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Çavuşoğlu Y, Başarıcı İ, Tüfekçioğlu O, Özpelit E, Özdemir E, Sivrikoz İA, Altay H, Değertekin M, Dinçer İ, İkitimur B, Kahveci G, Bozkurt MF, Erkılıç M, Kaya GÇ, Beksaç M, Salihoğlu A, Tokgözoğlu L. Current barriers and recommendations on the diagnosis of transthyretin amyloid cardiomyopathy: a Delphi study. Front Cardiovasc Med 2024; 11:1299261. [PMID: 38333414 PMCID: PMC10851939 DOI: 10.3389/fcvm.2024.1299261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/02/2024] [Indexed: 02/10/2024] Open
Abstract
Objectives This study has been conducted to investigate the non-invasive diagnostic journey of patients with a transthyretin amyloid cardiomyopathy (aTTR-CM) in Turkey, identify the challenges and uncertainties encountered on the path to diagnosis from the perspectives of expert physicians, and develop recommendations that can be applied in such cases. Methods This study employed a three-round modified Delphi method and included 10 cardiologists and five nuclear medicine specialists. Two hematologists also shared their expert opinions on the survey results related to hematological tests during a final face-to-face discussion. A consensus was reached when 80% or more of the panel members marked the "agree/strongly agree" or "disagree/strongly disagree" option. Results The panelists unanimously agreed that the aTTR-CM diagnosis could be established through scintigraphy (using either 99mTc-PYP, 99mTc-DPD, or 99mTc-HMPD) in a patient with suspected cardiac amyloidosis (CA) without a further investigation if AL amyloidosis is ruled out (by sFLC, SPIE and UPIE). In addition, scintigraphy imaging performed by SPECT or SPECT-CT should reveal a myocardial uptake of Grade ≥2 with a heart-to-contralateral (H/CL) ratio of ≥1.5. The cardiology panelists recommended using cardiovascular magnetic resonance (CMR) and a detailed echocardiographic scoring as a last resort before considering an endomyocardial biopsy in patients with suspected CA whose scintigraphy results were discordant/inconclusive or negative but still carried a high clinical suspicion of aTTR-CM. Conclusion The diagnostic approach for aTTR-CM should be customized based on the availability of diagnostic tools/methods in each expert clinic to achieve a timely and definitive diagnosis.
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Affiliation(s)
- Yüksel Çavuşoğlu
- Department of Cardiology, Eskisehir Osmangazi University Medical Faculty Hospital, Eskisehir, Turkey
| | - İbrahim Başarıcı
- Department of Cardiology, Akdeniz University Medical Faculty Hospital, Antalya, Turkey
| | - Omaç Tüfekçioğlu
- Department of Cardiology, University of Health Sciences Ankara City Hospital, Ankara, Turkey
| | - Ebru Özpelit
- Department of Cardiology, Dokuz Eylul University Medical Faculty Hospital, Izmir, Turkey
| | - Elif Özdemir
- Department of Nuclear Medicine, Ankara Yildirim Beyazit University, Ankara City Hospital, Ankara, Turkey
| | - İlknur Ak Sivrikoz
- Department of Nuclear Medicine, Eskişehir Osmangazi University Medical Faculty Hospital, Eskisehir, Turkey
| | - Hakan Altay
- Department of Cardiology, Baskent University Medical Faculty Hospital, Istanbul, Turkey
| | - Muzaffer Değertekin
- Department of Cardiology, Yeditepe University Medical Faculty Hospital, Istanbul, Turkey
| | - İrem Dinçer
- Department of Cardiology, Ankara University Medical Faculty Hospital, Ankara, Turkey
| | - Barış İkitimur
- Department of Cardiology, Istanbul University Medical Faculty Hospital, Istanbul, Turkey
| | - Gökhan Kahveci
- Department of Cardiology, Başakşehir Çam Sakura City Hospital, Istanbul, Turkey
| | - Murat Fani Bozkurt
- Department of Nuclear Medicine, Hacettepe University Medical Faculty Hospital, Ankara, Turkey
| | - Metin Erkılıç
- Department of Nuclear Medicine, Akdeniz University Medical Faculty Hospital, Antalya, Turkey
| | - Gamze Çapa Kaya
- Department of Nuclear Medicine, Dokuz Eylul University Medical Faculty Hospital, Izmir, Turkey
| | - Meral Beksaç
- Department of Internal Diseases, Division of Hematology, Ankara University Medical Faculty Hospital, Ankara, Turkey
| | - Ayşe Salihoğlu
- Department of Internal Diseases, Division of Hematology, Istanbul University Medical Faculty Hospital, Istanbul, Turkey
| | - Lale Tokgözoğlu
- Department of Cardiology, Hacettepe University Medical Faculty Hospital, Ankara, Turkey
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Saro R, Pavan D, Porcari A, Sinagra G, Mojoli M. Lights and Shadows of Clinical Applications of Cardiac Scintigraphy with Bone Tracers in Suspected Amyloidosis. J Clin Med 2023; 12:7605. [PMID: 38137674 PMCID: PMC10743682 DOI: 10.3390/jcm12247605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/20/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Radionuclide bone scintigraphy is the cornerstone of an imaging-based algorithm for accurate non-invasive diagnosis of transthyretin cardiac amyloidosis (ATTR-CA). In patients with heart failure and suggestive echocardiographic and/or cardiac magnetic resonance imaging findings, the positive predictive value of Perugini grade 2 or 3 myocardial uptake on a radionuclide bone scan approaches 100% for the diagnosis of ATTR-CA as long as there is no biochemical evidence of a clonal dyscrasia. The technetium-labelled tracers that are currently validated for non-invasive diagnosis of ATTR-CA include pyrophosphate (99mTc-PYP); hydroxymethylene diphosphonate (99mTc-HMDP); and 3,3-diphosphono-1,2-propanodicarboxylate (99mTc-DPD). Although nuclear scintigraphy has transformed the contemporary diagnostic approach to ATTR-CA, a number of grey areas remains, including the mechanism for binding tracers to the infiltrated heart, differences in the kinetics and distribution of these radiotracers, differences in protocols of image acquisition worldwide, the clinical significance of extra-cardiac uptake, and the use of this technique for prognostic stratification, monitoring disease progression and assessing the response to disease-modifying treatments. This review will deal with the most relevant unmet needs and clinical questions concerning scintigraphy with bone tracers in ATTR-CA, providing expert opinions on possible future developments in the clinical application of these radiotracers in order to offer practical information for the interpretation of nuclear images by physicians involved in the care of patients with this ATTR-CA.
