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Kim NH, D'Armini AM, Delcroix M, Jaïs X, Jevnikar M, Madani MM, Matsubara H, Palazzini M, Wiedenroth CB, Simonneau G, Jenkins DP. Chronic thromboembolic pulmonary disease. Eur Respir J 2024:2401294. [PMID: 39209473 DOI: 10.1183/13993003.01294-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 07/05/2024] [Indexed: 09/04/2024]
Abstract
Chronic thromboembolic pulmonary hypertension is a complication of pulmonary embolism and a treatable cause of pulmonary hypertension. The pathology is a unique combination of mechanical obstruction due to failure of clot resolution, and a variable degree of microvascular disease, that both contribute to pulmonary vascular resistance. Accordingly, multiple treatments have been developed to target the disease components. However, accurate diagnosis is often delayed. Evaluation includes high-quality imaging modalities, necessary for disease confirmation and for appropriate treatment planning. All patients with chronic thromboembolic pulmonary disease, and especially those with pulmonary hypertension, should be referred to expert centres for multidisciplinary team decision on treatment. The first decision remains assessment of operability, and the best improvement in symptoms and survival is achieved by the mechanical therapies, pulmonary endarterectomy and balloon pulmonary angioplasty. With the advances in multimodal therapies, excellent outcomes can be achieved with 3-year survival of >90%.
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Affiliation(s)
- Nick H Kim
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
| | - Andrea M D'Armini
- Department of Cardio-Thoracic and Vascular Surgery, Heart and Lung Transplantation and Pulmonary Hypertension Unit, Foundation IRCCS Policlinico San Matteo, University of Pavia School of Medicine, Pavia, Italy
| | - Marion Delcroix
- Clinical Department of Respiratory Disease, Pulmonary Hypertension Center, UZ Leuven, Leuven, Belgium
| | - Xavier Jaïs
- AP-HP, Department of Respiratory and Intensive Care Medicine, Bicêtre Hospital, University of Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Mitja Jevnikar
- AP-HP, Department of Respiratory and Intensive Care Medicine, Bicêtre Hospital, University of Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Michael M Madani
- Division of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, CA, USA
| | - Hiromi Matsubara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Massimiliano Palazzini
- Dipartimento DIMEC (Dipartimento di Scienze Mediche e Chirurgiche), Universita di Bologna, Bologna, Italy
| | | | - Gérald Simonneau
- Pneumologie Kremlin Bicetre University Hospital, National Reference Center for Pulmonary Hypertension, Paris Saclay University, Paris, France
| | - David P Jenkins
- Cardiothoracic Surgery and Transplantation, Royal Papworth Hospital, Cambridge, UK
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Remy-Jardin M, Guiffault L, Oufriche I, Duhamel A, Flohr T, Schmidt B, Remy J. Image quality of lung perfusion with photon-counting-detector CT: comparison with dual-source, dual-energy CT. Eur Radiol 2024:10.1007/s00330-024-10888-0. [PMID: 38967660 DOI: 10.1007/s00330-024-10888-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/20/2024] [Accepted: 05/13/2024] [Indexed: 07/06/2024]
Abstract
PURPOSE To evaluate the quality of lung perfusion imaging obtained with photon-counting-detector CT (PCD-CT) in comparison with dual-source, dual-energy CT (DECT). METHODS Seventy-one consecutive patients scanned with PCD-CT were compared to a paired population scanned with dual-energy on a 3rd-generation DS-CT scanner using (a) for DS-CT (Group 1): collimation: 64 × 0.6 × 2 mm; pitch: 0.55; (b) for PCD-CT (Group 2): collimation: 144 × 0.4 mm; pitch: 1.5; single-source acquisition. The injection protocol was similar in both groups with the reconstruction of perfusion images by subtraction of high- and low-energy virtual monoenergetic images. RESULTS Compared to Group 1, Group 2 examinations showed: (a) a shorter duration of data acquisition (0.93 ± 0.1 s vs 3.98 ± 0.35 s; p < 0.0001); (b) a significantly lower dose-length-product (172.6 ± 55.14 vs 339.4 ± 75.64 mGy·cm; p < 0.0001); and (c) a higher level of objective noise (p < 0.0001) on mediastinal images. On perfusion images: (a) the mean level of attenuation did not differ (p = 0.05) with less subjective image noise in Group 2 (p = 0.049); (b) the distribution of scores of fissure visualization differed between the 2 groups (p < 0.0001) with a higher proportion of fissures sharply delineated in Group 2 (n = 60; 84.5% vs n = 26; 26.6%); (c) the rating of cardiac motion artifacts differed between the 2 groups (p < 0.0001) with a predominance of examinations rated with mild artifacts in Group 2 (n = 69; 97.2%) while the most Group 1 examinations showed moderate artifacts (n = 52; 73.2%). CONCLUSION PCD-CT acquisitions provided similar morphologic image quality and superior perfusion imaging at lower radiation doses. CLINICAL RELEVANCE STATEMENT The improvement in the overall quality of perfusion images at lower radiation doses opens the door for wider applications of lung perfusion imaging in clinical practice. KEY POINTS The speed of data acquisition with PCD-CT accounts for mild motion artifacts. Sharply delineated fissures are depicted on PCD-CT perfusion images. High-quality perfusion imaging was obtained with a 52% dose reduction.
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Affiliation(s)
- Martine Remy-Jardin
- Department of Thoracic Imaging, University Hospital Center of Lille, LILLE, France.
- ULR 2694 METRICS Evaluation des technologies de santé et des pratiques médicales, LILLE, France.
- IMALLIANCE-Haut-de-France, Valenciennes, France.
| | - Lucas Guiffault
- Department of Thoracic Imaging, University Hospital Center of Lille, LILLE, France
| | - Idir Oufriche
- Department of Thoracic Imaging, University Hospital Center of Lille, LILLE, France
| | - Alain Duhamel
- ULR 2694 METRICS Evaluation des technologies de santé et des pratiques médicales, LILLE, France
- Department of Biostatistics, University of Lille, CHU Lille, LILLE, France
| | - Thomas Flohr
- Department of Computed Tomography Research & Development, Siemens Healthineers AG, Forchheim, Germany
| | - Bernhard Schmidt
- Department of Computed Tomography Research & Development, Siemens Healthineers AG, Forchheim, Germany
| | - Jacques Remy
- Department of Thoracic Imaging, University Hospital Center of Lille, LILLE, France
- Department of Radiology, Valenciennes Regional Hospital, Valenciennes, France
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Páez-Carpio A, Vollmer I, Zarco FX, Matute-González M, Domenech-Ximenos B, Serrano E, Barberà JA, Blanco I, Gómez FM. Imaging of chronic thromboembolic pulmonary hypertension before, during and after balloon pulmonary angioplasty. Diagn Interv Imaging 2024; 105:215-226. [PMID: 38413273 DOI: 10.1016/j.diii.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 02/29/2024]
Abstract
Balloon pulmonary angioplasty (BPA) has recently been elevated as a class I recommendation for the treatment of inoperable or residual chronic thromboembolic pulmonary hypertension (CTEPH). Proper patient selection, procedural safety, and post-procedural evaluation are crucial in the management of these patients, with imaging work-up playing a pivotal role. Understanding the diagnostic and therapeutic imaging algorithms of CTEPH, the imaging features of patients amenable to BPA, all imaging findings observed during and immediately after the procedure and the changes observed during the follow-up is crucial for all interventional radiologists involved in the care of patients with CTEPH. This article illustrates the imaging work-up of patients with CTEPH amenable to BPA, the imaging findings observed before, during and after BPA, and provides a detailed description of all imaging modalities available for CTEPH evaluation.
