Noninvasively Assessed Pulmonary Artery Stiffness Predicts Mortality in Pulmonary Arterial Hypertension

doi:10.1378/chest.07-1246

Chest

Volume 132, Issue 6, December 2007, Pages 1906-1912

https://doi.org/10.1378/chest.07-1246 Get rights and content

Aims: Decreased total compliance of the pulmonary vascular bed is associated with increased mortality in patients with pulmonary arterial hypertension (PAH). We investigated whether proximal pulmonary artery stiffness, in terms of area distensibility and noninvasively assessed relative area change (RAC), calculated as relative cross-sectional area change, predicts mortality in patients with PAH.

Methods and results

Eighty-six subjects underwent right-heart catheterization and MRI to assess area distensibility and RAC. Patients were followed up to 48 months. Kaplan-Meier plot and Cox proportional hazards regression analyses assessed the predictive value of area distensibility and RAC. In 70 patients, the diagnosis PAH was confirmed, and 16 subjects served as control subjects. In comparison with control subjects, proximal pulmonary arteries of patients were distended (685 ± 214 mm² vs 411 ± 153 mm², p < 0.001), less distensible (area distensibility = 0.46 ± 0.38·10⁻² mm Hg⁻¹ vs 3.69 ± 1.96·10⁻² mm Hg⁻¹, p < 0.0001), and RAC was smaller (20 ± 10% vs 58 ± 21%, p < 0.0001) [mean ± SD]. RAC showed an inverse curvilinear relation with mean pulmonary artery pressure (R² = 0.47). Eighteen patients (26%) died because of cardiopulmonary causes. Patients with a pulmonary artery RAC ≤ 16% had a worse prognosis than those with a value > 16% (log-rank p < 0.001). RAC predicted mortality better than area distensibility.

Conclusion

Noninvasively measured pulmonary artery RAC predicts mortality in patients with PAH.

Section snippets

Patient Selection

All patients referred to our institute for the evaluation and treatment of PAH from September 2001 to September 2005 were considered for enrollment in to this study. The diagnosis of PAH was assessed according to the 2003 Venice consensus guidelines on the diagnosis and treatment of PAH.¹⁵ All persons underwent an MRI scan of the heart and large pulmonary vessels within 1 week of initial right-heart catheterization. The selection of patients depended on whether the diagnosis of PAH could be

Results

Seventy PAH patients and 16 subjects without pulmonary hypertension were included in this study. Table 1summarizes patient characteristics, etiologies, and hemodynamics. The majority of patients were female and had a diagnosis of idiopathic PAH, and right-heart catheterization data yielded characteristics of RV pressure overload. In the 16 control subjects, the diagnosis of pulmonary hypertension was excluded by right-heart catheterization. The control subjects appeared to be younger, but this

Discussion

This MRI study shows that in PAH patients, the pulmonary artery becomes distended and less distensible. In comparison with subjects without PAH, both area distensibility and RAC are significantly lower in PAH patients. Furthermore, it was shown that noninvasively measured RAC is a predictor of mortality.

Conclusion

In patients with PAH, increased pulmonary artery pressure causes distension and possibly wall remodeling, both resulting in stiffening of the proximal pulmonary arteries. Noninvasively assessed pulmonary artery RAC is a good predictor of mortality.

Parameters of the Applied MRI Pulse Sequence

MRI pulse sequence type is steady-state free precession, and phase-encoding direction is anterior to posterior; field of view in read, 320 mm; field of view in phase, 81%; slice thickness, 5 mm; in-plane resolution, 150 × 256 pixels, 1.73 × 1.25 mm per pixel; temporal resolution, 35 ms; echo time, 1.6 ms; flip angle, 60°; retrospective ECG triggering, 25 phases reconstructed; receiver bandwidth, 930 Hz per pixel; and 11 phase-encoding lines per beat.