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Affiliation(s)
- Riccardo Saro
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100 Trieste, Italy; (R.S.); (A.P.); (G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Giuliano Isontina University Health Authority, 34149 Trieste, Italy
| | - Daniela Pavan
- Ospedale Santa Maria degli Angeli, Azienda Ospedaliera Friuli Occidentale (ASFO), 33170 Pordenone, Italy;
| | - Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100 Trieste, Italy; (R.S.); (A.P.); (G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Giuliano Isontina University Health Authority, 34149 Trieste, Italy
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100 Trieste, Italy; (R.S.); (A.P.); (G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Giuliano Isontina University Health Authority, 34149 Trieste, Italy
| | - Marco Mojoli
- Ospedale Santa Maria degli Angeli, Azienda Ospedaliera Friuli Occidentale (ASFO), 33170 Pordenone, Italy;
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Akincioglu C, Murthi M, Romsa J, Warrington J, Malhotra S. Comparison of cardio-focal and chest reconstruction of technetium-99m pyrophosphate scintigraphy for diagnosis of transthyretin cardiac amyloidosis: a quality assurance study. J Nucl Cardiol 2023; 30:2607-2614. [PMID: 38245067 DOI: 10.1007/s12350-023-03256-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/08/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND SPECT improves diagnostic specificity of Technetium-99m pyrophosphate (PYP) scintigraphy. Diagnostic performance of PYP data, reconstructed as either chest or cardio-focal SPECT is not known. METHODS In this quality assurance study, blinded evaluation of PYP SPECT/CT data from 102 Caucasian patients (mean age 76 ± 11 years, 67% men) was performed by two readers. Reader 1 reviewed planar and PYP chest SPECT, while reader 2 reviewed planar and cardio-focal PYP SPECT. Demographic, clinical, and other testing data were obtained from the electronic medical records. RESULTS A total of 41 patients (40%) were considered positive based on myocardial uptake on chest PYP SPECT. Of these, 98% of the patients had a Perugini score ≥ 2 on planar imaging. There was good agreement between the two readers for visual score ≥ 2 (k = .88, P < .001) and excellent agreement for myocardial uptake on tomographic imaging (98%, P < .001). Only one study was categorized as false negative by cardio-focal SPECT reconstruction. Non-diffuse myocardial uptake was identified in 22% of those with a positive PYP SPECT. CONCLUSION When read by experienced readers, chest and cardio-focal reconstruction of PYP SPECT have comparable diagnostic performance. A substantial proportion of patients with a positive PYP SPECT have a non-diffuse distribution of PYP. Given the possibility of misclassification of non-diffuse myocardial uptake on cardio-focal reconstruction alone, chest reconstruction of PYP scintigraphy should be strongly considered.
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Affiliation(s)
- Cigdem Akincioglu
- Division of Nuclear Medicine, Medical Imaging, Western University, London, ON, Canada.
| | - Mukunthan Murthi
- Department of Internal Medicine, Cook County Health, Chicago, IL, USA
| | - Jonathan Romsa
- Division of Nuclear Medicine, Medical Imaging, Western University, London, ON, Canada
| | - James Warrington
- Division of Nuclear Medicine, Medical Imaging, Western University, London, ON, Canada
| | - Saurabh Malhotra
- Division of Cardiology, Cook County Health, Chicago, IL, USA; Division of Cardiology, Rush Medical College, Chicago, IL, USA
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Hudson O, Hage FG. Single photon emission computed tomography pyrophosphate imaging for transthyretin cardiac amyloid. J Nucl Cardiol 2023; 30:2615-2617. [PMID: 37882939 DOI: 10.1007/s12350-023-03379-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 08/28/2023] [Indexed: 10/27/2023]
Affiliation(s)
- Olivia Hudson
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, 1900 University BLVD, GSB 446, Birmingham, AL, 35294, USA
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Fadi G Hage
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, 1900 University BLVD, GSB 446, Birmingham, AL, 35294, USA.
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
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Arbelo E, Protonotarios A, Gimeno JR, Arbustini E, Barriales-Villa R, Basso C, Bezzina CR, Biagini E, Blom NA, de Boer RA, De Winter T, Elliott PM, Flather M, Garcia-Pavia P, Haugaa KH, Ingles J, Jurcut RO, Klaassen S, Limongelli G, Loeys B, Mogensen J, Olivotto I, Pantazis A, Sharma S, Van Tintelen JP, Ware JS, Kaski JP. 2023 ESC Guidelines for the management of cardiomyopathies. Eur Heart J 2023; 44:3503-3626. [PMID: 37622657 DOI: 10.1093/eurheartj/ehad194] [Citation(s) in RCA: 200] [Impact Index Per Article: 200.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Staron A, Mendelson LM, Joshi T, Ruberg FL, Sanchorawala V. Factors affecting the accuracy of amyloidosis identification and referral to a specialty centre. Amyloid 2023; 30:297-302. [PMID: 36718932 DOI: 10.1080/13506129.2023.2171787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/27/2022] [Accepted: 01/19/2023] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Diagnostic algorithms for amyloidosis have evolved over the past decade, particularly with the incorporation of imaging-based techniques to detect amyloid cardiomyopathy. We sought to identify the key sources of amyloidosis misidentification in the community, which lead to false positive referrals to a tertiary centre. METHODS We conducted a retrospective review of all referrals to the Amyloidosis Centre from 2010 to 2021 and identified cases lacking amyloid pathology upon final adjudication after extensive assessment at the centre. Factors for false positive referrals were examined. RESULTS Among 2409 referrals of suspected amyloidosis, 147 (6%) demonstrated an absence of amyloid pathology. This percentage increased over time from 4% in 2010 to 13% in 2021. False positive referrals consisted of more people of colour. The most frequent source of inaccuracy was the erroneous staining of tissue specimens with Congo red, followed by suggestive findings on cardiac imaging. In recent years, misinterpretation of 99mtechnetium- pyrophosphate scintigraphy emerged as a major source of false positive referrals. CONCLUSION Recognising these potential sources of diagnostic error in the workup of amyloidosis can improve patient care. Referral to a centre of excellence for amyloidosis helps confirm an accurate diagnosis and avoid mistreatment.
