Routine breath-hold gradient echo MRI-derived right ventricular mass, volumes and function: accuracy, reproducibility and coherence study

The association of Pulmonary Hypertension and right ventricular systolic function - updates in diagnosis and treatment

Right ventricular (RV) systolic function is an essential but neglected component in cardiac evaluation, and its importance to the contribution to overall cardiac function is undermined. It is not only sensitive to the effect of left heart valve disease but is also more sensitive to changes in pressure overload than the left ventricle. Pulmonary Hypertension is the common and well-recognized complication of RV systolic dysfunction. It is also the leading cause of pulmonary valve disease and right ventricular dysfunction. Patients with a high pulmonary artery pressure (PAP) and a low RV ejection fraction have a seven-fold higher risk of death than heart failure patients with a normal PAP and RV ejection fraction. Furthermore, it is an independent predictor of survival in these patients. In this review, we examine the association of right ventricular systolic function with Pulmonary Hypertension by focusing on various pathological and clinical manifestations while assessing their impact. We also explore new 2022 ESC/ERS guidelines for diagnosing and treating right ventricular dysfunction in Pulmonary Hypertension.

Normative ranges of biventricular volumes and function in healthy term newborns

BACKGROUND

Cardiovascular magnetic resonance (CMR) is increasingly used in newborns with congenital heart disease. However, reporting on ventricular volumes and mass is hindered by an absence of normative data in this population.

DESIGN/METHODS

Healthy term (37-41 weeks gestation) newborns underwent non-sedated, free-breathing CMR within the first week of life using the 'feed and wrap' technique. End-diastolic volume (EDV), end-systolic volume (ESV) stroke volume (SV) and ejection fraction (EF) were calculated for both left ventricle (LV) and right ventricle (RV). Papillary muscles were separately contoured and included in the myocardial volume. Myocardial mass was calculated by multiplying myocardial volume by 1.05 g/ml. All data were indexed to weight and body surface area (BSA). Inter-observer variability (IOV) was performed on data from 10 randomly chosen infants.

RESULTS

Twenty healthy newborns (65% male) with a mean (SD) birth weight of 3.54 (0.46) kg and BSA of 0.23 (0.02) m2 were included. Normative LV parameters were indexed EDV 39.0 (4.1) ml/m2, ESV 14.5 (2.5) ml/m2 and ejection fraction (EF) 63.2 (3.4)%. Normative RV indexed EDV, ESV and EF were 47.4 (4.5) ml/m2, 22.6 (2.9) ml/m2 and 52.5 (3.3)% respectively. Mean LV and RV indexed mass were 26.4 (2.8) g/m2 and 12.5 (2.0) g/m2, respectively. There was no difference in ventricular volumes by gender. IOV was excellent with an intra-class coefficient > 0.95 except for RV mass (0.94).

CONCLUSION

This study provides normative data on LV and RV parameters in healthy newborns, providing a novel resource for comparison with newborns with structural and functional heart disease.

Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the use of cardiovascular magnetic resonance in pediatric congenital and acquired heart disease : Endorsed by The American Heart Association

Cardiovascular magnetic resonance (CMR) has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of CMR in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of CMR in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.

Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the Use of Cardiac Magnetic Resonance in Pediatric Congenital and Acquired Heart Disease: Endorsed by The American Heart Association

Cardiovascular magnetic resonance has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of cardiovascular magnetic resonance in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of cardiovascular magnetic resonance in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.

Application and Validation of the Tricuspid Annular Plane Systolic Excursion/Systolic Pulmonary Artery Pressure Ratio in Patients with Ischemic and Non-Ischemic Cardiomyopathy

The main aim of this study was to assess the prognostic utility of TAPSE/PASP as an echocardiographic parameter of maladaptive RV remodeling in cardiomyopathy patients using cardiac magnetic resonance (CMR) imaging. Furthermore, we sought to compare TAPSE/PASP to TAPSE. The association of the echocardiographic parameters TAPSE/PASP and TAPSE with CMR parameters of RV and LV remodeling was evaluated in 111 patients with ischemic and non-ischemic cardiomyopathy and cut-off values for maladaptive RV remodeling were defined. In a second step, the prognostic value of TAPSE/PASP and its cut-off value were analyzed regarding mortality in a validation cohort consisting of 221 patients with ischemic and non-ischemic cardiomyopathy. A low TAPSE/PASP (<0.38 mm/mmHg) and TAPSE (<16 mm) were associated with a lower RVEF and a long-axis RV global longitudinal strain (GLS) as well as higher RVESVI, RVEDVI and NT-proBNP. A low TAPSE/PASP, but not TAPSE, was associated with a lower LVEF and long-axis LV GLS, and a higher LVESVI, LVEDVI and T1 relaxation time at the interventricular septum and the RV insertion points. Furthermore, in the validation cohort, low TAPSE/PASP was associated with a higher mortality and TAPSE/PASP was an independent predictor of mortality. TAPSE/PASP is a predictor of maladaptive RV and LV remodeling associated with poor outcomes in cardiomyopathy patients.

Echocardiographic assessment of right ventricular systolic function in healthy Beagle dogs compared to high field cardiac magnetic resonance imaging

Ten healthy Beagle dogs were used to compare selected echocardiographic parameters of right ventricular (RV) systolic function with high field cardiac magnetic resonance imaging (MRI). All dogs underwent complete transthoracic echocardiography before and during anesthesia, as well as cardiac MRI with determination of morphology-based ejection fraction, and phase contrast angiography-derived stroke volume. A correlation analysis was carried out between echocardiographic and MRI parameters. The values of fractional area change, tricuspid annular plane systolic excursion, tissue Doppler imaging derived peak velocity of the isovolumic contraction wave and systolic wave of the lateral tricuspid valve annulus showed lower values under general anesthesia. Of all echocardiographic parameters of RV systolic function, only fractional area change (r = 0.671, P = 0.034) and tissue Doppler imaging derived peak velocity of the systolic wave of the lateral tricuspid valve annulus (r = 0.768; P = 0.01), showed a significant correlation with MRI derived stroke volume. None of the echocardiographic parameters correlated with MRI derived ejection fraction. When evaluating the RV echocardiographically, fractional area change and peak velocity of the systolic wave of the lateral tricuspid valve annulus appear to be the most reliable predictors of RV systolic function when compared to MRI under anesthesia.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Analysis of right ventricular mass from magnetic resonance imaging data: a simple post-processing algorithm for correction of partial-volume effects

