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Roller FC, Yildiz SM, Kriechbaum SD, Harth S, Breithecker A, Liebetrau C, Schüßler A, Mayer E, Hamm CW, Guth S, Krombach GA, Wiedenroth CB. Noninvasive prediction of pulmonary hemodynamics in chronic thromboembolic pulmonary hypertension by electrocardiogram-gated computed tomography. Eur J Radiol Open 2021; 8:100384. [PMID: 34712746 PMCID: PMC8528681 DOI: 10.1016/j.ejro.2021.100384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/11/2021] [Indexed: 11/11/2022] Open
Abstract
Easily measurable parameters from chest CT examinations enable prediction of pulmonary hemodynamics. ECG-gated CTPA is superior to non-gated CT. Non-invasive pH therapy monitoring or follow-up might be implemented in the future.
Purpose The aim of the study was to investigate the potential of electrocardiogram (ECG)-gated computed tomography pulmonary angiography (CTPA) as a predictor of disease severity in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Method Forty-five CTEPH patients with a mean age of 63.8 years±12.7 y (±standard deviation) who had undergone ECG-gated CTPA and right heart catheterization (RHC) were included in the study. Right ventricular to left ventricular volume ratio (RVV/LVV), diameter ratio on 4-chamber view (RVD4CH/LVD4CH), pulmonary trunk (PT) diameter, PT to aortic diameter ratio (PT/A), and septal angle were correlated to mean pulmonary artery pressure (mPAP). Moreover, RVV/LVV and RVD4CH/LVD4CH were adjusted to pulmonary diameter index (PADi) and PT/A index. Areas under the curve (AUC) for predicting mPAP above 40 mmHg, 35 mmHg, and 30 mmHg were calculated. Results RVD4CH/LVD4CH revealed the strongest correlation to mPAP before (r = 0.6507) and after (r = 0.7650; p < 0.0001) PT/A adjustment. The AUCs for predicting pH with mPAP over 40 mmHg and 30 mmHg were 0.9229 and 0.864, respectively. A cutoff value of 1.298 enabled prediction of pH with mPAP over 40 mmHg with a sensitivity, specificity, positive predictive, and negative predictive value of 80.00 %, 95.83 %, 88.46 %, and 94.12 %, respectively. Intra- and interobserver variability were excellent for all parameters. Conclusion Combining different and easily evaluable ECG-gated CTPA parameters enables excellent prediction of pulmonary hemodynamics in CTEPH patients. Ventricular diameter ratio on 4-chamber view adjusted by the PT/A ratio yielded the best correlation to mPAP.
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Key Words
- 4CH, four-chamber view
- AUC, Area under the curve
- CI, Confidence interval
- CT, Computed tomography
- CTEPH
- CTEPH, Chronic thromboembolic pulmonary hypertension
- CTPA
- CTPA, Computed tomography pulmonary angiography
- ECG, Electrocardiogram
- HU, Hounsfield units
- ICC, intra-class concordance correlation coefficient
- LV, Left ventricular
- LVD, Left ventricular diameter
- LVV, Left ventricular volume
- MDCT, Multidetector computed tomography
- NPV, Negative predictive value
- PADi, Pulmonary artery diameter index
- PH, Pulmonary hypertension
- PPV, Positive predictive value
- PT, Pulmonary trunk
- Pulmonary hypertension
- RHC, Right heart catheterization
- ROC, Receiver operating characteristics
- RV, Right ventricular
- RVD, Right ventricular diameter
- RVV, Right ventricular volume
- Right heart catheterization
- SD, Standard deviation
- mPAP, mean pulmonary artery pressure
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Affiliation(s)
- Fritz C Roller
- Department of Diagnostic and Interventional Radiology, University Hospital Giessen, Justus-Liebig-University Giessen, Klinikstraße 33, 35392, Giessen, Germany.,German Center for Lung Research (DZL), Giessen, Germany
| | - Selcuk M Yildiz
- Department of Diagnostic and Interventional Radiology, University Hospital Giessen, Justus-Liebig-University Giessen, Klinikstraße 33, 35392, Giessen, Germany.,German Center for Lung Research (DZL), Giessen, Germany
| | - Steffen D Kriechbaum
- Department of Cardiology, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany.,German Center for Lung Research (DZL), Giessen, Germany
| | - Sebastian Harth