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Affiliation(s)
- Alfredo Páez-Carpio
- Department of Radiology, CDI, Hospital Clínic Barcelona, Barcelona 08036, Spain; Department of Medical Imaging, University of Toronto, Toronto M5T 1W7, ON, Canada; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain.
| | - Ivan Vollmer
- Department of Radiology, CDI, Hospital Clínic Barcelona, Barcelona 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain
| | - Federico X Zarco
- Department of Radiology, CDI, Hospital Clínic Barcelona, Barcelona 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain
| | | | | | - Elena Serrano
- Department of Radiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat 08907, Spain
| | - Joan A Barberà
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain; Department of Pulmonary Medicine, ICR, Hospital Clínic Barcelona, Barcelona 08036, Spain; Biomedical Research Networking Centre on Respiratory Diseases (CIBERES), Madrid 28029, Spain
| | - Isabel Blanco
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain; Department of Pulmonary Medicine, ICR, Hospital Clínic Barcelona, Barcelona 08036, Spain; Biomedical Research Networking Centre on Respiratory Diseases (CIBERES), Madrid 28029, Spain
| | - Fernando M Gómez
- Interventional Radiology Unit, Department of Radiology, Hospital Universitari i Politècnic La Fe, València 46026, Spain; Interventional Radiology Unit, Department of Radiology, The Netherlands Cancer Institute, Amsterdam 1066 CX, the Netherlands
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Gertz RJ, Gerhardt F, Pienn M, Lennartz S, Kröger JR, Caldeira L, Pennig L, Schömig TH, Hokamp NG, Maintz D, Rosenkranz S, Bunck AC. Dual-layer dual-energy CT-derived pulmonary perfusion for the differentiation of acute pulmonary embolism and chronic thromboembolic pulmonary hypertension. Eur Radiol 2024; 34:2944-2956. [PMID: 37921925 PMCID: PMC11126515 DOI: 10.1007/s00330-023-10337-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/18/2023] [Accepted: 10/03/2023] [Indexed: 11/05/2023]
Abstract
OBJECTIVES To evaluate dual-layer dual-energy computed tomography (dlDECT)-derived pulmonary perfusion maps for differentiation between acute pulmonary embolism (PE) and chronic thromboembolic pulmonary hypertension (CTEPH). METHODS This retrospective study included 131 patients (57 patients with acute PE, 52 CTEPH, 22 controls), who underwent CT pulmonary angiography on a dlDECT. Normal and malperfused areas of lung parenchyma were semiautomatically contoured using iodine density overlay (IDO) maps. First-order histogram features of normal and malperfused lung tissue were extracted. Iodine density (ID) was normalized to the mean pulmonary artery (MPA) and the left atrium (LA). Furthermore, morphological imaging features for both acute and chronic PE, as well as the combination of histogram and morphological imaging features, were evaluated. RESULTS In acute PE, normal perfused lung areas showed a higher mean and peak iodine uptake normalized to the MPA than in CTEPH (both p < 0.001). After normalizing mean ID in perfusion defects to the LA, patients with acute PE had a reduced average perfusion (IDmean,LA) compared to both CTEPH patients and controls (p < 0.001 for both). IDmean,LA allowed for a differentiation between acute PE and CTEPH with moderate accuracy (AUC: 0.72, sensitivity 74%, specificity 64%), resulting in a PPV and NPV for CTEPH of 64% and 70%. Combining IDmean,LA in the malperfused areas with the diameter of the MPA (MPAdia) significantly increased its ability to differentiate between acute PE and CTEPH (sole MPAdia: AUC: 0.76, 95%-CI: 0.68-0.85 vs. MPAdia + 256.3 * IDmean,LA - 40.0: AUC: 0.82, 95%-CI: 0.74-0.90, p = 0.04). CONCLUSION dlDECT enables quantification and characterization of pulmonary perfusion patterns in acute PE and CTEPH. Although these lack precision when used as a standalone criterion, when combined with morphological CT parameters, they hold potential to enhance differentiation between the two diseases. CLINICAL RELEVANCE STATEMENT Differentiating between acute PE and CTEPH based on morphological CT parameters is challenging, often leading to a delay in CTEPH diagnosis. By revealing distinct pulmonary perfusion patterns in both entities, dlDECT may facilitate timely diagnosis of CTEPH, ultimately improving clinical management. KEY POINTS • Morphological imaging parameters derived from CT pulmonary angiography to distinguish between acute pulmonary embolism and chronic thromboembolic pulmonary hypertension lack diagnostic accuracy. • Dual-layer dual-energy CT reveals different pulmonary perfusion patterns between acute pulmonary embolism and chronic thromboembolic pulmonary hypertension. • The identified parameters yield potential to enable more timely identification of patients with chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- Roman Johannes Gertz
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
| | - Felix Gerhardt
- Department of Cardiology, Heart Center, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Michael Pienn
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Simon Lennartz
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jan Robert Kröger
- Department of Radiology, Neuroradiology and Nuclear Medicine, Ruhr University Bochum, Johannes Wesling University Hospital, Bochum, Germany
| | - Liliana Caldeira
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lenhard Pennig
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Thomas Henning Schömig
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Nils Große Hokamp
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - David Maintz
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Stephan Rosenkranz
- Department of Cardiology, Heart Center, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Alexander Christian Bunck
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Moore J, Remy J, Altschul E, Chusid J, Flohr T, Raoof S, Remy-Jardin M. Thoracic Applications of Spectral CT Scan. Chest 2024; 165:417-430. [PMID: 37619663 DOI: 10.1016/j.chest.2023.07.4225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023] Open
Abstract
TOPIC IMPORTANCE Thoracic imaging with CT scan has become an essential component in the evaluation of respiratory and thoracic diseases. Providers have historically used conventional single-energy CT; however, prevalence of dual-energy CT (DECT) is increasing, and as such, it is important for thoracic physicians to recognize the utility and limitations of this technology. REVIEW FINDINGS The technical aspects of DECT are presented, and practical approaches to using DECT are provided. Imaging at multiple energy spectra allows for postprocessing of the data and the possibility of creating multiple distinct image reconstructions based on the clinical question being asked. The data regarding utility of DECT in pulmonary vascular disorders, ventilatory defects, and thoracic oncology are presented. A pictorial essay is provided to give examples of the strengths associated with DECT. SUMMARY DECT has been most heavily studied in chronic thromboembolic pulmonary hypertension; however, it is increasingly being used across a wide spectrum of thoracic diseases. DECT combines morphologic and functional assessments in a single imaging acquisition, providing clinicians with a powerful diagnostic tool. Its role in the evaluation and treatment of thoracic diseases will likely continue to expand in the coming years as clinicians become more experienced with the technology.
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Affiliation(s)
- Jonathan Moore
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health Physician Partners, New York, NY
| | - Jacques Remy
- Univ Lille, Department of Thoracic Imaging, Lille, France
| | - Erica Altschul
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health Physician Partners, New York, NY
| | - Jesse Chusid
- Feinstein Institutes for Medical Research, and Imaging Services, Department of Radiology, Northwell Health, Manhasset, NY
| | - Thomas Flohr
- Department of Computed Tomography Research & Development, Siemens Healthineers, Forchheim, Germany
| | - Suhail Raoof
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health Physician Partners, New York, NY.
| | - Martine Remy-Jardin
- Univ Lille, Department of Thoracic Imaging, Lille, France; Univ Lille, CHU Lille, Evaluation des technologies de santé et des pratiques médicales, Lille, France
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Grafham GK, Bambrick M, Houbois C, Mafeld S, Donahoe L, de Perrot M, McInnis MC. Enhancing preoperative assessment in chronic thromboembolic pulmonary hypertension: A comprehensive analysis of interobserver agreement and proximity-based CT pulmonary angiography scoring. Heliyon 2023; 9:e20899. [PMID: 37954325 PMCID: PMC10632681 DOI: 10.1016/j.heliyon.2023.e20899] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/28/2023] [Accepted: 10/10/2023] [Indexed: 11/14/2023] Open
Abstract
Background Surgical risk in chronic thromboembolic pulmonary hypertension (CTEPH) depends on the proximity of thromboembolism on CT pulmonary angiography (CTPA). We assessed interobserver agreement for the quantification of thromboembolic lesions in CTEPH using a novel CTPA scoring index. Methods Forty CTEPH patients (mean age, 58 ± 16 years; 19 men) with preoperative CTPA who underwent pulmonary endarterectomy (PEA) (08/2020-09/2021) were retrospectively included. Three radiologists scored each CTPA for chronic thromboembolism (occlusions, eccentric thickening, webs) using a 32-vessel model of the pulmonary vasculature, with interobserver agreement evaluated using Fleiss' kappa. CT level of disease was determined by the most proximal chronic thromboembolism: level 1 (main pulmonary artery), 2 (lobar), 3 (segmental) and 4 (subsegmental), and compared to surgical level at PEA. Results Interobserver agreement for CT level of disease was moderate overall (κ = 0.52). Agreement was substantial overall at the main/lobar level (κ, mean = 0.71) when excluding the left upper lobe (κ = 0.17). Though segmental and subsegmental agreement suffered (κ = 0.31), we found substantial agreement for occlusions (κ = 0.72) compared to eccentric thickening (κ = 0.45) and webs (κ = 0.14). Correlation between CT level and surgical level was strong overall (τb = 0.73) and in the right lung (τb = 0.68), but weak in the left lung (τb = 0.42) (p < 0.05). Radiologists often over- and underestimated the proximal extent of disease in right and left lung, respectively. Conclusions CT level of disease demonstrated good agreement between radiologists and was highly predictive of the surgical level in CTEPH. Occlusions were the most reliable sign of chronic thromboembolism and are important in assessing the segmental vasculature.