Magnetic resonance imaging (MRI) of the right ventricle (RV) offers important diagnostic information, but the accuracy of this information is hampered by the complex geometry of the RV. Here, we propose a novel postprocessing algorithm that corrects for partial-volume effects in the analysis of standard MRI cine images of RV mass (RVm) and evaluate the method in clinical and preclinical data. Self-corrected RVm measurement was compared with conventionally measured RVm in 16 patients who showed different clinical indications for cardiac MRI and in 17 Wistar rats with different degrees of pulmonary congestion. The rats were studied under isoflurane anaesthesia. To evaluate the reliability of the proposed method, the measured end-systolic and end-diastolic RVm were compared. Accuracy was evaluated by comparing preclinical RVm to ex vivo RV weight (RVw). We found that use of the self-correcting algorithm improved reliability compared with conventional segmentation. For clinical data, the limits of agreement (LOAs) were -1.8 ± 8.6g (self-correcting) vs. 5.8 ± 7.8g (conventional), and coefficients of variation (CoVs) were 7.0% (self-correcting) vs. 14.3% (conventional). For preclinical data, LOAs were 21 ± 46 mg (self-correcting) vs. 64 ± 89 mg (conventional), and CoVs were 9.0% (self-correcting) and 17.4% (conventional). Self-corrected RVm also showed better correspondence with the ex vivo RVw: LOAs were -5 ± 80 mg (self-correcting) vs. 94 ± 116 mg (conventional) in end-diastole and -26 ± 74 mg (self-correcting) vs. 31 ± 98 mg (conventional) in end-systole. The new self-correcting algorithm improves the reliability and accuracy of RVm measurements in both clinical and preclinical MRI. It is simple and easy to implement and does not require any additional MRI data.NEW & NOTEWORTHY Magnetic resonance imaging (MRI) of the right ventricle (RV) offers important diagnostic information, but the accuracy of this information is hampered by the complex geometry of the RV. In particular, the crescent shape of the RV renders it particularly vulnerable to partial-volume effects. We present a new, simple, self-correcting algorithm that can be applied to correct partial-volume effects in MRI-based RV mass estimation. The self-correcting algorithm offers improved reliability and accuracy compared with the conventional approach.

Cardiovascular Magnetic Resonance in Congenital Heart Disease: Focus on Heart Failure

Over the past decade, cardiovascular magnetic resonance (CMR) has become a mainstream noninvasive imaging tool for assessment of adult and pediatric patients with congenital heart disease. It provides comprehensive anatomic and hemodynamic information that echocardiography and catheterization alone do not provide. Extracardiac anatomy can be delineated with high spatial resolution, intracardiac anatomy can be imaged in multiple planes, and functional assessment can be made accurately and with high reproducibility. In patients with heart failure, CMR provides not only reference standard evaluation of ventricular volumes and function but also information about the possible causes of dysfunction.

Cardiac magnetic resonance imaging: insights into developmental programming and its consequences for aging

Cardiovascular diseases (CVD) are important consequences of adverse perinatal conditions such as fetal hypoxia and maternal malnutrition. Cardiac magnetic resonance imaging (CMR) can produce a wealth of physiological information related to the development of the heart. This review outlines the current state of CMR technologies and describes the physiological biomarkers that can be measured. These phenotypes include impaired ventricular and atrial function, maladaptive ventricular remodeling, and the proliferation of myocardial steatosis and fibrosis. The discussion outlines the applications of CMR to understanding the developmental pathways leading to impaired cardiac function. The use of CMR, both in animal models of developmental programming and in human studies, is described. Specific examples are given in a baboon model of intrauterine growth restriction (IUGR). CMR offers great potential as a tool for understanding the sequence of dysfunctional adaptations of developmental origin that can affect the human cardiovascular system.

Comparison of Right Ventricular Function Between Three-Dimensional Transesophageal Echocardiography and Pulmonary Artery Catheter

OBJECTIVE

This study aimed to compare measurements of right ventricular function using three-dimensional transesophageal echocardiography (3D TEE), and pulmonary artery catheters (PACs) in patients undergoing cardiac surgery. The authors examined the practicality of using the 3D TEE.

DESIGN

Prospective observational.

SETTING

Cardiac operating room at a single university hospital.

PARTICIPANTS

All adult patients undergoing elective cardiac surgery at a single tertiary care university hospital over two years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume (RVESV), stroke volume (SV), and right ventricular ejection fraction (RVEF) were measured with both 3D TEE and PACs. Assessments were performed using correlation coefficients, paired t tests, and Bland-Altman plots. Thirty-one patients participated in this study. Each measurement showed good agreement. RVEDV and RVESV were slightly lower on 3D TEE than on PAC (205.9 mL v 220.2 mL, p = 0.0018; 143.0 mL v 155.5 mL, p = 0.0143, respectively), whereas no significant differences were observed for SV and RVEF (31.0% v 31.1%, p = 0.0569; 61.6 mL v 66.9 mL, p = 0.92, respectively). Linear regression analysis showed high correlation between 3D TEE and PAC for RVEDV (r = 0.87) and RVESV (r = 0.81), and moderate correlation for SV (r = 0.67) and RVEF (r = 0.67). In the Bland-Altman plot, most patients were within the 95% limits of the agreement throughout all measurements.

CONCLUSION

A high correlation was found between measurements made with a PAC and with 3D TEE in the assessment of right ventricular function. Three-dimensional TEE would be a potential alternative to PAC for assessment of right ventricular function during intraoperative periods.

Evaluation of right ventricular dyssynchrony in patients with acute inferior myocardial infarction and its relation with mortality

PURPOSE

The aim of this study was to evaluate right ventricle (RV) dyssynchrony and its relation with mortality using speckle-tracking echocardiography (STE) in patients with acute inferior myocardial infarction (IMI).