- Department of Diagnostic and Interventional Radiology, University Hospital Giessen, Justus-Liebig-University Giessen, Klinikstraße 33, 35392, Giessen, Germany.,German Center for Lung Research (DZL), Giessen, Germany
| | - Andreas Breithecker
- Department of Diagnostic and Interventional Radiology, University Hospital Giessen, Justus-Liebig-University Giessen, Klinikstraße 33, 35392, Giessen, Germany.,German Center for Lung Research (DZL), Giessen, Germany
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany.,German Center for Lung Research (DZL), Giessen, Germany
| | - Armin Schüßler
- Department of Diagnostic and Interventional Radiology, University Hospital Giessen, Justus-Liebig-University Giessen, Klinikstraße 33, 35392, Giessen, Germany.,German Center for Lung Research (DZL), Giessen, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany.,German Center for Lung Research (DZL), Giessen, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany.,Department of Cardiology, University Hospital Giessen, Justus-Liebig-University Giessen, Klinikstraße 33, Giessen, Germany.,German Center for Lung Research (DZL), Giessen, Germany.,German Center for Cardiovascular Research (DZHK), RheinMain Chapter, Frankfurt am Main, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
| | - Gabriele A Krombach
- Department of Diagnostic and Interventional Radiology, University Hospital Giessen, Justus-Liebig-University Giessen, Klinikstraße 33, 35392, Giessen, Germany.,German Center for Lung Research (DZL), Giessen, Germany
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Pulmonary hypertension due to left heart disease: diagnostic value of pulmonary artery distensibility. Eur Radiol 2020; 30:6204-6212. [PMID: 32548647 DOI: 10.1007/s00330-020-06959-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/28/2020] [Accepted: 05/14/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To evaluate how pulmonary artery (PA) distensibility performs in detecting pulmonary hypertension due to left heart disease (PH-LHD) in comparison with parameters from ungated computed tomography (CT) and echocardiography. METHODS One hundred patients (79 men, mean age = 63 ± 17 years) with either severe heart failure with reduced ejection fraction (HFrEF), aortic stenosis, or primary mitral regurgitation prospectively underwent right heart catheterization, ungated CT, ECG-gated CT, and echocardiography. During the ECG-gated CT, the right PA distensibility was calculated. In ungated CT, dPA, dPA/AA, the ratio of dPA to the diameter of the vertebra, segmental PA diameter, segmental PA-to-bronchus ratio, and the main PA volume were measured; the egg-and-banana sign was recorded. During echocardiography, the tricuspid regurgitation (TR) gradient was measured. The areas under the ROC curves (AUC) of these signs were computed and compared with DeLong test. Correlation between PA distensibility and PA pressure (PAP) was investigated through Pearson's coefficient. RESULTS PA distensibility was lower in patients with PH than in those without PH (11.4 vs. 21.2%, p < 0.001) and correlated negatively with mean PAP (r = - 0.72, p < 0.001). Age, PA size, and mean PAP were independent predictors of PA distensibility. PA distensibility < 18% detected PH-LHD with 96% sensitivity and 73% specificity; its AUC was 0.92, larger than that of any other sign at ungated CT and TR gradient (AUC ranging from 0.54 to 0.83, DeLong: p ranging from 0.020 to < 0.001). CONCLUSION PA distensibility on an ECG-gated CT can detect PH-LHD better than the parameters reflecting PA dilatation in ungated CT or TR gradient in the echocardiography of patients with severe HFrEF, aortic stenosis, or mitral regurgitation. KEY POINTS • In left heart disease, pulmonary artery distensibility is lower in patients with PH than in those without pulmonary hypertension (11.4 vs. 21.2%, p < 0.001). • In left heart disease, pulmonary artery distensibility detects pulmonary hypertension with an area under the receiver operating curve of 0.92. • In left heart disease, the area under the receiver operating curve of pulmonary artery distensibility for detecting pulmonary hypertension is larger than that of all other signs at ungated CT (p from 0.019 to < 0.001) and tricuspid regurgitation gradient at echocardiography (p = 0.020).