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Affiliation(s)
- Grace K. Grafham
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marie Bambrick
- Division of Cardiothoracic and Vascular Imaging, Joint Department of Medical Imaging, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Christian Houbois
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Sebastian Mafeld
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular and Interventional Radiology, Joint Department of Medical Imaging, Toronto General Hospital, Toronto, Ontario, Canada
| | - Laura Donahoe
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Marc de Perrot
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Micheal C. McInnis
- Division of Cardiothoracic and Vascular Imaging, Joint Department of Medical Imaging, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
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Delcroix M, de Perrot M, Jaïs X, Jenkins DP, Lang IM, Matsubara H, Meijboom LJ, Quarck R, Simonneau G, Wiedenroth CB, Kim NH. Chronic thromboembolic pulmonary hypertension: realising the potential of multimodal management. THE LANCET. RESPIRATORY MEDICINE 2023; 11:836-850. [PMID: 37591299 DOI: 10.1016/s2213-2600(23)00292-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/13/2023] [Accepted: 07/24/2023] [Indexed: 08/19/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism. Important advances have enabled better understanding, characterisation, and treatment of this condition. Guidelines recommending systematic follow-up after acute pulmonary embolism, and the insight that CTEPH can mimic acute pulmonary embolism on initial presentation, have led to the definition of CTEPH imaging characteristics, the introduction of artificial intelligence diagnosis pathways, and thus the prospect of easier and earlier CTEPH diagnosis. In this Series paper, we show how the understanding of CTEPH as a sequela of inflammatory thrombosis has driven successful multidisciplinary management that integrates surgical, interventional, and medical treatments. We provide imaging examples of classical major vessel targets, describe microvascular targets, define available tools, and depict an algorithm facilitating the initial treatment strategy in people with newly diagnosed CTEPH based on a multidisciplinary team discussion at a CTEPH centre. Further work is needed to optimise the use and combination of multimodal therapeutic options in CTEPH to improve long-term outcomes for patients.
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Affiliation(s)
- Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven-University of Leuven, Leuven, Belgium.
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Xavier Jaïs
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Irene M Lang
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Centre for CardioVascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Rozenn Quarck
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven-University of Leuven, Leuven, Belgium
| | - Gérald Simonneau
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | - Nick H Kim
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
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Bayat S, Wild J, Winkler T. Lung functional imaging. Breathe (Sheff) 2023; 19:220272. [PMID: 38020338 PMCID: PMC10644108 DOI: 10.1183/20734735.0272-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 10/08/2023] [Indexed: 12/01/2023] Open
Abstract
Pulmonary functional imaging modalities such as computed tomography, magnetic resonance imaging and nuclear imaging can quantitatively assess regional lung functional parameters and their distributions. These include ventilation, perfusion, gas exchange at the microvascular level and biomechanical properties, among other variables. This review describes the rationale, strengths and limitations of the various imaging modalities employed for lung functional imaging. It also aims to explain some of the most commonly measured parameters of regional lung function. A brief review of evidence on the role and utility of lung functional imaging in early diagnosis, accurate lung functional characterisation, disease phenotyping and advancing the understanding of disease mechanisms in major respiratory disorders is provided.
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Affiliation(s)
- Sam Bayat
- Department of Pulmonology and Physiology, CHU Grenoble Alpes, Grenoble, France
- Univ. Grenoble Alpes, STROBE Laboratory, INSERM UA07, Grenoble, France
| | - Jim Wild
- POLARIS, Imaging Group, Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Tilo Winkler
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Schüssler A, Lug Q, Kremer N, Harth S, Kriechbaum SD, Richter MJ, Guth S, Wiedenroth CB, Tello K, Steiner D, Seeger W, Krombach GA, Roller FC. Evaluation of diagnostic accuracy of dual-energy computed tomography in patients with chronic thromboembolic pulmonary hypertension compared to V/Q-SPECT and pulmonary angiogram. Front Med (Lausanne) 2023; 10:1194272. [PMID: 37425315 PMCID: PMC10324648 DOI: 10.3389/fmed.2023.1194272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/31/2023] [Indexed: 07/11/2023] Open
Abstract
Purpose The relevance of dual-energy computed tomography (DECT) for the detection of chronic thromboembolic pulmonary hypertension (CTEPH) still lies behind V/Q-SPECT in current clinical guidelines. Therefore, our study aimed to assess the diagnostic accuracy of DECT compared to V/Q-SPECT with invasive pulmonary angiogram (PA) serving as the reference standard. Methods A total of 28 patients (mean age 62.1 years ± 10.6SD; 18 women) with clinically suspected CTEPH were retrospectively included. All patients received DECT with the calculation of iodine maps, V/Q-SPECT, and PA. Results of DECT and V/Q-SPECT were compared, and the percent of agreement, concordance (utilizing Cohen's kappa), and accuracy (kappa2) to PA were calculated. Furthermore, radiation doses were analyzed and compared. Results In total, 18 patients were diagnosed with CTEPH (mean age 62.4 years ± 11.0SD; 10 women) and 10 patients had other diseases. Compared to PA, accuracy and concordance for DECT were superior to V/Q-SPECT in all patients (88.9% vs. 81.3%; k = 0.764 vs. k = 0.607) and in CTEPH patients (82.4% vs. 70.1%; k = 0.694 vs. k = 0.560). Furthermore, the mean radiation dose was significantly lower for DECT vs. V/Q-SPECT (p = 0.0081). Conclusion In our patient cohort, DECT is at least equivalent to V/Q-SPECT in diagnosing CTEPH and has the added advantage of significantly lower radiation doses in combination with simultaneous assessment of lung and heart morphology. Hence, DECT should be the subject of ongoing research, and if our results are further confirmed, it should be implemented in future diagnostic PH algorithms at least on par with V/Q-SPECT.
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Affiliation(s)
- Armin Schüssler
- Department of Diagnostic and Interventional Radiology, Justus-Liebig-University Giessen, Giessen, Germany
- Member of the German Center for Lung Research, Giessen, Germany
| | - Quirin Lug
- Department of Diagnostic and Interventional Radiology, Justus-Liebig-University Giessen, Giessen, Germany
- Member of the German Center for Lung Research, Giessen, Germany
| | - Nils Kremer
- Member of the German Center for Lung Research, Giessen, Germany
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute, Giessen, Germany
| | - Sebastian Harth
- Department of Diagnostic and Interventional Radiology, Justus-Liebig-University Giessen, Giessen, Germany
- Member of the German Center for Lung Research, Giessen, Germany
| | | | - Manuel J. Richter
- Member of the German Center for Lung Research, Giessen, Germany
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute, Giessen, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
| | | | - Khodr Tello
- Member of the German Center for Lung Research, Giessen, Germany
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute, Giessen, Germany
| | - Dagmar Steiner
- Department of Nuclear Medicine, Justus-Liebig-University Giessen, Giessen, Germany
| | - Werner Seeger
- Member of the German Center for Lung Research, Giessen, Germany
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute, Giessen, Germany
- DZHK (German Centre for Cardiovascular Research), Frankfurt am Main, Germany
| | - Gabriele Anja Krombach
- Department of Diagnostic and Interventional Radiology, Justus-Liebig-University Giessen, Giessen, Germany
- Member of the German Center for Lung Research, Giessen, Germany
| | - Fritz Christian Roller
- Department of Diagnostic and Interventional Radiology, Justus-Liebig-University Giessen, Giessen, Germany
- Member of the German Center for Lung Research, Giessen, Germany
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Simonneau G, Fadel E, Vonk Noordegraaf A, Toshner M, Lang IM, Klok FA, McInnis MC, Screaton N, Madani MM, Martinez G, Salaunkey K, Jenkins DP, Matsubara H, Brénot P, Hoeper MM, Ghofrani HA, Jaïs X, Wiedenroth CB, Guth S, Kim NH, Pepke-Zaba J, Delcroix M, Mayer E. Highlights from the International Chronic Thromboembolic Pulmonary Hypertension Congress 2021. Eur Respir Rev 2023; 32:32/167/220132. [PMID: 36754432 PMCID: PMC9910339 DOI: 10.1183/16000617.0132-2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/14/2022] [Indexed: 02/10/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism. It is caused by persistent obstruction of pulmonary arteries by chronic organised fibrotic clots, despite adequate anticoagulation. The pulmonary hypertension is also caused by concomitant microvasculopathy which may progress without timely treatment. Timely and accurate diagnosis requires the combination of imaging and haemodynamic assessment. Optimal therapy should be individualised to each case and determined by an experienced multidisciplinary CTEPH team with the ability to offer all current treatment modalities. This report summarises current knowledge and presents key messages from the International CTEPH Conference, Bad Nauheim, Germany, 2021. Sessions were dedicated to 1) disease definition; 2) pathophysiology, including the impact of the hypertrophied bronchial circulation, right ventricle (dys)function, genetics and inflammation; 3) diagnosis, early after acute pulmonary embolism, using computed tomography and perfusion techniques, and supporting the selection of appropriate therapies; 4) surgical treatment, pulmonary endarterectomy for proximal and distal disease, and peri-operative management; 5) percutaneous approach or balloon pulmonary angioplasty, techniques and complications; and 6) medical treatment, including anticoagulation and pulmonary hypertension drugs, and in combination with interventional treatments. Chronic thromboembolic pulmonary disease without pulmonary hypertension is also discussed in terms of its diagnostic and therapeutic aspects.