METHODS

One hundred and fifty-eight consecutive patients with acute IMI treated with primary percutaneous coronary intervention, and 44 healthy subjects were included. RV myocardial involvement (RVMI) was defined as an elevation >1 mm in V1 or V4R and/or the presence of a culprit lesion at the proximal portion of the first RV marginal branch after reviewing coronary angiography. Patients were followed for 3 years to determine the cardiovascular mortality.

RESULTS

Overall, 70 patients with IMI had RVMI. IMI patients had significantly higher RV peak systolic longitudinal strain dyssynchrony (PLSSD) index, lower peak longitudinal systolic strain (PLSS), longer time to PLSS, and time to PLSS differences compared to healthy controls while the patients with RVMI had significantly worse values compared to patients without RVMI and healthy controls. Twenty-seven patients (17.1%) died within 2 years. RVMI was more prevalent in mortality group, and they had significantly higher RV PSSD index, whereas they had lower RV free wall PLSS and longer time to PLSS differences. Receiver operating characteristics (ROC) analysis revealed that a RV PLSSD index > 65 ms predicted mortality with a sensitivity of 88.9% and specificity of 71.8% in IMI patients.

CONCLUSIONS

Intra- and inter-ventricular dyssynhcrony may develop in patients with acute IMI, especially in those with RV involvement, which might have a negative effect on the prognosis of these patients.

Evaluation of a Semi-automatic Right Ventricle Segmentation Method on Short-Axis MR Images

The purpose of this study was to evaluate a semi-automatic right ventricle segmentation method on short-axis cardiac cine MR images which segment all right ventricle contours in a cardiac phase using one seed contour. Twenty-eight consecutive short-axis, four-chamber, and tricuspid valve view cardiac cine MRI examinations of healthy volunteers were used. Two independent observers performed the manual and automatic segmentations of the right ventricles. Analyses were based on the ventricular volume and ejection fraction of the right heart chamber. Reproducibility of the manual and semi-automatic segmentations was assessed using intra- and inter-observer variability. Validity of the semi-automatic segmentations was analyzed with reference to the manual segmentations. The inter- and intra-observer variability of manual segmentations were between 0.8 and 3.2%. The semi-automatic segmentations were highly correlated with the manual segmentations (R² 0.79-0.98), with median difference of 0.9-4.8% and of 3.3% for volume and ejection fraction parameters, respectively. In comparison to the manual segmentation, the semi-automatic segmentation produced contours with median dice metrics of 0.95 and 0.87 and median Hausdorff distance of 5.05 and 7.35 mm for contours at end-diastolic and end-systolic phases, respectively. The inter- and intra-observer variability of the semi-automatic segmentations were lower than observed in the manual segmentations. Both manual and semi-automatic segmentations performed better at the end-diastolic phase than at the end-systolic phase. The investigated semi-automatic segmentation method managed to produce a valid and reproducible alternative to manual right ventricle segmentation.

Assessment of Right Ventricular Function in the Research Setting: Knowledge Gaps and Pathways Forward. An Official American Thoracic Society Research Statement

BACKGROUND

Right ventricular (RV) adaptation to acute and chronic pulmonary hypertensive syndromes is a significant determinant of short- and long-term outcomes. Although remarkable progress has been made in the understanding of RV function and failure since the meeting of the NIH Working Group on Cellular and Molecular Mechanisms of Right Heart Failure in 2005, significant gaps remain at many levels in the understanding of cellular and molecular mechanisms of RV responses to pressure and volume overload, in the validation of diagnostic modalities, and in the development of evidence-based therapies.

METHODS

A multidisciplinary working group of 20 international experts from the American Thoracic Society Assemblies on Pulmonary Circulation and Critical Care, as well as external content experts, reviewed the literature, identified important knowledge gaps, and provided recommendations.

RESULTS

This document reviews the knowledge in the field of RV failure, identifies and prioritizes the most pertinent research gaps, and provides a prioritized pathway for addressing these preclinical and clinical questions. The group identified knowledge gaps and research opportunities in three major topic areas: 1) optimizing the methodology to assess RV function in acute and chronic conditions in preclinical models, human studies, and clinical trials; 2) analyzing advanced RV hemodynamic parameters at rest and in response to exercise; and 3) deciphering the underlying molecular and pathogenic mechanisms of RV function and failure in diverse pulmonary hypertension syndromes.

CONCLUSIONS

This statement provides a roadmap to further advance the state of knowledge, with the ultimate goal of developing RV-targeted therapies for patients with RV failure of any etiology.

Can 3D RVEF be Prognostic for the Non-Ischemic Cardiomyopathy Patient but not the Ischemic Cardiomyopathy Patient? A Cardiovascular MRI Study