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3
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Chan IP, Weng MC, Hsueh T, Lin YC, Lin SL. Prognostic value of right pulmonary artery distensibility in dogs with pulmonary hypertension. J Vet Sci 2019; 20:e34. [PMID: 31364319 PMCID: PMC6669208 DOI: 10.4142/jvs.2019.20.e34] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 04/19/2019] [Accepted: 05/20/2019] [Indexed: 11/20/2022] Open
Abstract
The right pulmonary artery distensibility (RPAD) index has been used in dogs with pulmonary hypertension (PH) caused by heartworm infection, myxomatous mitral valve disease, or patent ductus arteriosus. We hypothesized that this index correlates with the tricuspid regurgitation pressure gradient (TRPG) assessed by echocardiography and could predict survival in dogs with PH secondary to various causes. To assess this hypothesis, the medical records of 200 client-owned dogs at a referral institution were retrospectively reviewed. The RPAD index and the ratios of acceleration time to peak pulmonary artery flow (AT) and to the ejection time of pulmonary artery flow (ET) were recorded for each dog. The owners were contacted for follow-up assessments. The findings indicated that the RPAD index was correlated with the TRPG (R² = 0. 362, p < 0.001). The survival time was significantly shorter in dogs with an RPAD index ≤ 21% that were followed up for 3 months and in dogs with an RPAD index ≤ 24% that were followed up for 1 year. Thus, the RPAD index was correlated with the TRPG and could predict the clinical outcome in dogs with PH caused by various diseases. This index could be used to evaluate the severity of PH in dogs without tricuspid regurgitation.
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Affiliation(s)
- I Ping Chan
- Veterinary Medical Teaching Hospital, National Chung Hsing University, Taichung 40227, Taiwan.,Department of Veterinary Medicine, National Chung Hsing University, Taichung 40227, Taiwan
| | - Min Chieh Weng
- Department of Veterinary Medicine, National Chung Hsing University, Taichung 40227, Taiwan
| | - Tung Hsueh
- Veterinary Medical Teaching Hospital, National Chung Hsing University, Taichung 40227, Taiwan.,Department of Veterinary Medicine, National Chung Hsing University, Taichung 40227, Taiwan
| | - Yun Chang Lin
- Department of Veterinary Medicine, National Chung Hsing University, Taichung 40227, Taiwan
| | - Shiun Long Lin
- Veterinary Medical Teaching Hospital, National Chung Hsing University, Taichung 40227, Taiwan.,Department of Veterinary Medicine, National Chung Hsing University, Taichung 40227, Taiwan.
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Huang L, Li J, Huang M, Zhuang J, Yuan H, Jia Q, Zeng D, Que L, Xi Y, Lin J, Dong Y. Prediction of pulmonary pressure after Glenn shunts by computed tomography-based machine learning models. Eur Radiol 2019; 30:1369-1377. [PMID: 31705256 DOI: 10.1007/s00330-019-06502-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/21/2019] [Accepted: 10/03/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVES This study aimed to develop non-invasive machine learning classifiers for predicting post-Glenn shunt patients with low and high risks of a mean pulmonary arterial pressure (mPAP) > 15 mmHg based on preoperative cardiac computed tomography (CT). METHODS This retrospective study included 96 patients with functional single ventricle who underwent a bidirectional Glenn procedure between November 1, 2009, and July, 31, 2017. All patients underwent post-procedure CT, followed by cardiac catheterization. Overall, 23 morphologic parameters were manually extracted from cardiac CT images for each patient. The Mann-Whitney U or chi-square test was applied to select the most significant predictors. Six machine learning algorithms including logistic regression, Naive Bayes, random forest (RF), linear discriminant analysis, support vector machine, and K-nearest neighbor were used for modeling. These algorithms were independently trained on 100 train-validation random splits with a 3:1 ratio. Their average performance was evaluated by area under the curve (AUC), accuracy, sensitivity, and specificity. RESULTS Seven CT morphologic parameters were selected for modeling. RF obtained the best performance, with mean AUC of 0.840 (confidence interval [CI] 0.832-0.850) and 0.787 (95% CI 0.780-0.794); sensitivity of 0.815 (95% CI 0.797-0.833) and 0.778 (95% CI 0.767-0.788), specificity of 0.766 (95% CI 0.748-0.785) and 0.746 (95% CI 0.735-0.757); and accuracy of 0.782 (95% CI 0.771-0.793) and 0.756 (95% CI 0.748-0.764) in the training and validation cohorts, respectively. CONCLUSIONS The CT-based RF model demonstrates a good performance in the prediction of mPAP, which may reduce the need for right heart catheterization in post-Glenn shunt patients with suspected mPAP > 15 mmHg. KEY POINTS • Twenty-three candidate descriptors were manually extracted from cardiac computed tomography images, and seven of them were selected for subsequent modeling. • The random forest model presents the best predictive performance for pulmonary pressure among all methods. • The computed tomography-based machine learning model could predict post-Glenn shunt pulmonary pressure non-invasively.