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Affiliation(s)
- Gérald Simonneau
- AP-HP, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Sud, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique and Institut National de la Santé et de la Recherche Médicale Unité 999, Le Kremlin-Bicêtre, France
| | - Elie Fadel
- Research and Innovation Unit, INSERM UMR-S 999, Marie Lannelongue Hospital, Université Paris-Sud, Université Paris-Saclay, Le Plessis-Robinson, France,Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie Lannelongue Hospital, Université Paris-Sud, Université Paris-Saclay, Le Plessis-Robinson, France,Université Paris-Sud and Université Paris-Saclay, School of Medicine, Kremlin-Bicêtre, France
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Universitair Medische Centra, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Mark Toshner
- Royal Papworth Hospital, University of Cambridge, Cambridge, UK
| | - Irene M. Lang
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Frederikus A. Klok
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Micheal C. McInnis
- Department of Medical Imaging, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Michael M. Madani
- Cardiovascular and Thoracic Surgery, University of California-San Diego, La Jolla, CA, USA
| | | | - Kiran Salaunkey
- Royal Papworth Hospital, University of Cambridge, Cambridge, UK
| | | | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Philippe Brénot
- Department of Radiology, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Marius M. Hoeper
- Department of Respiratory Medicine, Hannover Medical School and Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Hossein A. Ghofrani
- Pulmonary Vascular Research, Justus-Liebig University and Pulmonary Hypertension Division, University Hospital Giessen, Giessen, Germany,Department of Pneumology, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Xavier Jaïs
- AP-HP, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Sud, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique and Institut National de la Santé et de la Recherche Médicale Unité 999, Le Kremlin-Bicêtre, France
| | | | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Nick H. Kim
- Division of Pulmonary and Critical Care Medicine, University of California-San Diego, La Jolla, CA, USA
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium .,M. Delcroix and E. Mayer equal contribution (co-last authors)
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany,Meeting organiser,M. Delcroix and E. Mayer equal contribution (co-last authors)
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11
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Abozeed M, Conic S, Bullen J, Rizk A, Saeedan MB, Karim W, Heresi GA, Renapurkar RD. Dual energy CT based scoring in chronic thromboembolic pulmonary hypertension and correlation with clinical and hemodynamic parameters: a retrospective cross-sectional study. Cardiovasc Diagn Ther 2022; 12:305-313. [PMID: 35800352 PMCID: PMC9253168 DOI: 10.21037/cdt-21-686] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 04/02/2022] [Indexed: 06/14/2024]
Abstract
BACKGROUND We used a dual energy computed tomography (DECT) based scoring system in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and correlated it with functional and hemodynamic parameters. METHODS This was a retrospective study on 78 patients with CTEPH who underwent DECT. First, clot burden score was calculated by assigning a following score: pulmonary trunk-5, each main pulmonary artery-4, each lobar-3, each segmental-2, and subsegmental-1 per lobe; sum total was then calculated. Perfusion defect (PD) score was calculated by assigning 1 point to each segmental PD. Combined score was calculated by adding the clot burden and PD score. All three scores were correlated with clinical and hemodynamic parameters that included New York Heart Association (NYHA) functional class, 6-minute walk distance (6MWT) in feet, forced expiratory volume in one second (FEV1), forced vital capacity (FVC), diffusing capacity of the lung for carbon monoxide (DLCO), pulmonary arterial pressure (PAP) [systolic PAP (sPAP), diastolic PAP (dPAP) and mean PAP (mPAP)], pulmonary vascular resistance (PVR), right atrial pressure, cardiac output, and cardiac index. RESULTS Clot burden score, PD score, and combined score all positively correlated with sPAP (0.25, 0.34, 0.34), PVR (0.27, 0.30, 0.34), and mPAP (0.28, 0.31, 0.36). There was no statistically significant correlation of clot burden score, PD score and combined score with 6MWT, % predicted 6MWT, FEV1, FEV1%, FVC, FVC%, DLCO% and NYHA functional class. CONCLUSIONS DECT based scoring in CTEPH is feasible and correlates positively with sPAP, mPAP and PVR. Combined score has the highest magnitude of correlation.
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Affiliation(s)
- Mostafa Abozeed
- Sections of Thoracic and Cardiovascular Imaging Laboratory, Imaging Institute, Cleveland Clinic, OH, USA
| | - Sofija Conic
- Sections of Thoracic and Cardiovascular Imaging Laboratory, Imaging Institute, Cleveland Clinic, OH, USA
| | | | - Alain Rizk
- Sections of Thoracic and Cardiovascular Imaging Laboratory, Imaging Institute, Cleveland Clinic, OH, USA
| | - Mnahi Bin Saeedan
- Sections of Thoracic and Cardiovascular Imaging Laboratory, Imaging Institute, Cleveland Clinic, OH, USA
| | - Wadih Karim
- Sections of Thoracic and Cardiovascular Imaging Laboratory, Imaging Institute, Cleveland Clinic, OH, USA
| | - Gustavo A. Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, OH, USA
| | - Rahul D. Renapurkar
- Sections of Thoracic and Cardiovascular Imaging Laboratory, Imaging Institute, Cleveland Clinic, OH, USA
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12
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Chronic Thromboembolic Pulmonary Hypertension. Lung 2022; 200:283-299. [DOI: 10.1007/s00408-022-00539-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/18/2022] [Indexed: 10/18/2022]
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13
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Lefebvre B, Kyheng M, Giordano J, Lamblin N, de Groote P, Fertin M, Delobelle M, Perez T, Faivre JB, Remy J, Duhamel A, Remy-Jardin M. Dual-energy CT lung perfusion characteristics in pulmonary arterial hypertension (PAH) and pulmonary veno-occlusive disease and/or pulmonary capillary hemangiomatosis (PVOD/PCH): preliminary experience in 63 patients. Eur Radiol 2022; 32:4574-4586. [PMID: 35286410 DOI: 10.1007/s00330-022-08577-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/01/2021] [Accepted: 01/12/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the stratification of potential causes of PH, current guidelines recommend performing V/Q lung scintigraphy to screen for CTEPH. The recognition of CTEPH is based on the identification of lung segments or sub-segments without perfusion but preserved ventilation. The presence of mismatched perfusion defects has also been described in a small proportion of idiopathic pulmonary arterial hypertension (PAH) and pulmonary veno-occlusive disease and/or pulmonary capillary hemangiomatosis (PVOD/PCH). Dual-energy CT lung perfusion changes have not been specifically investigated in these two entities. PURPOSE To compare dual-energy CT (DECT) perfusion characteristics in PAH and PVOD/PCH, with specific interest in PE-type perfusion defects. MATERIALS AND METHODS Sixty-three patients with idiopathic or heritable PAH (group A; n = 51) and PVOD/PCH (group B; n = 12) were investigated with DECT angiography with reconstruction of morphologic and perfusion images. RESULTS The number of patients with abnormal perfusion did not differ between group A (35/51; 68.6%) and group B (6/12; 50%) (p = 0.31) nor did the mean number of segments with abnormal perfusion per patient (group A: 17.9 ± 4.9; group B: 18.3 ± 4.1; p = 0.91). The most frequent finding was the presence of patchy defects in group A (15/35; 42.9%) and a variable association of perfusion abnormalities in group B (4/6; 66.7%). The median percentage of segments with PE-type defects per patient was significantly higher in group B than in group A (p = 0.041). Two types of PE-type defects were depicted in 8 patients (group A: 5/51; 9.8%; group B: 3/12; 25%), superimposed on PH-related lung abnormalities (7/8) or normal lung (1/8). The iodine concentration was significantly lower in patients with abnormal perfusion (p < 0.001) but did not differ between groups. CONCLUSION Perfusion abnormalities did not differ between the two groups at the exception of a higher median percentage of segments with PE-type defects in patients with PVOD/PCH. KEY POINTS • Patchy perfusion defect was the most frequent pattern in PAH. • A variable association of perfusion abnormalities was seen in PVOD/PCH. • Lobular and PE-type perfusion defects larger than a sub-segment were depicted in both PAH and PVOD/PCH patients.
