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Farrell C, Balasubramanian A, Hays AG, Hsu S, Rowe S, Zimmerman SL, Hassoun PM, Mathai SC, Mukherjee M. A Clinical Approach to Multimodality Imaging in Pulmonary Hypertension. Front Cardiovasc Med 2022; 8:794706. [PMID: 35118142 PMCID: PMC8804287 DOI: 10.3389/fcvm.2021.794706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/22/2021] [Indexed: 11/24/2022] Open
Abstract
Pulmonary hypertension (PH) is a clinical condition characterized by progressive elevations in mean pulmonary artery pressures and right ventricular dysfunction, associated with significant morbidity and mortality. For resting PH to develop, ~50-70% of the pulmonary vasculature must be affected, suggesting that even mild hemodynamic abnormalities are representative of advanced pulmonary vascular disease. The definitive diagnosis of PH is based upon hemodynamics measured by right heart catheterization; however this is an invasive and resource intense study. Early identification of pulmonary vascular disease offers the opportunity to improve outcomes by instituting therapies that slow, reverse, or potentially prevent this devastating disease. Multimodality imaging, including non-invasive modalities such as echocardiography, computed tomography, ventilation perfusion scans, and cardiac magnetic resonance imaging, has emerged as an integral tool for screening, classifying, prognosticating, and monitoring response to therapy in PH. Additionally, novel imaging modalities such as echocardiographic strain imaging, 3D echocardiography, dual energy CT, FDG-PET, and 4D flow MRI are actively being investigated to assess the severity of right ventricular dysfunction in PH. In this review, we will describe the utility and clinical application of multimodality imaging techniques across PH subtypes as it pertains to screening and monitoring of PH.
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Affiliation(s)
- Christine Farrell
- Division of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Aparna Balasubramanian
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Allison G. Hays
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, United States
| | - Steven Hsu
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, United States
| | - Steven Rowe
- Division of Radiology, Johns Hopkins University, Baltimore, MD, United States
| | - Stefan L. Zimmerman
- Division of Radiology, Johns Hopkins University, Baltimore, MD, United States
| | - Paul M. Hassoun
- Division of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Monica Mukherjee
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, United States
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Keenan KE, Berman BP, Rýger S, Russek SE, Wang WT, Butman JA, Pham DL, Dagher J. Comparison of Phase Estimation Methods for Quantitative Susceptibility Mapping Using a Rotating-Tube Phantom. Radiol Res Pract 2021; 2021:1898461. [PMID: 34868681 PMCID: PMC8635951 DOI: 10.1155/2021/1898461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 10/08/2021] [Indexed: 11/17/2022] Open
Abstract
Quantitative Susceptibility Mapping (QSM) is an MRI tool with the potential to reveal pathological changes from magnetic susceptibility measurements. Before phase data can be used to recover susceptibility (Δχ), the QSM process begins with two steps: data acquisition and phase estimation. We assess the performance of these steps, when applied without user intervention, on several variations of a phantom imaging task. We used a rotating-tube phantom with five tubes ranging from Δχ=0.05 ppm to Δχ=0.336 ppm. MRI data was acquired at nine angles of rotation for four different pulse sequences. The images were processed by 10 phase estimation algorithms including Laplacian, region-growing, branch-cut, temporal unwrapping, and maximum-likelihood methods, resulting in approximately 90 different combinations of data acquisition and phase estimation methods. We analyzed errors between measured and expected phases using the probability mass function and Cumulative Distribution Function. Repeatable acquisition and estimation methods were identified based on the probability of relative phase errors. For single-echo GRE and segmented EPI sequences, a region-growing method was most reliable with Pr (relative error <0.1) = 0.95 and 0.90, respectively. For multiecho sequences, a maximum-likelihood method was most reliable with Pr (relative error <0.1) = 0.97. The most repeatable multiecho methods outperformed the most repeatable single-echo methods. We found a wide range of repeatability and reproducibility for off-the-shelf MRI acquisition and phase estimation approaches, and this variability may prevent the techniques from being widely integrated in clinical workflows. The error was dominated in many cases by spatially discontinuous phase unwrapping errors. Any postprocessing applied on erroneous phase estimates, such as QSM's background field removal and dipole inversion, would suffer from error propagation. Our paradigm identifies methods that yield consistent and accurate phase estimates that would ultimately yield consistent and accurate Δχ estimates.
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Affiliation(s)
- Kathryn E. Keenan
- National Institute of Standards and Technology, Physical Measurement Laboratory, 325 Broadway, Boulder, CO 80305, USA
| | - Ben P. Berman
- The MITRE Corporation, 7515 Colshire Dr, McLean, VA 22102, USA
| | - Slávka Rýger
- National Institute of Standards and Technology, Physical Measurement Laboratory, 325 Broadway, Boulder, CO 80305, USA
| | - Stephen E. Russek
- National Institute of Standards and Technology, Physical Measurement Laboratory, 325 Broadway, Boulder, CO 80305, USA
| | - Wen-Tung Wang
- Henry M. Jackson Foundation, 10 Center Drive, Bethesda, MD 20892, USA
| | - John A. Butman
- Clinical Center, National Institutes of Health, 10 Center Drive, Bethesda, MD 20814, USA
| | - Dzung L. Pham
- Henry M. Jackson Foundation, 10 Center Drive, Bethesda, MD 20892, USA
| | - Joseph Dagher
- The MITRE Corporation, 7515 Colshire Dr, McLean, VA 22102, USA
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k-t accelerated multi-VENC 4D flow MRI improves vortex assessment in pulmonary hypertension. Eur J Radiol 2021; 145:110035. [PMID: 34801875 DOI: 10.1016/j.ejrad.2021.110035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/27/2021] [Accepted: 11/12/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND 4D flow imaging can be used to evaluate vortex formation in the pulmonary artery seen in patients with pulmonary hypertension. We evaluated if a k-t accelerated multi-VENC (velocity encoding) 4D flow acquisition improves image quality, inter-reader agreement and correlation with hemodynamic parameters. METHODS A total of 14 patients with pulmonary hypertension (5 females, 9 males; mean age 61 ± 16 years) underwent 4D flow MRI (magnetic resonance imaging) and right heart catheterization. In addition to that, 13 healthy volunteers (2 females, 11 males, mean age 33 ± 12 years) also underwent 4D flow MRI. Multi- and single-VENC datasets were reconstructed and evaluated for vortex formation and vortex duration by two blinded readers and image quality was rated on a 5-point scale. RESULTS Both readers rated image quality as significantly higher on multi-VENC datasets (3.96 ± 0.71 vs. 2.56 ± 0.93, p < 0.001; 4.70 ± 0.61 vs. 4.07 ± 0.92, p = 0.003). Inter-reader correlation for vortex duration quantification was higher on multi-VENC datasets compared to single-VENC datasets (r = 0.63 vs. r = 0.44). No significant correlation was found between vortex duration and mean pulmonary artery pressure in patients with PH. CONCLUSION Multi-VENC 4D flow MRI significantly improves image quality and inter-reader agreement for the evaluation of vortex formation in the pulmonary artery.
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Kroeger JR, Pavesio FC, Mörsdorf R, Weiss K, Bunck AC, Baeßler B, Maintz D, Giese D. Velocity quantification in 44 healthy volunteers using accelerated multi-VENC 4D flow CMR. Eur J Radiol 2021; 137:109570. [PMID: 33596498 DOI: 10.1016/j.ejrad.2021.109570] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/25/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND To evaluate the feasibility of a k-t accelerated multi-VENC 4D phase contrast flow MRI acquisition of the main heart-surrounding vessels, its benefits over a traditional single-VENC acquisition and to present reference flow and velocity values in a large cohort of volunteers. METHODS 44 healthy volunteers were examined on a 3 T MRI scanner (Ingenia, Philips, Best, The Netherlands). 4D flow measurements were obtained with a FOV including the aorta and the pulmonary arteries. VENC values were set to 40, 100 and 200 cm/s and unfolded based on an MRI signal model. Unfolded multi-VENC data was compared to the single-VENC with VENC 200 cm/s. Flow and velocity quantification was performed in several regions of interest (ROI) placed in the ascending aorta and in the main pulmonary artery. Conservation of mass analysis was performed for single- and multi-VENC datasets. Values for mean and maximal flow velocity and stroke volume were calculated and compared to the literature. RESULTS Mean scan time was 13.8 ± 4 min. Differences between stroke volumes between the ascending aorta and the main pulmonary artery were significantly lower in multi-VENC datasets compared to single-VENC datasets (9.6 ± 7.8 mL vs. 25.4 ± 26.4 mL, p < 0.001). This was also true for differences in stroke volume between up- and downstream ROIs in the ascending aorta and pulmonary artery. Values for mean and maximal velocities and stroke volume were in-line with previous studies. To highlight potential clinical applications two exemplary 4D flow measurements in patients with different pathologies are shown and compared to single-VENC datasets. CONCLUSIONS k-t accelerated multi-VENC 4D phase contrast flow MRI acquisition of the great vessels is feasible in a clinically acceptable scan duration. It offers improvements over traditional single-VENC 4D flow, expectedly being valuable when vessels with different flow velocities or complex flow phenomena are evaluated.
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Affiliation(s)
- Jan Robert Kroeger
- Department of Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany; Department of Radiology, Neuroradiology and Nuclear Medicine, Johannes Wesling University Hospital, Ruhr University Bochum, Germany.
| | - Francesca Claudia Pavesio
- Department of Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.
| | - Richard Mörsdorf
- Department of Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.
| | - Kilian Weiss
- Department of Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany; Philips GmbH, Hamburg, Germany.
| | - Alexander Christian Bunck
- Department of Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.
| | - Bettina Baeßler
- Department of Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany; Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland.
| | - David Maintz
- Department of Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.
| | - Daniel Giese
- Department of Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.