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Affiliation(s)
- Andrew Staron
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Lisa M Mendelson
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Tracy Joshi
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Frederick L Ruberg
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
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7
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Park YJ, Lee J, Kim D, Choi JO, Kim SJ, Kim K, Choi JY. Direct comparison of diagnostic and clinical values between Tc-99 m DPD and Tc-99 m PYP scintigraphy in patients with cardiac amyloidosis. BMC Med Imaging 2023; 23:92. [PMID: 37460984 PMCID: PMC10353145 DOI: 10.1186/s12880-023-01054-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 07/03/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Technetium-99 m 3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) and technetium-99 m sodium pyrophosphate (PYP) are the two most commonly used radiotracers for cardiac amyloidosis (CA), but no studies have directly compared them. Therefore, in this study, we directly compared the diagnostic and clinical utility of DPD and PYP scintigraphy in patients with CA. METHODS Ten patients with CA were enrolled. Eight clinical variables and 12 scintigraphic parameters were used. Clinical variables were age, sex, estimated glomerular filtration rate (eGFR), N-terminal pro brain natriuretic peptide (NT-proBNP), and the results of electromyography (EMG), a sensory test, electrocardiogram, and echocardiography (EchoCG). Four heart retention ratios (heart/whole-body profile, heart/pelvis, heart/skull, and heart/contralateral lung) were calculated from the DPD and PYP scans and two visual scoring systems (Perugini and Dorbala systems) were used. Comparative analyses were performed between radiotracers and between visual scoring systems using clinical variables and scintigraphic parameters. RESULTS Twenty DPD parameters and nine PYP parameters had significant associations with age, eGFR, NT-proBNP, EchoCG, and EMG. DPD parameters had more frequent significant associations with clinical variables than PYP parameters. Compared to visual scores in the DPD scan, the proportion of patients with higher visual scores in the PYP scan was relatively greater than those with lower visual scores, and there were more patients with a visual score of 2 or higher in PYP scans than DPD scans. CONCLUSIONS DPD scintigraphy may reflect the disease severity of CA better than PYP scintigraphy, whereas PYP scintigraphy may be a more sensitive imaging modality for identifying CA involvement.
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Affiliation(s)
- Yong-Jin Park
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
- Department of Nuclear Medicine, Ajou University Medical Center, Ajou University School of Medicine, Suwon, 16499, Republic of Korea
| | - Joohee Lee
- Department of Nuclear Medicine, CHA Ilsan Medical Center, CHA University, Goyang, 10414, Republic of Korea
| | - Darae Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea
| | - Seok Jin Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea
| | - Kihyun Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea
| | - Joon Young Choi
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
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Schockling EJ, Farrell MB, Embry-Dierson M, Warren J, Jerome S. Cardiac Amyloidosis Imaging, Part 2: Quantification and Technical Considerations. J Nucl Med Technol 2023; 51:90-98. [PMID: 37268318 DOI: 10.2967/jnmt.123.265416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/29/2023] [Indexed: 06/04/2023] Open
Abstract
99mTc-pyrophosphate imaging has been around for a long time. In the 1970s, it was used to image recent myocardial infarction. However, it has recently been recognized for its value in detecting cardiac amyloidosis, leading to widespread use across the United States. Increased use led to considerable procedure variability. As the evidence base to support formal guidelines was being developed, experts from several professional medical societies issued imaging and interpretation recommendations titled "ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: part 1 of 2-Evidence Base and Standardized Methods of Imaging." To reach a consensus on a protocol that would benefit the bulk of laboratories, the experts considered several parameters and radiotracer kinetics. The most critical parameters concerned injection-to-imaging delay and planar imaging versus SPECT. Accordingly, the standardized protocol recommends the injection of 370-740 MBq (10-20 mCi) of 99mTc-pyrophosphate with imaging 3 h later. Planar images of the chest are acquired in the anterior and lateral views accompanied by SPECT images. Both the planar and the SPECT images are used to semiquantitatively grade the degree of myocardial uptake compared with the amount of uptake in the ribs using a 0-3 scale. A grade of 2 or 3 on the SPECT images is considered positive for cardiac amyloidosis. The planar images are used to calculate a heart-to-contralateral-lung ratio. A ratio greater than 1.3 at 3 h helps to confirm the diagnosis of cardiac amyloid if the SPECT images have positive findings. This article is part of a 3-part series in this issue of the Journal of Nuclear Medicine Technology Part 1 details the etiology of cardiac amyloidosis and 99mTc-pyrophosphate imaging acquisition parameters. Part 2, this article, describes the procedure evolution over 50 y, image processing, and quantification. It further discusses radiotracer kinetics and 2 important technical considerations: injection-to-imaging delay and planar imaging versus SPECT. Part 3 covers study interpretation along with cardiac amyloidosis diagnosis and treatment.
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Affiliation(s)
- Eric J Schockling
- Outpatient Cardiovascular Diagnostics, Norton Healthcare, LLC, Louisville, Kentucky
| | | | | | | | - Scott Jerome
- University of Maryland School of Medicine, Westminster, Maryland
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Shoura S, Malhotra S. Clinical Application of 99mTc-Pyrophosphate Scintigraphy for Diagnosis of Cardiac Amyloidosis: A Case Series. J Nucl Med Technol 2023; 51:125-128. [PMID: 37268320 DOI: 10.2967/jnmt.123.265614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/10/2023] [Indexed: 06/04/2023] Open
Abstract
Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy resulting from deposition of insoluble amyloid protein in the myocardial interstitium. The accumulation of amyloid protein causes the myocardium to thicken and stiffen, leading to diastolic dysfunction and, eventually, heart failure. Two primary types of amyloidosis-transthyretin and immunoglobulin light chain-account for nearly 95% of all CA diagnoses. Three case studies are presented. The first demonstrates a patient positive for transthyretin amyloidosis, the second demonstrates a patient positive for light-chain CA, and the third demonstrates a patient showing blood-pool uptake on the [99mTc]Tc-pyrophosphate scan but negative for CA.
