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Nebhwani M, Chaibekava K, Achten A, Oerlemans MIFJ, Michels M, van der Meer P, Nienhuis HLA, Weerts J, van Empel V, Rocca HPBL, Wijk SSV, van der Pol J, Knackstedt C. Detection of cardiac amyloidosis on routine bone scintigraphy: an important gatekeeper role for the nuclear medicine physician. Int J Cardiovasc Imaging 2024; 40:1183-1192. [PMID: 38520623 PMCID: PMC11213735 DOI: 10.1007/s10554-024-03085-z] [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: 10/26/2023] [Accepted: 03/11/2024] [Indexed: 03/25/2024]
Abstract
Cardiac amyloidosis (CA)-mostly transthyretin-related (ATTR-CA)-has recently gained interest in cardiology. Bone scintigraphy (BS) is one of the main screening tools for ATTR-CA but also used for various other reasons. The objective was to evaluate whether all CA cases are detected and what happens during follow-up. All routine BS performed at the Maastricht University Medical Center (May 2012-August 2020) were screened for the presence of CA. Scans performed for suspected CA were excluded. A Perugini stage ≥1 was classified as positive necessitating further examination. The electronic medical record system was evaluated for any contact with cardiology or other specialists until 2021. Of the 2738 BS evaluated, 40 scans (1.46%; median age 73.5 [IQR: 65.8-79.5], 82.5% male) were positive (Perugini grade 1: 31/77.5%, grade 2: 6/15%, grade 3: 3/7.5%); the potential diagnosis ATTR-CA was not seen in 38 patients (95%) by the nuclear medicine specialist. During follow-up, 19 out of those 40 patients (47.5%) underwent cardiac evaluation without diagnosing CA. Available echocardiograms of patients with a positive BS showed left ventricular hypertrophy, a preserved ejection fraction, and diastolic dysfunction ≥2 in 9/47%, 10/53%, and 4/21% of patients, respectively. Additionally, 20 (50%) patients presented to at least one specialty with symptoms indicative of cardiac amyloidosis. The prevalence of a positive BS indicating potential CA in an unselected population is low but substantial. The majority was not detected which asks for better awareness for CA of all involved specialists to ensure appropriate treatment and follow-up.
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Affiliation(s)
- Mohit Nebhwani
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Karina Chaibekava
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Anouk Achten
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | | | - Michelle Michels
- Department of Cardiology, Erasmus MC, Cardiovascular Institute, Thoraxcenter, Rotterdam, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Center, Groningen, The Netherlands
| | - Hans L A Nienhuis
- Department of Rheumatology & Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jerremy Weerts
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Vanessa van Empel
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | | | - Jochem van der Pol
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
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Juntunen E, Suomalainen O, Mätzke S, Heliö T, Loimaala A, Uusitalo V. Cardiac morbidity and the cause of death in elderly patients with prostate cancer and incidental cardiac uptake on bone scintigraphy. Clin Physiol Funct Imaging 2024; 44:49-55. [PMID: 37421321 DOI: 10.1111/cpf.12848] [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: 10/06/2022] [Revised: 06/26/2023] [Accepted: 07/06/2023] [Indexed: 07/10/2023]
Abstract
Cardiac transthyretin amyloidosis (ATTR) is a possible incidental finding on bone scintigraphy imaged due to prostate cancer. We investigated its significance in 1426 elderly prostate cancer patients (>70 years) who underwent bone scintigraphy in three nuclear medicine departments in Finland. Patients with Perugini grade two or three uptakes were considered positive for cardiac uptake. Heart failure diagnoses and pacemaker implantations were collected from the hospital's records. Mortality data were gathered from the Finnish national statistical service (Statistics Finland). The Median follow-up time was 4 years (interquartile range: 2-5 years). Cardiac uptake was detected in 37 individuals (2.6%), and it was associated with an elevated risk of both overall and cardiovascular death in univariable analysis. However, cardiac uptake did not predict overall mortality in the multivariable analysis when adjusted to age, bone metastases or the diagnosis of heart failure (p > 0.05). The risk of heart failure was higher in patients with cardiac uptake (47% vs. 15%, p < 0.001), while the risk of pacemaker implantations was not elevated (5% vs. 5%, p = 0.89). In conclusion, cardiac uptake on bone scintigraphy imaged due to prostate cancer is associated with an elevated risk of heart failure and both overall and cardiovascular death. However, cardiac uptake was not independently associated with overall mortality when adjusted to age, bone metastasis or heart failure. Therefore, they are essential to consider when incidental cardiac uptake is detected on bone scintigraphy. The need for pacemaker implantation was not elevated in patients with cardiac uptake.