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Critser PJ, Higano NS, Lang SM, Kingma PS, Fleck RJ, Hirsch R, Taylor MD, Woods JC. Cardiovascular magnetic resonance imaging derived septal curvature in neonates with bronchopulmonary dysplasia associated pulmonary hypertension. J Cardiovasc Magn Reson 2020; 22:50. [PMID: 32698897 PMCID: PMC7376717 DOI: 10.1186/s12968-020-00643-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 05/29/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) associated with pulmonary hypertension (PH) is a significant source of morbidity and mortality in premature infants. Recent advances have allowed the use of cardiovascular magnetic resonance (CMR) in the assessment of respiratory and cardiac disease in infants with BPD. In adults and older pediatric patients, decreased CMR interventricular septal curvature correlates with increased mean pulmonary artery pressure and pulmonary vascular resistance. The current study sought to determine the relationship of CMR derived septal curvature in neonates with BPD and BPD-PH with a need for PH therapy. METHODS Forty moderate or severe BPD and 12 mild BPD or control infants were imaged without contrast between 38 and 47 weeks post-menstrual age on a neonatal-sized, neonatal intensive care unit-sited 1.5 T CMR scanner. CMR indices including eccentricity index (CMR-EI) and septal curvature were measured and compared to BPD severity and clinical outcomes including hospital length of stay (LOS), duration of respiratory support, respiratory support level at discharge and PH therapy. RESULTS CMR-EI was directly associated and septal curvature was inversely associated with BPD severity. In a univariate analysis, CMR-EI and septal curvature were associated with increased hospital LOS, duration of respiratory support, respiratory support at hospital discharge, and need for PH therapy. In multivariable analysis CMR-EI was associated with hospital LOS and duration of respiratory support and septal curvature was associated with respiratory support at hospital discharge. Septal curvature was the only clinical or CMR variable associated with need for PH therapy (R2 = 0.66, p = 0.0014) in multivariable analysis demonstrating improved discrimination beyond CMR-EI. CONCLUSIONS CMR derived septal curvature correlates significantly with clinical outcomes including hospital LOS, duration of respiratory support, respiratory support level at hospital discharge, and PH therapy in neonates with BPD and BPD-PH. Further, CMR derived septal curvature demonstrated improved discrimination of need for PH therapy and respiratory support at discharge compared to clinical variables and other CMR indices, supporting septal curvature as a non-invasive marker of PH in this population with potential to guide management strategies.
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Affiliation(s)
- Paul J Critser
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nara S Higano
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Sean M Lang
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA
| | - Paul S Kingma
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Robert J Fleck
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 5033, Cincinnati, OH, 45229, USA
| | - Russel Hirsch
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA
| | - Michael D Taylor
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA
| | - Jason C Woods
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA.
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 5033, Cincinnati, OH, 45229, USA.
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Critser PJ, Higano NS, Tkach JA, Olson ES, Spielberg DR, Kingma PS, Fleck RJ, Lang SM, Moore RA, Taylor MD, Woods JC. Cardiac Magnetic Resonance Imaging Evaluation of Neonatal Bronchopulmonary Dysplasia-associated Pulmonary Hypertension. Am J Respir Crit Care Med 2020; 201:73-82. [PMID: 31539272 PMCID: PMC6938152 DOI: 10.1164/rccm.201904-0826oc] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 09/19/2019] [Indexed: 12/25/2022] Open
Abstract
Rationale: Patients with bronchopulmonary dysplasia (BPD)-associated pulmonary hypertension (PH) have increased morbidity and mortality. Noninvasive assessment relies on echocardiograms (echos), which are technically challenging in this population. Improved assessment could augment decisions regarding PH therapies.Objectives: We hypothesized that neonatal cardiac magnetic resonance imaging (MRI) will correlate with BPD severity and predict short-term clinical outcomes, including need for PH therapies for infants with BPD.Methods: A total of 52 infants (31 severe BPD, 9 moderate BPD, and 12 with either mild or no BPD) were imaged between 39 and 47 weeks postmenstrual age on a neonatal-sized, neonatal ICU-sited 1.5-T magnetic resonance (MR) scanner. MR left ventricular eccentricity index (EI), main pulmonary artery-to-aorta (PA/AO) diameter ratio, and pulmonary arterial blood flow were determined. Echos obtained for clinical indications were reviewed. MRI and echo indices were compared with BPD severity and clinical outcomes, including length of stay (LOS), duration of respiratory support, respiratory support at discharge, and PH therapy.Measurements and Main Results: PA/AO ratio increased with BPD severity. Increased PA/AO ratio, MR-EI, and echo-EIs were associated with increased LOS and duration of respiratory support. No correlation was seen between pulmonary arterial blood flow and BPD outcomes. Controlling for gestational age, birth weight, and BPD severity, MR-EI was associated with LOS and duration of respiratory support. Increased PA/AO ratio and MR-EI were associated with PH therapy during hospitalization and at discharge.Conclusions: MRI can provide important image-based measures of cardiac morphology that relate to disease severity and clinical outcomes in neonates with BPD.
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Affiliation(s)
| | - Nara S. Higano
- Center for Pulmonary Imaging Research
- Division of Pulmonary Medicine
| | | | - Emilia S. Olson
- Center for Pulmonary Imaging Research
- Department of Radiology, and
| | - David R. Spielberg
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Pulmonary Medicine Service, Texas Children’s Hospital, Houston, Texas; and
| | - Paul S. Kingma
- Division of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Robert J. Fleck
- Department of Radiology, and
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sean M. Lang
- Division of Cardiology
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ryan A. Moore
- Division of Cardiology
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Michael D. Taylor
- Division of Cardiology
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jason C. Woods
- Center for Pulmonary Imaging Research
- Division of Pulmonary Medicine
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Wang HH, Tseng WYI, Yu HY, Chang MC, Peng HH. Phase-contrast magnetic resonance imaging for analyzing hemodynamic parameters and wall shear stress of pulmonary arteries in patients with pulmonary arterial hypertension. MAGNETIC RESONANCE MATERIALS IN PHYSICS BIOLOGY AND MEDICINE 2019; 32:617-627. [PMID: 31270715 DOI: 10.1007/s10334-019-00767-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 05/29/2019] [Accepted: 06/24/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate flow-related parameters in pulmonary arteries of patients with pulmonary arterial hypertension (PAH). MATERIALS AND METHODS Eleven PAH patients and twelve control participants were recruited. PAH and controls had similar age and gender distribution. 2D phase-contrast MRI (PC-MRI) was performed in the main, right, and left pulmonary artery (MPA, RPA, and LPA). The flow velocity, wall shear stress (WSS), and oscillatory shear index (OSI) were measured. RESULTS PAH patients displayed prolonged acceleration time (Tacce) and increased ratio of flow change to acceleration volume in pulmonary arteries (both P < 0.001). The temporally averaged WSS values of MPA, RPA, and LPA in PAH patients were significantly lower than those of control participants (P < 0.001). The OSI in the pulmonary arteries was higher in PAH patients than control participants (P < 0.05). The ROC analysis indicated the ratio of maximum flow change to acceleration volume, WSS, and Tacce exhibited sufficient sensitivity and specificity to detect patients with PAH. The WSS demonstrated strong correlations with Tacce and the ratio value in the two groups (R2 = 0.78-0.96). CONCLUSIONS We used a clinically feasible 2D PC-MRI sequence with a reasonable scanning time to compute aforementioned indices. The quantitative parameters provided sufficient information to differentiate PAH patients from control participants.
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Affiliation(s)
- Hung-Hsuan Wang
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, No. 101, Section 2, Kuang-Fu Road, BMES Building, R415, Hsinchu, 30013, Taiwan
| | - Wen-Yih Isaac Tseng
- Institute of Medical Device and Imaging, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsi-Yu Yu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Chu Chang
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, No. 101, Section 2, Kuang-Fu Road, BMES Building, R415, Hsinchu, 30013, Taiwan
| | - Hsu-Hsia Peng
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, No. 101, Section 2, Kuang-Fu Road, BMES Building, R415, Hsinchu, 30013, Taiwan.
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Macdonald JA, Franҫois CJ, Forouzan O, Chesler NC, Wieben O. MRI assessment of aortic flow in patients with pulmonary arterial hypertension in response to exercise. BMC Med Imaging 2018; 18:55. [PMID: 30577768 PMCID: PMC6303959 DOI: 10.1186/s12880-018-0298-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 12/09/2018] [Indexed: 11/30/2022] Open
Abstract
Background While primarily a right heart disease, pulmonary arterial hypertension (PAH) can impact left heart function and aortic flow through a shifted interventricular septum from right ventricular pressure overload and reduced left ventricular preload, among other mechanisms. In this study, we used phase contrast (PC) MRI and a modest exercise challenge to examine the effects of PAH on systemic circulation. While exercise challenges are typically performed with ultrasound in the clinic, MRI exercise studies allow for more reproducible image alignment, more accurate flow quantification, and improved tissue contrast. Methods Six PAH patients and fifteen healthy controls (8 older age-matched, 7 younger) exercised in the magnet bore with an MRI-compatible exercise device that allowed for scanning immediately following cessation of exercise. PC scans were performed in the ascending aorta during a breath hold immediately after modest exercise to non-invasively measure stroke volume (SV), cardiac output (CO), aortic peak systolic flow (PSF), and aortic wall stiffness via relative area change (RAC). Results Images following exercise showed mild blurring, but were high enough quality to allow for segmentation of the aorta. While SV was approximately 30% lower in PAH patients (SVPAH,rest = 67 ± 16 mL; SVPAH,stress = 90 ± 42 mL) than age-matched controls (SV,older,rest = 93 ± 16 mL; SVolder,stress = 133 ± 40 mL) at both rest and following exercise, CO was similar for both groups following exercise (COPAH,stress = 10.8 ± 5.7 L/min; COolder,stress = 11.8 ± 5.0 L/min). This was achieved through a compensatory increase in heart rate in the PAH subjects (74% increase as compared to 29% in age-matched controls). The PAH subjects also demonstrated reduced aortic peak systolic flow relative to the healthy controls (PSFPAH,rest = 309 ± 52 mL/s; PSFolder,rest = 416 ± 114 mL/s; PSFPAH,stress = 388 ± 113 mL/s; PSFolder,stress = 462 ± 176 mL/s). PAH patients and older controls demonstrated stiffer aortic walls when compared to younger controls (RACPAH,rest = 0.15 ± 0.05; RAColder,rest = 0.17 ± 0.05; RACyoung,rest = 0.28 ± 0.08). Conclusions PC MRI following a modest exercise challenge was capable of detecting differences in left heart dynamics likely induced from PAH. These results demonstrated that PAH can have a significant influence on systemic flow, even when the patient has no prior left heart disease. Image quantification following exercise could likely be improved in future studies through the implementation of free-breathing or real-time MRI acquisitions. Trial registration Retrospectively registered on 02/26/2018 (TRN:NCT03523910).