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Affiliation(s)
- Briac Lefebvre
- Univ Lille, CHU Lille, Department of Thoracic Imaging, Cardio-Pulmonary Institute, Boulevard Jules Leclercq, F-59000, Lille, France
| | - Maeva Kyheng
- Department of Biostatistics, University Center of Lille, F-59000, Lille, France
- EA2694-Santé Publique: épidémiologie et qualité des soins, F-59000, Lille, France
| | - Jessica Giordano
- Univ Lille, CHU Lille, Department of Thoracic Imaging, Cardio-Pulmonary Institute, Boulevard Jules Leclercq, F-59000, Lille, France
| | - Nicolas Lamblin
- Univ Lille, CHU Lille, Department of Cardiology, Cardio-Pulmonary Institute, F-59000, Lille, France
- INSERM U1167, Institut Pasteur de Lille, F-59000, Lille, France
| | - Pascal de Groote
- Univ Lille, CHU Lille, Department of Cardiology, Cardio-Pulmonary Institute, F-59000, Lille, France
- INSERM U1167, Institut Pasteur de Lille, F-59000, Lille, France
| | - Marie Fertin
- Univ Lille, CHU Lille, Department of Cardiology, Cardio-Pulmonary Institute, F-59000, Lille, France
- INSERM U1167, Institut Pasteur de Lille, F-59000, Lille, France
| | - Marie Delobelle
- Univ Lille, CHU Lille, Department of Cardiology, Cardio-Pulmonary Institute, F-59000, Lille, France
| | - Thierry Perez
- Univ Lille, CHU Lille, Department of Pulmonary Function, Cardio-Pulmonary Institute, F-59000, Lille, France
- INSERM U1019 - CNRS UMR 8204, Institut Pasteur de Lille - CIIL - Center for Infection and Immunity of Lille, Lille, France
| | - Jean-Baptiste Faivre
- Univ Lille, CHU Lille, Department of Thoracic Imaging, Cardio-Pulmonary Institute, Boulevard Jules Leclercq, F-59000, Lille, France
| | - Jacques Remy
- Univ Lille, CHU Lille, Department of Thoracic Imaging, Cardio-Pulmonary Institute, Boulevard Jules Leclercq, F-59000, Lille, France
| | - Alain Duhamel
- Department of Biostatistics, University Center of Lille, F-59000, Lille, France
- EA2694-Santé Publique: épidémiologie et qualité des soins, F-59000, Lille, France
| | - Martine Remy-Jardin
- Univ Lille, CHU Lille, Department of Thoracic Imaging, Cardio-Pulmonary Institute, Boulevard Jules Leclercq, F-59000, Lille, France.
- EA2694-Santé Publique: épidémiologie et qualité des soins, F-59000, Lille, France.
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14
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Pinilo J, Hutt A, Labreuche J, Faivre JB, Flohr T, Schmidt B, Duhamel A, Remy J, Remy-Jardin M. Evaluation Of a New Reconstruction Technique for Dual-Energy (DECT) Lung Perfusion: Preliminary Experience In 58 Patients. Acad Radiol 2022; 29 Suppl 2:S202-S214. [PMID: 34446359 DOI: 10.1016/j.acra.2021.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/16/2021] [Accepted: 07/24/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE To compare dual-energy (DE) lung perfused blood volume generated by subtraction of virtual monoenergetic images (Lung Mono) with images obtained by three-compartment decomposition (Lung PBV). MATERIAL AND METHODS The study included 58 patients (28 patients with and 30 patients without PE) with reconstruction of Lung PBV images (i.e., the reference standard) and Lung Mono images. The inter-technique comparison was undertaken at a patient and segment level. RESULTS The distribution of scores of subjective image noise (patient level) significantly differed between the two reconstructions (p<0.0001), with mild noise in 58.6% (34/58) of Lung Mono images vs 25.9% (15/58) of Lung PBV images. Detection of perfusion defects (segment level) was concordant in 1104 segments (no defect: n=968; defects present: n=138) and discordant in 2 segments with a PE-related defect only depicted on Lung Mono images. Among the 28 PE patients, the distribution of gradient of attenuation between perfused areas and defects was significantly higher on Lung Mono images compared to Lung PBV (median= 73.5 HU (QI=65.0; Q3=86.0) vs 24.5 HU (22.0; 30.0); p<0.0001). In all patients, fissures were precisely identified in 77.6% of patients (45/58) on Lung Mono images while blurred (30/58; 51.7%) or not detectable (28/58; 48.3%) on Lung PBV images. CONCLUSION Lung Mono perfusion imaging allows significant improvement in the overall image quality and improved detectability of PE-type perfusion defects.
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15
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Systemic-pulmonary collateral supply associated with clinical severity of chronic thromboembolic pulmonary hypertension: a study using intra-aortic computed tomography angiography. Eur Radiol 2022; 32:7668-7679. [PMID: 35420297 PMCID: PMC9668953 DOI: 10.1007/s00330-022-08768-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 03/11/2022] [Accepted: 03/23/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To assess whether systemic-pulmonary collaterals are associated with clinical severity and extent of pulmonary perfusion defects in chronic thromboembolic pulmonary hypertension (CTEPH). METHODS This prospective study was approved by a local ethics committee. Twenty-four patients diagnosed with inoperable CTEPH were enrolled between July 2014 and February 2017. Systemic-pulmonary collaterals were detected using pulmonary vascular enhancement on intra-aortic computed tomography (CT) angiography. The pulmonary enhancement parameters were calculated, including (1) Hounsfield unit differences (HUdiff) between pulmonary trunks and pulmonary arteries (PAs) or veins (PVs), namely HUdiff-PA and HUdiff-PV, on the segmental base; (2) the mean HUdiff-PA, mean HUdiff-PV, numbers of significantly enhanced PAs and PVs, on the patient base. Pulmonary perfusion defects were recorded and scored using the lung perfused blood volume (PBV) based on intravenous dual-energy CT (DECT) angiography. Pearson's or Spearman's correlation coefficients were used to evaluate correlations between the following: (1) segment-based intra-aortic CT and intravenous DECT parameters (2) patient-based intra-aortic CT parameters and clinical severity parameters or lung PBV scores. Statistical significance was set at p < 0.05. RESULTS Segmental HUdiff-PV was correlated with the segmental perfusion defect score (r = 0.45, p < 0.01). The mean HUdiff-PV was correlated with the mean pulmonary arterial pressure (PAP) (r = 0.52, p < 0.01), cardiac output (rho = - 0.41, p = 0.05), and lung PBV score (rho = 0.43, p = 0.04). And the number of significantly enhanced PVs was correlated with the mean PAP (r = 0.54, p < 0.01), pulmonary vascular resistance (r = 0.54, p < 0.01), and lung PBV score (rho = 0.50, p = 0.01). CONCLUSIONS PV enhancement measured by intra-aortic CT angiography reflects clinical severity and pulmonary perfusion defects in CTEPH. KEY POINTS • Intra-aortic CT angiography demonstrated heterogeneous enhancement within the pulmonary vasculature, showing collaterals from the systemic arteries to the pulmonary circulation in CTEPH. • The degree of systemic-pulmonary collateral development was significantly correlated with the clinical severity of CTEPH and may be used to evaluate disease progression. • The distribution of systemic-pulmonary collaterals is positively correlated with perfusion defects in the lung segments in CTEPH.
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16
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Abstract
PURPOSE OF REVIEW In the past decades, the diagnostic and therapeutic management of chronic thromboembolic pulmonary hypertension (CTEPH) has been revolutionized. RECENT FINDINGS Advances in epidemiological knowledge and follow-up studies of pulmonary embolism patients have provided more insight in the incidence and prevalence. Improved diagnostic imaging techniques allow accurate assessment of the location and extend of the thromboembolic burden in the pulmonary artery tree, which is important for the determination of the optimal treatment strategy. Next to the pulmonary endarterectomy, the newly introduced technique percutaneous pulmonary balloon angioplasty and/or P(A)H-targeted medical therapy has been shown to be beneficial in selected patients with CTEPH and might also be of importance in patients with chronic thromboembolic pulmonary vascular disease. SUMMARY In this era of a comprehensive approach to CTEPH with different treatment modalities, a multidisciplinary approach guides management decisions leading to optimal treatment and follow-up of patients with CTEPH.