Background: While left ventricular ejection fraction (LVEF) has been shown to have prognostic value in ischemic cardiomyopathy (ICMX) patients, right ventricular ejection fraction (RVEF) has not been systematically evaluated in either ICMX or non-ischemic cardiomyopathy (NICMX) patients. Moreover, an accurate estimation of RVEF is problematic due to the geometry of the right ventricle (RV). Over the years, there have been improvements in the resolution, image acquisition and post-processing software for cardiac magnetic resonance imaging (CMR), such that CMR has become the “gold standard” for measuring RV volumetrics and RVEF. We hypothesize that CMR defines RVEF more so than LVEF and might have prognostic capabilities in ischemic and non-ischemic cardiomyopathy patients (ICMX and NICMX). Methods: Patients that underwent CMR at our institution between January 2005 and October 2012 were retrospectively selected if three-dimensional (3D) LVEF < 35%. Patients were further divided into ICMX and NICMX groups. The electronic medical record (EMR) database inquiry determined all-cause mortality and major adverse cardiovascular events (MACE). Additionally, a Social Security Death Index (SSI) database inquiry was performed to determine all-cause mortality in patients who were lost to follow-up. Patients were further sub-grouped on the basis of 3D RVEF ≥ 20%. Separately, patients were sub-grouped by LVEF ≥ 20% in both ICMX and NICMX cases. A cut-off of ≥20% was chosen for the RVEF based on the results of prior studies showing significance based on Kaplan–Meier (KM) survival curves. Cumulative event rates were estimated for each subgroup using the KM analysis and were compared using the log-rank test. The 3D RV/LVEFs were compared to all-cause mortality and MACE. ICMX patients were defined using the World Health Organization (WHO) criteria. Results: From a 7000-patient CMR database, 753 heart failure patients were selected. Eighty-seven patients met WHO definition of ICMX and NICMX (43 ICMX and 44 NICMX). The study patients were followed for a median of 3 years (Interquartile range or IQR 1.5–6.5 years). The mean age of patients was 58 ± 13 years; 79% were male. In ICMX, mean 3D LVEF was 21% ± 6% and mean 3D RVEF was 38% ± 14%, while for NICMX, mean 3D LVEF was 16% ± 6% and mean 3D RVEF was 30% ± 14% (p < 0.005 for intra- and inter-group comparison). It should be noted that LVEF < RVEF in both groups and the ejection fraction (EF) in NICMX was less than the corresponding EF in ICMX. Overall mortality was higher in ICMX than NICMX (12/40, 30% vs. 7/43, 16%; p < 0.05). Patients were stratified based on both RVEF and LVEF with a threshold of EF ≥ 20% separately. RVEF but not LVEF was a significant predictor of death for NICMX (χ² = 8; p < 0.005), while LVEF did not predict death in ICMX (χ² = 2, p = not significant). Similarly, time to MACE was predicted by RVEF for NICMX (χ² = 9; p < 0.005) but not by LVEF in ICMX (χ² = 1; p = NS). Importantly, RVEF, while predictive of NICMX MACE, did not emerge as a predictor of survival or MACE in ICMX. Conclusions: Via 3D CMR in non-ischemic CMX patients, RVEF has important value in predicting death and time to first MACE while 3D LVEF is far less predictive.

Right ventricular dyssynchrony and its improvements after pulmonary rehabilitation in patients with chronic obstructive pulmonary disease

PURPOSE

Whether pathologic alterations of right ventricle (RV) in chronic obstructive pulmonary disease (COPD) affect intra- and interventricular dyssynchrony due to changes in mechanical activation of the septum and RV is unclear. The aim of this study was to determine mechanical activation and its changes after pulmonary rehabilitation program (PRP) with speckle tracking echocardiography (STE) in COPD patients.

METHODS

After the exclusion of 15 patients due to poor echogenicity and 5 patients not tolerating PRP out of 69 consecutive COPD patients undergoing PRP, the remaining 49 patients and 41 healthy subjects were enrolled. The mechanical activations of both ventricles were evaluated at admission and after PRP with STE.

RESULTS

Chronic obstructive pulmonary disease patients had intra- and interventricular dyssynchrony compared to controls. The interventricular dyssynchrony assessed by time to peak longitudinal systolic strain (PLSS) difference between RV free wall and left ventricle (LV) lateral wall and intraventricular dyssynchrony assessed by RV peak systolic strain dyssynchrony (PSSD) index were improved after PRP. In all, 18 patients were hospitalized due to symptoms of right heart failure within 1 year. The time to PLSS difference between RV free wall and LV lateral wall and RV PSSD index were independent predictors of hospitalization. Receiver operating characteristics (ROC) analysis revealed that a time to PLSS difference between RV free wall and LV lateral wall >15 ms predicted hospitalization within 1 year with 77.8% sensitivity and 64.5% specificity.

CONCLUSIONS

Chronic obstructive pulmonary disease was associated with intra- and interventricular dyssynchrony. PRP had an important impact on the improvement of both intra-, and interventricular dyssynchrony, which might be used in predicting hospitalization within 1 year.

Diagnosis of chronic thromboembolic pulmonary hypertension

Chronic thromboembolic pulmonary hypertension (CTEPH) is the only potentially curable form of pulmonary hypertension. Rapid and accurate diagnosis is pivotal for successful treatment. Clinical signs and symptoms can be nonspecific and risk factors such as history of venous thromboembolism may not always be present. Echocardiography is the recommended first diagnostic step. Cardiopulmonary exercise testing is a complementary tool that can help to identify patients with milder abnormalities and chronic thromboembolic disease, triggering the need for further investigation. Ventilation/perfusion (V'/Q') scintigraphy is the imaging methodology of choice to exclude CTEPH. Single photon emission computed tomography V'/Q' is gaining popularity over planar imaging. Assessment of pulmonary haemodynamics by right heart catheterisation is mandatory, although there is increasing interest in noninvasive haemodynamic evaluation. Despite the status of digital subtraction angiography as the gold standard, techniques such as computed tomography (CT) and magnetic resonance imaging are increasingly used for characterising the pulmonary vasculature and assessment of operability. Promising new tools include dual-energy CT, combination of rotational angiography and cone beam CT, and positron emission tomography. These innovative procedures not only minimise misdiagnosis, but also provide additional vascular information relevant to treatment planning. Further research is needed to determine how these modalities will fit into the diagnostic algorithm for CTEPH.

Effect of hydration status on atrial and ventricular volumes and function in healthy adult volunteers

BACKGROUND

Assessment of cardiac chamber volumes is a fundamental part of cardiac magnetic resonance (CMR) imaging. While the effects of inter- and intraobserver variability have been studied and have a recognized effect on the comparability of serial cardiac MR imaging studies, the effect of differences in hydration status has not been evaluated.

OBJECTIVE

To evaluate the effects of volume administration on cardiac chamber volumes.

MATERIALS AND METHODS

Thirteen healthy adults underwent a baseline cardiac MR to evaluate cardiac chamber volumes after an overnight fast. They were then given two saline boluses of 10 ml/kg of body weight and the cardiac MR was repeated immediately after each bolus.

RESULTS

From the baseline scan to the final scan there was a significant increase in all four cardiac chamber end-diastolic volumes. Right atrial volumes increased 8.0%, from 61.1 to 66.0 ml/m2 (P<0.001), and left atrial volumes increased 10.0%, from 50.0 to 55.0 ml/m2 (P<0.001). Right ventricular volumes increased 6.0%, from 91.1 to 96.5 ml/m2 (P<0.001), and left ventricular volumes increased 3.2%, from 87.0 to 89.8 ml/m2 (P<0.001).

