Standardization of 99mTechnetium pyrophosphate imaging methodology to diagnose TTR cardiac amyloidosis

Sabahat Bokhari, Rachelle Morgenstern, Richard Weinberg, Mona Kinkhabwala, Demetrios Panagiotou, Adam Castano, Albert DeLuca, Andrew Kontak, Zhezhen Jin, Mathew S Maurer

Technetium pyrophosphate ((99m)Tc-PYP) imaging to diagnose transthyretin cardiac amyloidosis (ATTR-CA) has been increasingly utilized. The objective of this study is to provide a standardized (99m)Tc-PYP imaging protocol to diagnose ATTR-CA. 104 scans from 45 subjects with biopsy-proven ATTR-CA or light-chain cardiac amyloidosis (AL) were assessed. Multiple scans were obtained using different counts (750 vs 2000 K), times to acquisition (1 vs 2 to 4 hours), processing matrix (256 vs 128), and (99m)Tc-PYP dose. Image quality and extracardiac activity was assessed. Quantitative methods using heart-to-contralateral ratios (H/CL) and a visual semiquantitative scale were used to diagnose ATTR-CA.19 The correlation between H/CL ratios and reproducibility of semiquantitative visual scores, acquired using various imaging parameters, were evaluated. All imaging parameters had good to excellent image quality. 750 vs 2000 K counts, 1 hour acquisition and 256 matrix, had lower extracardiac activity (P = .00018). 10 mCi of (99m)Tc-PYP v. higher doses showed excellent image quality and less extracardiac activity (P = .0015). Correlation of H/CL ratios was strong (r ≥ 0.92) and reproducibility of semiquantitative visual scores was high (Kappa = 95%). An imaging protocol using 750 K counts, 10 mCi of (99m)Tc-PYP, and a 256 matrix was chosen as the standardized imaging protocol since it provided the shortest overall study time (1 vs 2 to 4 hours) and lowest radiation exposure (3 vs 8 to 10 mSv).