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Affiliation(s)
- Eero Juntunen
- Clinical Physiology and Nuclear Medicine, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Olli Suomalainen
- Heart and Lung Center, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Sorjo Mätzke
- Clinical Physiology and Nuclear Medicine, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Tiina Heliö
- Heart and Lung Center, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Antti Loimaala
- Clinical Physiology and Nuclear Medicine, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Valtteri Uusitalo
- Clinical Physiology and Nuclear Medicine, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
- Radiology, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
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3
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Sebastián Palacid F, Álvarez Mena N, Del Carmen Zambrano Infantino R, García Aragón M, Alonso Rodríguez M, Pérez López B, Gamazo Laherrán C, González Soto MJ, Ruano Pérez R. Absolute quantification of myocardial uptake of 99mTc-DPD in patients with cardiac amyloidosis due to transthyretin deposits (ATTR). Rev Esp Med Nucl Imagen Mol 2023; 42:302-309. [PMID: 37105317 DOI: 10.1016/j.remnie.2023.04.007] [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: 01/26/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE To determine the diagnostic contribution of the absolute quantification of the myocardial deposit of 99mTc-DPD in patients with cardiac amyloidosis due to transthyretin deposits (ATTR). MATERIALS AND METHODS SPECT/CT was performed in 41 patients with positive scintigraphic results for ATTR cardiac amyloidosis. The patients were divided into two groups (Perugini grades 2 and 3) and the SUVmax at the level of the bone and both ventricles and the percentage of dose calculated in these areas were calculated. The Student's t-test was used to compare results and the area under the curve (AUC) was calculated to assess differential efficacy and establish discriminatory cut-off points between both groups of patients. RESULTS Statistically significant differences were observed in all the study variables, with the exception of bone SUVmax. The differences with the greatest statistical power were observed in the variables SUVmaxRV and the percentage of dose in both ventricles (p < 0.001). The cut-off point obtained for the variable SUVmaxLV was 8.620 (sensitivity 87.9% and specificity 100%; AUC 0.966), while that of the variable SUVmaxRV was 6.195 (sensitivity 81.8% and specificity 100%; AUC 0.955). CONCLUSIONS The absolute quantification of myocardial uptake of 99mTc-DPD in the SPECT/CT images of patients with suspected cardiac amyloidosis due to transthyretin deposits represents a new diagnostic tool that allows adequate classification of patients according to the Perugini visual grading scale.
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Affiliation(s)
| | - Noelia Álvarez Mena
- Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valladolid, Valladolid. Spain
| | | | - María García Aragón
- Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valladolid, Valladolid. Spain
| | | | - Berta Pérez López
- Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valladolid, Valladolid. Spain
| | - Claudia Gamazo Laherrán
- Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valladolid, Valladolid. Spain
| | | | - Ricardo Ruano Pérez
- Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valladolid, Valladolid. Spain
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Treglia G, Martinello C, Dondi F, Albano D, Bertagna F, Rizzo A, Delgado Bolton RC, Tersalvi G, Muoio B, Riegger M, Cecchin D. Prevalence of Incidental Findings Suspicious for Transthyretin Cardiac Amyloidosis among Patients Undergoing Bone Scintigraphy: A Systematic Review and a Meta-Analysis. J Clin Med 2023; 12:5698. [PMID: 37685765 PMCID: PMC10488435 DOI: 10.3390/jcm12175698] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/13/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND The myocardial uptake of bone-seeking tracers suspicious for transthyretin cardiac amyloidosis (ATTR-CA) can be incidentally detected in patients undergoing bone scintigraphy for noncardiac reasons. We conducted a systematic review and meta-analysis to assess the prevalence of these scintigraphic findings. METHODS A comprehensive literature search was performed using two bibliographic databases (PubMed/MEDLINE and Cochrane Library), searching for articles related to the review question. Eligible articles were selected, and relevant data were extracted by two authors. The pooled prevalence of incidental findings suspicious for ATTR-CA among patients undergoing bone scintigraphy was calculated on a per-patient-based analysis using a random-effects model. The pooled measure was provided with 95% confidence interval (95% CI) values. RESULTS Among 219 records, 11 articles were selected for the systematic review and 10 for the meta-analysis. The pooled prevalence of incidental findings suspicious for ATTR-CA was 1.1% (95% CI: 0.7-1.4%) with heterogeneity due to the characteristics of the included studies, patients, and index tests. These findings are more prevalent in older men. CONCLUSIONS The prevalence of incidental findings of ATTR-CA among patients undergoing bone scintigraphy is low but not negligible. Nuclear medicine physicians should suggest, in the scintigraphic report, further clinical investigations when these findings are detected. Prospective studies are warranted.