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The reported RIs of the MPA and RPA dimensions in normal dogs could increase the diagnostic accuracy of transthoracic echocardiography in the identification of pulmonary artery enlargement in dogs.
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Three hundred and thirty-six patients undergoing TAVR between July 2012 and March 2016 were retrospectively included and followed for all-cause mortality until November 2017. All patients underwent retrospectively ECG-gated CTA prior to TAVR. Main pulmonary artery (MPA) area was measured in systole and in diastole. D_PA was calculated as: [(area-MPA_max–area-MPA_min)/area-MPA_max]%. ROC analysis was performed to assess the AUC for persistent-PH. Youden Index was used to determine the optimal threshold of D_PA for persistent-PH. Two groups were compared based on a D_PA threshold of 8% (specificity of 70% for persistent-PH). Kaplan-Meier, Cox proportional-hazard, and logistic regression analyses were performed. The primary clinical endpoint was defined as persistent-PH post-TAVR. The secondary endpoint was defined as all-cause mortality 2 years after TAVR.
Median follow-up time was 413 (interquartiles 339–757) days. A total of 183 (54%) had persistent-PH and 68 (20%) patients died within 2-years after TAVR. Patients with D_PA<8% had significantly more persistent-PH (67% vs 47%, p<0.001) and 2-year deaths (28% vs 15%, p=0.006), compared to patients with D_PA>8%. Adjusted multivariable regression analyses showed that D_PA<8% was independently associated with persistent-PH (OR 2.10 [95%-CI 1.3–4.5], p=0.007) and 2-year mortality (HR 2.91 [95%-CI 1.5–5.8], p=0.002). Kaplan-Meier analysis showed that 2-year mortality of patients with D_PA<8% was significantly higher compared to patients with D_PA≥8% (mortality 28% vs 15%; log-rank p=0.003).
D_PA on preprocedural CTA is independently associated with persistent-PH and two-year mortality in patients who undergo TAVR.
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Current cardiac magnetic resonance (CMR) imaging in pulmonary arterial hypertension (PAH) focuses on measures of ventricular function and coupling.
The purpose of this study was to evaluate pulmonary artery (PA) global longitudinal strain (GLS) as a prognostic marker in patients with PAH.
The authors included 169 patients with PAH from the ASPIRE (Assessing the Spectrum of Pulmonary hypertension Identified at a REferral centre) and INITIATE (Integrated computatioNal modelIng of righT heart mechanIcs and blood flow dynAmics in congeniTal hEart disease) registries, and 82 normal controls with similar age and gender distributions. PA GLS was derived from CMR feature tracking. Right ventricular measurements including volumes, ejection fraction, and right ventricular GLS were also derived from CMR. Patients were followed up a median of 34 months with all-cause mortality as the primary endpoint. Other known risk scores were collected, including the REVEAL (Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management) 2.0 and COMPERA (Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension) 2.0 scores.
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PA GLS confers incremental prognostic utility over the established risk scores for identifying patients with PAH at higher risk of death, who may be targeted for closer monitoring and/or intensified therapy.

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The authors have no conflicts of interest to disclose.

Dr. Gan was financially supported by the Netherlands Organisation for Scientific Research, Mozaiek grant, project number 017.001.154. Dr. Lankhaar was financially supported by the Netherlands Heart Foundation grant NHS2003B274.

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Chest

Original ResearchPulmonary HypertensionNoninvasively Assessed Pulmonary Artery Stiffness Predicts Mortality in Pulmonary Arterial Hypertension

Methods and results

Conclusion

Section snippets

Patient Selection

Results

Discussion

Conclusion

Parameters of the Applied MRI Pulse Sequence

J Am Coll Cardiol

J Am Soc Echocardiogr

J Biomech

J Biomech

J Am Soc Echocardiogr

Am Heart J

Am J Cardiol

Am J Cardiol

J Am Soc Echocardiogr

Relation between pressure and diameter in main pulmonary artery of man

J Appl Physiol

Compliance of the human pulmonary arterial system in disease

Circ Res

Hemodynamics.

Original Research
Pulmonary Hypertension
Noninvasively Assessed Pulmonary Artery Stiffness Predicts Mortality in Pulmonary Arterial Hypertension