CONCLUSION

Hydration status has a significant effect on the end-diastolic volumes of all cardiac chambers assessed by cardiac MR. Thus, hydration represents a "variable" that should be taken into account when assessing cardiac chamber volumes, especially when performing serial imaging studies in a patient.

Prognostic Role of Right Ventricular Function in Patients With Heart Failure Undergoing Cardiac Resynchronization Therapy

BACKGROUND

Because 20% to 40% of patients undergoing cardiac resynchronization therapy (CRT) do not respond to it, identification of potential factors predicting response is a relevant research topic.

HYPOTHESIS

There is a possible association between right ventricular function and response to CRT.

METHODS

We analyzed 227 patients from the Cardiac Resynchronization Therapy Modular Registry (CRT-MORE) who received CRT according to current guidelines from March to December 2013. Response to therapy was defined as a decrease of ≥15% in left ventricular end-systolic volume (LVESV) at 6 months.

RESULTS

The tricuspid annular plane systolic excursion (TAPSE) value that best predicted improvement in LVESV (sensitivity 68%, specificity 54%) was 17 mm. Stratifying patients according to TAPSE, LVESV decreased ≥15% in 78% of patients with TAPSE >17 mm (vs 59% in patients with TAPSE ≤17 mm; P = 0.006). At multivariate analysis, TAPSE >17 mm was independently associated with LVESV improvement (odds ratio: 1.97, 95% confidence interval: 1.03-3.80, P < 0.05), together with ischemic etiology (odds ratio: 0.39, 95% confidence interval: 0.20-0.75, P < 0.01). These results were confirmed for New York Heart Association class III to IV patients (79% echocardiographic response rate in patients with TAPSE >17 mm vs 55% in patients with TAPSE <17 mm; P = 0.012).

CONCLUSIONS

Baseline signs of right ventricular dysfunction suggest possible remodeling after CRT. A TAPSE value of 17 mm was identified as a good cutoff for predicting a better response to CRT in patients with both mildly symptomatic and severe heart failure.

Right ventricular assessment at cardiac MRI: initial clinical experience utilizing an IS-SENSE reconstruction

Cardiac MR is considered the gold standard in assessing RV function. The purpose of this study is to evaluate the clinical utility of an investigational iterative reconstruction algorithm in the quantitative assessment of RV function. This technique has the potential to improve the clinical utility of CMR in the evaluation of RV pathologies, particularly in patients with dyspnea, by shortening acquisition times without adversely influencing imaging performance. Segmented cine images were acquired on 9 healthy volunteers and 29 patients without documented RV pathologies using conventional GRAPPA acquisition with factor 2 acceleration (GRAPPA 2), a spatio-temporal TSENSE acquisition with factor 4 acceleration (TSENSE 4), and iteratively reconstructed Sparse SENSE acquisition with factor 4 acceleration (IS-SENSE 4). 14 subjects were re-analyzed and intraclass correlation coefficients (ICC) were calculated and Bland-Altman plots generated to assess agreement. Two independent reviewers qualitatively scored images. Comparison of acquisition techniques was performed using univariate analysis of variance (ANOVA). Differences in RV EF, BSA-indexed ESV (ESVi), BSA-indexed EDV (EDVi), and BSA-indexed SV (SVi) were shown to be statistically insignificant via ANOVA testing. R(2) values for linear regression of TSENSE 4 and IS-SENSE 4 versus GRAPPA 2 were 0.34 and 0.72 for RV-EF, and 0.61 and 0.76 for RV-EDVi. ICC values for intraobserver and interobserver quantification yielded excellent agreement, and Bland-Altman plots assessing agreement were generated as well. Qualitative review yielded small, but statistically significant differences in image quality and noise between TSENSE 4 and IS-SENSE 4. All three techniques were rated nearly artifact free. Segmented imaging acquisitions with IS-SENSE reconstruction and an acceleration factor of 4 accurately and reliably quantitates RV systolic function parameters, while maintaining image quality. TSENSE-4 accelerated acquisitions showed poorer correlation to standard imaging, and inferior interobserver and intraobserver agreement. IS-SENSE has the potential to shorten cine acquisition times by 50 %, improving imaging options in patients with intermittent arrhythmias or difficulties with breath holding.

Quantitative Assessment of Left Ventricular Function and Myocardial Mass: A Comparison of Coronary CT Angiography with Cardiac MRI and Echocardiography

Background

The purpose of this study was to compare the left ventricular parameters obtained from multi-detector row computed tomography (MDCT) studies with two-dimensional echocardiography (2DE), and magnetic resonance imaging (MRI), which is accepted as the gold standard in the evaluation of left ventricular functions. The study also aimed to evaluate whether or not there is a relationship between the MR-Argus and CMR tools software programs which are used in post-process calculations of data obtained by MRI.

Material/Methods

Forty patients with an average age of 51.4±14.9 years who had been scanned with cardiac MDCT were evaluated with cardiac MRI and 2DE. End-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), ejection fraction (EF), cardiac output (CO), and myocardial mass values calculated by MDCT, MRI, and 2DE were compared with each other. Two different MR software programs were used to compare left ventricular functions. The CMR tools LV tutorials method is accepted as the gold standard because it can be used in three-dimensional functional evaluation. The Pearson Correlation and Bland-Altman analysis were performed to compare the results from the two MR methods (MR-Argus and CMR tools) and the results from both the MDCT and the 2DE with the CMR tools results.

Results

Strong positive correlations for EF values were found between the MDCT and CMR tools (r=0.702 p<0.001), and between the MR-Argus and CMR tools (r=0.746 p<0.001). The correlation between the 2DE and CMR tools (r=0.449 p<0.004), however, was only moderate. Similar results were obtained for the other parameters. The strongest correlation for ESV, EDV, and EF was between the two MR software programs. The correlation coefficient between the MDCT and CMR tools is close to the correlation coefficient between the two software programs. While the correlation between 2DE and CMR tools was satisfactory for ESV, EDV, and CO values, it was at a moderate level for the other parameters.