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Affiliation(s)
- Giorgio Treglia
- Division of Nuclear Medicine, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, 6501 Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, 1011 Lausanne, Switzerland
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | | | - Francesco Dondi
- Division of Nuclear Medicine, Università degli Studi di Brescia and ASST Spedali Civili di Brescia, 25123 Brescia, Italy
| | - Domenico Albano
- Division of Nuclear Medicine, Università degli Studi di Brescia and ASST Spedali Civili di Brescia, 25123 Brescia, Italy
| | - Francesco Bertagna
- Division of Nuclear Medicine, Università degli Studi di Brescia and ASST Spedali Civili di Brescia, 25123 Brescia, Italy
| | - Alessio Rizzo
- Department of Nuclear Medicine, Candiolo Cancer Institute, 10060 Turin, Italy
| | - Roberto C. Delgado Bolton
- Department of Diagnostic Imaging (Radiology) and Nuclear Medicine, University Hospital San Pedro and Centre for Biomedical Research of La Rioja (CIBIR), 26006 Logroño, Spain
- Servicio Cántabro de Salud, 39011 Santander, Spain
| | - Gregorio Tersalvi
- Department of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
- Department of Internal Medicine, Ente Ospedaliero Cantonale, 6850 Mendrisio, Switzerland
| | - Barbara Muoio
- Division of Medical Oncology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, 6501 Bellinzona, Switzerland
| | - Martin Riegger
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
- Division of Orthopedics and Traumatology, Department of Surgery, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
| | - Diego Cecchin
- Nuclear Medicine Unit, Department of Medicine (DIMED), Padova University Hospital, 35128 Padua, Italy
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Delbarre MA, Girardon F, Roquette L, Blanc-Durand P, Hubaut MA, Hachulla É, Semah F, Huglo D, Garcelon N, Marchal E, El Esper I, Tribouilloy C, Lamblin N, Duhaut P, Schmidt J, Itti E, Damy T. Deep Learning on Bone Scintigraphy to Detect Abnormal Cardiac Uptake at Risk of Cardiac Amyloidosis. JACC Cardiovasc Imaging 2023; 16:1085-1095. [PMID: 37227330 DOI: 10.1016/j.jcmg.2023.01.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 12/09/2022] [Accepted: 01/05/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Cardiac uptake on technetium-99m whole-body scintigraphy (WBS) is almost pathognomonic of transthyretin cardiac amyloidosis. The rare false positives are often related to light-chain cardiac amyloidosis. However, this scintigraphic feature remains largely unknown, leading to misdiagnosis despite characteristic images. A retrospective review of all WBSs in a hospital database to detect those with cardiac uptake may allow the identification of undiagnosed patients. OBJECTIVES The authors sought to develop and validate a deep learning-based model that automatically detects significant cardiac uptake (Perugini grade ≥2) on WBS from large hospital databases in order to retrieve patients at risk of cardiac amyloidosis. METHODS The model is based on a convolutional neural network with image-level labels. The performance evaluation was performed with C-statistics using a 5-fold cross-validation scheme stratified so that the proportion of positive and negative WBSs remained constant across folds and using an external validation data set. RESULTS The training data set consisted of 3,048 images: 281 positives (Perugini grade ≥2) and 2,767 negatives. The external validation data set consisted of 1,633 images: 102 positives and 1,531 negatives. The performance of the 5-fold cross-validation and external validation was as follows: 98.9% (± 1.0) and 96.1% for sensitivity, 99.5% (± 0.4) and 99.5% for specificity, and 0.999 (SD = 0.000) and 0.999 for the area under the curve of the receiver-operating characteristic curves. Sex, age <90 years, body mass index, injection-acquisition delay, radionuclides, and the indication of WBS only slightly affected performances. CONCLUSIONS The authors' detection model is effective at identifying patients with cardiac uptake Perugini grade ≥2 on WBS and may help in the diagnosis of patients with cardiac amyloidosis.