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17
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de Perrot M, Gopalan D, Jenkins D, Lang IM, Fadel E, Delcroix M, Benza R, Heresi GA, Kanwar M, Granton JT, McInnis M, Klok FA, Kerr KM, Pepke-Zaba J, Toshner M, Bykova A, Armini AMD, Robbins IM, Madani M, McGiffin D, Wiedenroth CB, Mafeld S, Opitz I, Mercier O, Uber PA, Frantz RP, Auger WR. Evaluation and management of patients with chronic thromboembolic pulmonary hypertension - consensus statement from the ISHLT. J Heart Lung Transplant 2021; 40:1301-1326. [PMID: 34420851 DOI: 10.1016/j.healun.2021.07.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 07/22/2021] [Indexed: 02/08/2023] Open
Abstract
ISHLT members have recognized the importance of a consensus statement on the evaluation and management of patients with chronic thromboembolic pulmonary hypertension. The creation of this document required multiple steps, including the engagement of the ISHLT councils, approval by the Standards and Guidelines Committee, identification and selection of experts in the field, and the development of 6 working groups. Each working group provided a separate section based on an extensive literature search. These sections were then coalesced into a single document that was circulated to all members of the working groups. Key points were summarized at the end of each section. Due to the limited number of comparative trials in this field, the document was written as a literature review with expert opinion rather than based on level of evidence.
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Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Deepa Gopalan
- Department of Radiology, Imperial College Healthcare NHS Trust, London & Cambridge University Hospital, Cambridge, UK
| | - David Jenkins
- National Pulmonary Endarterectomy Service, Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Irene M Lang
- Department of Cardiology, Pulmonary Hypertension Unit, Medical University of Vienna, Vienna, Austria
| | - Elie Fadel
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Pulmonary Hypertension Centre, UZ Leuven, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU, Leuven, Belgium
| | - Raymond Benza
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - John T Granton
- Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | - Micheal McInnis
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Kim M Kerr
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK
| | - Mark Toshner
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK; Heart Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Anastasia Bykova
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Andrea M D' Armini
- Unit of Cardiac Surgery, Intrathoracic-Trasplantation and Pulmonary Hypertension, University of Pavia, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Ivan M Robbins
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Madani
- Department of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, California
| | - David McGiffin
- Department of Cardiothoracic Surgery, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Campus Kerckhoff of the University of Giessen, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Sebastian Mafeld
- Division of Vascular and Interventional Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Olaf Mercier
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Patricia A Uber
- Pauley Heart Center, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Robert P Frantz
- Department of Cardiovascular Disease, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - William R Auger
- Pulmonary Hypertension and CTEPH Research Program, Temple Heart and Vascular Institute, Temple University, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
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18
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Delcroix M, Torbicki A, Gopalan D, Sitbon O, Klok FA, Lang I, Jenkins D, Kim NH, Humbert M, Jais X, Vonk Noordegraaf A, Pepke-Zaba J, Brénot P, Dorfmuller P, Fadel E, Ghofrani HA, Hoeper MM, Jansa P, Madani M, Matsubara H, Ogo T, Grünig E, D'Armini A, Galie N, Meyer B, Corkery P, Meszaros G, Mayer E, Simonneau G. ERS statement on chronic thromboembolic pulmonary hypertension. Eur Respir J 2021; 57:13993003.02828-2020. [PMID: 33334946 DOI: 10.1183/13993003.02828-2020] [Citation(s) in RCA: 269] [Impact Index Per Article: 89.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/05/2020] [Indexed: 12/25/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism, either symptomatic or not. The occlusion of proximal pulmonary arteries by fibrotic intravascular material, in combination with a secondary microvasculopathy of vessels <500 µm, leads to increased pulmonary vascular resistance and progressive right heart failure. The mechanism responsible for the transformation of red clots into fibrotic material remnants has not yet been elucidated. In patients with pulmonary hypertension, the diagnosis is suspected when a ventilation/perfusion lung scan shows mismatched perfusion defects, and confirmed by right heart catheterisation and vascular imaging. Today, in addition to lifelong anticoagulation, treatment modalities include surgery, angioplasty and medical treatment according to the localisation and characteristics of the lesions.This statement outlines a review of the literature and current practice concerning diagnosis and management of CTEPH. It covers the definitions, diagnosis, epidemiology, follow-up after acute pulmonary embolism, pathophysiology, treatment by pulmonary endarterectomy, balloon pulmonary angioplasty, drugs and their combination, rehabilitation and new lines of research in CTEPH.It represents the first collaboration of the European Respiratory Society, the International CTEPH Association and the European Reference Network-Lung in the pulmonary hypertension domain. The statement summarises current knowledge, but does not make formal recommendations for clinical practice.
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Affiliation(s)
- Marion Delcroix
- Clinical Dept of Respiratory Diseases, Pulmonary Hypertension Center, UZ Leuven, Leuven, Belgium .,BREATHE, Dept CHROMETA, KU Leuven, Leuven, Belgium.,Co-chair
| | - Adam Torbicki
- Dept of Pulmonary Circulation, Thrombo-embolic Diseases and Cardiology, Center of Postgraduate Medical Education, ECZ-Otwock, Otwock, Poland.,Section editors
| | - Deepa Gopalan
- Dept of Radiology, Imperial College Hospitals NHS Trusts, London, UK.,Section editors
| | - Olivier Sitbon
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Frederikus A Klok
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Section editors
| | - Irene Lang
- Medical University of Vienna, Vienna, Austria.,Section editors
| | - David Jenkins
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK.,Section editors
| | - Nick H Kim
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA, USA.,Section editors
| | - Marc Humbert
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Xavier Jais
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Section editors
| | - Joanna Pepke-Zaba
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK.,Section editors
| | - Philippe Brénot
- Marie Lannelongue Hospital, Paris-South University, Le Plessis Robinson, France
| | - Peter Dorfmuller
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,Dept of Pneumology, Kerckhoff-Clinic Bad Nauheim, Bad Nauheim, Germany
| | - Elie Fadel
- Hannover Medical School, Hannover, Germany
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,Dept of Pneumology, Kerckhoff-Clinic Bad Nauheim, Bad Nauheim, Germany
| | | | - Pavel Jansa
- 2nd Department of Medicine, Dept of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Michael Madani
- Sulpizio Cardiovascular Centre, University of California, San Diego, CA, USA
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Takeshi Ogo
- National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Ekkehard Grünig
- Thoraxklinik Heidelberg at Heidelberg University Hospital, Heidelberg, Germany
| | - Andrea D'Armini
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | | | - Bernhard Meyer
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | | | | | - Eckhard Mayer
- Dept of Thoracic Surgery, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany.,Equal contribution.,Co-chair
| | - Gérald Simonneau
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Equal contribution.,Co-chair
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19
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Diagnostic Impact of Quantitative Dual-Energy Computed Tomography Perfusion Imaging for the Assessment of Subsegmental Pulmonary Embolism. J Comput Assist Tomogr 2021; 45:151-156. [PMID: 33186173 DOI: 10.1097/rct.0000000000001106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the quantitative differences of dual-energy computed tomography perfusion imaging measurements in subsegmental pulmonary embolism (SSPE), between normal lung parenchyma (NLP) and hypoperfused segments (HPS) with and without thrombus on computed tomography angiography (CTA). METHODS Lung attenuation, iodine density, and normalized uptake values were measured from HPS and NLP on iodine maps of 43 patients with SSPE. Presence of pulmonary embolism (PE) on CTA was recorded. One-way repeated-measures analysis of variance and Kruskal-Wallis analyses with post hoc comparisons were conducted. RESULTS The numbers of HPS with and without SSPE on CTA were 45 (55.6%) and 36 (44.4%), respectively. Lung attenuation of NLP was significantly different from HPS (P < 0.001). Iodine density and normalized uptake values of HPS with PE were significantly lower than those of HPS without PE, which is significantly lower than NLP (P < 0.001). CONCLUSIONS Subsegmental pulmonary embolism causes HPS on dual-energy computed tomography perfusion imaging, which demonstrates different iodine density and normalized uptake values depending on the presence of thrombus.
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20
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Morphologic and Functional Dual-Energy CT Parameters in Patients With Chronic Thromboembolic Pulmonary Hypertension and Chronic Thromboembolic Disease. AJR Am J Roentgenol 2020; 215:1335-1341. [PMID: 32991219 DOI: 10.2214/ajr.19.22743] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The objective of our study was to compare morphologic and functional dual-energy CT (DECT) parameters in patients with chronic thromboembolic disease (CTED) and chronic thromboembolic pulmonary hypertension (CTEPH). MATERIALS AND METHODS. Using the local CTEPH registry, we identified 28 patients with CTED and 72 patients with CTEPH. On each DECT examination, a clot burden score was calculated by assigning the following scores for chronic changes by location: pulmonary trunk, 5; each main pulmonary artery (MPA), 4; each lobar branch, 3; each segmental branch, 2; and each subsegmental branch, 1. The total clot burden score was calculated by adding the individual scores from both lungs. Functional parameters were assessed using perfused blood volume (PBV) maps and included lung enhancement (in Hounsfield units), percentage of PBV, MPA peak enhancement (in Hounsfield units), maximum enhancement corresponding to 100, and the ratio of MPA peak enhancement to lung enhancement. A perfusion defect (PD) score was calculated by assigning 1 point to each segmental PD. Patients with CTED and patients with CTEPH were matched using propensity score matching to account for potential confounders. RESULTS. After matching, the CTEPH group showed a higher PD score than the CTED group and unilateral disease was more common in the CTED group than in the CTEPH group. In the unmatched sample, patients with CTED showed increased percentages of PBV for both lungs (PBV total) and for the right lung as compared with the CTEPH group (adjusted p = 0.040 and 0.028, respectively); after adjustment for clot burden, the difference between groups was still noted but was not statistically significant. No statistically significant differences were noted in the various functional DECT parameters after propensity score matching. CONCLUSION. Patients with CTED show anatomic and functional changes in the pulmonary vasculature and lung parenchyma similar to those seen in patients with CTEPH. Functional DECT parameters support the observation that CTED is an intermediate clinical phenotype in the population with chronic pulmonary embolism.