Conclusions

Left ventricular functional analysis can be performed easily and reliably with cardiac MDCT used for coronary artery evaluation and it also gives more accurate results than 2DE.

Assessment of the precision and reproducibility of ventricular volume, function, and mass measurements with ferumoxytol-enhanced 4D flow MRI

PURPOSE

To compare the precision and interobserver agreement of ventricular volume, function, and mass quantification by 3D time-resolved (4D) flow MRI relative to cine steady-state free precession (SSFP).

MATERIALS AND METHODS

With Institutional Research Board approval, informed consent, and HIPAA compliance, 22 consecutive patients with congenital heart disease (CHD) (10 males, 6.4 ± 4.8 years) referred for 3T ferumoxytol-enhanced cardiac MRI were prospectively recruited. Complete ventricular coverage with standard 2D short-axis cine SSFP and whole chest coverage with axial 4D flow were obtained. Two blinded radiologists independently segmented images for left ventricular (LV) and right ventricular (RV) myocardium at end systole (ES) and end diastole (ED). Statistical analysis included linear regression, analysis of variance (ANOVA), Bland-Altman (BA) analysis, and intraclass correlation (ICC).

RESULTS

Significant positive correlations were found between 4D flow and SSFP for ventricular volumes (r = 0.808-0.972, P < 0.001), ejection fraction (EF) (r = 0.900-928, P < 0.001), and mass (r = 0.884-0.934, P < 0.001). BA relative limits of agreement for both ventricles were between -52% to 34% for volumes, -29% to 27% for EF, and -41% to 48% for mass, with wider limits of agreement for the RV compared to the LV. There was no significant difference between techniques with respect to mean square difference of ED-ES mass for either LV (F = 2.05, P = 0.159) or RV (F = 0.625, P = 0.434). Interobserver agreement was moderate to good with both 4D flow (ICC 0.523-0.993) and SSFP (ICC 0.619-0.982), with overlapping confidence intervals.

CONCLUSION

Quantification of ventricular volume, function, and mass can be accomplished with 4D flow MRI with precision and interobserver agreement comparable to that of cine SSFP. J. Magn. Reson. Imaging 2016;44:383-392.

Contrast Enhancement of the Right Ventricle during Coronary CT Angiography--Is It Necessary?

Purpose

It is unclear if prolonged contrast media injection, to improve right ventricular visualization during coronary CT angiography, leads to increased detection of right ventricle pathology. The purpose of this study was to evaluate right ventricle enhancement and subsequent detection of right ventricle disease during coronary CT angiography.

Materials and Methods

472 consecutive patients referred for screening coronary CT angiography were retrospectively evaluated. Every patient underwent multidetector-row CT of the coronary arteries: 128x 0.6mm coll., 100-120kV, rot. time 0.28s, ref. mAs 350 and received an individualized (P3T) contrast bolus injection of iodinated contrast medium (300 mgI/ml). Patient data were analyzed to assess right ventricle enhancement (HU) and right ventricle pathology. Image quality was defined good when right ventricle enhancement >200HU, moderate when 140-200HU and poor when <140HU.

Results

Good image quality was found in 372 patients, moderate in 80 patients and poor in 20 patients. Mean enhancement of the right ventricle cavity was 268HU±102. Patients received an average bolus of 108±24 ml at an average peak flow rate of 6.1±2.2 ml/s. In only three out of 472 patients (0.63%) pathology of the right ventricle was found (dilatation) No other right ventricle pathology was detected.

Conclusion

Right ventricle pathology was detected in three out of 472 patients; the dilatation observed in these three cases may have been picked up even without dedicated enhancement of the right ventricle. Based on our findings, right ventricle enhancement can be omitted during screening coronary CT angiography.

Relationship between Right Ventricular Longitudinal Strain, Invasive Hemodynamics, and Functional Assessment in Pulmonary Arterial Hypertension

BACKGROUND AND OBJECTIVES

Right ventricular longitudinal strain (RVLS) is a new parameter of RV function. We evaluated the relationship of RVLS by speckle-tracking echocardiography with functional and invasive parameters in pulmonary arterial hypertension (PAH) patients.

SUBJECTS AND METHODS

Thirty four patients with World Health Organization group 1 PAH (29 females, mean age 45±13 years old). RVLS were analyzed with velocity vector imaging.

RESULTS

Patients with advanced symptoms {New York Heart Association (NYHA) functional class III/IV} had impaired RVLS in global RV (RVLSglobal, -17±5 vs. -12±3%, p<0.01) and RV free wall (RVLSFW, -19±5 vs. -14±4%, p<0.01 to NYHA class I/II). Baseline RVLSglobal and RVLSFW showed significant correlation with 6-minute walking distance (r=-0.54 and r=-0.57, p<0.01 respectively) and logarithmic transformation of brain natriuretic peptide concentration (r=0.65 and r=0.65, p<0.01, respectively). These revealed significant correlations with cardiac index (r=-0.50 and r=-0.47, p<0.01, respectively) and pulmonary vascular resistance (PVR, r=0.45 and r=0.45, p=0.01, respectively). During a median follow-up of 33 months, 25 patients (74%) had follow-up examinations. Mean pulmonary arterial pressure (mPAP, 54±13 to 46±16 mmHg, p=0.03) and PVR (11±5 to 6±2 wood units, p<0.01) were significantly decreased with pulmonary vasodilator treatment. RVLSglobal (-12±5 to -16±5%, p<0.01) and RVLSFW (-14±5 to -18±5%, p<0.01) were significantly improved. The decrease of mPAP was significantly correlated with improvement of RVLSglobal (r=0.45, p<0.01) and RVLSFW (r=0.43, p<0.01). The PVR change demonstrated significant correlation with improvement of RVLSglobal (r=0.40, p<0.01).

CONCLUSION

RVLS correlates with functional and invasive hemodynamic parameters in PAH patients. Decrease of mPAP and PVR as a result of treatment was associated with improvement of RVLS.

