Volume 1, Issue 2, Pages (April 2017)

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Date of download: 6/29/2016 Copyright © The American College of Cardiology. All rights reserved. From: Cardiac Imaging and Stress Testing Asymptomatic.

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Volume 1, Issue 2, Pages 49-53 (April 2017) Transthyretin Cardiac Amyloidosis: A Noninvasive Multimodality Approach to Diagnosis Using Transthoracic Echocardiography, 99m-Tc-Labeled Phosphate Bone Scanning, and Cardiac Magnetic Resonance Imaging Akhil Shukla, MB BCh, BSci, David Wong, MBBS, RANZACR, Julie A. Humphries, MBBS, BHMS(Ed), FRACP, FCSANZ, FASE, Benjamin T. Fitzgerald, MBBS, FRACP, Katrina Newbigin, MBBS, RANZACR, John Bashford, MBBS, FRACP, Gregory M. Scalia, MBBS, MMedSci, FRACP, FCSANZ, FACC, FASE CASE Volume 1, Issue 2, Pages 49-53 (April 2017) DOI: 10.1016/j.case.2017.01.012 Copyright © 2017 American Society of Echocardiography Terms and Conditions

Figure 1 (A) Tc99m-HDP whole-body bone scan with single photon emission CT imaging demonstrating diffusely increased tracer uptake throughout the myocardium (arrow) and the right shoulder. (B) Axial tomographic scan, as viewed from the feet, of Tc99m-HDP bone scan tracer (yellow) in the walls (arrows) of the left ventricle (LV; RV, right ventricle). (C) Twelve-lead electrocardiogram did not show the classical low voltages of AL cardiac amyloidosis but rather showed significant conduction disease with first-degree atrioventricular block, leftward axis, and a right bundle branch block. CASE 2017 1, 49-53DOI: (10.1016/j.case.2017.01.012) Copyright © 2017 American Society of Echocardiography Terms and Conditions

Figure 2 (A) Transthoracic echocardiographic parasternal long-axis view showing increased left ventricular posterior wall (PW) thickness of 15 mm and septal thickness of 17 mm. (B) Right ventricular (RV) free wall thickness increased at 13 mm on the subcostal view. (C) Apical longitudinal strain map with low normal global longitudinal strain (−18.8%) with classical “apical-sparing” pattern characteristic of cardiac amyloidosis. (D) Diffuse delayed myocardial gadolinium enhancement of the left ventricular myocardium (arrows). (E) Elevated native T1 values (indicated by the colors red and orange, arrows) suggesting diffuse amyloidosis with high extracellular water/protein volume. CASE 2017 1, 49-53DOI: (10.1016/j.case.2017.01.012) Copyright © 2017 American Society of Echocardiography Terms and Conditions

Figure 3 Schema for the workup of cardiac amyloidosis. The fundamental determination is whether a marrow illness (multiple myeloma/AL amyloid-plasma cell dyscrasias) is present. If not, the use of Tc99 m bone scan imaging is used to diagnose TTR amyloidosis (wild type or genetic). Reproduced with permission from Falk et al.6 CASE 2017 1, 49-53DOI: (10.1016/j.case.2017.01.012) Copyright © 2017 American Society of Echocardiography Terms and Conditions

CASE 2017 1, 49-53DOI: (10.1016/j.case.2017.01.012) Copyright © 2017 American Society of Echocardiography Terms and Conditions