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21
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Imaging of Pulmonary Hypertension: Pictorial Essay. Chest 2019; 156:211-227. [PMID: 30981724 DOI: 10.1016/j.chest.2019.04.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 04/01/2019] [Indexed: 11/20/2022] Open
Abstract
Pulmonary hypertension (PH) is an end result of a diverse array of complex clinical conditions that invoke hemodynamic and pathophysiological changes in the pulmonary vasculature. Many patients' symptoms begin with dyspnea on exertion for which screening tests such as chest roentgenograms and more definitive noninvasive tests such as CT scans are ordered initially. It is imperative that clinicians are cognizant of subtle clues on these imaging modalities that alert them to the possibility of PH. These clues may serve as a stepping stone towards more advanced noninvasive (echocardiogram) and invasive (right heart catheterization) testing. On the CT scan, the signs are classified into mediastinal and lung parenchymal abnormalities. In addition to suspecting the diagnosis of PH, this paper provides a pictorial essay to guide health care professionals in identifying the etiology of PH. This paper also provides concrete definitions, wherever possible, of what constitutes abnormalities in PH, such as dilated pulmonary arteries, pruning of vessels, and increased thickness of free wall of the right ventricle. The sensitivities and specificities of each sign are enumerated. The common radiographic and clinical features of many different etiologies of PH are tabulated for the convenience of the readers. Some newer imaging modalities such as dual-energy CT of the chest that hold promise for the future are also described.
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22
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Kiely DG, Levin DL, Hassoun PM, Ivy D, Jone PN, Bwika J, Kawut SM, Lordan J, Lungu A, Mazurek JA, Moledina S, Olschewski H, Peacock AJ, Puri G, Rahaghi FN, Schafer M, Schiebler M, Screaton N, Tawhai M, van Beek EJ, Vonk-Noordegraaf A, Vandepool R, Wort SJ, Zhao L, Wild JM, Vogel-Claussen J, Swift AJ. EXPRESS: Statement on imaging and pulmonary hypertension from the Pulmonary Vascular Research Institute (PVRI). Pulm Circ 2019; 9:2045894019841990. [PMID: 30880632 PMCID: PMC6732869 DOI: 10.1177/2045894019841990] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 03/01/2019] [Indexed: 01/08/2023] Open
Abstract
Pulmonary hypertension (PH) is highly heterogeneous and despite treatment advances it remains a life-shortening condition. There have been significant advances in imaging technologies, but despite evidence of their potential clinical utility, practice remains variable, dependent in part on imaging availability and expertise. This statement summarizes current and emerging imaging modalities and their potential role in the diagnosis and assessment of suspected PH. It also includes a review of commonly encountered clinical and radiological scenarios, and imaging and modeling-based biomarkers. An expert panel was formed including clinicians, radiologists, imaging scientists, and computational modelers. Section editors generated a series of summary statements based on a review of the literature and professional experience and, following consensus review, a diagnostic algorithm and 55 statements were agreed. The diagnostic algorithm and summary statements emphasize the key role and added value of imaging in the diagnosis and assessment of PH and highlight areas requiring further research.
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Affiliation(s)
- David G. Kiely
- Sheffield Pulmonary Vascular Disease
Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
| | - David L. Levin
- Department of Radiology, Mayo Clinic,
Rochester, MN, USA
| | - Paul M. Hassoun
- Department of Medicine John Hopkins
University, Baltimore, MD, USA
| | - Dunbar Ivy
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | - Pei-Ni Jone
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | | | - Steven M. Kawut
- Department of Medicine, Perelman School
of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jim Lordan
- Freeman Hospital, Newcastle Upon Tyne,
Newcastle, UK
| | - Angela Lungu
- Technical University of Cluj-Napoca,
Cluj-Napoca, Romania
| | - Jeremy A. Mazurek
- Division of Cardiovascular Medicine,
Hospital
of the University of Pennsylvania,
Philadelphia, PA, USA
| | | | - Horst Olschewski
- Division of Pulmonology, Ludwig
Boltzmann Institute Lung Vascular Research, Graz, Austria
| | - Andrew J. Peacock
- Scottish Pulmonary Vascular Disease,
Unit, University of Glasgow, Glasgow, UK
| | - G.D. Puri
- Department of Anaesthesiology and
Intensive Care, Post Graduate Institute of Medical Education and Research,
Chandigarh, India
| | - Farbod N. Rahaghi
- Brigham and Women’s Hospital, Harvard
Medical School, Boston, MA, USA
| | - Michal Schafer
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | - Mark Schiebler
- Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Merryn Tawhai
- Auckland Bioengineering Institute,
Auckland, New Zealand
| | - Edwin J.R. van Beek
- Edinburgh Imaging, Queens Medical
Research Institute, University of Edinburgh, Edinburgh, UK
| | | | - Rebecca Vandepool
- University of Arizona, Division of
Translational and Regenerative Medicine, Tucson, AZ, USA
| | - Stephen J. Wort
- Royal Brompton Hospital, London,
UK
- Imperial College, London, UK
| | | | - Jim M. Wild
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
- Academic Department of Radiology,
University of Sheffield, Sheffield, UK
| | - Jens Vogel-Claussen
- Institute of diagnostic and
Interventional Radiology, Medical Hospital Hannover, Hannover, Germany
| | - Andrew J. Swift
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
- Academic Department of Radiology,
University of Sheffield, Sheffield, UK
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23
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Rahaghi FN, Minhas JK, Heresi GA. Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism: New Imaging Tools and Modalities. Clin Chest Med 2018; 39:493-504. [PMID: 30122174 PMCID: PMC6317734 DOI: 10.1016/j.ccm.2018.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Imaging continues to be the modality of choice for the diagnosis of venous thromboembolic disease, particularly when incorporated into diagnostic algorithms. Improvement in imaging techniques as well as new imaging modalities and processing methods have improved diagnostic accuracy and additionally are being leveraged in prognostication and decision making for choice of intervention. In this article, we review the role of imaging in diagnosis and prognostication of venous thromboembolism. We also discuss emerging imaging approaches that may in the near future find clinical usefulness in improving diagnosis and prognostication as well as differentiating disease phenotypes.
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Affiliation(s)
- Farbod N. Rahaghi
- Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Harvard Medical School. 15 Francis Street, Boston MA 02115, ; Phone: 617-632-6770
| | - Jasleen K. Minhas
- Department of Medicine, North Shore Medical Center, 81 highland Ave Salem MA 10970, Phone: 978-354-4801
| | - Gustavo A. Heresi
- Respiratory Institute, Cleveland Clinic, Mail code A90, 9500 Euclid Ave, OH 44195, Phone: 216-636-5327
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24
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Masy M, Giordano J, Petyt G, Hossein-Foucher C, Duhamel A, Kyheng M, De Groote P, Fertin M, Lamblin N, Bervar JF, Remy J, Remy-Jardin M. Dual-energy CT (DECT) lung perfusion in pulmonary hypertension: concordance rate with V/Q scintigraphy in diagnosing chronic thromboembolic pulmonary hypertension (CTEPH). Eur Radiol 2018; 28:5100-5110. [PMID: 29846802 DOI: 10.1007/s00330-018-5467-2] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 03/29/2018] [Accepted: 04/09/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To evaluate the concordance between DECT perfusion and ventilation/perfusion (V/Q) scintigraphy in diagnosing chronic thromboembolic pulmonary hypertension (CTEPH). METHODS Eighty patients underwent V/Q scintigraphy and DECT perfusion on a 2nd- and 3rd-generation dual-source CT system. The imaging criteria for diagnosing CTEPH relied on at least one segmental triangular perfusion defect on DECT perfusion studies and V/Q mismatch on scintigraphy examinations. RESULTS Based on multidisciplinary expert decisions that did not include DECT perfusion, 36 patients were diagnosed with CTEPH and 44 patients with other aetiologies of PH. On DECT perfusion studies, there were 35 true positives, 6 false positives and 1 false negative (sensitivity 0.97, specificity 0.86, PPV 0.85, NPV 0.97). On V/Q scans, there were 35 true positives and 1 false negative (sensitivity 0.97, specificity 1, PPV 1, NPV 0.98). There was excellent agreement between CT perfusion and scintigraphy in diagnosing CTEPH (kappa value 0.80). Combined information from DECT perfusion and CT angiographic images enabled correct reclassification of the 6 false positives and the unique false negative case of DECT perfusion. CONCLUSION There is excellent agreement between DECT perfusion and V/Q scintigraphy in diagnosing CTEPH. The diagnostic accuracy of DECT perfusion is reinforced by the morpho-functional analysis of data sets. KEY POINTS • Chronic thromboembolic pulmonary hypertension (CTEPH) is potentially curable by surgery. • The triage of patients with pulmonary hypertension currently relies on scintigraphy. • Dual-energy CT (DECT) can provide standard diagnostic information and lung perfusion from a single acquisition. • There is excellent agreement between DECT perfusion and scintigraphy in separating CTEPH and non-CTEPH patients.