RV mass measurement at end-systole: Improved accuracy, Reproducibility, and reduced segmentation time

PURPOSE

To evaluate the accuracy, reproducibility, and contouring time of RV mass in end-systole (ES) and end-diastole (ED). Magnetic resonance imaging (MRI) has been shown to be accurate and reproducible for the evaluation of right ventricular (RV) volume and function. RV mass, assessed in end-diastolic (ED) phase, is one of the least reproducible variables. The choice of end-systolic (ES) phase could offer an alternative to improve reproducibility, since the selection of the basal slice and the visualization of the usually thin RV wall are easier in this phase.

MATERIALS AND METHODS

To evaluate accuracy, 11 sheep were imaged in vivo and their RV free walls were weighed after removing epicardial fat. To evaluate reproducibility, 30 normal subjects and 30 subjects with pulmonary arterial hypertension (PAH) were imaged and interobserver and intraobserver variabilities were assessed in the ES and the ED. Segmentation time was recorded after visual selection of ES and ED phases.

RESULTS

ES RV mass measurement has less absolute variability (5.2% ± 3.2) compared to ED (10.6% ± 6.3) using weighed RV mass in sheep as the gold standard (P < 0.001). ES segmentation yielded higher intraobserver (intraclass correlation coefficients [ICC] = 0.94-0.99; coefficient of variability [CoV] = 6-7.3%) and interobserver (ICC = 0.85-0.98; CoV = 10.9-11.7%) reproducibility than ED segmentation. Segmentation time in humans was 25-28% faster in ES (P < 0.001).

CONCLUSION

The MRI assessment of RV mass is more accurate, reproducible, and faster in the ES phase.

Relation of right ventricular mass and volume to functional health status in repaired tetralogy of Fallot

After repair of tetralogy of Fallot, right ventricular (RV) mass and mass:volume ratio may reflect RV remodeling and adverse outcomes. This study aimed to evaluate the relation of RV mass to functional health status and subsequent adverse RV remodeling and to determine whether RV mass measurement in systole could improve reproducibility. In 53 patients with tetralogy of Fallot (median 29 years old) who previously underwent cardiovascular magnetic resonance and completed the Short Form 36, version 2 (Optum, Eden Prairie, MN), short-axis images were analyzed for RV end-diastolic volume and diastolic and systolic mass, indexed to body surface area. The most recent subsequent cardiovascular magnetic resonance study (before pulmonary valve or conduit replacement) was evaluated for change in RV end-diastolic volume and ejection fraction. Diastolic indexed mass ≥37.3 g/m(2) (odds ratio 7.6, p = 0.02) predicted decreased general health scores. In patients with normal RV ejection fraction, indexed mass correlated with Physical Component Summary and general health scores. RV diastolic mass:volume ratio >0.2 had a strong association with subsequent increase in RV end-diastolic volume (odds ratio 26.1, p = 0.002). Systolic RV mass measurement had excellent correlation with diastolic measurement (r = 0.97, p <0.0001), but did not improve intraobserver or interobserver variability. In conclusion, RV mass relates to functional health status and adverse RV remodeling and can be measured with good reproducibility. RV mass should be routinely evaluated in this population and is best measured in diastole; further study is necessary to evaluate longitudinal changes in functional health status and RV parameters.

CMR-derived TAPSE measurement: a semi-quantitative method of right ventricular function assessment in patients with hypertrophic cardiomyopathy

Aim

To compare cardiovascular magnetic resonance (CMR)-derived right ventricular fractional shortening (RVFS), tricuspid annular plane systolic excursion with a reference point within the right ventricular apex (TAPSE_in) and with one outside the ventricle (TAPSE_out) with the standard volumetric approach in patients with hypertrophic cardiomyopathy (HCM).

Methods and results

105 patients with HCM and 20 healthy subjects underwent CMR. In patients with HCM, TAPSE_in (r = 0.31, p = 0.001) and RVFS (r = 0.35, p = 0.0002) revealed a significant but weak correlation with right ventricular ejection fraction (RVEF), whereas TAPSE_out (r = 0.57, p < 0.0001) showed a moderate correlation with RVEF. The ability to predict RVEF < 45 % in HCM patients was best for TAPSE_out. In patients with hypertrophic obstructive cardiomyopathy (HOCM), RVEF showed a significant but weak correlation with TAPSE_out (r = 0.36, p = 0.02) and no correlation with TAPSE_in (r = 0.05, p = 0.07) and RVFS (r = 0.02, p = 0.2). In patients with hypertrophic non-obstructive cardiomyopathy (HNCM), there was a moderate correlation between RVEF and TAPSE_out (r = 0.57, p < 0.0001) and a weak correlation with TAPSE_in (r = 0.39, p = 0.001) and RVFS (r = 0.38, p = 0.002). In the 20 healthy controls, there was a strong correlation between RVEF and all semi-quantitative measurements.

Conclusion

CMR-derived TAPSE_in is not suitable to determine right ventricular function in HCM patients. TAPSE_out showed a good correlation with RVEF in HNCM patients but only a weak correlation in HOCM patients. TAPSE_out might be used for screening but the detection of subtle changes in RV function requires the 3D volumetric approach.

Congenitally corrected transposition of the great arteries in an 83-year-old asymptomatic patient: description and literature review

We describe the case of an 83-year-old asymptomatic man followed in our centre. Transoesophageal echocardiography disclosed congenitally corrected transposition of great arteries (CCTGA) with no associated anomalies and only mild aortic regurgitation. Cardiac MR confirmed the diagnosis and revealed preserved systemic ventricle systolic function with a normal perfusional pathway. This report is a demonstration that CCTGA without associated anomalies can reach older life in an asymptomatic condition. This is the oldest asymptomatic living patient with CCTGA ever described.

Validation of global longitudinal strain and strain rate as reliable markers of right ventricular dysfunction: comparison with cardiac magnetic resonance and outcome

Background

Right ventricular (RV) dysfunction in ischemic cardiomyopathy (ICM) is associated with poor prognosis, but RV assessment by conventional echocardiography remains difficult. We sought to validate RV global longitudinal strain (RVGLS) and global longitudinal strain rate (RVGLSR) against cardiac magnetic resonance (CMR) and outcome in ICM.