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Affiliation(s)
- Lei Huang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People's Republic of China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Jiahua Li
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, People's Republic of China
| | - Meiping Huang
- Department of Catheterization Lab, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Jian Zhuang
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Haiyun Yuan
- Department of Catheterization Lab, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Qianjun Jia
- Department of Catheterization Lab, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Dewen Zeng
- Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Lifeng Que
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, People's Republic of China
| | - Yue Xi
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, People's Republic of China
| | - Jijin Lin
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People's Republic of China. .,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.
| | - Yuhao Dong
- Department of Catheterization Lab, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China.
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5
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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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6
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Hur DJ, Sugeng L. Non-invasive Multimodality Cardiovascular Imaging of the Right Heart and Pulmonary Circulation in Pulmonary Hypertension. Front Cardiovasc Med 2019; 6:24. [PMID: 30931315 PMCID: PMC6427926 DOI: 10.3389/fcvm.2019.00024] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 02/20/2019] [Indexed: 12/13/2022] Open
Abstract
Pulmonary hypertension (PH) is defined as resting mean pulmonary arterial pressure (mPAP) ≥25 millimeters of mercury (mmHg) via right heart (RH) catheterization (RHC), where increased afterload in the pulmonary arterial vasculature leads to alterations in RH structure and function. Mortality rates have remained high despite therapy, however non-invasive imaging holds the potential to expedite diagnosis and lead to earlier initiation of treatment, with the hope of improving prognosis. While historically the right ventricle (RV) had been considered a passive chamber with minimal role in the overall function of the heart, in recent years in the evaluation of PH and RH failure the anatomical and functional assessment of the RV has received increased attention regarding its performance and its relationship to other structures in the RH-pulmonary circulation. Today, the RV is the key determinant of patient survival. This review provides an overview and summary of non-invasive imaging methods to assess RV structure, function, flow, and tissue characterization in the setting of imaging's contribution to the diagnostic, severity stratification, prognostic risk, response of treatment management, and disease surveillance implications of PH's impact on RH dysfunction and clinical RH failure.
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Affiliation(s)
- David J Hur
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States.,Division of Cardiology, Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States
| | - Lissa Sugeng
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States.,Echocardiography Laboratory, Yale New Haven Hospital, New Haven, CT, United States
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7
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is one of the potentially curable causes of pulmonary hypertension and is definitively treated with pulmonary thromboendartectomy. CTEPH can be overlooked, as its symptoms are nonspecific and can be mimicked by a wide range of diseases that can cause pulmonary hypertension. Early diagnosis of CTEPH and prompt evaluation for surgical candidacy are paramount factors in determining future outcomes. Imaging plays a central role in the diagnosis of CTEPH and patient selection for pulmonary thromboendartectomy and balloon pulmonary angioplasty. Currently, various imaging tools are used in concert, with techniques such as computed tomography (CT) and conventional pulmonary angiography providing detailed structural information, tests such as ventilation-perfusion (V/Q) scanning providing functional data, and magnetic resonance imaging providing a combination of morphologic and functional information. Emerging techniques such as dual-energy CT and single photon emission computed tomography-CT V/Q scanning promise to provide both anatomic and functional information in a single test and may change the way we image these patients in the near future. In this review, we discuss the roles of various imaging techniques and discuss their merits, limitations, and relative strengths in depicting the structural and functional changes of CTEPH. We also explore newer imaging techniques and the potential value they may offer.
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Abstract
Pulmonary hypertension (PH) is defined as resting mean pulmonary artery pressure ≥25 mmHg measured by right heart catheterization. PH is a progressive, life-threatening disease with a variety of etiologies. Swift and accurate diagnosis of PH and appropriate classification in etiologic group will allow for earlier treatment and improved outcomes. A number of imaging tools are utilized in the evaluation of PH, such as chest X-ray, computed tomography (CT), ventilation/perfusion (V/Q) scan, and cardiac magnetic resonance imaging. Newer imaging tools such as dual-energy CT and single-photon emission computed tomography/computed tomography V/Q scanning have also emerged; however, their place in the diagnostic evaluation of PH remains to be determined. In general, each imaging technique provides incremental information, with varying degrees of sensitivity and specificity, which helps suspect the presence and identify the etiology of PH. The present study aims to provide a comprehensive review of the utility, advantages, and shortcomings of the imaging modalities that may be used to evaluate patients with PH.