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Affiliation(s)
- Marc-Antoine Delbarre
- Department of Internal Medicine, Amiens University Hospital, Amiens, France; Research Unit 7517, Mécanisme physiopathologiques et conséquences des calcifications cardiovasculaires (MP3CV), Jules Verne Picardie University, Amiens, France. https://twitter.com/ma_delbarre
| | | | - Lucien Roquette
- Department of Research and Development, Codoc SAS, Paris, France
| | - Paul Blanc-Durand
- Department of Nuclear Medicine, Henri Mondor University Hospital, Assistance-Publique Hôpitaux de Paris (APHP), Créteil, France; Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Mondor de la Recherche Biomédicale (IMRB), Team 8, Université Paris Est Créteil (UPEC), Créteil, France; Institut National de Recherhe en Informatique et en automatique, Epione Team, Sophia Antipolis Epione Team, Sophia Antipolis, France
| | - Marc-Antoine Hubaut
- Department of Nuclear Medicine, Roger Salengro Hospital, Lille University Hospital, Lille, France
| | - Éric Hachulla
- Department of Internal Medicine and Clinical Immunology, Referral Centre for Centre for Rare Systemic Autoimmune Diseases North and North-West of France, Centre Hospitalier et Universitaire (University Hospital Center) Lille, Lille, France; University of Lille, Inserm, U1286 Institute for Translational Research in Inflammation, Lille, France
| | - Franck Semah
- Department of Nuclear Medicine, Roger Salengro Hospital, Lille University Hospital, Lille, France
| | - Damien Huglo
- Department of Nuclear Medicine, Claude Huriez Hospital, Lille University Hospital, Lille, France
| | - Nicolas Garcelon
- Department of Research and Development, Codoc SAS, Paris, France
| | - Etienne Marchal
- Nuclear Medicine Department, Amiens University Hospital, Amiens, France
| | - Isabelle El Esper
- Nuclear Medicine Department, Amiens University Hospital, Amiens, France
| | - Christophe Tribouilloy
- Research Unit 7517, Mécanisme physiopathologiques et conséquences des calcifications cardiovasculaires (MP3CV), Jules Verne Picardie University, Amiens, France; Department of Cardiology, Amiens University Hospital, Amiens, France
| | - Nicolas Lamblin
- Department of Cardiology, Cœur-Poumons Institut, Lille University Hospital, Lille, France; Inserm UMR1167, Institut Pasteur of Lille, Lille, France
| | - Pierre Duhaut
- Department of Internal Medicine, Amiens University Hospital, Amiens, France; Research Unit 7517, Mécanisme physiopathologiques et conséquences des calcifications cardiovasculaires (MP3CV), Jules Verne Picardie University, Amiens, France
| | - Jean Schmidt
- Department of Internal Medicine, Amiens University Hospital, Amiens, France; Research Unit 7517, Mécanisme physiopathologiques et conséquences des calcifications cardiovasculaires (MP3CV), Jules Verne Picardie University, Amiens, France
| | - Emmanuel Itti
- Department of Nuclear Medicine, Henri Mondor University Hospital, Assistance-Publique Hôpitaux de Paris (APHP), Créteil, France
| | - Thibaud Damy
- Department of Cardiology, French Referral Center for Cardiac Amyloidosis, Henri Mondor University Hospital, Assistance-Publique Hôpitaux de Paris (APHP), Créteil, France; InsermUnit U955, Clinical Epidemiology and Ageing, Paris-Est Créteil University, Val-de-Marne, Créteil, France. https://twitter.com/ThibaudDamy
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Te Beek ET, Lafeber A, Postema JWA, Constandse J, Ronner E, Ten Broek MRJ. Feasibility of Left Ventricle Ejection Fraction Calculation Using Electrocardiographically Gated SPECT Acquisition of 99m Tc-HDP Bone Scintigraphy in Cardiac Amyloidosis. Clin Nucl Med 2023; 48:448-450. [PMID: 36800245 DOI: 10.1097/rlu.0000000000004597] [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: 02/18/2023]
Abstract
ABSTRACT We performed bone scintigraphy in 6 patients with suspected cardiac amyloidosis. To evaluate feasibility of left ventricle function analysis, we additionally performed electrocardiographically gated SPECT acquisition. The cardiac-gated SPECT data confirmed adequate tracer uptake for automatic myocardial contour determination. LVEF estimations ranged between 24% and 54%. Comparison with LVEF estimations from prior echocardiography generally showed only small differences. In one patient, the LVEF measurements from both methods seemed discordant, probably reflecting actual LVEF worsening, which was confirmed at follow-up echocardiography. Therefore, our results may suggest that cardiac-gated SPECT acquisition at bone scintigraphy can provide meaningful estimates of LVEF.
