Zhanhong Ma

Computed tomographic pulmonary angiography in the assessment of severity of chronic thromboembolic pulmonary hypertension and right ventricular dysfunction

PURPOSE The aim was to investigate the role of computed tomographic pulmonary angiography (CTPA) in the assessment of severity and right ventricular function in chronic thromboembolic pulmonary hypertension (CTEPH). MATERIALS AND METHODS Clinical and radiological data of 56 patients with CTEPH January 2006-October 2009 were retrospectively reviewed in the present study. All patients received CTPA with a 64-row CT using the retrospective ECG-Gated mode before digital subtraction pulmonary angiography and right-heart catheterization. CTPA findings including Right Ventricular diameter (RVd) and left ventricular diameter (LVd) were measured at the end diastole. CT Pulmonary Artery Obstruction Indexes including Qanadli Index and Mastora Index were used in the assessment of severity of pulmonary arterial obstruction. Hemodynamic parameters and pulmonary hypertension classification were evaluated by right-heart catheterization in all patients. Right ventricular function was measured with echocardiography in 49 patients. RESULTS Qanadli Index and Mastora Index respectively were (37.93±14.74)% and (30.92±16.91)%, which showed a significant difference (Z=-5.983, P=0.000) and a good correlation (r=0.881, P=0.000). Neither Qanadli nor Mastora Index correlated with pulmonary hypertension classification (r=-0.009, P=0.920) or New York Heart Association heart function classification (r=-0.031, P=0.756). Neither Qanadli nor Mastora Index correlated with any echocardiographic right ventricular parameters (P>0.05), while RVd/LVd by CTPA correlated with echocardiographic right ventricular functional parameters (P<0.05). Both Qanadli (r=-0.288, P=0.006) and Mastora Index (r=-0.203, P=0.032) demonstrated a weakly negative correlation with SPO2. CTPA findings correlated with hemodynamic variables. Backward linear regression analysis revealed that the RVd/LVd, Right Ventricular Anterior Wall Thickness (RVAWT), Main Pulmonary Artery trunk diameter (MPAd) were shown to be independently associated with mean Pulmonary Artery Pressure (mPAP) levels (model: r2=0.351, P=0.025; RVd/LVd: beta=11.812, P=0.000; RVAWT: beta=2.426, P=0.000; MPAd: beta=0.677, P=0.003). CONCLUSION Computed tomographic pulmonary angiography is a valuable tool to evaluate hemodynamics, right ventricular function of CTEPH, but neither Qanadli Index nor Mastora Index can reflect pulmonary arterial obstruction in CTEPH accurately.

Cardiovascular parameters of computed tomographic pulmonary angiography to assess pulmonary vascular resistance in patients with chronic thromboembolic pulmonary hypertension

OBJECTIVES The purpose is to identify the role of cardiovascular parameters of computed tomographic pulmonary angiography (CTPA) to assess pulmonary vascular resistance (PVR) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). BACKGROUND The assessment of PVR is of great importance in the management of patients with CTEPH. The role of CPTA in assessment of PVR of CTEPH remains to be explored. METHODS Clinical and radiological data of 90 patients (55 men, age 17-84 years) with CTEPH were retrospectively reviewed in this study. All patients received CTPA before right-heart catheterization. Cardiovascular parameters and Pulmonary Artery Obstruction Indices including Qanadli Index and Mastora Index were evaluated on CTPA. Hemodynamic PVR was calculated with the standard formula according to data from right-heart catheterization. The correlation of cardiovascular parameters of CTPA and PVR was analyzed. RESULTS In Cardiovascular parameters, neither Qanadli Index(r=0.134, p=0.208) nor Mastora Index (r=0.149, p=0.90) did correlate with PVR. Cobb angle(r=0.613, p=0.000), the ratio of right to left ventricular area(r=0.422, p=0.000)and the ratio of right to left ventricular transverse diameter (r=0.410, p=0.000) respectively correlated with PVR. By receiver operating characteristic curve analysis, a Cobb angle cutoff value of 67.55° had a sensitivity of 72.5% and a specificity of 84.0% to determine PVR ≥1000 (dyn.sec/cm(5)) and its Area Under Curve is (0.800 ± 0.048). By stepwise linear regression analysis, Cobb angle was only one variable (R=0.601) shown to be independently associated with PVR, leading to the following equation: PVR=25.796 × Cobb angle-585.935(F=37.929, p=0.000). CONCLUSION The analysis of CTPA-derived cardiovascular parameters, especially the Cobb angle, is a reliable tool for estimating PVR in patients with CTEPH, but Pulmonary Artery Obstruction Indices do not correlate with PVR.

Multiparametric MRI in differentiating pulmonary artery sarcoma and pulmonary thromboembolism: a preliminary experience.