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Affiliation(s)
- Sami Shoura
- Department of Internal Medicine, Cook County Health, Chicago, Illinois
| | - Saurabh Malhotra
- Division of Cardiology, Cook County Health, Chicago, Illinois; and
- Division of Cardiology, Rush Medical College, Chicago, Illinois
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10
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Doukky R. ASNC SPECT-MPI quality metrics: a race to the top. J Nucl Cardiol 2023; 30:911-914. [PMID: 37193923 DOI: 10.1007/s12350-023-03284-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 04/18/2023] [Indexed: 05/18/2023]
Affiliation(s)
- Rami Doukky
- Division of Cardiology, Cook County Health, 1901 W. Harrison St., Chicago, IL, 60612, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
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Jerome S, Farrell MB, Warren J, Embry-Dierson M, Schockling EJ. Cardiac Amyloidosis Imaging, Part 3: Interpretation, Diagnosis, and Treatment. J Nucl Med Technol 2023; 51:102-116. [PMID: 37268322 DOI: 10.2967/jnmt.123.265492] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/10/2023] [Indexed: 06/04/2023] Open
Abstract
Cardiac amyloidosis was thought to be rare, undiagnosable, and incurable. However, recently it has been discovered to be common, diagnosable, and treatable. This knowledge has led to a resurgence in nuclear imaging with 99mTc-pyrophosphate-a scan once believed to be extinct-to identify cardiac amyloidosis, particularly in patients with heart failure but preserved ejection fraction. The renewed interest in 99mTc-pyrophosphate imaging has compelled technologists and physicians to reacquaint themselves with the procedure. Although 99mTc-pyrophosphate imaging is relatively simple, interpretation and diagnostic accuracy require an in-depth knowledge of amyloidosis etiology, clinical manifestations, disease progression, and treatment. Diagnosing cardiac amyloidosis is complicated because typical signs and symptoms are nonspecific and usually attributed to other cardiac disorders. In addition, physicians must be able to differentiate between monoclonal immunoglobulin light-chain amyloidosis (AL) and transthyretin amyloidosis (ATTR). Several clinical and noninvasive diagnostic imaging (echocardiography and cardiac MRI) red flags have been identified that suggest a patient may have cardiac amyloidosis. The intent of these red flags is to raise physician suspicion of cardiac amyloidosis and guide a series of steps (a diagnostic algorithm) for narrowing down and diagnosing the specific amyloid type. One element in the diagnostic algorithm is to identify monoclonal proteins indicative of AL. Monoclonal proteins are detected by serum or urine immunofixation electrophoresis and serum free light-chain assay. Another element is identifying and grading cardiac amyloid deposition using 99mTc-pyrophosphate imaging. When monoclonal proteins are present and the 99mTc-pyrophosphate scan is positive, the patient should be further evaluated for cardiac AL. The absence of monoclonal proteins and a positive 99mTc-pyrophosphate scan is diagnostic for cardiac ATTR. Patients with cardiac ATTR need to undergo genetic testing to differentiate between wild-type ATTR and variant ATTR. This article is the third in a 3-part series in this issue of the Journal of Nuclear Medicine Technology Part 1 reviewed amyloidosis etiology and outlined 99mTc-pyrophosphate study acquisition. Part 2 described 99mTc-pyrophosphate image quantification and protocol technical considerations. This article discusses scan interpretation along with cardiac amyloidosis diagnosis and treatment.
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Affiliation(s)
- Scott Jerome
- University of Maryland School of Medicine, Westminster, Maryland
| | | | | | | | - Eric J Schockling
- Outpatient Cardiovascular Diagnostics, Norton Healthcare, LLC, Louisville, Kentucky
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12
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Asif T, Gupta A, Murthi M, Soman P, Singh V, Malhotra S. Echocardiographic indices of left ventricular function and filling pressure are not related to blood pool activity on pyrophosphate scintigraphy. J Nucl Cardiol 2023; 30:708-715. [PMID: 35578000 DOI: 10.1007/s12350-022-02989-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 04/08/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Pyrophosphate (PYP) imaging has a high diagnostic accuracy for transthyretin cardiac amyloidosis (ATTR-CA). Indeterminate findings are often reported due to persistent blood pool activity, presumed to be from low cardiac output. We evaluated the relationship between blood pool activity on PYP imaging and echocardiographic indices of cardiac function. METHODS Clinical and imaging data of 189 patients referred for PYP scintigraphy were evaluated. All patients underwent planar imaging and SPECT (diagnostic standard). Among those with a negative PYP SPECT, persistent left ventricular blood pool activity on planar images was inferred by a visual score ≥2 or a heart-to-contralateral (HCL) ratio ≥ 1.5. Absence of blood pool activity was inferred when both visual score was < 2 and HCL was < 1.5. Left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), stroke volume index (SVi), and left atrial pressure (LAP) were calculated from standard transthoracic echocardiograms. RESULTS ATTR-CA was present in 43 (23%) patients. Among those with a negative PYP SPECT, 11 patients had significant blood pool activity. Patients with ATTR-CA had a lower LVEF, SVi, and GLS, with a higher LAP, compared to those without ATTR-CA. Among those without ATTR-CA, there were no significant differences in these parameters. CONCLUSION Approximately 8% of patients with a negative PYP SPECT have significant blood pool activity. Measures of cardiac function are not different among those with and without blood pool activity. PYP SPECT should be routinely performed in all patients to avoid false image interpretation.
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Affiliation(s)
- Talal Asif
- Division of Cardiology, Cook County Health, Chicago, IL, USA
| | - Aman Gupta
- Division of Cardiovascular Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Mukunthan Murthi
- Department of Internal Medicine, Cook County Health, Chicago, IL, USA
| | - Prem Soman
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vasvi Singh
- Midwest Heart and Vascular Specialists, HCA Midwest Health, Kansas City, MO, USA
| | - Saurabh Malhotra
- Division of Cardiology, Cook County Health, Chicago, IL, USA.
- Division of Cardiology, Rush Medical College, Chicago, IL, 60612, USA.
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Asif T, Vij A, Radzik B, Stern H, Simples P, Ghadiali Q, Malhotra S. Multimodality imaging for diagnosis of subclinical hereditary transthyretin cardiac amyloidosis. J Nucl Cardiol 2023; 30:792-799. [PMID: 34873643 DOI: 10.1007/s12350-021-02865-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 10/29/2021] [Indexed: 11/28/2022]
Abstract
We present a case of a patient with worsening visual acuity and dense vitreal debris who was found to have vitreal transthyretin amyloid (ATTR) infiltration. Cardiac workup, performed to identify systemic amyloidosis, demonstrated focal myocardial amyloid infiltration on pyrophosphate (PYP) scintigraphy and cardiac magnetic resonance (CMR), resulting in a diagnosis of subclinical ATTR cardiac amyloidosis (ATTR-CA). Patient was identified as a carrier of p.S70R mutation which results in an aggressive ATTR phenotype. Patient is tolerating transthyretin silencer therapy well. Through this case, we discuss the role of a multimodality imaging approach for the diagnosis of subclinical ATTR-CA.
