Perugini Grade 3 Uptake Does Not Exclude AL Cardiac Amyloidosis

Figures

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  Figure 1. 12-Lead ECG Showing Permanent Atrial Fibrillation With Low QRS Voltages in the Precordial Leads Low voltage on surface electrocardiogram, particularly when discordant with increased left ventricular wall thickness on echocardiography, represents a classical red flag for infiltrative cardiomyopathies, including cardiac amyloidosis. In the present case, these electrocardiographic features contributed to raising suspicion for a nonischemic etiology of heart failure despite the presence of concomitant coronary artery disease.

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  Figure 2. Transthoracic Echocardiography Demonstrated Preserved Left Ventricular Ejection Fraction With Increased Wall Thickness and Biatrial Enlargement Global longitudinal strain (GLS) analysis revealed severely reduced myocardial deformation (−10.8%) with relative preservation of apical segments, producing a characteristic “apical sparing” pattern. This strain distribution is highly suggestive of cardiac amyloidosis and represents an important noninvasive clue in patients with heart failure with preserved ejection fraction and disproportionate biomarker elevation.

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  Figure 3. Tc-99m Pyrophosphate Scintigraphy Showing Perugini Grade 3 Myocardial Uptake (Top) Whole-body planar bone scintigraphy demonstrates intense and diffuse myocardial tracer uptake exceeding bone uptake, consistent with Perugini grade 3 myocardial uptake. (Bottom) Hybrid SPECT/CT images (axial, coronal, sagittal, and maximum intensity projection) confirm diffuse myocardial tracer accumulation. SPECT/CT = single-photon emission computed tomography/computed tomography.