PURPOSE We aimed to define multiparametric magnetic resonance imaging (MRI) findings to differentiate between pulmonary artery sarcoma (PAS) and pulmonary thromboembolism (PTE). METHODS Eleven patients with suspected PTE were prospectively included to undergo pulmonary MRI before surgery or biopsy. MRI protocol included an unenhanced sequence, diffusion-weighted imaging (DWI, b=800 s/mm2) and a dynamic contrast-enhanced sequence. Morphologic characteristics including distribution, filling defect, and intensity were observed on T1-, T2-, and fat-suppressed T2-weighted imaging, DWI, and contrast-enhanced MRI. Apparent diffusion coefficient (ADC) values were calculated. RESULTS Six patients were pathologically diagnosed as PAS and the other five as chronic PTE. There were no significant differences in age, gender, presenting symptoms, D-dimer, and N-terminal pro-brain natriuretic peptide between the two groups (P > 0.05). Among MRI findings that were tested for their ability to diagnose PAS, area under the curve (AUC) was significantly higher than 0.5 for main pulmonary artery involvement (AUC, 0.83±0.13; P = 0.011), hyperintensity on fat-suppressed T2-weighted imaging (AUC, 0.82±0.14; P = 0.025), hyperintensity on DWI (AUC, 0.88±0.12; P = 0.002), contrast enhancement (AUC, 0.92±0.10; P < 0.001) and pleural effusion (AUC, 0.82±0.14; P = 0.025). Moreover, grape-like appearance in distal pulmonary artery and cardiac invasion had 100% specificity for diagnosis of PAS. However, ADC value of PAS was not significantly different than that of chronic PTE (U, 12.00; P = 0.584). CONCLUSION Hyperintense filling defect in main pulmonary artery on fat-suppressed T2-weighted imaging and DWI and contrast enhancement may help to discriminate PAS from PTE.

Echocardiographic characteristics of pulmonary artery involvement in Takayasu arteritis.

Up to 50% patients with Takayasu arteritis have pulmonary artery involvement. Hence, the early identification of pulmonary artery involvement to facilitate prompt treatment is required.

Technetium-99m-labelled HL91 and technetium-99m-labelled MIBI SPECT imaging for the detection of ischaemic viable myocardium: a preliminary study

Purpose:  The assessment of myocardial viability has become an important aspect of the diagnostic and prognostic work‐up of patients with coronary artery disease. Technetium‐99m labelled sestamibi (99mTc‐MIBI) myocardial perfusion imaging may underestimate the viability of ischaemic myocardium. Technetium‐99m labelled 4,9‐diaza‐3,3,10,10‐tetramethyldodecan‐2,11‐dione dioxime (99mTc‐HL91) is a hypoxia‐avid agent which can identify acutely ischaemic viable myocardium in a canine model using a standard gamma camera. The aim of this study was to evaluate uptake character of ischaemic viable myocardium and diagnostic performance of single‐photon emission computed tomography (SPECT) imaging by 99mTc‐HL91 and 99mTc‐MIBI in detecting ischaemic viable myocardium in coronary heart disease.

Dual-source CT coronary angiographic evaluation of coronary artery fistulas.

The aim of the present study was to retrospectively evaluate the incidence and morphological features of coronary artery fistulas (CAFs) detected by dual-source computed tomography coronary angiography (DS-CTCA). Between January 2011 and January 2013, 19,584 consecutive patients that had undergone electrocardiogram-triggering DS-CTCA were retrospectively reviewed. Image reconstructions were performed and image quality was evaluated. The medical information of the patients with CAF was reviewed from the medical records. Among the 19,584 patients, 66 patients were diagnosed with CAFs by CTCA, including 60 patients with coronary pulmonary artery fistulas (CPAFs) and six with coronary left ventricular fistulas. Therefore, the incidence of CAFs was 0.34%. Image quality was considered to be excellent in 61 patients and moderate in five cases. CPAFs were identified as small and tortuous vessels in 24 patients and dilated vessels close to the surface of the pulmonary artery (PA) in 36 patients. The coronary left ventricular fistulas were identified as dilated vessels that were draining into the posterior wall of the left ventricle. Among the 66 patients, 54 patients had one traceable fistula and the remaining 12 patients were shown to have two fistula vessels. The average diameter of the detected fistulas, measured with CTCA, was 3.1±1.9 mm. A high-density flow jet of contrast agent shunting from the fistula into the low density PA was observed in 46 patients with CPAF. The results indicate that DS-CTCA is a reliable noninvasive tool that allows the accurate delineation of CAFs.

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.

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.