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Affiliation(s)
- Talal Asif
- Division of Cardiology, Truman Medical Center, University of Missouri, Kansas City, USA
- Division of Cardiology, Cook County Health, Chicago, USA
| | - Aviral Vij
- Division of Cardiology, Cook County Health, Chicago, USA
- Division of Cardiology, Rush Medical College, Chicago, USA
| | - Bartlomiej Radzik
- Division of Pathology, Cook County Health, 1901 W. Harrison Street, Suite 3620, Chicago, 60612, USA
| | - Hudson Stern
- Division of Ophthalmology, Cook County Health, Chicago, USA
| | - Patricia Simples
- Division of Pathology, Cook County Health, 1901 W. Harrison Street, Suite 3620, Chicago, 60612, USA
| | | | - Saurabh Malhotra
- Division of Cardiology, Cook County Health, Chicago, USA.
- Division of Cardiology, Rush Medical College, Chicago, USA.
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14
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Khedraki R, Robinson AA, Jordan T, Grodin JL, Mohan RC. A Review of Current and Evolving Imaging Techniques in Cardiac Amyloidosis. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023; 25:43-63. [PMID: 38239280 PMCID: PMC10795761 DOI: 10.1007/s11936-023-00976-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/30/2022] [Indexed: 03/07/2023]
Abstract
Purpose of review Establishing an early, efficient diagnosis for cardiac amyloid (CA) is critical to avoiding adverse outcomes. We review current imaging tools that can aid early diagnosis, offer prognostic information, and possibly track treatment response in CA. Recent findings There are several current conventional imaging modalities that aid in the diagnosis of CA including electrocardiography, echocardiography, bone scintigraphy, cardiac computed tomography (CT), and cardiac magnetic resonance (CMR) imaging. Advanced imaging techniques including left atrial and right ventricular strain, and CMR T1 and T2 mapping as well as ECV quantification may provide alternative non-invasive means for diagnosis, more granular prognostication, and the ability to track treatment response. Summary Leveraging a multimodal imaging toolbox is integral to the early diagnosis of CA; however, it is important to understand the unique role and limitations posed by each modality. Ongoing studies are needed to help identify imaging markers that will lead to an enhanced ability to diagnose, subtype and manage this condition.
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Affiliation(s)
- Rola Khedraki
- Section of Advanced Heart Failure, Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, 9898 Genesee Ave., AMP-300, La Jolla, San Diego, CA 92037, USA
| | - Austin A. Robinson
- Section of Advanced Heart Failure, Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, 9898 Genesee Ave., AMP-300, La Jolla, San Diego, CA 92037, USA
| | - Timothy Jordan
- Section of Advanced Heart Failure, Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, 9898 Genesee Ave., AMP-300, La Jolla, San Diego, CA 92037, USA
| | - Justin L. Grodin
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, USA
| | - Rajeev C. Mohan
- Section of Advanced Heart Failure, Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, 9898 Genesee Ave., AMP-300, La Jolla, San Diego, CA 92037, USA
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15
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Saleem M, Sadat B, Van Harn M, Ananthasubramaniam K. Towards a Diagnosis of Cardiac Amyloidosis: Single Center Experience with 99m Technetium Pyrophosphate Planar Imaging and Opportunities for Standardization of Diagnostic Workflow. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:378. [PMID: 36837580 PMCID: PMC9959230 DOI: 10.3390/medicina59020378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/09/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023]
Abstract
Background and Objectives: Cardiac amyloidosis is a disorder caused by amyloid fibril deposition in the extracellular space of the heart. Almost all forms of clinical cardiac amyloidosis are transthyretin amyloidosis (ATTR) or light chain amyloidosis. 99m technetium pyrophosphate (99mTc PYP scan) has changed the landscape of the non-biopsy diagnosis of ATTR cardiac amyloidosis (ATTR-CA) by providing remarkably high diagnostic accuracy. We examined our experience with PYP scans in patients undergoing workup for ATTR-CA and evaluated the diagnostic workflow in patients with intermediate PYP scan results. Materials and Methods: Retrospective chart review study in which we analyzed data of 84 patients who underwent c-99m pyrophosphate (PYP) SPECT scan for the diagnosis of ATTR-CA from 2017 till 2021 at our institution. We identified three groups: Low uptake (PYPL uptake ratio < 1.2 + visual grade 1/0), n = 30, Intermediate uptake (PYPI uptake ratio 1.2-1.49, visual grade 2/3), n = 25 and High uptake (PYPH uptake ratio ≥ 1.5 + visual grade 2/3), n = 29. We reviewed patients' demographics, medical histories, echo parameters and diagnostic testing including light chain analysis, cardiac magnetic resonance results, and biopsies. Results: Mean patients' age was 73, male-to=female ratio 3:1, 59% of patients were African American. Cardiovascular comorbidities, cardiac biomarkers (BNP and Troponin) and amyloid-related neuropathy were similar in all groups. A statistically significant difference in septal thickness/posterior wall thickness and final diagnosis were found between the groups. The distribution of overall diagnostic testing ratios for the PYPI group included serum protein electrophoresis 92%, urine protein electrophoresis 65%, free light chain 80%, CMR 32%, tissue biopsy done in 20% and BM biopsy in 16%, which are similar to the ratios of other groups. Overall, 25% (n = 5, 4 TTR-CA and 1 AL Amyloid) of patients in the PYPI group had a final diagnosis of CA established with additional testing (p = 0.001 vs. other groups). Conclusions: The 99mPYP scan is an accurate noninvasive test for cardiac ATTR-CA. Importantly, 25% of the PYPI group had a final diagnosis of ATTR-CA reiterating that diagnosis needs to be pursued in PYPI cases based on clinical suspicion. Routine evaluation and exclusion of light chain disease and establishing a consistent workflow for amyloid diagnosis and continued education for technologists and readers of PYP scans is key to a successful amyloidosis workup.
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Affiliation(s)
- Mariam Saleem
- Department of Cardiovascular Medicine, Ascension Providence Southfield Hospital, Southfield, MI 48075, USA
| | - Besher Sadat
- Department of Cardiovascular Medicine, University of Texas Medical Branch of Galveston, Galveston, TX 77555, USA
| | - Meredith Van Harn
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI 48202, USA
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16
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Grossman GB. Quantitation in ATTR cardiac amyloidosis: the next step is almost there! J Nucl Cardiol 2023; 30:140-143. [PMID: 35854040 DOI: 10.1007/s12350-022-03044-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Gabriel Blacher Grossman
- Moinhos de Vento Hospital, Ramiro Barcelos Street 910/201, Porto Alegre, CEP 90035-000, Brazil.