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Affiliation(s)
- Matthieu Masy
- Department of Thoracic Imaging, Calmette Hospital (EA 2694); CHRU et Université de Lille 2 Nord de France, F-59000, Lille, France
| | - Jessica Giordano
- Department of Thoracic Imaging, Calmette Hospital (EA 2694); CHRU et Université de Lille 2 Nord de France, F-59000, Lille, France
| | - Grégory Petyt
- Department of Nuclear Medicine; Salengro Hospital, University of Lille, CHU Lille, F-59000, Lille, France
| | - Claude Hossein-Foucher
- Department of Nuclear Medicine; Salengro Hospital, University of Lille, CHU Lille, F-59000, Lille, France
| | - Alain Duhamel
- Department of Biostatistics (EA 2694), CHRU et Université de Lille 2 Nord de France, F-59000, Lille, France
| | - Maeva Kyheng
- Department of Biostatistics (EA 2694), CHRU et Université de Lille 2 Nord de France, F-59000, Lille, France
| | - Pascal De Groote
- Department of Cardiology; Cardiology Hospital, University of Lille, CHU Lille, F-59000, Lille, France
- INSERM U1167, Institut Pasteur de Lille, F-59000, Lille, France
| | - Marie Fertin
- Department of Cardiology; Cardiology Hospital, University of Lille, CHU Lille, F-59000, Lille, France
- INSERM U1167, Institut Pasteur de Lille, F-59000, Lille, France
| | - Nicolas Lamblin
- Department of Cardiology; Cardiology Hospital, University of Lille, CHU Lille, F-59000, Lille, France
- INSERM U1167, Institut Pasteur de Lille, F-59000, Lille, France
| | - Jean-François Bervar
- Department of Pulmonology, Calmette Hospital; University of Lille, CHU Lille, F-59000, Lille, France
| | - Jacques Remy
- Department of Thoracic Imaging, Calmette Hospital (EA 2694); CHRU et Université de Lille 2 Nord de France, F-59000, Lille, France
| | - Martine Remy-Jardin
- Department of Thoracic Imaging, Calmette Hospital (EA 2694); CHRU et Université de Lille 2 Nord de France, F-59000, Lille, France.
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25
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Felloni P, Duhamel A, Faivre JB, Giordano J, Khung S, Deken V, Remy J, Remy-Jardin M. Regional Distribution of Pulmonary Blood Volume with Dual-Energy Computed Tomography: Results in 42 Subjects. Acad Radiol 2017; 24:1412-1421. [PMID: 28711443 DOI: 10.1016/j.acra.2017.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 04/27/2017] [Accepted: 05/10/2017] [Indexed: 10/19/2022]
Abstract
RATIONALE AND OBJECTIVES The noninvasive approach of lung perfusion generated from dual-energy computed tomography acquisitions has entered clinical practice. The purpose of this study was to analyze the regional distribution of iodine within distal portions of the pulmonary arterial bed on dual-source, dual-energy computed tomography examinations in a cohort of subjects without cardiopulmonary pathologies. MATERIALS AND METHODS The study population included 42 patients without cardiorespiratory disease, enabling quantitative and qualitative analysis of pulmonary blood volume after administration of a 40% contrast agent. Qualitative analysis was based on visual assessment. Quantitative analysis was obtained after semiautomatic division of each lung into 18 areas. RESULTS The iodine concentration did not significantly differ between the right (R) and left (L) lungs (P = .49), with a mean attenuation of 41.35 Hounsfield units (HU) and 41.14 HU, respectively. Three regional gradients of attenuation were observed between: (a) lung bases and apices (P < .001), linked to the conditions of examination (mean Δ: 6.23 in the R lung; 5.96 in the L lung); (b) posterior and anterior parts of the lung (P < .001) due to gravity (mean Δ: 11.92 in the R lung ; 15.93 in the L lung); and (c) medullary and cortical lung zones (P < .001) (mean Δ: 9.35 in the R lung ; 8.37 in the L lung). The intensity of dependent-nondependent (r = 0.42; P < .001) and corticomedullary (r = 0.58; P < .0001) gradients was correlated to the overall iodine concentration. CONCLUSION Distribution of pulmonary blood volume is influenced by physiological gradients and scanning conditions.
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26
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Giordano J, Khung S, Duhamel A, Hossein-Foucher C, Bellèvre D, Lamblin N, Remy J, Remy-Jardin M. Lung perfusion characteristics in pulmonary arterial hypertension (PAH) and peripheral forms of chronic thromboembolic pulmonary hypertension (pCTEPH): Dual-energy CT experience in 31 patients. Eur Radiol 2016; 27:1631-1639. [PMID: 27480438 DOI: 10.1007/s00330-016-4500-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/24/2016] [Accepted: 06/30/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare lung perfusion in PAH and pCTEPH on dual-energy CT (DECT) examinations. MATERIALS AND METHODS Thirty-one patients with PAH (group 1; n = 19) and pCTEPH (group 2; n = 12) underwent a dual-energy chest CTA with reconstruction of diagnostic and perfusion images. Perfusion alterations were analysed at a segmental level. V/Q scintigraphy was available in 22 patients (group 1: 13/19; group 2: 9/12). RESULTS CT perfusion was abnormal in 52.6 % of group 1 patients and in 100 % of group 2 patients (p = 0.0051). The patterns of perfusion alteration significantly differed between the two groups (p < 0.0001): (1) in group 1, 96.6 % of segments with abnormal perfusion showed patchy defects; (2) in group 2, the most frequent abnormalities consisted of patchy (58.5 %) and PE-type (37.5 %) defects. Paired comparison of CT perfusion and scintigraphy showed concordant findings in 76.9 % of group 1 (10/13) and 100 % of group 2 (9/9) patients, with a predominant or an exclusive patchy pattern in group 1 and a mixed pattern of abnormalities in group 2. CONCLUSION Lung perfusion alterations at DECT are less frequent and more homogeneous in PAH than in pCTEPH, with a high level of concordant findings with V/Q scintigraphy. KEY POINTS • Depiction of chronic pulmonary embolism exclusively located on peripheral arteries is difficult. • The main differential diagnosis of pCTEPH is PAH. • The pattern of DECT perfusion changes can help differentiate PAH and pCETPH. • In PAH, almost all segments with abnormal perfusion showed patchy defects. • In pCTEPH, patchy and PE-type defects were the most frequent abnormalities.
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Affiliation(s)
- Jessica Giordano
- Department of Thoracic Imaging, Hospital Calmette (EA 2694), CHRU et Université de Lille 2 Nord de France, 59000, Lille, France
| | - Suonita Khung
- Department of Thoracic Imaging, Hospital Calmette (EA 2694), CHRU et Université de Lille 2 Nord de France, 59000, Lille, France
| | - Alain Duhamel
- Department of Biostatistics, University Lille, CHU Lille, EA 2694, 59000, Lille, France
| | - Claude Hossein-Foucher
- Department of Nuclear Medicine, Hospital Salengro, University Lille, CHU Lille, 59000, Lille, France
| | - Dimitri Bellèvre
- Department of Nuclear Medicine, Hospital Salengro, University Lille, CHU Lille, 59000, Lille, France
| | - Nicolas Lamblin
- Department of Cardiology, Cardiology Hospital, University Lille, CHU Lille, 59000, Lille, France
| | - Jacques Remy
- Department of Thoracic Imaging, Hospital Calmette (EA 2694), CHRU et Université de Lille 2 Nord de France, 59000, Lille, France
| | - Martine Remy-Jardin
- Department of Thoracic Imaging, Hospital Calmette (EA 2694), CHRU et Université de Lille 2 Nord de France, 59000, Lille, France.
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