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Cardio-pulmonary MRI for detection of treatment response after a single BPA treatment session in CTEPH patients

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Abstract

Objectives

Chronic thromboembolic pulmonary hypertension (CTEPH) can be treated with balloon pulmonary angioplasty (BPA) in inoperable patients. Sensitive non-invasive imaging methods are missing to detect treatment response after a single BPA treatment session. Therefore, the aim of this study was to measure treatment response after a single BPA session using cardio-pulmonary MRI.

Materials and methods

Overall, 29 patients with CTEPH were examined with cardio-pulmonary MRI before and 62 days after their initial BPA session. Pulmonary blood flow (PBF), first-pass bolus kinetic parameters, and biventricular mass and function were determined. Multiple linear regression analysis was implemented to estimate the relationship of PBF change in the treated lobe with treatment change of full width at half maximum (FWHM), cardiac output (CO), ventricular mass index (VMI), pulmonary transit time (PTT) and PBF change in the non-treated lobes. Paired Wilcoxon rank sum test and Spearman rho correlation were used.

Results

After BPA regional PBF increased in the treated lobe (p < 0.0001) as well as in non-treated lobes (p = 0.015). PBF treatment changes in the treated lobe were significantly larger compared with the non-treated lobes (p = 0.0049). Change in NT proBNP, MRI-derived mean pulmonary artery pressure (mPAP), PTT, FWHM, right ventricular (RV) ejection fraction, RV stroke volume, CO, VMI and PBF in the non-treated lobes correlated with PBF change in the treated lobe (p < 0.05). PBF changes in the treated lobe were independently predicted by PTT as well as PBF change in the non-treated lobes.

Conclusion

Cardio-pulmonary MRI detects and quantifies treatment response after a single BPA treatment session.

Key Points

• Two months after BPA regional parenchymal pulmonary perfusion (PBF) increased in the total lung parenchyma (p = 0.005), the treated lobes (p < 0.0001) and non-treated lobes (p = 0.015).

• The PBF treatment changes in the treated lobe were significantly larger than in the non-treated lobes (p = 0.0049).

• Change in NT proBNP, MRI-derived mean pulmonary artery pressure, pulmonary transit time, full width at half maximum, right ventricular (RV) ejection fraction, RV stroke volume, cardiac output, ventricular mass index and PBF in the non-treated lobes correlated with PBF change in the treated lobe (p < 0.05).

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Abbreviations

6MWD:

Six-minute walking distance

BPA:

Balloon pulmonary angioplasty

BSA:

Body surface area

CO:

Cardiac output

CTEPH:

Chronic thromboembolic pulmonary hypertension

DCE:

Dynamic contrast enhanced

EDV:

End-diastolic volume

EF:

Ejection fraction

ESV:

End-systolic volume

FWHM:

Full width at half maximum

LV:

Left ventricular

mPAP:

Mean pulmonary artery pressure

NT-proBNP:

N-terminal pro B-type natriuretic peptide

NYHA FC:

New York Heart Association functional classification

PBF:

Pulmonary blood flow

PE:

Pulmonary embolism

PEA:

Pulmonary endarterectomy

PH:

Pulmonary hypertension

PTT:

Pulmonary transit time

PVR:

Pulmonary vascular resistance

RHC:

Right-sided heart catheterization

RV:

Right ventricular

SV:

Stroke volume

TTP:

Time to peak

TWIST:

Time-resolved angiography with stochastic trajectories

VMI:

Ventricular mass index

References

  1. Olsson KM, Wiedenroth CB, Kamp JC et al (2017) Balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension: the initial German experience. Eur Respir J 49:1602409. https://doi.org/10.1183/13993003.02409-2016

    Article  PubMed  Google Scholar 

  2. Lang IM, Madani M (2014) Update on chronic thromboembolic pulmonary hypertension. Circulation 130:508–518. https://doi.org/10.1161/CIRCULATIONAHA.114.009309

    Article  PubMed  Google Scholar 

  3. Hoeper MM, Madani MM, Nakanishi N, Meyer B, Cebotari S, Rubin LJ (2014) Chronic thromboembolic pulmonary hypertension. Lancet Respir Med 2:573–582. https://doi.org/10.1016/S2213-2600(14)70089-X

  4. Kim NH, Delcroix M, Jenkins DP et al (2013) Chronic thromboembolic pulmonary hypertension. J Am Coll Cardiol 62:D92–D99. https://doi.org/10.1016/j.jacc.2013.10.024

    Article  Google Scholar 

  5. Pepke-Zaba J, Delcroix M, Lang I et al (2011) Chronic thromboembolic pulmonary hypertension (CTEPH): results from an international prospective registry. Circulation 124:1973–1981. https://doi.org/10.1161/CIRCULATIONAHA.110.015008

    Article  PubMed  Google Scholar 

  6. Hoeper MM (2016) Residual Pulmonary hypertension after pulmonary endarterectomy: the fog is clearing. https://doi.org/10.1161/CIRCULATIONAHA.116.022595

