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• W4226336783 abstract "HomeCirculation: Heart FailureVol. 15, No. 5Response by Shah et al to Letter Regarding Article, “False-Positive 99mTechnetium-Pyrophosphate Scintigraphy in Two Patients With Hypertrophic Cardiomyopathy” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse by Shah et al to Letter Regarding Article, “False-Positive 99mTechnetium-Pyrophosphate Scintigraphy in Two Patients With Hypertrophic Cardiomyopathy” Keyur B. Shah, MD, Krishnasree Rao, MD and Cory R. Trankle, MD Keyur B. ShahKeyur B. Shah Pauley Heart Center, Department of Medicine, Virginia Commonwealth University, Richmond. Search for more papers by this author , Krishnasree RaoKrishnasree Rao Pauley Heart Center, Department of Medicine, Virginia Commonwealth University, Richmond. Search for more papers by this author and Cory R. TrankleCory R. Trankle https://orcid.org/0000-0002-3891-7004 Pauley Heart Center, Department of Medicine, Virginia Commonwealth University, Richmond. Search for more papers by this author Originally published5 Apr 2022https://doi.org/10.1161/CIRCHEARTFAILURE.121.008697Circulation: Heart Failure. 2022;15Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: April 5, 2022: Ahead of Print In Response:On behalf of our coauthors, we thank Drs Cuddy, Dorbala, and Falk for the critical review of our case report on 99mtechnetium-pyrophosphate imaging in 2 patients with hypertrophic cardiomyopathy.1 We truly appreciate your expertise on the topic of TTR (transthyretin) amyloidosis, and your letter brings to light key points that are surfacing as the technology is more broadly applied.In regard to your inquiry, single-photon emission computed tomography was performed in both cases 1 hour after administration of the radiotracer, and the initial interpretation was that 99mtechnetium-pyrophosphate uptake was in the myocardium without persistent blood pool accumulation. We reevaluated the single-photon emission computed tomography images with an independent radiologist who was not familiar with the two cases. On this second review, the radiologist concluded that there is excess blood pool activity (Figure) that led to the false-positive findings reported in the original article. The reread of the images was equivocal. Although it is our program’s current practice to obtain delayed (3 hours) images in cases when the blood pool has not cleared the radiotracer by 1 hour, these studies were performed before implementation of this as the standard protocol. Therefore, we regrettably agree with your assessment that the imaging did not meet current established criteria to conclusively diagnose TTR amyloidosis.Download figureDownload PowerPointFigure. Single-photon emission computed tomography of patients suspected to have transthyretin cardiac amyloidosis. Axial single-photon emission computed tomography (SPECT) image of a patient (not case) with confirmed wild-type transthyretin cardiac amyloidosis shown in A exemplifies myocardial uptake in the left ventricle. B (case 1) and C (case 2) show axial SPECT images for patients in our published case report with nonspecific granular uptake that do not show definitive localization to the myocardium.The fact that that these images were misinterpreted at a program that cares for a large population of patients with thick heart cardiomyopathies and amyloidosis should itself be a platform for discussion. In addition to the technical error described above, we have observed other challenges while implementing 99mtechnetium-pyrophosphate imaging into routine practice. These include (1) triaging a high volume of referrals with intermediate or equivocal findings, (2) contextualizing images that were ordered without evaluating for a plasma cell disorder, (3) mitigating additional unnecessary testing born out of equivocal test, and (4) reducing the disconnect between the imaging experts and cardiologists to improve imaging interpretation. Your seminal study defining the value of this testing for TTR amyloidosis (100% positive predictive value) was reflective of referral center populations that were evaluated at long-established specialty centers with imaging experts well versed in optimizing 99mtechnetium-pyrophosphate performance.2 We expect that our experience with these two patients will not be unique as 99mtechnetium-pyrophosphate imaging is broadly applied across centers with variable expertise in amyloidosis and nuclear scintigraphy and used in patients with a wider spectrum of pretest probabilities for TTR amyloidosis.We believe our error offers an invaluable learning opportunity for our colleagues, as the manuscript and these correspondences illustrate the confusing results and downstream effects of nonadherence to the principles your review article described.3 We propose a correction to change the title to “False-Positive 99mTechnetium-Pyrophosphate Scintigraphy in Two Patients With Hypertrophic Cardiomyopathy: An Error in Interpretation.”Article InformationDisclosures Dr Shah is a consultant for Ionis, Eidos, and Pfizer. He serves on the steering/advisory committees for Ionis and Eidos. The other authors report no conflicts.FootnotesFor Disclosures, see page 540.References1. Schafer EB, Tushak Z, Trankle CR, Rao K, Cartagena LC, Shah KB. False-positive 99mtechnetium-pyrophosphate scintigraphy in two patients with hypertrophic cardiomyopathy.Circ Heart Fail. 2021; 14:e007558. doi: 10.1161/CIRCHEARTFAILURE.120.007558LinkGoogle Scholar2. Gillmore JD, Maurer MS, Falk RH, Merlini G, Damy T, Dispenzieri A, Wechalekar AD, Berk JL, Quarta CC, Grogan M, et al.. Nonbiopsy diagnosis of cardiac transthyretin amyloidosis.Circulation. 2016; 133:2404–2412. doi: 10.1161/CIRCULATIONAHA.116.021612LinkGoogle Scholar3. Hanna M, Ruberg FL, Maurer MS, Dispenzieri A, Dorbala S, Falk RH, Hoffman J, Jaber W, Soman P, Witteles RM, et al.. Cardiac scintigraphy with technetium-99m-labeled bone-seeking tracers for suspected amyloidosis: JACC review topic of the week.J Am Coll Cardiol. 2020; 75:2851–2862. doi: 10.1016/j.jacc.2020.04.022CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails May 2022Vol 15, Issue 5 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.121.008697PMID: 35378983 Originally publishedApril 5, 2022 PDF download Advertisement SubjectsHeart FailureNuclear Cardiology and PET" @default.
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