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Affiliation(s)
- Jacob A Macdonald
- Department of Medical Physics, University of Wisconsin, 1111 Highland Avenue, Room 1005, Madison, WI, 53705, USA.
| | | | - Omid Forouzan
- Department of Biomedical Engineering, University of Wisconsin, Madison, USA
| | - Naomi C Chesler
- Department of Biomedical Engineering, University of Wisconsin, Madison, USA
| | - Oliver Wieben
- Department of Medical Physics, University of Wisconsin, 1111 Highland Avenue, Room 1005, Madison, WI, 53705, USA.,Department of Radiology, University of Wisconsin, Madison, USA.,Department of Biomedical Engineering, University of Wisconsin, Madison, USA
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Pulmonary arterial stiffness assessed by cardiovascular magnetic resonance imaging is a predictor of mild pulmonary arterial hypertension. Int J Cardiovasc Imaging 2018; 35:1881-1892. [DOI: 10.1007/s10554-018-1397-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 06/13/2018] [Indexed: 11/27/2022]
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10
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Sirajuddin A, Donnelly EF, Crabtree TP, Henry TS, Iannettoni MD, Johnson GB, Kazerooni EA, Maldonado F, Olsen KM, Wu CC, Mohammed TL, Kanne JP. ACR Appropriateness Criteria ® Suspected Pulmonary Hypertension. J Am Coll Radiol 2018; 14:S350-S361. [PMID: 28473092 DOI: 10.1016/j.jacr.2017.01.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 11/15/2022]
Abstract
Pulmonary hypertension may be idiopathic or related to a large variety of diseases. Various imaging examinations that may be helpful in diagnosing and determining the etiology of pulmonary hypertension are discussed. Imaging examinations that may aid in the diagnosis of pulmonary hypertension include chest radiography, ultrasound echocardiography, ventilation/perfusion scans, CT, MRI, right heart catheterization, pulmonary angiography, and fluorine-18-2-fluoro-2-deoxy-d-glucose PET/CT. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Edwin F Donnelly
- Panel Vice-Chair, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Traves P Crabtree
- Southern Illinois University School of Medicine, Springfield, Illinois; Society of Thoracic Surgeons
| | - Travis S Henry
- University of California, San Francisco, San Francisco, California
| | | | | | | | - Fabien Maldonado
- Vanderbilt University Medical Center, Nashville, Tennessee; American College of Chest Physicians
| | | | - Carol C Wu
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tan-Lucien Mohammed
- Specialty Chair, University of Florida College of Medicine, Gainesville, Florida
| | - Jeffrey P Kanne
- Panel Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Venner C, Odille F, Voilliot D, Chaouat A, Chabot F, Felblinger J, Bonnemains L. Can MRI detect pulmonary hypertension in a population pre-selected by echocardiography? Acta Radiol 2018; 59:180-187. [PMID: 28595488 DOI: 10.1177/0284185117712541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The place of magnetic resonance imaging (MRI) in the assessment of pulmonary hypertension (PH) remains controversial. Several studies proposed to use MRI to assess pulmonary pressure but the level of proof is low. Purpose To evaluate the diagnostic power of cardiac MRI within a non-selected population of patients suspected of PH after an echocardiography. Material and Methods Fifty-six consecutive patients, suspected of PH after an echocardiography, were assessed with right heart catheterization and cardiac MRI (including a high temporal resolution pulmonary flow curve). We extracted from the MRI data the main parameters proposed by all precedent studies available in the literature. We looked for multivariate linear relations between those parameters and the mean pulmonary arterial pressure (mPAP), and eventually assessed with a logit regression the ability of those parameters to diagnose PH in our population. Results The multivariate model retained only two parameters: the right ventricle ejection fraction and the pulmonary trunk minimum area. The prediction of mPAP (r2 = 0.5) yielded limits of agreement of 15 mmHg. However, the prediction of PH within the population was feasible and the method yielded a specificity of 80% for a sensitivity of 100%. Conclusion The performance of MRI to assess mPAP is too low to be used as a replacement for right heart catheterization but MRI could be used as second line examination after echocardiography to avoid right heart catheterization for normal patients.
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Affiliation(s)
- Clement Venner
- Department of Cardiology, CHU Nancy, Nancy, France
- U947, INSERM, Nancy, France
- IADI, Université de Lorraine, Nancy, France
| | - Freddy Odille
- U947, INSERM, Nancy, France
- IADI, Université de Lorraine, Nancy, France
| | - Damien Voilliot
- Department of Cardiology, CHU Nancy, Nancy, France
- U947, INSERM, Nancy, France
- IADI, Université de Lorraine, Nancy, France
| | - Ari Chaouat
- Department of Pneumology, CHU Nancy, Nancy, France
| | | | - Jacques Felblinger
- U947, INSERM, Nancy, France
- IADI, Université de Lorraine, Nancy, France
- CIC-IT 1433, CHU Nancy, Nancy, France
| | - Laurent Bonnemains
- U947, INSERM, Nancy, France
- IADI, Université de Lorraine, Nancy, France
- Department of Cardiac Surgery, CHU Strasbourg, Strasbourg, France
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12
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Abstract
Pulmonary hypertension is defined by a mean pulmonary artery pressure greater than 25 mm Hg. Chronic thromboembolic pulmonary hypertension (CTEPH) is defined as pulmonary hypertension in the presence of an organized thrombus within the pulmonary vascular bed that persists at least 3 months after the onset of anticoagulant therapy. Because CTEPH is potentially curable by surgical endarterectomy, correct identification of patients with this form of pulmonary hypertension and an accurate assessment of surgical candidacy are essential to provide optimal care. Patients most commonly present with symptoms of exertional dyspnea and otherwise unexplained decline in exercise capacity. Atypical chest pain, a nonproductive cough, and episodic hemoptysis are observed less frequently. With more advanced disease, patients often develop symptoms suggestive of right ventricular compromise. Physical examination findings are minimal early in the course of this disease, but as pulmonary hypertension progresses, may include nonspecific finding of right ventricular failure, such as a tricuspid regurgitation murmur, pedal edema, and jugular venous distention. Chest radiographs may suggest pulmonary hypertension, but are neither sensitive nor specific for the diagnosis. Radioisotopic ventilation-perfusion scanning is sensitive for detecting CTEPH, making it a valuable screening study. Conventional catheter-based pulmonary angiography retains an important role in establishing the presence and extent of chronic thromboembolic disease. However, computed tomographic and magnetic resonance imaging are playing a growing diagnostic role. Innovative technologies such as dual-energy computed tomography, dynamic contrast-enhanced magnetic resonance imaging, and optical coherence tomography show promise for contributing diagnostic information and assisting in the preoperative characterization of patients with CTEPH.
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13
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Quantitative magnetic resonance imaging phantoms: A review and the need for a system phantom. Magn Reson Med 2017; 79:48-61. [DOI: 10.1002/mrm.26982] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 09/01/2017] [Accepted: 10/04/2017] [Indexed: 01/16/2023]
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14
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Goss KN, Everett AD, Mourani PM, Baker CD, Abman SH. Addressing the challenges of phenotyping pediatric pulmonary vascular disease. Pulm Circ 2017; 7:7-19. [PMID: 28680562 PMCID: PMC5448545 DOI: 10.1086/689750] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 09/14/2016] [Indexed: 12/20/2022] Open
Abstract
Pediatric pulmonary vascular disease (PVD) and pulmonary hypertension (PH) represent phenotypically and pathophysiologically diverse disease categories, contributing substantial morbidity and mortality to a complex array of pediatric conditions. Here, we review the multifactorial nature of pediatric PVD, with an emphasis on improved recognition, phenotyping, and endotyping strategies for pediatric PH. Novel tailored approaches to diagnosis and treatment in pediatric PVD, as well as the implications for long-term outcomes, are highlighted.