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Affiliation(s)
- Mona Ascha
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rahul D Renapurkar
- Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Adriano R Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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9
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Doğan H, de Roos A, Geleijins J, Huisman MV, Kroft LJM. The role of computed tomography in the diagnosis of acute and chronic pulmonary embolism. Diagn Interv Radiol 2016; 21:307-16. [PMID: 26133321 DOI: 10.5152/dir.2015.14403] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pulmonary embolism (PE) is a potentially life threatening condition requiring adequate diagnosis and treatment. Computed tomography pulmonary angiography (CTPA) is excellent for including and excluding PE, therefore CT is the first-choice diagnostic imaging technique in patients suspected of having acute PE. Due to its wide availability and low invasiveness, CTPA tends to be overused. Correct implementation of clinical decision rules in diagnostic workup for PE improves adequate use of CT. Also, CT adds prognostic value by evaluating right ventricular (RV) function. CT-assessed RV dysfunction and to lesser extent central emboli location predicts PE-related mortality in normotensive and hypotensive patients, while PE embolic obstruction index has limited prognostic value. Simple RV/left ventricular (LV) diameter ratio measures >1.0 already predict risk for adverse outcome, whereas ratios <1.0 can safely exclude adverse outcome. Consequently, assessing the RV/LV diameter ratio may help identify patients who are potential candidates for treatment at home instead of treatment in the hospital. A minority of patients develop chronic thromboembolic pulmonary hypertension (CTEPH) following acute PE, which is a life-threatening condition that can be diagnosed by CT. In proximal CTEPH, involving the more central pulmonary arteries, thrombectomy usually results in good outcome in terms of both functional status and long-term survival rate. CT is becoming the imaging method of choice for diagnosing CTEPH as it can identify patients who may benefit from thrombectomy. New CT developments such as distensibility measurements and dual-energy or subtraction techniques may further refine diagnosis and prognosis for improved patient care.
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Affiliation(s)
- Halil Doğan
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.
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10
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Köster LS, Kirberger RM. A syndrome of severe idiopathic pulmonary parenchymal disease with pulmonary hypertension in Pekingese. VETERINARY MEDICINE-RESEARCH AND REPORTS 2016; 7:19-31. [PMID: 30050834 PMCID: PMC6053043 DOI: 10.2147/vmrr.s92729] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This paper describes 35 Pekingese dogs with a syndrome characterized by dyspnea, cyanosis, episodic syncope, soft pulmonary “velcro” crackles, pulmonary hypertension (PH), and computed tomography and radiographic changes consistent with pulmonary parenchymal disease. The medical data base was searched with the criteria “Pekingese” and “syncope” or “dyspnea” or “tachypnea” or “pulmonary hypertension”, over a 36-month period. Inclusion criteria were echocardiographic changes consistent with noninvasive diagnosis of PH, either subjectively by B-mode or objectively by Doppler. Dogs were excluded (n=106) if there were insufficient or poor-quality radiographic or echocardiographic records or if diseases other than chronic pulmonary disease were found to be the etiology. The records of 35 dogs met these criteria and presented with a respiratory crises preceded by a history of chronic exercise intolerance and episodic syncope. The average age was 14.5 years (range: 7–19 years), with 21 males and 14 females. Most of the dogs had an interstitial lung pattern with radiographic evidence of right heart enlargement. There was a 77% (n=27) mortality and a median survival of 60 days (interquartile range: 9–210 days). This study highlights a cor pulmonale syndrome from PH due to chronic pulmonary parenchymal disease, with a grave prognosis, in middle-aged to geriatric population of Hong Kong Pekingese.
