Study 71064 - ATTR Cardiac Amyloidosis — Imaging eCRF

Bone scintigraphy reporting · v1.1

1

General Information

Date of Report*

Subject ID*

Camera*

2

Methods

Field of View*

ChestChest + Whole Body

SPECT Imaging*

SPECT OnlySPECT/CT

Activity*

Unit

mCiMBq

Injection Time

Planar Scan Time

Total Incubation

3

Cardiac Findings

Image Interpretability*

UninterpretableAcceptable

Semi-quantitative Grading (Perugini)*

Grade 0 — No myocardial uptake, normal bone uptakeGrade 1 — Myocardial < bone uptakeGrade 2 — Myocardial ≥ bone uptakeGrade 3 — Myocardial > bone w/ reduced/absent bone uptake

4

SPECT Interpretation

Segmental uptake present?*

YesNo

Blood pool only*

YesNo

Left ventricle

Diffuse LV uptakeFocal LV uptake

Focal LV uptake — location

AnteriorLateralSeptalInferior

LV 4-Segment Model

Right ventricle

Diffuse RV uptakeFocal RV uptake

5

Planar Imaging & Radiotracer

Planar Imaging*

Anterior + Lateral StaticWhole Body

Radiotracer*

DPDHMDPPYP

6

Overall Interpretation

Overall Interpretation*

Not suggestive of ATTR cardiac amyloidosisEquivocal (after exclusion of plasma cell dyscrasia)Strongly suggestive (after exclusion of plasma cell dyscrasia)

7

Incidental Findings & Comments

Incidental Findings

General Comments

Complete fields marked *