopathy with significant impact on right heart chambers. While left ventricular involvement has been extensively characterized, data on right-sided structure, function, deformation, and tissue characterization by cardiac magnetic resonance (CMR) remain limited. This study aimed to comprehensively assess right atrial (RA) and right ventricular (RV) remodeling in ATTR-CA and explore their relationship with late gadolinium enhancement (LGE).

Methods: A cross-sectional study was performed on patients with confirmed ATTR-CA who underwent CMR between January 2020 and January 2025. A comparator group of 13 age-, sex-, and BMI-matched healthy volunteers was included. Standard cine SSFP sequences were used to quantify right heart volumes, ejection fractions, and RA function. Myocardial strain analysis of RA and RV was performed using feature-tracking CMR (CMR-FT). LGE was evaluated. Group comparisons were performed, and associations between functional parameters and LGE were analyzed. Continuous variables were expressed as mean ± standard deviation or median (interquartile range). Groups were compared using t-tests/Mann-Whitney U/chi-squared. Associations between function and LGE were evaluated using non-parametric tests. P < 0.05 was significant.

Results: We studied 34 ATTR-CA patients (mean age 70.3±8.6 years, 82% male). Compared with controls, ATTR-CA patients had lower RV stroke volume (53±24 vs. 70±27 mL, p=0.04), with a trend toward reduced RV ejection fraction. RA volumes and areas were significantly enlarged (indexed RA volume 75.7±35.1 vs. 30.8±27.3 mL/m², p< 0.001), while RA ejection fraction was markedly reduced (30.7±18.0% vs. 51.2±9.5%, p< 0.001). CMR-FT demonstrated impaired RV global longitudinal strain (−9.8±8.1% vs. −17.1±5.3%, p=0.005), with greater involvement of medial and apical segments. RA strain was also profoundly reduced across global and regional measures (all p< 0.001). LGE was present in the RV in 65% of patients and in the RA in 76%. The presence of RV-LGE was associated with lower TAPSE (12.1 vs. 18.1 mm, p=0.005) and reduced RA ejection fraction (21.0% vs. 52.4%, p=0.02). Patients with extensive RV-LGE exhibited the greatest functional impairment.

Conclusion: CMR reveals that ATTR-CA significantly compromises RV and RA structure, function, and deformation, even in the setting of preserved or moderately reduced RV ejection fraction. RA strain and ejection fraction, together with RV strain, provide sensitive markers of right heart dysfunction. The presence and extent of LGE in right-sided chambers are linked to more severe impairment, underscoring the importance of incorporating tissue characterization into routine evaluation. These findings highlight the value of multiparametric CMR, including deformation analysis, for earlier detection, risk stratification, and clinical management in ATTR-CA.

Comparison of right atrium and right ventricle structures and function values of patients with ATTR-CA and healthy volunteers

VARIABLES	ATTR-CA (n=34) Media ± SD	HEALTHY VOLUNTEER (n=13) Media ± SD	p
RVEF (%)	48,64 ± 10,32	53,83 ± 11,08	0,1416
RV EDV (ml)	118,93 ± 39,37	133,09 ± 51,13	0,3221
RV ESV (ml)	62,32 ± 29,44	62,84 ± 27,16	0,9565
RV Stroke volume (ml)	52,96 ± 24,20	70,27 ± 26,58	0,040
RV Index EDV (ml/m²)	63,69 ± 25,68	72,25 ± 26,50	0,3346
RV Index ESV (ml/m²)	33,33 ± 18,49	33,68 ± 13,70	0,9517
TAPSE (mm)	13,25 ± 6,83	16,74 ± 6,51	0,1243
RA Area (cm²)	24,53 ± 7,23	15,89 ± 4,32	< 0,001
RA Index Area (cm²/m²)	20,60 ± 6,76	14,90 ± 5,75	< 0,001
RA Volume (ml)	87,65 ± 44,40	37,47 ± 17,09	< 0,001
RA Index Volume(ml/m²)	75,7 ± 35,1	30,8 ± 27,3	< 0,001
RAEF	30,71 ± 17,96	51,20 ± 9,50	< 0,001
RV GLS (%)	-9,79 ± 8,05	-17,12 ± 5,27	0,0052
RV Segmental Longitudinal Strain
Basal	-14,53 ± 21,25	-24,55 ± 6,73	0,1077
Medial	-8,81 ± 7,41	-17,69 ± 11,32	0,0055
Apical	-7,21 ± 9,96	-13,3 ± 5,81	0,0499
Apical to basal ratio	0,56 ± 0,42	0,68 ± 0,37	0,720
Septal wall	-9,84 ± 11,28	-18,33 ± 6,72	0,0173
Lateral wall	-8,56 ± 5,68	-13,51 ± 4,91	0,0111
RA GLS	6,28 ± 12,81	27,93 ± 19,43	< 0,001
RA Segmental Longitudinal Strain
Septal wall	7,56 ± 16,38	29,60 ± 18,23	< 0,001
Lateral wall	2,82 ± 6,84	21,22 ± 15,69	< 0,001