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Affiliation(s)
- Liza S Köster
- Section of Medicine, Department of Clinical Sciences, Integrative Mammalian Research (IMR) Center, Ross University School of Veterinary Medicine (RUSVM), Basseterre, St Kitts, West Indies,
| | - Robert M Kirberger
- Diagnostic Imaging Section, Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Onderstepoort, South Africa
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Shen Y, Wan C, Tian P, Wu Y, Li X, Yang T, An J, Wang T, Chen L, Wen F. CT-base pulmonary artery measurement in the detection of pulmonary hypertension: a meta-analysis and systematic review. Medicine (Baltimore) 2014; 93:e256. [PMID: 25501096 PMCID: PMC4602811 DOI: 10.1097/md.0000000000000256] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
To summarize the performance of CT-based main pulmonary artery diameter or pulmonary artery to aorta ratio (PA:A ratio) measurement in detection of pulmonary hypertension by a systematic review and meta-analysis. A comprehensive literature search was performed to identify studies determining diagnostic accuracy of main pulmonary artery diameter or PA:A ratio measurement for pulmonary hypertension. The Quality Assessment of Diagnostic Accuracy Studies tool was used to assess the quality of the included studies. A bivariate random-effects model was used to pool sensitivity, specificity, positive/negative likelihood ratio (PLR/NLR), and diagnostic odds ratio (DOR). Summary receiver operating characteristic (SROC) curves and area under the curve (AUC) were used to summarize overall diagnostic performance. This meta-analysis included 20 publications involving 2134 subjects. Summary estimates for main pulmonary artery diameter measurement in the diagnosis of pulmonary hypertension were as follows: sensitivity, 0.79 (95% CI 0.72-0.84); specificity, 0.83 (95% CI 0.75-0.89); PLR, 4.68 (95% CI 3.13-6.99); NLR, 0.26 (95% CI 0.20-0.33); DOR, 18.13 (95% CI 10.87-30.24); and AUC 0.87. The corresponding summary performance estimates for using the PA:A ratio were as follows: sensitivity, 0.74 (95% CI 0.66-0.80); specificity, 0.81 (95% CI 0.74-0.86); PLR, 3.83 (95% CI, 2.70-5.43); NLR, 0.33 (95% CI 0.24-0.44); DOR, 11.77 (95% CI 6.60-21.00); and AUC 0.84. Both main pulmonary artery diameter and PA:A ratio are helpful for diagnosing pulmonary hypertension. Nevertheless, the results of pulmonary artery measurement should be interpreted in parallel with the results of traditional tests such as echocardiography.
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Affiliation(s)
- Yongchun Shen
- From the Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University and Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, Chengdu 610041, China
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Kochav J, Simprini L, Weinsaft JW. Imaging of the right heart--CT and CMR. Echocardiography 2014; 32 Suppl 1:S53-68. [PMID: 25244072 DOI: 10.1111/echo.12212] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Right ventricular (RV) structure and function is of substantial importance in a broad variety of clinical conditions. Cardiac magnetic resonance (CMR) and computed tomography (CT) each provide three-dimensional RV imaging, high-resolution evaluation of RV structure/anatomy, and accurate functional assessment without geometric assumptions. This is of particular significance for the RV, where complex geometry compromises reliance on indices derived from two-dimensional (2D) imaging planes. CMR flow-based imaging can be applied to right-sided heart valves, enabling evaluation of hemodynamic and valvular dysfunction that may contribute to or result from RV dysfunction. Tissue characterization imaging by both CMR and CT provides valuable complementary assessment of the RV. Changes in myocardial tissue composition provide a mechanistic substrate for RV dysfunction and cardiac arrhythmias. This review provides an overview of RV imaging by both CMR and CT, with focus on assessment of RV structure/function, flow, and tissue characterization. Emerging evidence and established guidelines are discussed in the context of imaging contributions to diagnosis, prognostic risk stratification and disease management of clinical conditions that impact the right ventricle.