- Cardionuclear Clinic, Porto Alegre, Brazil.
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17
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Saitou T, Aikawa T, Manabe O, Nagase A, Kudo T, Oyama-Manabe N. Comparison of 1-h with 3-h planar 99mTc-pyrophosphate scintigraphy in patients with suspected transthyretin cardiac amyloidosis using SPECT as a reference standard. Ann Nucl Med 2023; 37:99-107. [PMID: 36352186 PMCID: PMC9646466 DOI: 10.1007/s12149-022-01807-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/31/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The purpose of this study was to examine the diagnostic value of planar 99mTc-pyrophosphate (PYP) imaging at 1 and 3 h after tracer administration in patients with suspected transthyretin cardiac amyloidosis (ATTR-CA) using SPECT as a reference standard. We also tested whether blood pool activity of PYP is associated with renal dysfunction. METHODS PYP images of 109 consecutive patients with suspected ATTR-CA were retrospectively reviewed. The myocardial PYP uptake was visually graded on a scale of 0 to 3 and quantified with the heart-to-contralateral (H/CL) ratio in accordance with the current expert consensus recommendations. The diagnostic value of planar images for identifying positive PYP SPECT was assessed by a receiver-operating characteristic curve analysis with the area under the curve (AUC). The uptake ratios of the ascending and descending aorta, left atrium, and trapezius muscle divided by the liver uptake were measured on SPECT images and compared to the renal function. RESULTS A total of 41 patients (38%) had myocardial PYP uptake on SPECT images. In comparison with the visual scores on 1-h anterior planar images, those on 3-h anterior planar images had lower sensitivity (80.5% vs. 97.6%) and higher specificity (86.8% vs. 55.9%) for identifying positive PYP SPECT. The ROC analysis showed that the combination of visual scores on both 1-h and 3-h anterior planar images had significantly higher AUC values in comparison with 1-h anterior planar images alone (0.90 [95% CI 0.83-0.94] vs. 0.83 [95% CI 0.75-0.88]; P < 0.001), which was comparable to the AUC values on 3-h anterior planar images alone (0.88 [95% CI 0.80-0.92]; P = 0.071). In comparison with visual scores on 1-h or 3-h anterior planar images alone, the combination of visual scores and H/CL ratio did not significantly improve the diagnostic value for identifying positive PYP SPECT (P = 0.73 and P = 0.50, respectively). The uptake ratios of ascending aorta/liver, descending aorta/liver, left atrium/liver, and trapezius muscle/liver were not significantly associated with the serum creatinine level or estimated glomerular filtration rate (P > 0.05 for all). CONCLUSIONS In the assessment of ATTR-CA using PYP imaging, visual scores on 3-h anterior planar images for identifying positive PYP SPECT had lower sensitivity and higher specificity in comparison with those on 1-h anterior planar images. The diagnostic value of the visual scores on 1-h and 3-h anterior planar images was not improved by adding the H/CL ratio. Blood pool activity of PYP was not significantly associated with renal dysfunction.
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Affiliation(s)
- Toshinori Saitou
- Department of Radiology, Hokkaido Cardiovascular Hospital, 1-30, Minami-27, Nishi-13, Chuo-ku, Sapporo, 064-8622 Japan
| | - Tadao Aikawa
- Department of Cardiology, Hokkaido Cardiovascular Hospital, 1-30, Minami-27, Nishi-13, Chuo-ku, Sapporo, 064-8622 Japan ,Department of Radiology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-Cho, Omiya-ku, Saitama, 330-8503 Japan
| | - Osamu Manabe
- Department of Radiology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-Cho, Omiya-ku, Saitama, 330-8503 Japan
| | - Atsushi Nagase
- Department of Radiology, Hokkaido Cardiovascular Hospital, 1-30, Minami-27, Nishi-13, Chuo-ku, Sapporo, 064-8622 Japan
| | - Tamaki Kudo
- Department of Radiology, Hokkaido Cardiovascular Hospital, 1-30, Minami-27, Nishi-13, Chuo-ku, Sapporo, 064-8622 Japan
| | - Noriko Oyama-Manabe
- Department of Radiology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-Cho, Omiya-ku, Saitama, 330-8503 Japan
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18
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Takata K, Shibutani N, Horita H. [Utility of the Method for Calculating the Heart to Contralateral Ratio for Cardiac Amyloidosis by Using Ray-summation Images in 99mTc-pyrophosphate Scintigraphy]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2022; 78:1399-1405. [PMID: 36288937 DOI: 10.6009/jjrt.2022-1297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE The purpose of this study was to avoid the influence of background activity in the calculation of heart to contralateral ratio (H/CL) in 99mTc-pyrophosphate (PYP) scintigraphy for diagnosis of cardiac amyloidosis. Therefore, we investigated the utility of the H/CL calculation method using ray-summation (ray-sum) images created by multi-planar reconstruction and summing slices of the heart range from single-photon emission computed tomography (SPECT) images. METHODS The subjects were 33 patients who underwent 99mTc-PYP planar and SPECT/CT at 3 hours after injection. Ray-summation axial (ray-sum axial) and ray-summation coronal (ray-sum coronal) images were created and H/CL was calculated. We compared the differences in sensitivity, specificity, accuracy, and area under the curve (AUC) between the conventional method and our method, and calculated the cutoff values. RESULTS Comparison of the conventional method and our method showed no significant difference in sensitivity and AUC, while specificity was significantly improved to 97% (p=0.003) of ray-sum axial image and 90% (p=0.01) of ray-sum coronal image, and accuracy was significantly improved to 94% (p=0.02) of ray-sum axial image. CONCLUSION The H/CL calculation method using ray-sum images had higher diagnostic performance than the conventional method, with optimal cutoff of ray-sum axial images 3.07 and ray-sum coronal images 2.77.