Clinical and imaging manifestations of Takayasu's arteritis with pulmonary hypertension: A retrospective cohort study in China

BACKGROUND Takayasus arteritis with pulmonary artery involvement (PTA) is uncommon and part of which may be accompanied by pulmonary hypertension (PH). This study herein investigated the clinical presentation, imaging features, and outcomes in PTA patients with and without PH. METHODS A total of 57 PTA patients were selected at the Beijing Chao-Yang Hospital from January 2011 to July 2017. Patients were placed into two groups, PTA-with-PH or PTA-without-PH. The clinical characteristics, imaging features, and outcomes of patients in these two groups were investigated. RESULTS Among the 57 PTA patients, 24 were in the PTA-without-PH group and 33 were in the PTA-with-PH group. The disease duration in PTA-with-PH patients was longer than that of PTA-without-PH patients. The mean follow-up duration of 43 patients was 33.5 ± 20.3 months, while three patients in the PTA-with-PH were deceased. The PTA-with-PH group had significantly higher prevalence of chest tightness and dyspnea, shorter 6-minute walk distance (6MWD) and higher Borg scores after walk than that the PTA-without-PH group. Imaging analyses revealed that patients had five different arterial lesions (stenosis, occlusion, vascular wall thickening, in situ thrombosis, and aneurysm), but aneurysms were only detected in patients in PTA-with-PH patients at 42%. Compared with PTA-without-PH patients, PTA-with-PH patients tended to have occlusion lesions, but less likely to have vascular wall thickening. CONCLUSIONS Compared with PTA-without-PH patients, PTA-with-PH patients had longer disease duration, more severe symptoms and tended to be deceased during the follow-up time. In addition, PTA-with-PH patients tended to have aneurysm and occlusion vessel lesions.

A Case of Pulmonary Hypertension Due to Fistulas Between Multiple Systemic Arteries and the Right Pulmonary Artery in an Adult Discovered for Occulted Dyspnoea

BACKGROUND Pulmonary hypertension (PH) can be caused by a fistula between the systemic and pulmonary arteries. Here, we report a case of PH due to multiple fistulas between systemic arteries and the right pulmonary artery where the ventilation/perfusion scan showed no perfusion in the right lung. METHODS A 32-year-old male patient was hospitalised for community-acquired pneumonia. After treatment with antibiotics, the pneumonia was alleviated but dyspnoea persisted. Pulmonary hypertension was diagnosed using right heart catheterisation, which detected the mean pulmonary artery pressure as 37mmHg. The anomalies were confirmed by contrast-enhanced CT scan (CT pulmonary angiography), systemic arterial angiography and pulmonary angiography. RESULTS Following embolisation of the largest fistula, the haemodynamics and oxygen dynamics did not improve, and even worsened to some extent. After supportive therapy including diuretics and oxygen, the patients dyspnoea, WHO function class and right heart function by transthoracic echocardiography all improved during follow-up. CONCLUSIONS Pulmonary hypertension can be present even when the right lung perfusion is lost. Closure of fistulas by embolisation, when those fistulas act as the proliferating vessels, may be harmful.

Differential Diagnosis of Pulmonary Artery Sarcoma and Central Chronic Pulmonary Thromboembolism Using CT and MR Images

BACKGROUND Clinical and imaging manifestations are similar in pulmonary artery sarcomas (PAS) and thromboembolic diseases, especially central chronic pulmonary thromboembolism (CPTE). The feasibility of utilising clinical imaging tools such as computed tomography (CT) and magnetic resonance imaging (MRI) for differential diagnosis of PAS and CPTE has not been fully explored, especially MRI. METHODS Patients with PAS (n=18) and central CPTE (n=20) treated at our hospital between January 2013 and September 2016 were identified retrospectively. Computed tomography and MRI findings of pulmonary artery (PA) filling defects including the location, the involvement of pulmonary artery, morphology, signal intensities and enhancement in MRI, calcification, sizes of right atrium and ventricle, inner diameters of the pulmonary artery trunk and branches, and mediastinal collateral circulation in both groups were examined, and differences were analysed by Fisher exact test and independent sample t-test. RESULTS Compared to those of central CPTE, PAS lesions were in full shape or expansive growth (p<0.001), and the proximal end of the tumours was often bulging or lobulated (p<0.001). These lesions were aneurysm- or grape-like distally (p<0.01) with inhomogeneous enhancement (p<0.001). The MRI contrast enhancement pattern of PAS lesions were cloudy with inhomogeneous delayed enhancement and the time-density curves for some of the lesions increased gradually. CONCLUSION Computed tomographic and MR imaging manifestations may resemble PAS and central CPTE; however, some manifestations still have great value for the differential diagnosis of these two conditions, specifically the morphology and MRI enhancement patterns.