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Affiliation(s)
| | | | | | - Jan Constandse
- Cardiology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Eelko Ronner
- Cardiology, Reinier de Graaf Hospital, Delft, the Netherlands
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AlJaroudi WA, Hage FG. Review of cardiovascular imaging in the Journal of Nuclear Cardiology 2022: single photon emission computed tomography. J Nucl Cardiol 2023; 30:452-478. [PMID: 36797458 DOI: 10.1007/s12350-023-03216-4] [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: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 02/18/2023]
Abstract
In this review, we will summarize a selection of articles on single-photon emission computed tomography published in the Journal of Nuclear Cardiology in 2022. The aim of this review is to concisely recap major advancements in the field to provide the reader a glimpse of the research published in the journal over the last year. This review will place emphasis on myocardial perfusion imaging using single-photon emission computed tomography summarizing advances in the field including in prognosis, non-perfusion variables, attenuation compensation, machine learning and camera design. It will also review nuclear imaging advances in amyloidosis, left ventricular mechanical dyssynchrony, cardiac innervation, and lung perfusion. We encourage interested readers to go back to the original articles, and editorials, for a comprehensive read as necessary but hope that this yearly review will be helpful in reminding readers of articles they have seen and attracting their attentions to ones they have missed.
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Affiliation(s)
- Wael A AlJaroudi
- Division of Cardiovascular Medicine, Augusta University, Augusta, GA, USA
| | - Fadi G Hage
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, GSB 446, 1900 University BLVD, Birmingham, AL, 35294, USA.
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
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Argiro' A, Zampieri M, Mazzoni C, Catalucci T, Biondo B, Tomberli A, Gabriele M, Di Mario C, Perfetto F, Cappelli F. Red flags for the diagnosis of cardiac amyloidosis: simple suggestions to raise suspicion and achieve earlier diagnosis. J Cardiovasc Med (Hagerstown) 2022; 23:493-504. [PMID: 35904994 DOI: 10.2459/jcm.0000000000001337] [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: 11/05/2022]
Abstract
Cardiac amyloidosis is an infiltrative disease characterized by extracellular deposition of insoluble amyloid fibrils in the heart leading to organ dysfunction. Despite recent diagnostic advances, the diagnosis of cardiac amyloidosis is often delayed or even missed. Furthermore, a long diagnostic delay is associated with adverse outcomes, with the early diagnosed patients showing the longest survival. In this narrative review we aimed to summarize the 'red flags' that may facilitate the correct diagnosis. The red flags may be classified as clinical, biohumoral, electrocardiographic, echocardiographic, and cardiac magnetic resonance features and should promptly raise the suspicion of cardiac amyloidosis in order to start a correct diagnostic pathway and targeted treatment strategies that may improve patients' outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | - Carlo Di Mario
- Tuscan Regional Amyloidosis Centre
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre
- IV Internal Medicine Division, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department
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9
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Halme HL, Ihalainen T, Suomalainen O, Loimaala A, Mätzke S, Uusitalo V, Sipilä O, Hippeläinen E. Convolutional neural networks for detection of transthyretin amyloidosis in 2D scintigraphy images. EJNMMI Res 2022; 12:27. [PMID: 35524861 PMCID: PMC9079204 DOI: 10.1186/s13550-022-00897-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transthyretin amyloidosis (ATTR) is a progressive disease which can be diagnosed non-invasively using bone avid [99mTc]-labeled radiotracers. Thus, ATTR is also an occasional incidental finding on bone scintigraphy. In this study, we trained convolutional neural networks (CNN) to automatically detect and classify ATTR from scintigraphy images. The study population consisted of 1334 patients who underwent [99mTc]-labeled hydroxymethylene diphosphonate (HMDP) scintigraphy and were visually graded using Perugini grades (grades 0-3). A total of 47 patients had visual grade ≥ 2 which was considered positive for ATTR. Two custom-made CNN architectures were trained to discriminate between the four Perugini grades of cardiac uptake. The classification performance was compared to four state-of-the-art CNN models. RESULTS Our CNN models performed better than, or equally well as, the state-of-the-art models in detection and classification of cardiac uptake. Both models achieved area under the curve (AUC) ≥ 0.85 in the four-class Perugini grade classification. Accuracy was good in detection of negative vs. positive ATTR patients (grade < 2 vs grade ≥ 2, AUC > 0.88) and high-grade cardiac uptake vs. other patients (grade < 3 vs. grade 3, AUC = 0.94). Maximum activation maps demonstrated that the automated deep learning models were focused on detecting the myocardium and not extracardiac features. CONCLUSION Automated convolutional neural networks can accurately detect and classify different grades of cardiac uptake on bone scintigraphy. The CNN models are focused on clinically relevant image features. Automated screening of bone scintigraphy images using CNN could improve the early diagnosis of ATTR.