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Affiliation(s)
- Kei Takata
- Department of Radiology, Toyama University Hospital
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19
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Khatri W, Polydefkis M, Vaishnav J, Saad E, Solnes LB, Rowe SP. Large Pleural Effusion: A Pitfall in the Quantitation of 99m Tc-PYP Imaging for ATTR Cardiac Amyloidosis. Clin Nucl Med 2022; 47:e594-e595. [PMID: 35384890 DOI: 10.1097/rlu.0000000000004168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Transthyretin cardiac amyloidosis (ATTR and ATTRv) is an underrecognized cause of heart failure that results from myocardial deposition of misfolded protein (TTR or prealbumin). The diagnosis can be confirmed by uptake of 99m Tc-pyrophosphate ( 99m Tc-PYP) in the heart with serologic studies to rule out light chain disease. We present the case of a 70-year-old woman who underwent a 99m Tc-PYP scan. The patient had a large right-sided pleural effusion that lowered counts in the right chest on planar imaging, interfered with ratio-based grading of PYP uptake, and highlighted the importance of obtaining SPECT/CT for problem-solving in cases where uptake ratios may be spurious.
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Affiliation(s)
- Wajahat Khatri
- From the Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science
| | | | - Joban Vaishnav
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elie Saad
- From the Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science
| | - Lilja B Solnes
- From the Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science
| | - Steven P Rowe
- From the Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science
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20
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Malhotra S, Singh V, Pilati S, Trepashko D. Comparable image interpretation of 1- and 3-hour technetium-99m HDP scintigraphy for transthyretin cardiac amyloidosis. J Nucl Cardiol 2022; 29:2020-2023. [PMID: 35676550 DOI: 10.1007/s12350-022-03021-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/18/2022] [Indexed: 11/24/2022]
Affiliation(s)
- Saurabh Malhotra
- Division of Cardiology, John H. Stroger Hospital of Cook County, 1901 W. Harrison Street, Suite 3620, Chicago, IL, 60612, USA.
- Division of Cardiology, Rush Medical College, Chicago, IL, USA.
| | - Vasvi Singh
- Midwest Heart and Vascular Specialists, HCA Midwest Health, Kansas City, MO, USA
| | | | - Donald Trepashko
- Division of Nuclear Medicine, Cook County Health, Chicago, IL, USA
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21
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Antonopoulos AS, Panagiotopoulos I, Kouroutzoglou A, Koutsis G, Toskas P, Lazaros G, Toutouzas K, Tousoulis D, Tsioufis K, Vlachopoulos C. Prevalence and Clinical Outcomes of Transthyretin Amyloidosis: A Systematic Review and Meta-analysis. Eur J Heart Fail 2022; 24:1677-1696. [PMID: 35730461 DOI: 10.1002/ejhf.2589] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 06/10/2022] [Accepted: 06/18/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Systematic evidence on the prevalence and clinical outcome of transthyretin amyloidosis (ATTR) is missing. We explored: a) the prevalence of cardiac amyloidosis in various patient subgroups, b) survival estimates for ATTR subtypes and c) the effects of novel therapeutics on the natural course of disease. METHODS A systematic review of literature published in Medline before 31/12/2021 was performed for the prevalence of cardiac amyloidosis & all-cause mortality of ATTR patients. Extracted data included sample size, age, sex, and all-cause mortality at 1, 2 and 5-years. Subgroup analyses were performed for ATTR subtype i.e., wild type ATTR (wtATTR) vs. hereditary ATTR (htATTR), htATTR genotypes and treatment subgroups. RESULTS We identified a total of 62 studies (n=277,882 individuals) reporting the prevalence of cardiac amyloidosis, which was high among patients with a hypertrophic cardiomyopathy phenotype, HFpEF, and elderly with aortic stenosis. Data on ATTR mortality were extracted from 95 studies (n=18,238 ATTR patients). Patients with wtATTR were older (p=7x10-10 ) and more frequently male (p=5x10-20 ) vs. htATTR. The 2-year survival of ATTR was 73.3% (95%CI 71.6-76.2); for non-subtyped ATTR 70.4% (95%CI 66.9-73.9), for wtATTR (76.0%, 95%CI: 73.0-78.9) and for htATTR (77.2%, 95%CI: 74.0-80.4); in meta-regression analysis wtATTR was associated with higher survival after adjusting for confounders. There was an interaction between survival and htATTR genotypes (p=10-15 , Val30Met having the lowest and Val122Ile/Thr60Ala the highest mortality). ATTR 2-year survival was higher on tafamidis/patisiran compared to natural disease course (79.9%, 95%CI: 74.4-85.3 vs. 72.4%, 95%CI 69.8-74.9, p<0.05). CONCLUSIONS We report the prevalence of ATTR in various population subgroups and provide survival estimates for the natural course of disease and the effects of novel therapeutics. Important gaps in worldwide epidemiology research in ATTR were identified. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Alexios S Antonopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Ioannis Panagiotopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Alexandrina Kouroutzoglou
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Georgios Koutsis
- Neurogenetics Unit, 1st Department of Neurology, National and Kapodistrian University of Athens, Eginition University Hospital, Athens, Greece
| | - Pantelis Toskas
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Georgios Lazaros
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Charalambos Vlachopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
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22
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New Advanced Imaging Parameters and Biomarkers—A Step Forward in the Diagnosis and Prognosis of TTR Cardiomyopathy. J Clin Med 2022; 11:jcm11092360. [PMID: 35566485 PMCID: PMC9101617 DOI: 10.3390/jcm11092360] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 11/17/2022] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is an infiltrative disorder characterized by extracellular myocardial deposits of amyloid fibrils, with poor outcome, leading to heart failure and death, with significant treatment expenditure. In the era of a novel therapeutic arsenal of disease-modifying agents that target a myriad of pathophysiological mechanisms, timely and accurate diagnosis of ATTR-CM is crucial. Recent advances in therapeutic strategies shown to be most beneficial in the early stages of the disease have determined a paradigm shift in the screening, diagnostic algorithm, and risk classification of patients with ATTR-CM. The aim of this review is to explore the utility of novel specific non-invasive imaging parameters and biomarkers from screening to diagnosis, prognosis, risk stratification, and monitoring of the response to therapy. We will summarize the knowledge of the most recent advances in diagnostic, prognostic, and treatment tailoring parameters for early recognition, prediction of outcome, and better selection of therapeutic candidates in ATTR-CM. Moreover, we will provide input from different potential pathways involved in the pathophysiology of ATTR-CM, on top of the amyloid deposition, such as inflammation, endothelial dysfunction, reduced nitric oxide bioavailability, oxidative stress, and myocardial fibrosis, and their diagnostic, prognostic, and therapeutic implications.
