Patients with AL amyloidosis who present with severe heart failure due to cardiac involvement rarely survive more than six months. Survival after cardiac transplantation is markedly reduced due to the progression of amyloidosis. Autologous stem cell transplantation (ASCT) has become a common therapy for AL amyloidosis, but there is an exceedingly high treatment-related mortality in patients with heart failure.
We developed a treatment strategy of cardiac transplant followed by ASCT. 26 patients were evaluated, and of 18 eligible patients, nine patients underwent cardiac transplantation. Eight of these patients subsequently received an ASCT.
Six of seven evaluable patients achieved a complete hematologic remission, and one achieved a partial remission. At a median follow-up of 56 months from cardiac transplant, five of seven patients are alive without recurrent amyloidosis. Their survival is comparable to 17,389 patients who received heart transplants for non-amyloid heart disease: 64% in non-amyloid vs. 60% in amyloid patients at seven years (p= 0.83). Seven of eight transplanted patients have had no evidence of amyloid in their cardiac allograft.
This demonstrates that cardiac transplantation followed by ASCT is feasible in selected patients with AL amyloidosis and heart failure, and that such a strategy may lead to improved overall survival. (clinicaltrials.gov, NCT00456040)