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Affiliation(s)
- Jonathan Kochav
- Duke University School of Medicine, Durham, North Carolina; Weill Cornell Medical College, New York, New York
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Guo X, Liu M, Ma Z, Wang S, Yang Y, Zhai Z, Wang C, Zhai R. Flow characteristics of the proximal pulmonary arteries and vena cava in patients with chronic thromboembolic pulmonary hypertension: correlation between 3.0 T phase-contrast MRI and right heart catheterization. Diagn Interv Radiol 2014; 20:414-20. [PMID: 25163757 DOI: 10.5152/dir.2014.13501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to determine the correlation between flow characteristics of the proximal pulmonary arteries and vena cava obtained by 3.0 T phase-contrast magnetic resonance imaging (MRI) and hemodynamic characteristics by right heart catheterization in patients with chronic thromboembolic pulmonary hypertension. MATERIALS AND METHODS Twenty consecutive patients with chronic thromboembolic pulmonary hypertension and 20 sex- and age-matched healthy volunteers were included prospectively. All patients and controls underwent phase-contrast MRI to determine the flow characteristics including peak velocity, mean velocity, and mean blood flow of the proximal pulmonary artery and vena cava. All patients underwent right heart catheterization to determine the hemodynamics. RESULTS Peak velocity and mean velocity of the proximal pulmonary artery were significantly lower in the patient group. In patients, both peak velocity and mean blood flow were sequentially decreased in the main pulmonary artery, left and right pulmonary arteries, and left and right interlobar pulmonary arteries. Inferior vena cava had higher peak velocity, mean velocity, and mean blood flow than superior vena cava. Peak velocity of the main pulmonary artery correlated with mean and diastolic pulmonary artery pressure. Peak velocity of both inferior and superior vena cava strongly correlated with the pulmonary vascular resistance index (PVRI) (r=-0.68, P < 0.001 and r=-0.74, P < 0.001, respectively). Mean velocity of the main pulmonary artery and right pulmonary artery strongly correlated with PVRI and mean pulmonary artery pressure. Mean velocity of the superior vena cava and mean blood flow of the main pulmonary artery strongly correlated with PVRI and right cardiac work index. CONCLUSION Blood flow in the proximal pulmonary artery and vena cava evaluated by phase-contrast MRI correlate with hemodynamic parameters of right heart catheterization and can be used to noninvasively evaluate the severity of chronic thromboembolic pulmonary hypertension and, potentially, to follow up the treatment response.
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Affiliation(s)
- Xiaojuan Guo
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
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Pawade T, Holloway B, Bradlow W, Steeds RP. Noninvasive imaging for the diagnosis and prognosis of pulmonary hypertension. Expert Rev Cardiovasc Ther 2013; 12:71-86. [DOI: 10.1586/14779072.2014.867806] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Pienn M, Kovacs G, Tscherner M, Johnson TR, Kullnig P, Stollberger R, Olschewski A, Olschewski H, Bálint Z. Determination of cardiac output with dynamic contrast-enhanced computed tomography. Int J Cardiovasc Imaging 2013; 29:1871-8. [PMID: 23974909 DOI: 10.1007/s10554-013-0279-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 08/17/2013] [Indexed: 10/26/2022]
Abstract
Cardiac output (CO) is an important diagnostic and prognostic factor in the haemodynamic evaluation of patients. The gold standard for CO measurement, thermodilution, requires an invasive right-heart catheterisation (RHC). In this pilot study we aimed to determine the accuracy of non-invasive CO determination from dynamic contrast-enhanced computed tomography (CT) compared to thermodilution. Patients who underwent diagnostic or follow-up RHC due to suspected or known pulmonary vascular disease at our department and required a thoracic CT between June 2011 and August 2012 were included. CO was determined from CT attenuation-time curves in the pulmonary artery and the ascending aorta using a dynamic contrast-enhanced CT sequence. CO determined in N = 18 patients by dynamic CT in the pulmonary artery was in very good agreement with thermodilution data (r = 0.84). Bland-Altman analysis showed a systematic overestimation of 0.7 ± 0.6 l/min compared to thermodilution. Data from the ascending aorta also showed a good correlation, but with a larger scattering of the values. The average effective dose for the dynamic investigation was 1.2 ± 0.7 mSv. CO determined with dynamic contrast-enhanced CT in the main pulmonary artery reliably predicts the values obtained by thermodilution during RHC. This non-invasive technique might provide an alternative for repeated invasive right-heart catheter investigations in the follow-up of pulmonary arterial hypertension patients.
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Affiliation(s)
- Michael Pienn
- Ludwig Boltzmann Institute for Lung Vascular Research, Stiftingtalstrasse 24, 8010, Graz, Austria
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Sauvage N, Reymond E, Jankowski A, Prieur M, Pison C, Bouvaist H, Ferretti GR. ECG-gated computed tomography to assess pulmonary capillary wedge pressure in pulmonary hypertension. Eur Radiol 2013; 23:2658-65. [DOI: 10.1007/s00330-013-2911-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 04/23/2013] [Accepted: 05/07/2013] [Indexed: 11/29/2022]
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