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23
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Pitfalls of the Semi-Quantitative Analyzing 99mTc-Pyrophosphate Planar Images for Diagnosing Transthyretin Cardiac Amyloidosis: A Possible Solution. Diagnostics (Basel) 2022; 12:diagnostics12010094. [PMID: 35054261 PMCID: PMC8774906 DOI: 10.3390/diagnostics12010094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/19/2021] [Accepted: 12/29/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Two different approaches, 1-h heart-to-contralateral (H/CL) ratio and 3-h visual grading scale relative to ribs (VGSr), have been established to interpret 99mTc-PYP planar images for the detection of amyloid transthyretin cardiac amyloidosis (ATTR-CA). Since they are prone to pitfalls, this pilot study aimed to explore the diagnostic practicality of the 3-h visual grading scale relative to the upper segment of sternum (VGSs) approach for interpreting 99mTc-PYP planar images. Methods: A total of 42 patients were enrolled in this retrospective study. SPECT/CT approach and planar approaches including H/CL ratio, VGSr, and VGSs were utilized to interpret the 99mTc-PYP images obtained at both 1 and 3 h. The classification criteria of the latest expert consensus recommendations were considered as the gold standard. The concordance between the interpretation of each approach and the gold standard was investigated. Results: In addition to 1- and 3-h SPECT/CT approaches, the interpretation of planar images using the 3-h VGSs approach was also applicable, which turns identical to the gold standard (κ = 1.000; p < 0.001). Conclusions: For the interpretation of 99mTc-PYP planar images, the 3-h VGSs approach should be the optimal method, particularly in the case without available or feasible tomography imaging. Only one imaging session (planar and SPECT/CT) at 3 h would be sufficient for the detection of ATTR-CA, and favorable for patient satisfaction.
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24
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Ruan D, Sun L. Diagnostic efficacy of bone scintigraphy in transthyretin cardiac amyloidosis: an updated systematic review and Bayesian bivariate meta-analysis. Clin Transl Imaging 2021. [DOI: 10.1007/s40336-021-00471-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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25
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Wu Z, Yu C. Diagnostic performance of CMR, SPECT, and PET imaging for the detection of cardiac amyloidosis: a meta-analysis. BMC Cardiovasc Disord 2021; 21:482. [PMID: 34620092 PMCID: PMC8499558 DOI: 10.1186/s12872-021-02292-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 09/17/2021] [Indexed: 12/24/2022] Open
Abstract
Background Noninvasive myocardial imaging modalities, such as cardiac magnetic resonance (CMR), single photon emission computed tomography (SPECT), and Positron emission tomography (PET), are well-established and extensively used to detect cardiac amyloid (CA). The purpose of this study is to directly compare CMR, SPECT, and PET scans in the diagnosis of CA, and to provide evidence for further scientific research and clinical decision-making. Methods PubMed, Embase, and Cochrane Library were searched. Studies used CMR, SPECT and/or PET for the diagnosis of CA were included. Pooled sensitivity, specificity, positive and negative likelihood ratio (LR), diagnostic odds ratio (DOR), their respective 95% confidence intervals (CIs) and the area under the summary receiver operating characteristic (SROC) curve (AUC) were calculated. Quality assessment of included studies was conducted. Results A total of 31 articles were identified for inclusion in this meta-analysis. The pooled sensitivities of CMR, SPECT and PET were 0.84, 0.98 and 0.78, respectively. Their respective overall specificities were 0.87, 0.92 and 0.95. Subgroup analysis demonstrated that 99mTc-HMDP manifested the highest sensitivity (0.99). 99mTc-PYP had the highest specificity (0.95). The AUC values of 99mTc-DPD, 99mTc-PYP, 99mTc-HMDP were 0.89, 0.99, and 0.99, respectively. PET scan with 11C-PIB demonstrated a pooled sensitivity of 0.91 and specificity of 0.97 with an AUC value of 0.98. Conclusion Our meta-analysis reveals that SEPCT scans present better diagnostic performance for the identification of CA as compared with other two modalities. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02292-z.
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Affiliation(s)
- Zhaoye Wu
- Department of Nuclear Medicine, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Chunjing Yu
- Department of Nuclear Medicine, Affiliated Hospital of Jiangnan University, Wuxi, China.
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26
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Nuclear Imaging for the Diagnosis of Cardiac Amyloidosis in 2021. Diagnostics (Basel) 2021; 11:diagnostics11060996. [PMID: 34070853 PMCID: PMC8228334 DOI: 10.3390/diagnostics11060996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 05/24/2021] [Accepted: 05/27/2021] [Indexed: 01/15/2023] Open
Abstract
Cardiac amyloidosis is caused by the deposition of misfolded protein fibrils into the extracellular space of the heart. The diagnosis of cardiac amyloidosis remains challenging because of the heterogeneous manifestations of the disease. There are many different types of amyloidosis with light-chain (AL) amyloidosis and transthyretin (ATTR) amyloidosis being the most common types of cardiac amyloidosis. Endomyocardial biopsy is considered the gold standard for diagnosing cardiac amyloidosis and differentiating amyloid subtypes, but its use is limited because of the invasive nature of the procedure, with risks for complications and the need for specialized training and centers to perform the procedure. Radionuclide cardiac imaging has recently become the most commonly performed test for the diagnosis of ATTR amyloidosis but is of limited value for the diagnosis of AL amyloidosis. Positron emission tomography has been increasingly used for the diagnosis of cardiac amyloidosis and its applications are expected to expand in the future. Imaging protocols are under refinement to achieve better quantification of the disease burden and prediction of prognosis.
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Gerber J, Miller EJ. Optimal interpretation of Tc99m PYP in 2020: Avoiding the million-dollar mistake. J Nucl Cardiol 2021; 28:503-506. [PMID: 33442822 DOI: 10.1007/s12350-020-02503-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 09/28/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Jaime Gerber
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Edward J Miller
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA.
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Shetty M. A cardiology fellow's take-home points from ASNC's Webinar: Cases in Tc 99m-PYP evaluation of ATTR cardiac amyloidosis - interpretation and reporting. J Nucl Cardiol 2021; 28:604-609. [PMID: 33655447 PMCID: PMC7924912 DOI: 10.1007/s12350-020-02516-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/14/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Mrinali Shetty
- University of Chicago (NorthShore), NorthShore University Health System, 2650 Ridge Ave, Suite 1304, Evanston, IL, 60201, USA.
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