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Affiliation(s)
- Kara N Goss
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Allen D Everett
- Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter M Mourani
- Section of Pediatric Critical Care, Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Christopher D Baker
- Pediatric Pulmonary Medicine, Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Steven H Abman
- Pediatric Pulmonary Medicine, Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
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15
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Metkus TS, Mullin CJ, Grandin EW, Rame JE, Tampakakis E, Hsu S, Kolb TM, Damico R, Hassoun PM, Kass DA, Mathai SC, Tedford RJ. Heart Rate Dependence of the Pulmonary Resistance x Compliance (RC) Time and Impact on Right Ventricular Load. PLoS One 2016; 11:e0166463. [PMID: 27861600 PMCID: PMC5115737 DOI: 10.1371/journal.pone.0166463] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 10/28/2016] [Indexed: 12/28/2022] Open
Abstract
Background The effect of heart rate (HR) and body surface area (BSA) on pulmonary RC time and right ventricular (RV) load is unknown. Methods To determine the association of HR and BSA with the pulmonary RC time and measures of RV load, we studied three large patient cohorts including subjects with 1) known or suspected pulmonary arterial hypertension (PAH) (n = 1008), 2) pulmonary hypertension due to left heart disease (n = 468), and 3) end-stage heart failure with reduced ejection fraction (n = 150). To corroborate these associations on an individual patient level, we performed an additional analysis using high-fidelity catheters in 22 patients with PAH undergoing right atrial pacing. Results A faster HR inversely correlated with RC time (p<0.01 for all), suggesting augmented RV pulsatile loading. Lower BSA directly correlated with RC time (p<0.05) although the magnitude of this effect was smaller than for HR. With incremental atrial pacing, cardiac output increased and total pulmonary resistance (TPR) fell. However, effective arterial elastance, its mean resistive component (TPR/heart period; 0.60±0.27 vs. 0.79±0.45;p = 0.048), and its pulsatile component (0.27±0.18 vs 0.39±0.28;p = 0.03) all increased at faster HR. Conclusion Heart rate and BSA are associated with pulmonary RC time. As heart rate increases, the pulsatile and total load on the RV also increase. This relationship supports a hemodynamic mechanism for adverse effects of tachycardia on the RV.
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Affiliation(s)
- Thomas S. Metkus
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Christopher J. Mullin
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - E. Wilson Grandin
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - J. Eduardo Rame
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Emmanouil Tampakakis
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Steven Hsu
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Todd M. Kolb
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Rachel Damico
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Paul M. Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - David A. Kass
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Ryan J. Tedford
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
- * E-mail:
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17
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Abstract
Involvement of the respiratory system is common in connective tissue diseases (CTDs), and the resultant lung injury can affect every part of the lung: the pleura, alveoli, interstitium, vasculature, lymphatic tissue, and large and/or small airways. Most of the parenchymal manifestations of CTD are similar to those found in interstitial lung diseases (ILDs), especially idiopathic interstitial pneumonias, and can be classified using the same system. Although there is some overlap, each CTD is associated with a characteristic pattern of pulmonary involvement. For this reason, thin-section CT as well as pulmonary function tests and serum markers are utilized for diagnosis, disease severity assessment, and therapeutic efficacy evaluation of ILD associated with CTD. In addition, newly developed pulmonary magnetic resonance imaging (MRI) procedures have been recommended as useful alternative imaging options for patients with CTD. This review article will (1) address radiological findings for chest radiography and conventional or thin-section CT currently used for six major types of CTD, rheumatoid arthritis, scleroderma (progressive systemic sclerosis), polymyositis/dermatomyositis, systemic lupus erythematosus, Sjögren syndrome and mixed connective tissue disease; (2) briefly deal with radiation dose reduction for thin-section CT examination; and (3) discuss clinically applicable or state-of-the-art MR imaging for CTD patients.
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18
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Freed BH, Collins JD, François CJ, Barker AJ, Cuttica MJ, Chesler NC, Markl M, Shah SJ. MR and CT Imaging for the Evaluation of Pulmonary Hypertension. JACC Cardiovasc Imaging 2016; 9:715-32. [PMID: 27282439 PMCID: PMC4905589 DOI: 10.1016/j.jcmg.2015.12.015] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 12/14/2015] [Accepted: 12/16/2015] [Indexed: 01/08/2023]
Abstract
Imaging plays a central role in the diagnosis and management of all forms of pulmonary hypertension (PH). Although Doppler echocardiography is essential for the evaluation of PH, its ability to optimally evaluate the right ventricle and pulmonary vasculature is limited by its 2-dimensional planar capabilities. Magnetic resonance and computed tomography are capable of determining the etiology and pathophysiology of PH, and can be very useful in the management of these patients. Exciting new techniques such as right ventricle tissue characterization with T1 mapping, 4-dimensional flow of the right ventricle and pulmonary arteries, and computed tomography lung perfusion imaging are paving the way for a new era of imaging in PH. These imaging modalities complement echocardiography and invasive hemodynamic testing and may be useful as surrogate endpoints for early phase PH clinical trials. Here we discuss the role of magnetic resonance imaging and computed tomography in the diagnosis and management of PH, including current uses and novel research applications, and we discuss the role of value-based imaging in PH.
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Affiliation(s)
- Benjamin H Freed
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jeremy D Collins
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Alex J Barker
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael J Cuttica
- Department of Radiology, University of Wisconsin, Madison, Wisconsin
| | - Naomi C Chesler
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael Markl
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Feinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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19
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Abstract
Pulmonary hypertension (PH) is a life-threatening, multifactorial pathophysiological haemodynamic condition, diagnosed when the mean pulmonary arterial pressure equals or exceeds 25 mmHg at rest during right heart catheterization. Cardiac MRI, in general, and MR phase-contrast (PC) imaging, in particular, have emerged as potential techniques for the standardized assessment of cardiovascular function, morphology and haemodynamics in PH. Allowing the quantification and characterization of macroscopic cardiovascular blood flow, MR PC imaging offers non-invasive evaluation of haemodynamic alterations associated with PH. Techniques used to study the PH include both the routine two-dimensional (2D) approach measuring predominant velocities through an acquisition plane and the rapidly evolving four-dimensional (4D) PC imaging, which enables the assessment of the complete time-resolved, three-directional blood-flow velocity field in a volume. Numerous parameters such as pulmonary arterial mean velocity, vessel distensibility, flow acceleration time and volume and tricuspid regurgitation peak velocity, as well as the duration and onset of vortical blood flow in the main pulmonary artery, have been explored to either diagnose PH or find non-invasive correlates to right heart catheter parameters. Furthermore, PC imaging-based analysis of pulmonary arterial pulse-wave velocities, wall shear stress and kinetic energy losses grants novel insights into cardiopulmonary remodelling in PH. This review aimed to outline the current applications of 2D and 4D PC imaging in PH and show why this technique has the potential to contribute significantly to early diagnosis and characterization of PH.
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Affiliation(s)
- Ursula Reiter
- 1 Division of General Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Gert Reiter
- 2 Research and Development, Siemens Healthcare, Graz, Austria
| | - Michael Fuchsjäger
- 1 Division of General Radiology, Department of Radiology, Medical University of Graz, Austria
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20
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Abstract
Despite advances in the care of preterm infants, these infants remain at risk bronchopulmonary dysplasia (BPD), which results in prolonged need for supplemental oxygen, recurrent respiratory exacerbations, and exercise intolerance. Recent investigations have highlighted the important contribution of the developing pulmonary circulation to lung development, showing that these infants are also at risk for pulmonary vascular disease (PVD), including pulmonary hypertension (PH) and pulmonary vascular abnormalities. Several epidemiologic studies have delineated the incidence of PH in preterm infants and the impact on outcomes. These studies have also highlighted gaps in the understanding of PVD in BPD.
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Affiliation(s)
- Peter M Mourani
- Section of Pediatric Critical Care, Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado, School of Medicine, 13121 East 17th Avenue, MS8414, Aurora, CO 80045, USA.
| | - Steven H Abman
- Section of Pulmonary Medicine, Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado, School of Medicine, Mail Stop B395, 13123 East 16th Avenue, Aurora, CO 80045, USA
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21
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Multiparametric Magnetic Resonance Imaging in Pulmonary Hypertension. CURRENT CARDIOVASCULAR IMAGING REPORTS 2015. [DOI: 10.1007/s12410-015-9360-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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22
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Falahatpisheh A, Rickers C, Gabbert D, Heng EL, Stalder A, Kramer HH, Kilner PJ, Kheradvar A. Simplified Bernoulli's method significantly underestimates pulmonary transvalvular pressure drop. J Magn Reson Imaging 2015; 43:1313-9. [PMID: 26584006 DOI: 10.1002/jmri.25097] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/03/2015] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To determine whether neglecting the flow unsteadiness in simplified Bernoulli's equation significantly affects the pulmonary transvalvular pressure drop estimation. MATERIALS AND METHODS 3.0T magnetic resonance imaging (MRI) 4D velocity mapping was performed on four healthy volunteers, seven patients with repaired tetralogy of Fallot, and thirteen patients with transposition of the great arteries repaired by arterial switch. Pulmonary transvalvular pressure drop was estimated based on two methods: General Bernoulli's Equation (GBE), ie, the most complete form; and Simplified Bernoulli's Equation (SBE), known as 4V(2) . More than 2300 individual pressure drop measurements were used to compare the simplified and the general Bernoulli's methods. A linear mixed-effects model was employed for statistical analyses, fully accounting for clustering of observations among the methods and systolic phases. RESULTS The simplified Bernoulli's method systematically underestimated the pressure drop compared to general Bernoulli's method during the entire systolic phase (P < 0.05), including the peak systole, where on average ΔpSBE/ΔpGBE=78%. CONCLUSION The simplified Bernoulli method underestimated the pressure drop during all systolic phases in all the studied subjects. Therefore, it is necessary to take into account the flow unsteadiness for more accurate estimation of the pressure drop. J. Magn. Reson. Imaging 2016;43:1313-1319.
