1) A 62-year old female presented with severe shortness of breath and heart failure symptoms. Tests showed very low ejection fraction and elevated ferritin levels. 2) She was treated with diuretics, ACE inhibitors, and aldactone, and her symptoms improved. However, her ferritin remained high, suggesting hemochromatosis. 3) Cardiac MRI and nuclear imaging with MDP and PYP scans confirmed cardiac amyloidosis of the ATTR type. The patient was diagnosed with cardiac amyloidosis and treatment options were discussed.

1. LAHORE
CHAPTER PCS/
PSIC
35th meeting 2019
Dr. Muhammad Ayub, FCPS
Diplomate Certification Board of Nuclear Cardiology
Diplomate Certification Board of Cardiovascular CT
Consultant Cardiovascular Imaging

2. What is this image?
• Tc-99m MIBI Scan
• Tc-99m MDP Scan
• Tc-99m PyP Scan
• None of the above

3. The Story
 62 year old female presented with severe shortness of
breath due to decompensated heart failure with
generalized anasarca including pleural, pericardial
effusions and ascites.

4. Electrocardiogram

5. ECHO
EF=20-
25%

6. Lab Tests
 Hypochromic microcytic anemia
 Pleural Fluid: Transudate
 Chemistry= Normal except:
 Urea =55
 Creatinine=1.2
 Elevated Ferritin level = 690 (N= 4-204)

7. Treatment
 Loop diuretics (IV and Oral)
 ACE inhibitors
 Aldactone
 Stopped iron

8. Follow-up
Echo
Pro BNP= 108.8
Ref N: < 125
S Ferritin= 440
EF= 60%

9. Complication of Treatment

10. What was initial Cause of Heart Failure?
Could it be Hemochromatosis as serum ferritin
was very high??

11. Cardiac MRI for suspected
Hemochromatosis

12. Cardiac MRI LGE
5 Minutes 9 Minutes

14. What type of amyloidosis
 AL Type?
 Can be confirmed by presence of monoclonal band on
serum immuno-electrophoresis
 ATTR Type
 May be shown with bone imaging agents like MDP or
PYP

15. Investigations for Cardiac Amyloidosis
AL Type

16. Investigations for ATTR Cardiac
Amyloidosis Tc-99m-MDP Scan
Lt/Rt Ratio= 1.15
Negative for ATTR Amyloidosis

18. Investigations for Cardiac Amyloidosis
ATTR Type Tc-99m PYP Scan
Ratio= 1.6
Positive for ATTR
Amyloidosis

19. Final Diagnosis
 Cardiac Amyloidosis (Type ATTR)

20. Treatment options
 Treatment for Heart Failure
 Liver Transplant
 Heart Transplant
 Experimental Drugs
 Tafamidis 61mg daily
 Tafamidis Maglumine 20-80 mg daily

21. Thank you for
your attention
ACKNOWLEDGEMENTS:
• Nuclear Medicine Department Punjab
Institute of Cardiology, Lahore for
MDP and PYP Scintigraphy
• Children hospital Lahore for Cardiac
MRI
• Dr. Shahbaz Sarwar for
Echocardiography