Vol.:(0123456789) 1 3 The International Journal of Cardiovascular Imaging https://doi.org/10.1007/s10554-020-01879-5 IMAGES IN CV APPLICATIONS A heart with red fags Cátia Costa Oliveira 1,2,3  · Vitor Hugo Pereira 1,2,3  · Carla Rodrigues 1  · Catarina Vieira 1  · Alberto Salgado 1 Received: 25 April 2020 / Accepted: 5 May 2020 © Springer Nature B.V. 2020 A 67 year old woman complaining of nausea, anorexia, weight loss (8 pounds in 3 months), asthenia and dyspnea for minor eforts was admitted for investigation. Her physical examination revealed an arrhythmic heartbeat, without other alterations. The ECG revealed atrial fbrillation and low volt- age in limb and precordial leads. Transthoracic echocar- diogram showed preserved systolic biventricular function with impaired left ventricular (LV) diastolic function and moderate pulmonary hypertension. A severe LV concentric hypertrophy pattern more pronounced at the interventricular septum (26 mm vs posterior wall 18 mm) and hypertrophy of the free right ventricular wall (12 mm) were identifed (Fig. 1a, b). Cardiac magnetic resonance confrmed the LV hypertrophy with septal predominance (24 mm) associated with late difuse subendocardial gadolinium enhancement (LGE) and difculty at nulling the myocardium (Fig. 1c). (99m)Tc-DPD scintigraphy was negative for amyloid tran- sthyretin deposition. The patient underwent bone marrow and salivary gland biopsies. Salivary gland biopsy con- frmed the deposition of amyloid substance. Bone marrow biopsy was consistent with multiple myeloma. Patient was referred for hematology and started chemotherapy. She died 6 months later due to disease progression. Cardiac amyloidosis (CA) is a rare condition with an esti- mated prevalence of 8 to 12 per million. When left and right ventricular myocardial thickening, valvular thickening, peri- cardial efusion, diastolic dysfunction and a characteristic pattern of global longitudinal strain (GLS) with apical spar- ing are observed in echocardiographic studies, CA should be suspected [1]. GLS pattern appreciated in CA is both sensitive and specifc to identify and diferentiate CA from other causes of LV hypertrophy [2]. The ‘speckled’ pattern because of the higher echogenicity of amyloid protein than the surrounding myocardial tissue is a typical feature of CA. In CMR, a global subendocardial late gadolinium enhance- ment with diferent contrast kinetics and a difculty in nul- ling the myocardium (“nulling pattern”) are the most typical fndings of CA [2]. This case remembers CA as a cause of heart failure and its most relevant imaging fndings. * Cátia Costa Oliveira catiaandreiaoliveira@gmail.com 1 Cardiology Department, Hospital de Braga, Braga, Portugal 2 University of Minho, School of Medicine, Braga, Portugal 3 ICVS/3B’s-PT Government Associate Laboratory, Braga/Guimarães, Portugal