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Affiliation(s)
- Ahmad Falahatpisheh
- University of California Irvine, Department of Biomedical Engineering, Edwards Lifesciences Center of Advanced Cardiovascular Technology; Irvine California USA
| | - Carsten Rickers
- University Hospital Schleswig-Holstein Campus Kiel, Department of Pediatric Cardiology; Kiel Germany
| | - Dominik Gabbert
- University Hospital Schleswig-Holstein Campus Kiel, Department of Pediatric Cardiology; Kiel Germany
| | - Ee Ling Heng
- Royal Brompton Hospital, London, UK, NIHR Cardiovascular Biomedical Research Unit of Royal Brompton and Harefield NHS Foundation Trust and Imperial College; London UK
| | | | - Hans-Heiner Kramer
- University Hospital Schleswig-Holstein Campus Kiel, Department of Pediatric Cardiology; Kiel Germany
| | - Philip J. Kilner
- Royal Brompton Hospital, London, UK, NIHR Cardiovascular Biomedical Research Unit of Royal Brompton and Harefield NHS Foundation Trust and Imperial College; London UK
| | - Arash Kheradvar
- University of California Irvine, Department of Biomedical Engineering, Edwards Lifesciences Center of Advanced Cardiovascular Technology; Irvine California USA
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23
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Terada M, Takehara Y, Isoda H, Uto T, Matsunaga M, Alley M. Low WSS and High OSI Measured by 3D Cine PC MRI Reflect High Pulmonary Artery Pressures in Suspected Secondary Pulmonary Arterial Hypertension. Magn Reson Med Sci 2015; 15:193-202. [PMID: 26567758 PMCID: PMC5600056 DOI: 10.2463/mrms.mp.2015-0038] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Purpose: Institutional Review Board (IRB)-approved prospective study was conducted to test whether objective and quantitative hemodynamic markers wall shear stress (WSS) and oscillatory shear index (OSI) measured by three-dimensional (3D) cine phase-contrast (PC) can reflect pulmonary arterial hypertension (PAH). Patients and Methods: Seventeen consecutive patients of suspected secondary PAH were examined for pulmonary artery pressures (PAPs) with right heart catheterization (RHC) and three-dimensional (3D) cine PC MR. Based on the RHC data, patients were subdivided into two groups of 12 non-PAH (median age of 74.5 years) and 5 PAH (median age of 77 years) patients. Based on 3D cine PC magnetic resonance (MR), hemodynamic parameters including spatially averaged systolic WSS (sWSS), diastolic WSS (dWSS), mean WSS (mWSS), OSI and blood vessel section area (BVSA) at the pulmonary arterial trunk were calculated. Streamline images in the pulmonary arteries were also assessed. All the parameters were compared between non-PAH and PAH groups. Results: sWSS (N/m2) and mWSS (N/m2) of PAH group was lower than that of non-PAH group (0.594 ± 0.067 vs. 0.961 ± 0.590, P = 0.001), (0.365 ± 0.035 vs. 0.489 ± 0.132, P = 0.027). OSI of PAH group was higher than that of non-PAH (0.214 ± 0.026 vs. 0.130 ± 0.046, P = 0.001). sWSS, mWSS, and dWSS were inversely correlated and OSI was positively correlated to mean PAP or systolic PAP with r values of –0.638 (P = 0.005), –0.643 (P = 0.005), –0.485 (P = 0.049), and 0.625 (P = 0.007); or –0.622 (P = 0.008), –0.629 (P = 0.007), –0.484 (P = 0.049), and 0.594 (P = 0.012), respectively. sWSS was also inversely correlated to BVSA with r value of –0.488 (P = 0.049), and OSI was correlated to BVSA with r value of 0.574 (P = 0.016). Vortex or helical flows were observed more frequently in PAH patients. Conclusions: The low sWSS and mWSS as well as high OSI measured with 3D cine PC MR could be potential hemodynamic markers for the increased PAP in suspected secondary PAH patients.
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Affiliation(s)
- Masaki Terada
- Department of Diagnostic Radiological Technology, Iwata City Hospital
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24
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Pektas A, Olgunturk R, Cevik A, Terlemez S, Kacar E, Oner YA. Magnetic resonance imaging in pediatric pulmonary hypertension. Tex Heart Inst J 2015; 42:209-15. [PMID: 26175631 DOI: 10.14503/thij-13-3998] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The present study aims to determine the efficacy and reliability of cardiovascular magnetic resonance imaging in establishing the diagnosis and prognosis of pulmonary hypertension in children. This is a retrospective comparison of 25 children with pulmonary hypertension and a control group comprising 19 healthy children. The diagnosis of pulmonary hypertension was made when the mean pulmonary artery pressure was ≥25 mmHg by catheter angiography. The children with pulmonary hypertension had significantly lower body mass indices than did the healthy children (P=0.048). In addition, the children with pulmonary hypertension had significantly larger main pulmonary artery diameters and ascending aortic diameters (both P=0.001) but statistically similar ratios of main pulmonary artery diameter-to-ascending aortic diameter. If the main pulmonary artery diameter was ≥25 mm, pediatric pulmonary hypertension was diagnosed with 72% sensitivity and 84% specificity. In the event that the ratio of main pulmonary artery diameter-to-ascending aorta diameter was ≥1, pediatric pulmonary hypertension was diagnosed with 60% sensitivity and 53% specificity. When compared with children who had New York Heart Association functional class II pulmonary hypertension, the children with functional class III pulmonary hypertension had significantly larger main (P=0.046), right (P=0.036), and left (P=0.003) pulmonary arteries. Cardiovascular magnetic resonance imaging is useful in the diagnosis of children with pulmonary hypertension. Pediatric pulmonary hypertension can be diagnosed with high sensitivity and specificity when the main pulmonary artery diameter measures ≥25 mm.
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25
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Pulmonary hypertension: NHLBI Workshop on the Primary Prevention of Chronic Lung Diseases. Ann Am Thorac Soc 2015; 11 Suppl 3:S178-85. [PMID: 24754827 DOI: 10.1513/annalsats.201312-443ld] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Pulmonary vascular dysfunction (PVD) precedes the onset of clinical signs and symptoms of pulmonary arterial hypertension (PAH). PAH is defined by the elevation of pulmonary arterial pressure, which often progresses to right ventricular (RV) dysfunction and failure. PAH affects subjects of all ages, and is associated with diverse medical conditions, most of which are rare. Several factors pose immediate challenges to the development of strategies for primary prevention of PAH, including: (1) the idiopathic or primary form of the disease is extremely rare, limiting screening practicality; (2) methods for the detection of preclinical PVD are currently not established; (3) the understanding of determinants of pulmonary vascular growth, structure, and function in normal and PAH states is insufficient; (4) relatively small numbers of "at-risk" subjects are available for long-term studies to accurately assess disease development; and (5) preventative therapies for PVD are lacking. Despite these limitations, leveraging known at-risk patient populations for study, as well as growing progress across multiple disciplines, ranging from systems biology to advanced and more sensitive functional imaging modalities, may facilitate the opportunity to significantly improve primary prevention research and implementation over the next decade.
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26
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Rolf A, Rixe J, Kim WK, Guth S, Körlings N, Möllmann H, Nef HM, Liebetrau C, Krombach G, Kramm T, Mayer E, Hamm CW. Pulmonary vascular remodeling before and after pulmonary endarterectomy in patients with chronic thromboembolic pulmonary hypertension: a cardiac magnetic resonance study. Int J Cardiovasc Imaging 2014; 31:613-9. [DOI: 10.1007/s10554-014-0580-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 12/12/2014] [Indexed: 11/24/2022]
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27
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Neilan TG, Bakker JP, Sharma B, Owens RL, Farhad H, Shah RV, Abbasi SA, Kohli P, Wilson J, DeMaria A, Jerosch-Herold M, Kwong RY, Malhotra A. T1 measurements for detection of expansion of the myocardial extracellular volume in chronic obstructive pulmonary disease. Can J Cardiol 2014; 30:1668-75. [PMID: 25442461 PMCID: PMC4258158 DOI: 10.1016/j.cjca.2014.08.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/14/2014] [Accepted: 08/14/2014] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND We aimed to assess whether chronic obstructive pulmonary disease (COPD) is associated with expansion of the myocardial extracellular volume (ECV) using T1 measurements. METHODS Adult COPD patients Global Initiative for Chronic Obstructive Lung Disease [GOLD] stage 2 or higher and free of known cardiovascular disease were recruited. All study patients underwent measures of pulmonary function, 6-minute walk test, serum measures of inflammation, overnight polysomnography, and a contrast cardiac magnetic resonance study. RESULTS Eight patients with COPD were compared with 8 healthy control subjects. The mean predicted forced expiratory volume at 1 second of COPD subjects was 68%. Compared with control subjects, patients had normal left ventricular (LV) and right ventricular size, mass, and function. However, compared with control subjects, the LV remodelling index (median, 0.87; interquartile range [IQR], 0.71-1.14; vs median, 0.62; IQR, 0.60-0.77; P ¼ 0.03) and active left atrial emptying fraction was increased (median, 46; IQR, 41-49; vs median, 38; IQR, 33-43; P ¼ 0.005), and passive left atrial emptying fraction was reduced (median, 24; IQR, 20-30; vs median, 44; IQR, 31-51; P ¼ 0.007). The ECV was increased in patients with COPD (median, 0.32; IQR, 0.05; vs median, 0.27; IQR, 0.05; P = 0.001). The ECV showed a strong positive association with LV remodelling (r = 0.72; P = 0.04) and an inverse association with the 6-minute walk duration (r = -0.79; P = 0.02) and passive left atrial emptying fraction (r = -0.68; P = 0.003). CONCLUSIONS Expansion of the ECV, suggestive of diffuse myocardial fibrosis, is present in COPD and is associated with LV remodelling, and reduced left atrial function and exercise capacity.
