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Figure 3 Macroscopic/histologic findings (top) and scintigraphic images using 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) (middle) or 99mTc-methylene diphosphonate (99mTc-MDP) (bottom) as the tracer in a group A patient with transthyretin amyloidosis who underwent combined heart-liver transplantation (left) and a group B patient with monoclonal immunoglobulin light-chain (AL) amyloidosis (right). Two paradoxes are apparent: 1) despite similar left ventricular (LV) thickness and amount of amyloidotic infiltration in the two patients, myocardial 99mTc-DPD uptake is characteristically strong (without bone uptake) in the patient with TTR-related amyloidosis and absent in the patient with AL amyloidosis (who had only bone uptake); 2) conversely, use of a different tracer (99mTc-MDP) results in absence of visually detectable myocardial uptake (accompanied by normal bone uptake) in both patients. The macrohistologic sections show pale gray-blue amyloid infiltrations at Azan Mallory trichrome staining, whereas Congo-red staining (lower insets) shows typical green birefringence under cross-polarized light microscopy. In the patient with TTR, immunohistochemical staining against TTR is positive (upper inset). RV = right ventricle.
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