Focal myocardial perfusion abnormalities in cardiac amyloidosis as compared with CMR, bone scintigraphy, and 11 C-PiB PE
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Department of Radiology, Faculty of Medicine, Kagawa University, Kagawa, Japan Department of Cardiorenal and Cerebrovascular Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
Received Aug 4, 2020; accepted Aug 5, 2020 doi:10.1007/s12350-020-02349-0
INTRODUCTION Cardiac amyloidosis is characterized by the deposition of amyloid fibrils in the myocardium. Nuclear imaging such as bone scintigraphy and amyloid positron emission tomography (PET) seem valuable to identify the extent of amyloid myocardial infiltration. At present, the utility of myocardial perfusion scintigraphy (MPS) is limited. We present a case of cardiac amyloidosis with focal MPS abnormalities. CASE PRESENTATION A 79-year-old male with elevated BNP and cardiomegaly on chest radiograph presented to our hospital. Transthoracic echocardiography showed left ventricular hypertrophy. He was referred for 99mTc-tetrofosmin (99mTc-TF) scintigraphy, cardiac magnetic resonance (CMR), 99mTc-pyrophosphate (99mTc-PYP) scintigra-
Reprint requests: Takashi Norikane, MD, PhD, Department of Radiology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa761-0793, Japan; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2020 American Society of Nuclear Cardiology.
phy, and 11C Pittsburgh Compound B (11C-PiB) PET for diagnosis. On rest 99mTc-TF single photon emission computed tomography (SPECT), focal decreased accumulation was shown in the mid-basal inferoseptal wall (Figures 1 and 3A). Cine CMR imaging revealed asymmetrical thickening of the left ventricle especially in the septum. On CMR perfusion imaging, focal subendocardial and subepicardial perfusion defects were detected in the mid-inferoseptal wall (Figure 2A). Late gadolinium enhancement (LGE) and high native T1 values were observed in the same region (Figure 2B and C). 99mTc-PYP SPECT showed diffuse uptake in the left ventricle and a marked focal uptake in the mid-inferoseptal wall (Figure 3B). On 11C-PiB PET/CT, an increased focal uptake was noted in the mid-inferoseptal wall (Figure 3C). He was diagnosed with cardiac amyloidosis. It was traditionally considered that amyloid fibril deposition is symmetrical and diffuse in the heart, with
Ensako et al Focal myocardial perfusion abnormalities in cardiac amyloidosis
Journal of Nuclear CardiologyÒ
Figure 1. 99mTc-tetrofosmin scintigraphy. (A) The top three rows are short-axis images of the left ventricle, the next three rows are vertical long-axis images, and the bottom three rows are horizontal long axis at rest. (B) MPS polar map imaging. A slightly decreased uptake was observed in the mid-basal inferoseptal wall.
symmetrical hypertrophy and global subendocardial LGE also considered as typical findings in cardiac amyloidosis. However, asymmetrical hypertrophy and variable LGE including localized and patchy patterns have also been observed.1 Some MPSs show normal accumulation,2 while others show abnormalities. The
feasibility of MPS is controversial. It is speculated that MPS abnormalities
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