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Affiliation(s)
- Tomas G Neilan
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital; Cardiac MR PET CT Program, Division of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jessie P Bakker
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
| | - Bhavneesh Sharma
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Robert L Owens
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Hoshang Farhad
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ravi V Shah
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Siddique A Abbasi
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Puja Kohli
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Joel Wilson
- Division of Cardiovascular Medicine, University of California San Diego, San Diego, California, USA
| | - Anthony DeMaria
- Division of Cardiovascular Medicine, University of California San Diego, San Diego, California, USA
| | - Michael Jerosch-Herold
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond Y Kwong
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Atul Malhotra
- Pulmonary and Critical Care Division, University of California San Diego, San Diego, California, USA
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28
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Terada M, Matsuyoshi K, Yamada E, Anzawa Y, Oosugi M. [Study of scan parameters using three-dimensional cine phase contrast imaging for pulmonary artery velocity measurement]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2014; 70:1219-24. [PMID: 25410327 DOI: 10.6009/jjrt.2014_jsrt_70.11.1219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pulmonary artery flow velocity, flow volume and their derived biomarkers, such as acceleration time (AT), acceleration volume (AV) and peak velocity (PV), vary depending on the severity and type of pulmonary disease. Therefore, accurate measurements of pulmonary artery velocity are very important for assessing the severity of pulmonary disease. The purpose of this study was to optimize the imaging parameters for pulmonary artery flow velocity using 3D cine PC MR, and to evaluate AT, AV, and PV for pulmonary hypertension. We changed the flip angle (FA) and view per segment (VPS). FA influenced the signal intensity, which was calculated from the magnitude images. Smaller VPS improved the accuracy of PV. Consequently, optimal setting of FA and VPS was important for hemodynamic analysis. We established the optimal FA and VPS for use in the hemodynamic analysis. AV and PV at the right pulmonary artery differed significantly between healthy volunteers and patients with pulmonary hypertension. Hemodynamic analysis of 3D cine PC MR imaging was considered promising for the evaluation of pulmonary disease.
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Abstract
Chronic obstructive pulmonary disorder (COPD) is a systemic disease that affects the cardiovascular system through multiple pathways. Pulmonary hypertension, ventricular dysfunction, and atherosclerosis are associated with smoking and COPD, causing significant morbidity and poor prognosis. Coupling between the pulmonary and cardiovascular system involves mechanical interdependence and inflammatory pathways that potentially affect the entire circulation. Although treatments specific for COPD-related cardiovascular and pulmonary vascular disease are limited, early diagnosis, study of pathophysiology, and monitoring the effects of treatment are enhanced with improved imaging techniques. In this article, we review recent advancements in the imaging of the vasculature and the heart in patients with COPD. We also explore the potential mechanism of coupling between the progression of COPD and vascular disease. Imaging methods reviewed include specific implementations of computed tomography, magnetic resonance imaging, dual-energy computed tomography, positron emission tomography, and echocardiography. Specific applications to the proximal and distal pulmonary vasculature, as well as to the heart and systemic circulation, are also discussed.
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Quantitative magnetic resonance imaging of pulmonary hypertension: a practical approach to the current state of the art. J Thorac Imaging 2014; 29:68-79. [PMID: 24552882 DOI: 10.1097/rti.0000000000000079] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Pulmonary hypertension is a condition of varied etiology, commonly associated with poor clinical outcome. Patients are categorized on the basis of pathophysiological, clinical, radiologic, and therapeutic similarities. Pulmonary arterial hypertension (PAH) is often diagnosed late in its disease course, with outcome dependent on etiology, disease severity, and response to treatment. Recent advances in quantitative magnetic resonance imaging (MRI) allow for better initial characterization and measurement of the morphologic and flow-related changes that accompany the response of the heart-lung axis to prolonged elevation of pulmonary arterial pressure and resistance and provide a reproducible, comprehensive, and noninvasive means of assessing the course of the disease and response to treatment. Typical features of PAH occur primarily as a result of increased pulmonary vascular resistance and the resultant increased right ventricular (RV) afterload. Several MRI-derived diagnostic markers have emerged, such as ventricular mass index, interventricular septal configuration, and average pulmonary artery velocity, with diagnostic accuracy similar to that of Doppler echocardiography. Furthermore, prognostic markers have been identified with independent predictive value for identification of treatment failure. Such markers include large RV end-diastolic volume index, low left ventricular end-diastolic volume index, low RV ejection fraction, and relative area change of the pulmonary trunk. MRI is ideally suited for longitudinal follow-up of patients with PAH because of its noninvasive nature and high reproducibility and is advantageous over other biomarkers in the study of PAH because of its sensitivity to change in morphologic, functional, and flow-related parameters. Further study on the role of MRI image based biomarkers in the clinical environment is warranted.
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Barker AJ, Roldán-Alzate A, Entezari P, Shah SJ, Chesler NC, Wieben O, Markl M, François CJ. Four-dimensional flow assessment of pulmonary artery flow and wall shear stress in adult pulmonary arterial hypertension: results from two institutions. Magn Reson Med 2014; 73:1904-13. [PMID: 24974951 DOI: 10.1002/mrm.25326] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 05/27/2014] [Accepted: 05/27/2014] [Indexed: 12/31/2022]
Abstract
PURPOSE To compare pulmonary artery flow using Cartesian and radially sampled four-dimensional flow-sensitive (4D flow) MRI at two institutions. METHODS Nineteen healthy subjects and 17 pulmonary arterial hypertension (PAH) subjects underwent a Cartesian 4D flow acquisition (institution 1) or a three-dimensional radial acquisition (institution 2). The diameter, peak systolic velocity (Vmax), peak flow (Qmax), stroke volume (SV), and wall shear stress (WSS) were computed in two-dimensional analysis planes at the main, right, and left pulmonary artery. Interobserver variability, interinstitutional differences, flow continuity, and the hemodynamic measurements in healthy and PAH subjects were assessed. RESULTS Vmax, Qmax, SV, and WSS at all locations were significantly lower (P < 0.05) in PAH compared with healthy subjects. The limits of agreement were 0.16 m/s, 2.4 L/min, 10 mL, and 0.31 N/m(2) for Vmax, Qmax, SV, and WSS, respectively. Differences between Qmax and SV using Cartesian and radial sequences were not significant. Plane placement and acquisition exhibited isolated, site-based differences between Vmax and WSS. CONCLUSIONS 4D flow MRI was used to detect differences in pulmonary artery hemodynamics for PAH subjects. Flow and WSS in healthy and PAH subject cohorts were similar between Cartesian- and radial-based 4D flow MRI acquisitions with minimal interobserver variability.
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Affiliation(s)
- Alex J Barker
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Alassas K, Mergo P, Ibrahim ES, Burger C, Safford R, Parikh P, Shapiro B. Cardiac MRI as a diagnostic tool in pulmonary hypertension. Future Cardiol 2014; 10:117-30. [DOI: 10.2217/fca.13.97] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT: Pulmonary hypertension is characterized by alterations in the viscoelastic properties of the pulmonary arteries, leading to increased pulmonary arterial stiffness and elevated pressures. Early detection and accurate quantification of pulmonary hypertension are limitations to conventional noninvasive imaging and may have therapeutic implications. Cardiac MRI provides important information that can aid the clinician, particularly relating to morphologic right ventricular alterations and quantification of stiffness, as well as providing a novel prognostic framework.
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Affiliation(s)
- Khadija Alassas
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Patricia Mergo
- Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - El-Sayed Ibrahim
- Division of Nephrology & Hypertension, Department of Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Charles Burger
- Division of Pulmonary Medicine, Department of Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Robert Safford
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Pragnesh Parikh
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Brian Shapiro
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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Assessment of pulmonary artery pulse wave velocity in children: An MRI pilot study. Magn Reson Imaging 2013; 31:1690-4. [DOI: 10.1016/j.mri.2013.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 08/06/2013] [Accepted: 08/20/2013] [Indexed: 11/22/2022]
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Truong U, Fonseca B, Dunning J, Burgett S, Lanning C, Ivy DD, Shandas R, Hunter K, Barker AJ. Wall shear stress measured by phase contrast cardiovascular magnetic resonance in children and adolescents with pulmonary arterial hypertension. J Cardiovasc Magn Reson 2013; 15:81. [PMID: 24034144 PMCID: PMC3848825 DOI: 10.1186/1532-429x-15-81] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 09/03/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a devastating disease with significant morbidity and mortality. At the macroscopic level, disease progression is observed as a complex interplay between mean pulmonary artery pressure, pulmonary vascular resistance, pulmonary vascular stiffness, arterial size, and flow. Wall shear stress (WSS) is known to mediate or be dependent on a number of these factors. Given that WSS is known to promote architectural vessel remodeling, it is imperative that the changes of this factor be quantified in the presence of PAH. METHODS In this study, we analyzed phase contrast imaging of the right pulmonary artery derived from cardiovascular magnetic resonance to quantify the local, temporal and circumferentially averaged WSS of a PAH population and a pediatric control population. In addition, information about flow and relative area change were derived. RESULTS Although the normotensive and PAH shear waveform exhibited a WSS profile which is uniform in magnitude and direction along the vessel circumference at systole, time-averaged WSS (2.2 ± 1.6 vs. 6.6 ± 3.4 dynes/cm(2), P = 0.018) and systolic WSS (8.2 ± 5.0 v. 20.0 ± 9.1 dynes/cm(2), P = 0.018) was significantly depressed in the PAH population as compared to the controls. BSA-indexed PA diameter was significantly larger in the PAH population (1.5 ± 0.4 vs. 0.7 ± 0.1 cm/m(2), P = 0.003). CONCLUSIONS In the presence of preserved flow rates through a large PAH pulmonary artery, WSS is significantly decreased. This may have implications for proximal pulmonary artery remodeling and cellular function in the progression of PAH.
