Multimodality Imaging in Cardiac Amyloidosis

Figure 1. Figure illustrating types of amyloidosis.

Figure 2. ECGs in a patient with suspected cardiac amyloidosis showing (A) low QRS voltages in all leads with atrial fibrillation and (B) atrial fibrillation with pseudo-infarct pattern with LBBB.

Figure 3. 2D ECHO image depicting increased concentric LV wall thickness, granular myocardial texture, thickened valves and small pericardial effusion.

Figure 4. Doppler echocardiography key findings in cardiac amyloidosis.

Figure 5. Schematic diagram highlighting the strain imaging pattern (apical sparing) on a bullseye plot in cardiac amyloidosis. Red = severely depressed, Orange = mildly depressed, pink= normal.

Figure 6. Calculation of LV strain and correlation with bullseye image in patients with cardiac amyloidosis showing “cherry on top” appearance.

Figure 7. CMR images in cardiac amyloidosis: (a) Short-axis cine image showing concentric LV hypertrophy and restricted ventricular cavity due to fibrotic thickening. (b) Long-axis cine view illustrating endocardial thickening with preserved basal contractility and apical restriction. (c) Four-chamber view showing biatrial enlargement suggestive of diastolic restriction. (d) Late gadolinium enhancement (LGE) image revealing dense subendocardial enhancement of the apical and mid-ventricular regions, consistent with cardiac amyloidosis.

Figure 8. Simplified nuclear imaging protocol in cardiac amyloidosis.

Figure 9. SPECT-CT imaging in cardiac amyloidosis. The middle row and bottom row images demonstrate intense myocardial tracer uptake on SPECT corresponding to the left ventricular myocardium on CT (upper row), with activity equal to or greater than bone uptake. This finding is consistent with a positive 99mTc-pyrophosphate (PYP) scan, characteristic of transthyretin (ATTR) cardiac amyloidosis.

Figure 10. Algorithmic approach to a suspected case of cardiac amyloidosis. + = Positive/present; − = Negative/absent.