RV: right ventricle, RA: right atrium, EDV: end-diastolic volume, ESV: end-systolic volume, RVEF: right ventricular ejection fraction, TAPSE: anterior systolic motion of the tricuspid annulus, RAEF: right atrium ejection fraction, RV GLS: global longitudinal strain of the right ventricle, RA GLS: global longitudinal strain of the right atrium, SD: standard deviation.

Structure and function of right chambers according to the presence and extent of LGE in the RV in patients with ATTR-CA

VARIABLES	Right ventricle LGE
VARIABLES	No LGE (n=12) Median ± IQR	Focused (n=16) Median ± IQR	Widespread (n=6) Median ± IQR	p
RVEF (%)	54,59 ± 17,66	48,00 ± 9,50	43,20 ± 3,30	0,159
RV EDV (ml)	107,00 ± 44,67	114,0± 44,00	110,60± 21,79	0,958
RV ESV (ml)	51,50 ± 24,87	55,00 ± 21,50	51,00 ± 19,55	0,722
RV STROKE VOLUME (ml)	57,97 ± 24,02	56,00 ± 32,47	45,40 ± 31,81	0,409
RV Index EDV (ml/m²)	59,45 ± 13,30	65,00 ± 21,50	59,96 ± 16,00	0,970
RV Index ESV (ml/m²)	26,65 ± 12,36	29,82 ± 10,50	28,30 ± 14,40	0,598
TAPSE (mm)	18,07 ± 7,40	13,20 ± 4,02	5,86 ± 6,36	0,006
RA area (cm²)	22,00 ± 9,65	21,75 ± 9,50	23,80 ± 4,00	0,995
RA Index area (cm²/m²)	20,50 ± 5,90	20,90 ± 8,36	20,50 ±2,54	0,874
RA Volume (ml)	84,78 ± 59,61	80,80 ±34,00	82,70 ± 8,70	0,985
RA Index Volume (ml/m²)	76,3 ± 50,8	75,1 ± 35,8	72,8 ± 11,6	0,965
RAEF	52,41 ± 31,74	25,59 ± 13,85	13,68 ± 3,14	0,012
RV GLS	-13,30 ± 10,95	-12,60 ± 7,90	-7,50 ± 3,90	0,484
RV Segmental strain
Basal	-18,95 ± 18,85	-21,00± 17,50	-9,80 ± 6,10	0,395
Medial	-9,20 ± 8,02	-7,90 ± 4,70	-9,60 ± 4,70	0,560
Apical	-12,85 ± 8,53	-7,70 ± 6,70	-6,10 ± 1,90	0,141
Septal wall	-8,65 ± 14,68	-8,70 ± 9,60	-8,90 ± 3,50	0,857
Lateral wall	-12,35 ± 8,38	-5,50 ± 8,40	-7,80 ± 2,00	0,198
RA GLS	2,70 ± 6,25	2,20 ± 5,30	1,80 ± 1,30	0,980
RA Segmental strain
Septal wall	4,20 ± 6,50	8,00 ± 11,80	3,60 ± 4,90	0,500
Lateral wall	3,90 ± 12,35	1,80 ± 5,60	1,10 ± 10,60	0,676

LGE: late gadolinium enhancement, RV: right ventricle, RA: right atrium, EDV: end-diastolic volume, ESV: end-systolic volume, RVEF: right ventricular ejection fraction, TAPSE: anterior systolic motion of the tricuspid annulus, RAEF: right atrium ejection fraction, RV GLS: global longitudinal strain of the right ventricle, RA GLS: global longitudinal strain of the right atrium, IQR: interquartile range.

Strain longitudinal in right chambers in ATTR-CA patient