Methods

In 57 patients (43 men, 64 ± 12 years) with ICM who underwent conventional and strain echocardiography and CMR, RVGLS and RVGLSR were measured off-line. RV dysfunction was determined by CMR [RV ejection fraction (RVEF) < 50%]. Patients were followed over 15 ± 9 months for a composite of death and hospitalization for worsening heart failure.

Results

RVGLS showed significant correlations with CMR RVEF (r = -0.797, p < 0.01), RV fractional area change (RVFAC, r = -0.530, p < 0.01), and tricuspid annular plane systolic excursion (TAPSE, r = -0.547, p < 0.01). RVGLSR showed significant correlations between CMR RVEF (r = -0.668, p < 0.01), RVFAC (r = -0.394, p < 0.01), and TAPSE (r = -0.435, p < 0.01). RVGLS and RVGLSR showed significant correlations with pulmonary vascular resistance (r = 0.527 and r = 0.500, p < 0.01, respectively). The best cutoff value of RVGLS for detection of RV dysfunction was -15.4% [areas under the curve (AUC) = 0.955, p < 0.01] with a sensitivity of 81% and specificity 95%. The best cutoff value for RVGLSR was -0.94 s^-1 (AUC = 0.871, p < 0.01), sensitivity 72%, specificity 86%. During follow-up, there were 12 adverse events. In Cox-proportional hazard regression analysis, impaired RVGLS [hazard ratio (HR) = 5.46, p = 0.030] and impaired RVGLSR (HR = 3.95, p = 0.044) were associated with adverse clinical outcome.

Conclusion

Compared with conventional echocardiographic parameters, RVGLS and RVGLSR correlate better with CMR RVEF and outcome.

The prevalence and prognostic significance of right ventricular systolic dysfunction in nonischemic dilated cardiomyopathy

BACKGROUND

Cardiovascular magnetic resonance is the gold-standard technique for the assessment of ventricular function. Although left ventricular volumes and ejection fraction are strong predictors of outcome in dilated cardiomyopathy (DCM), there are limited data regarding the prognostic significance of right ventricular (RV) systolic dysfunction (RVSD). We investigated whether cardiovascular magnetic resonance assessment of RV function has prognostic value in DCM.

METHODS AND RESULTS

We prospectively studied 250 consecutive DCM patients with the use of cardiovascular magnetic resonance. RVSD, defined by RV ejection fraction≤45%, was present in 86 (34%) patients. During a median follow-up period of 6.8 years, there were 52 deaths, and 7 patients underwent cardiac transplantation. The primary end point of all-cause mortality or cardiac transplantation was reached by 42 of 86 patients with RVSD and 17 of 164 patients without RVSD (49% versus 10%; hazard ratio, 5.90; 95% confidence interval [CI], 3.35-10.37; P<0.001). On multivariable analysis, RVSD remained a significant independent predictor of the primary end point (hazard ratio, 3.90; 95% CI, 2.16-7.04; P<0.001), as well as secondary outcomes of cardiovascular mortality or cardiac transplantation (hazard ratio, 3.35; 95% CI, 1.76-6.39; P<0.001), and heart failure death, heart failure hospitalization, or cardiac transplantation (hazard ratio, 2.70; 95% CI, 1.32-5.51; P=0.006). Assessment of RVSD improved risk stratification for all-cause mortality or cardiac transplantation (net reclassification improvement, 0.31; 95% CI 0.10-0.53; P=0.001).

CONCLUSIONS

RVSD is a powerful, independent predictor of transplant-free survival and adverse heart failure outcomes in DCM. Cardiovascular magnetic resonance assessment of RV function is important in the evaluation and risk stratification of DCM patients.

Evaluation of patients with chronic thromboembolic pulmonary hypertension for pulmonary endarterectomy

Pulmonary hypertension as a result of chronic thromboembolic disease (CTEPH) is potentially curable with pulmonary endarterectomy surgery. Consequently, correctly diagnosing patients with this type of pulmonary hypertension and evaluating these patients with the goal of establishing their candidacy for surgical intervention is of utmost importance. And as advancements in surgical techniques have allowed successful resection of segmental-level chronic thromboembolic disease, the number of CTEPH patients that are deemed suitable surgical candidates has expanded, making it even more important that the evaluation be conducted with greater precision. This article will review a diagnostic approach to patients with suspected chronic thromboembolic disease with an emphasis on the criteria considered in selecting patients for pulmonary endarterectomy surgery.

Diagnostic accuracy of cardiovascular magnetic resonance imaging of right ventricular morphology and function in the assessment of suspected pulmonary hypertension results from the ASPIRE registry

BACKGROUND

Cardiovascular Magnetic Resonance (CMR) imaging is accurate and reproducible for the assessment of right ventricular (RV) morphology and function. However, the diagnostic accuracy of CMR derived RV measurements for the detection of pulmonary hypertension (PH) in the assessment of patients with suspected PH in the clinic setting is not well described.

METHODS

We retrospectively studied 233 consecutive treatment naïve patients with suspected PH including 39 patients with no PH who underwent CMR and right heart catheterisation (RHC) within 48 hours. The diagnostic accuracy of multiple CMR measurements for the detection of mPAP ≥ 25 mmHg was assessed using Fisher's exact test and receiver operating characteristic (ROC) analysis.

RESULTS

Ventricular mass index (VMI) was the CMR measurement with the strongest correlation with mPAP (r = 0.78) and the highest diagnostic accuracy for the detection of PH (area under the ROC curve of 0.91) compared to an ROC of 0.88 for echocardiography calculated mPAP. Late gadolinium enhancement, VMI ≥ 0.4, retrograde flow ≥ 0.3 L/min/m² and PA relative area change ≤ 15% predicted the presence of PH with a high degree of diagnostic certainty with a positive predictive value of 98%, 97%, 95% and 94% respectively. No single CMR parameter could confidently exclude the presence of PH.

CONCLUSION

CMR is a useful alternative to echocardiography in the evaluation of suspected PH. This study supports a role for the routine measurement of ventricular mass index, late gadolinium enhancement and the use of phase contrast imaging in addition to right heart functional indices in patients undergoing diagnostic CMR evaluation for suspected pulmonary hypertension.