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Affiliation(s)
- Hanna-Leena Halme
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Toni Ihalainen
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Olli Suomalainen
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Antti Loimaala
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Sorjo Mätzke
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Valtteri Uusitalo
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Outi Sipilä
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Eero Hippeläinen
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland. .,Department of Physics, University of Helsinki, Helsinki, Finland.
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10
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Uusitalo V, Suomalainen O, Loimaala A, Mätzke S, Heliö T. Prognostic Value of 99mTc-HMDP Scintigraphy in Elderly Patients With Chronic Heart Failure. Heart Lung Circ 2022; 31:629-637. [PMID: 35063379 DOI: 10.1016/j.hlc.2021.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 11/20/2021] [Accepted: 11/28/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND This study evaluated the prevalence and prognostic significance of cardiac transthyretin amyloidosis (ATTR) diagnosed using 99mTc- hydroxymethylene-diphosphonate (99mTc-HMDP) scintigraphy in an elderly heart failure population. METHODS This retrospective study included 335 patients aged >70 years with heart failure and who underwent 99mTc-HMDP scintigraphy due to non-cardiac reasons in three imaging centres in Finland (Kymenlaakso Central Hospital, Jorvi Central Hospital, and Meilahti University Hospital). A Perugini grade >2 and heart-to-contralateral ratio (H/CL) of ≥1.30 were considered positive for cardiac ATTR. The overall and cardiovascular mortality were obtained from the national statistical service (Statistics Finland). RESULTS There were 234 deaths, of which 70 were classified as being due to cardiovascular causes during a median follow-up of 1 (1-3) year. Transthyretin amyloidosis was diagnosed in 22 patients (6.6%) using visual analysis and 17 patients using the H/CL ratio (5.1%). Patients with ATTR were older (85±5 vs 80±5 yrs; p=0.002) and had higher N-terminal pro-brain natriuretic peptide (NT-ProBNP) levels (1,451 [813-3,799] vs 6,192 [2,030-8,833] ng/L; p=0.02). Age, bone metastases, and glomerular filtration rate were independent predictors of overall mortality in multivariable analysis. Age, glomerular filtration rate, ≥grade 2 visual cardiac uptake, and H/CL ratio were independent predictors of cardiovascular mortality. CONCLUSIONS Cardiac uptake suggestive of ATTR was found in 5% of elderly patients with chronic heart failure. The presence of cardiac uptake on bone scintigraphy did not convey independent prognostic value on overall mortality but was independently associated with cardiovascular mortality.
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Affiliation(s)
- Valtteri Uusitalo
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Olli Suomalainen
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Antti Loimaala
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sorjo Mätzke
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tiina Heliö
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Scheel PJ, Mukherjee M, Hays AG, Vaishnav J. Multimodality Imaging in the Evaluation and Prognostication of Cardiac Amyloidosis. Front Cardiovasc Med 2022; 9:787618. [PMID: 35402557 PMCID: PMC8989413 DOI: 10.3389/fcvm.2022.787618] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy resulting from deposition of misfolded immunoglobulin light chains (AL-CA) or transthyretin (ATTR-CA) proteins in the myocardium. Survival varies between the different subtypes of amyloidosis and degree of cardiac involvement, but accurate diagnosis is essential to ensure initiation of therapeutic interventions that may slow or potentially prevent morbidity and mortality in these patients. As there are now effective treatment options for CA, identifying underlying disease pathogenesis is crucial and can be guided by multimodality imaging techniques such as echocardiography, magnetic resonance imaging, and nuclear scanning modalities. However, as use of cardiac imaging is becoming more widespread, understanding optimal applications and potential shortcomings is increasingly important. Additionally, certain imaging modalities can provide prognostic information and may affect treatment planning. In patients whom imaging remains non-diagnostic, tissue biopsy, specifically endomyocardial biopsy, continues to play an essential role and can facilitate accurate and timely diagnosis such that appropriate treatment can be started. In this review, we examine the multimodality imaging approach to the diagnosis of CA with particular emphasis on the prognostic utility and limitations of each imaging modality. We also discuss how imaging can guide the decision to pursue tissue biopsy for timely diagnosis of CA.
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