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Affiliation(s)
- Uyen Truong
- Division of Pediatric Cardiology, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Brian Fonseca
- Division of Pediatric Cardiology, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Jamie Dunning
- Department for Bioengineering, University of Colorado, 13123 E. 16th Avenue B100, Aurora, CO 80045, USA
| | - Shawna Burgett
- Department for Bioengineering, University of Colorado, 13123 E. 16th Avenue B100, Aurora, CO 80045, USA
| | - Craig Lanning
- Department for Bioengineering, University of Colorado, 13123 E. 16th Avenue B100, Aurora, CO 80045, USA
| | - D Dunbar Ivy
- Division of Pediatric Cardiology, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Robin Shandas
- Division of Pediatric Cardiology, Children’s Hospital Colorado, Aurora, CO 80045, USA
- Department for Bioengineering, University of Colorado, 13123 E. 16th Avenue B100, Aurora, CO 80045, USA
| | - Kendall Hunter
- Department for Bioengineering, University of Colorado, 13123 E. 16th Avenue B100, Aurora, CO 80045, USA
| | - Alex J Barker
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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Han Y, Yang Z, Yu T, Yu J, Xue M, Zhang Z, Li D. [The assessment of right ventricular function and pulmonary artery hemodynamics in patients with pulmonary hypertension by 1.5T MRI]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2012; 15:471-5. [PMID: 22901995 PMCID: PMC5999951 DOI: 10.3779/j.issn.1009-3419.2012.08.04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVE Pulmonary hypertension (PH) is characterized by rising pulmonary arterial pressure, decreasing right ventricular (RV) function, and ultimately, RV failure. Therefore, it is important to monitor RV function and pulmonary artery hemodynamics accurately and noninvasively. This study evaluates cardiac magnetic resonance imaging (CMRI) in assessing RV function and pulmonary artery hemodynamics in patients with PH. METHODS Cine-MRI and phase-contrast MRI (PC-MRI) were performed in 25 PH patients and 30 healthy volunteers. Cine-MRI images were post-processed on Report Card software and the following parameters were obtained: RV end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), ejection fraction (EF), and myocardial mass (MM). Except for EF, all of the above parameters were normalized to body surface area (BSA). PC-MRI images were post-processed on Report Card software, peak velocity and distensibility of main pulmonary artery (MPA) could also be obtained. Student t test was employed for statistical assessment. RESULTS Compared with controls, RV EDV, ESV and MM index in PH patients were significantly increased (P<0.01), EF was significantly impaired (P<0.01), peak velocity and distensibility of MPA were significantly lower (P<0.01). SV index between the two groups had no significant difference (P>0.05). CONCLUSIONS Cardiac MRI is of great value in the assessment of RV function and MPA hemodynamic parameters in patients with PH.
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Affiliation(s)
- Yan Han
- Department of Radiology, Tianjin Medical University General Hospital, Tianjin 300052, China
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Magnetic resonance imaging to assess the effect of exercise training on pulmonary perfusion and blood flow in patients with pulmonary hypertension. Eur Radiol 2012; 23:324-31. [PMID: 22886553 DOI: 10.1007/s00330-012-2606-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 06/27/2012] [Accepted: 06/29/2012] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To evaluate whether careful exercise training improves pulmonary perfusion and blood flow in patients with pulmonary hypertension (PH), as assessed by magnetic resonance imaging (MR). METHODS Twenty patients with pulmonary arterial hypertension or inoperable chronic thromboembolic PH on stable medication were randomly assigned to control (n = 10) or training groups (n = 10). Training group patients received in-hospital exercise training; patients of the sedentary control group received conventional rehabilitation. Medication remained unchanged during the study period. Changes of 6-min walking distance (6MWD), MR pulmonary flow (peak velocity) and MR perfusion (pulmonary blood volume) were assessed from baseline to week 3. RESULTS After 3 weeks of training, increases in mean 6MWD (P = 0.004) and mean MR flow peak velocity (P = 0.012) were significantly greater in the training group. Training group patients had significantly improved 6MWD (P = 0.008), MR flow (peak velocity -9.7 ± 8.6 cm/s, P = 0.007) and MR perfusion (pulmonary blood volume +2.2 ± 2.7 mL/100 mL, P = 0.017), whereas the control group showed no significant changes. CONCLUSION The study indicates that respiratory and physical exercise may improve pulmonary perfusion in patients with PH. Measurement of MR parameters of pulmonary perfusion might be an interesting new method to assess therapy effects in PH. The results of this initial study should be confirmed in a larger study group.
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Ramtohal RL, O’Kane PD, Radvan JR, Bull R, Ponnamperuma C, George SK. ‘New World’ imaging for an ‘Old World’ disease: Use of cardiac magnetic resonance imaging and 3D transesophageal echocardiography in severe rheumatic mitral valve disease. J Cardiol Cases 2012; 6:e4-e7. [DOI: 10.1016/j.jccase.2012.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 01/16/2012] [Accepted: 02/09/2012] [Indexed: 10/28/2022] Open
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Rajaram S, Swift AJ, Capener D, Elliot CA, Condliffe R, Davies C, Hill C, Hurdman J, Kidling R, Akil M, Wild JM, Kiely DG. Comparison of the diagnostic utility of cardiac magnetic resonance imaging, computed tomography, and echocardiography in assessment of suspected pulmonary arterial hypertension in patients with connective tissue disease. J Rheumatol 2012; 39:1265-74. [PMID: 22589263 DOI: 10.3899/jrheum.110987] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Pulmonary arterial hypertension (PAH) is a life-threatening complication of connective tissue diseases (CTD). Our aim was to compare the diagnostic utility of noninvasive imaging modalities, i.e., magnetic resonance imaging (MRI), computed tomography (CT), and echocardiography, in evaluation of these patients. METHODS In total, 81 consecutive patients with CTD and suspected PH underwent cardiac MRI, CT, and right heart catheterization (RHC) within 48 hours. Functional cardiac MRI variables [ventricle areas and ratios, delayed myocardial enhancement, position of the interventricular septum, right ventricular mass, ventricular mass index (VMI), and pulmonary artery distensibility] were all evaluated. The pulmonary artery size, pulmonary artery/aortic ratio (PA/Ao), left and right ventricular (RV) diameter ratio, RV wall thickness, and grade of tricuspid regurgitation were measured on CT. Tricuspid gradient (TG) and size of the RV were assessed using echocardiography. RESULTS In our study of 81 patients with CTD, 55 had PAH, 22 had no PH, and 4 had PH owing to left heart disease. There was good correlation between mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) measured by RHC and VMI derived from MRI (mPAP, r = 0.69, p < 0.001; PVR, r = 0.78, p < 0.001) and systolic area ratio (mPAP, r = 0.69, p < 0.001; PVR, r = 0.68, p < 0.001) and TG derived from echocardiography (mPAP, r = 0.84, p < 0.001; PVR, r = 0.76, p < 0.001). In contrast, CT measures showed only moderate correlation. MRI and echocardiography each performed better as a diagnostic test for PAH than CT-derived measures: VMI ≥ 0.45 had a sensitivity of 85% and specificity 82%; and TG ≥ 40 mm Hg had a sensitivity of 86% and specificity 82%. Univariate Cox regression analysis showed the MRI measurements were better at predicting mortality. Patients with RV end diastolic volume < 135 ml had a better prognosis than those with a value > 135 ml, with a 1-year survival of 95% versus 66%, respectively. CONCLUSION In patients with CTD and suspected PAH, cardiac MRI and echocardiography have greater diagnostic utility than CT in the assessment of patients with suspected PAH, and MRI has prognostic value.
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Affiliation(s)
- Smitha Rajaram
- Unit of Academic Radiology, University of Sheffield, Sheffield, UK.
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Skrok J, Shehata ML, Mathai S, Girgis RE, Zaiman A, Mudd JO, Boyce D, Lechtzin N, Lima JAC, Bluemke DA, Hassoun PM, Vogel-Claussen J. Pulmonary arterial hypertension: MR imaging-derived first-pass bolus kinetic parameters are biomarkers for pulmonary hemodynamics, cardiac function, and ventricular remodeling. Radiology 2012; 263:678-87. [PMID: 22509050 DOI: 10.1148/radiol.12111001] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE To prospectively compare contrast material-enhanced (CE) magnetic resonance (MR) imaging-derived right-to-left ventricle pulmonary transit time (PTT), left ventricular (LV) full width at half maximum (FWHM), and LV time to peak (TTP) between patients with pulmonary arterial hypertension (PAH) and healthy volunteers and to correlate these measurements with survival markers in patients with PAH. MATERIALS AND METHODS This HIPAA-compliant study received institutional review board approval. Written informed consent was obtained from all participants. Forty-three patients (32 with PAH [29 women; median age, 55.4 years], 11 with scleroderma but not PAH [seven women; median age, 58.9 years]) underwent right-sided heart catheterization and 3-T CE cardiac MR imaging. Eighteen age- and sex-matched healthy control subjects (12 women; median age, 51.7 years) underwent only CE MR imaging. A short-axis saturation-recovery gradient-echo section was acquired in the basal third of both ventricles, and right-to-left-ventricle PTT, LV FWHM, and LV TTP were calculated. Statistical analysis included Kruskal-Wallis test, Wilcoxon rank sum test, Spearman correlation coefficient, multiple linear regression analysis, and Lin correlation coefficient analysis. RESULTS Patients had significantly longer PTT (median, 8.2 seconds; 25th-75th percentile, 6.9-9.9 seconds), FWHM (median, 8.2 seconds; 25th-75th percentile, 5.7-11.4 seconds), and TTP (median, 4.8 seconds; 25th-75th percentile, 3.9-6.5 seconds) than did control subjects (median, 6.4 seconds; 25th-75th percentile, 5.7-7.1 seconds; median, 5.2 seconds; 25th-75th percentile, 4.1-6.1 seconds; median, 3.2 seconds; 25th-75th percentile, 2.8-3.8 seconds, respectively; P < .01 for each) and subjects with scleroderma but not PAH (median, 6.5 seconds; 25th-75th percentile, 5.6-7.0 seconds; median, 5.0 seconds; 25th-75th percentile, 4.0-7.3 seconds; median, 3.6 seconds; 25th-75th percentile, 2.7-4.0 seconds, respectively; P < .02 for each). PTT, LV FWHM, and LV TTP correlated with pulmonary vascular resistance index (P < .01), right ventricular stroke volume index (P ≤ .01), and pulmonary artery capacitance (P ≤ .02). In multiple linear regression models, PTT, FWHM, and TTP were associated with mean pulmonary arterial pressure and cardiac index. CONCLUSION CE MR-derived PTT, LV FWHM, and LV TTP are noninvasive compound markers of pulmonary hemodynamics and cardiac function in patients with PAH. Their predictive value for patient outcome warrants further investigation.
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Affiliation(s)
- Jan Skrok
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Nelson Basement MRI 110, 600 N Wolfe St, Baltimore, MD 21287, USA
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Cardiovascular magnetic resonance for the assessment of pulmonary arterial hypertension: toward a comprehensive CMR exam. Magn Reson Imaging 2012; 30:1047-58. [PMID: 22503091 DOI: 10.1016/j.mri.2012.03.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 02/24/2012] [Accepted: 03/01/2012] [Indexed: 11/22/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disorder characterized by abnormally increased blood pressure of the pulmonary circulation. The clinical course of the untreated PAH involves rapid progression to right ventricular (RV) failure and death. Right heart catheterization is the gold-standard method for confirming PAH. However, the technique's invasiveness and associated risks preclude its use on a regular basis. Different imaging techniques have been implemented for evaluating PAH, including echocardiography, computed tomography and nuclear medicine. However, these techniques have their own limitations. During the past decade, cardiovascular magnetic resonance (CMR) has been increasingly used for the evaluation of different cardiovascular diseases, including PAH, due to its high resolution, high tissue contrast, and the plethora of anatomical and physiological parameters that can be measured with this modality. This article presents an up-to-date review of the implementation of CMR for evaluating PAH. This is achieved by describing a comprehensive CMR protocol that includes several imaging sequences for assessing different cardiovascular parameters pertaining to PAH. In contrast to the previously published articles, the presented CMR protocol evaluates both RV function and pulmonary artery hemodynamics, which are both affected in PAH. Each imaging sequence is explained along with the image analysis steps required for deriving the cardiovascular parameters of interest. Then, based on an extensive literature review, the article illustrates the significance of the derived cardiovascular parameters and their association with PAH. The article concludes with a discussion of the advantages of the proposed CMR exam for better understanding of the disease pathophysiology and treatment planning.
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Kellihan HB, Stepien RL. Pulmonary hypertension in canine degenerative mitral valve disease. J Vet Cardiol 2012; 14:149-64. [PMID: 22364721 DOI: 10.1016/j.jvc.2012.01.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 01/10/2012] [Accepted: 01/11/2012] [Indexed: 11/27/2022]
Abstract
Pulmonary hypertension secondary to degenerative mitral valve disease has been recognized clinically for many years in veterinary medicine, and clinical diagnosis of this syndrome in dogs has been enhanced greatly by widespread use of echocardiography and Doppler echocardiography. Medical therapy is now available to treat this clinical complication of mitral valve disease, making timely diagnosis even more important to patient longevity and quality of life.
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Affiliation(s)
- Heidi B Kellihan
- Section of Cardiology, Department of Medicine, School of Veterinary Medicine, University of Wisconsin, 2015 Linden Dr., Madison, WI 53706, USA.
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Black blood MRI has diagnostic and prognostic value in the assessment of patients with pulmonary hypertension. Eur Radiol 2011; 22:695-702. [DOI: 10.1007/s00330-011-2306-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 09/03/2011] [Accepted: 09/28/2011] [Indexed: 02/06/2023]
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Weber TF, von Tengg-Kobligk H, Kopp-Schneider A, Ley-Zaporozhan J, Kauczor HU, Ley S. High-resolution phase-contrast MRI of aortic and pulmonary blood flow during rest and physical exercise using a MRI compatible bicycle ergometer. Eur J Radiol 2011; 80:103-8. [DOI: 10.1016/j.ejrad.2010.06.045] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Revised: 06/22/2010] [Accepted: 06/25/2010] [Indexed: 10/19/2022]
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Estimation of pulmonary vascular resistance in patients with pulmonary fibrosis by phase-contrast magnetic resonance imaging. Jpn J Radiol 2011; 29:563-9. [DOI: 10.1007/s11604-011-0598-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Accepted: 04/06/2011] [Indexed: 10/17/2022]
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Okajima Y, Ohno Y, Washko GR, Hatabu H. Assessment of pulmonary hypertension what CT and MRI can provide. Acad Radiol 2011; 18:437-53. [PMID: 21377593 DOI: 10.1016/j.acra.2011.01.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 01/06/2011] [Accepted: 01/12/2011] [Indexed: 01/06/2023]
Abstract
RATIONALES AND OBJECTIVES Pulmonary hypertension (PH) is a life-threatening condition, characterized by elevated pulmonary arterial pressure, which is confirmed based on invasive right heart catheterization (RHC). Noninvasive examinations may support diagnosis of PH before proceeding to RHC and play an important role in management and treatment of the disease. Although echocardiography is considered a standard tool in diagnosis, recent advances have made computed tomography (CT) and magnetic resonance (MR) imaging promising tools, which may provide morphologic and functional information. In this article, we review image-based assessment of PH with a focus on CT and MR imaging. CONCLUSIONS CT may provide useful morphologic information for depicting PH and seeking for underlying diseases. With the accumulated technological advancement, CT and MRI may provide practical tools for not only morphologic but also functional assessment of patients with PH.
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Affiliation(s)
- Yuka Okajima
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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Ley S, Grünig E, Kiely DG, van Beek E, Wild J. Computed tomography and magnetic resonance imaging of pulmonary hypertension: Pulmonary vessels and right ventricle. J Magn Reson Imaging 2011; 32:1313-24. [PMID: 21105137 DOI: 10.1002/jmri.22373] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Pulmonary hypertension (PH) is very heterogeneous and the classification identifies five major groups including many associated disease processes. The treatment of PH depends on the underlying cause and accurate classification is paramount. A comprehensive assessment to identify the cause and severity of PH is therefore needed. Furthermore, follow-up assessments are required to monitor changes in disease status and response to therapy. Traditionally, the diagnostic imaging work-up of PH comprised mainly echocardiography, invasive right heart catheterization, and ventilation/perfusion scintigraphy. Due to technical advances, multidetector row computed tomography (CT) and magnetic resonance imaging (MRI) have become important and complementary investigations in the evaluation of patients with suspected PH. Both modalities are reviewed and recommendations for clinical use are given.
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Affiliation(s)
- Sebastian Ley
- Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany.
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Sergiacomi G, Bolacchi F, Cadioli M, Angeli ML, Fucci F, Crusco S, Rogliani P, Pezzuto G, Romeo F, Mariano E, Simonetti G. Combined Pulmonary Fibrosis and Emphysema: 3D Time-resolved MR Angiographic Evaluation of Pulmonary Arterial Mean Transit Time and Time to Peak Enhancement. Radiology 2010; 254:601-8. [DOI: 10.1148/radiol.09081546] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Alunni JP, Degano B, Arnaud C, Tétu L, Blot-Soulétie N, Didier A, Otal P, Rousseau H, Chabbert V. Cardiac MRI in pulmonary artery hypertension: correlations between morphological and functional parameters and invasive measurements. Eur Radiol 2010; 20:1149-59. [PMID: 20094890 DOI: 10.1007/s00330-009-1664-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Revised: 09/09/2009] [Accepted: 10/14/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare cardiac MRI with right heart catheterisation in patients with pulmonary hypertension (PH) and to evaluate its ability to assess PH severity. MATERIALS AND METHODS Forty patients were included. MRI included cine and phase-contrast sequences, study of ventricular function, cardiac cavity areas and ratios, position of the interventricular septum (IVS) in systole and diastole, and flow measurements. We defined four groups according to the severity of PH and three groups according to IVS position: A, normal position; B, abnormal in diastole; C, abnormal in diastole and systole. RESULTS IVS position was correlated with pulmonary artery pressures and PVR (pulmonary vascular resistance). Median pulmonary artery pressures and resistance were significantly higher in patients with an abnormal septal position compared with those with a normal position. Correlations were good between the right ventricular ejection fraction and PVR, right ventricular end-systolic volume and PAP, percentage of right ventricular area change and PVR, and diastolic and systolic ventricular area ratio and PVR. These parameters were significantly associated with PH severity. CONCLUSION Cardiac MRI can help to assess the severity of PH.
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Affiliation(s)
- Jean-Philippe Alunni
- Department of Radiology, CHU Rangueil, 1 avenue Jean-Poulhès, TSA 50032, 31059, Toulouse Cedex 9, France
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Abstract
This article discusses the role of magnetic resonance angiography (MRA) in evaluating the pulmonary arterial system. For depiction of pulmonary arterial anatomy and morphology, MRA techniques are compared with CT angiography and digital subtraction x-ray angiography. Perfusion, flow, and function are emphasized, as the integrated MR examination offers a comprehensive assessment of vascular morphology and function. Advances in MR technology that improve spatial and temporal resolution and compensate for potential artifacts are reviewed as they pertain to pulmonary MRA. Current and emerging gadolinium contrast-enhanced and non-contrast-enhanced MRA techniques are discussed. The role of pulmonary MRA, clinical protocols, imaging findings, and interpretation pitfalls are reviewed for clinical indications.
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Affiliation(s)
- Elizabeth M Hecht
- Department of Radiology, New York University School of Medicine, 560 First Avenue, TCH-HW202, New York, NY 10016, USA.
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Devaraj A, Hansell D. Computed tomography signs of pulmonary hypertension: old and new observations. Clin Radiol 2009; 64:751-60. [DOI: 10.1016/j.crad.2008.12.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2008] [Revised: 11/28/2008] [Accepted: 12/02/2008] [Indexed: 10/21/2022]
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