  7. Hinrichs JB, Renne J, Hoeper MM, Olsson KM, Wacker FK, Meyer BC (2016) Balloon pulmonary angioplasty: applicability of C-Arm CT for procedure guidance. Eur Radiol 26:4064–4071. https://doi.org/10.1007/s00330-016-4280-z

  8. Sato H, Ota H, Sugimura K et al (2016) Balloon pulmonary angioplasty improves biventricular functions and pulmonary flow in chronic thromboembolic pulmonary hypertension. Circ J 80:1470–1477. https://doi.org/10.1253/circj.CJ-15-1187

  9. Ogo T, Fukuda T, Tsuji A et al (2017) Efficacy and safety of balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension guided by cone-beam computed tomography and electrocardiogram-gated area detector computed tomography. Eur J Radiol 89:270–276. https://doi.org/10.1016/j.ejrad.2016.12.013

    Article  PubMed  Google Scholar 

  10. Mizoguchi H, Ogawa A, Munemasa M, Mikouchi H, Ito H, Matsubara H (2012) Refined balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension. Circ Cardiovasc Interv 5:748–755. https://doi.org/10.1161/CIRCINTERVENTIONS.112.971077

  11. Mayer E, Jenkins D, Lindner J et al (2011) Surgical management and outcome of patients with chronic thromboembolic pulmonary hypertension: Results from an international prospective registry. J Thorac Cardiovasc Surg 141:702–710. https://doi.org/10.1016/j.jtcvs.2010.11.024

    Article  PubMed  Google Scholar 

  12. Jenkins DP, Madani M, Mayer E et al (2013) Surgical treatment of chronic thromboembolic pulmonary hypertension. Eur Respir J 41:735–742. https://doi.org/10.1183/09031936.00058112

    Article  CAS  PubMed  Google Scholar 

  13. Shimura N, Kataoka M, Inami T et al (2015) Additional percutaneous transluminal pulmonary angioplasty for residual or recurrent pulmonary hypertension after pulmonary endarterectomy. Int J Cardiol 183C:138–142. https://doi.org/10.1016/j.ijcard.2015.01.034

    Article  Google Scholar 

  14. Inami T, Kataoka M, Shimura N et al (2014) Pressure-wire-guided percutaneous transluminal pulmonary angioplasty: a breakthrough in catheter-interventional therapy for chronic thromboembolic pulmonary hypertension. JACC Cardiovasc Interv 7:1297–1306. https://doi.org/10.1016/j.jcin.2014.06.010

    Article  PubMed  Google Scholar 

  15. Champion HC, Michelakis ED, Hassoun PM (2009) Comprehensive invasive and noninvasive approach to the right ventricle-pulmonary circulation unit: state of the art and clinical and research implications. Circulation 120:992–1007. https://doi.org/10.1161/CIRCULATIONAHA.106.674028

    Article  PubMed  Google Scholar 

  16. Roik M, Wretowski D, Łabyk A et al (2016) Refined balloon pulmonary angioplasty driven by combined assessment of intra-arterial anatomy and physiology - Multimodal approach to treated lesions in patients with non-operable distal chronic thromboembolic pulmonary hypertension - Technique, safety and efficacy of 50 consecutive angioplasties. Int J Cardiol 203:228–235. https://doi.org/10.1016/j.ijcard.2015.10.116

    Article  PubMed  Google Scholar 

  17. Maschke SK, Renne J, Werncke T et al (2017) Chronic thromboembolic pulmonary hypertension: Evaluation of 2D-perfusion angiography in patients who undergo balloon pulmonary angioplasty. Eur Radiol 27:4264–4270. https://doi.org/10.1007/s00330-017-4806-z

    Article  PubMed  Google Scholar 

  18. Roik M, Wretowski D, Łabyk A et al (2017) Refined balloon pulmonary angioplasty-A therapeutic option in very elderly patients with chronic thromboembolic pulmonary hypertension. J Interv Cardiol. https://doi.org/10.1111/joic.12387

  19. Leuchte HH, El Nounou M, Tuerpe JC et al (2007) N-terminal pro-brain natriuretic peptide and renal insufficiency as predictors of mortality in pulmonary hypertension. Chest 131:402–409. https://doi.org/10.1378/chest.06-1758

  20. Nagaya N, Nishikimi T, Uematsu M et al (2000) Plasma brain natriuretic peptide as a prognostic indicator in patients with primary pulmonary hypertension. Circulation 102:865–870

    Article  CAS  PubMed  Google Scholar 

  21. Simonneau G, D'Armini AM, Ghofrani HA et al (2016) Predictors of long-term outcomes in patients treated with riociguat for chronic thromboembolic pulmonary hypertension: data from the CHEST-2 open-label, randomised, long-term extension trial. Lancet Respir Med 4:372–380. https://doi.org/10.1016/S2213-2600(16)30022-4

    Article  CAS  PubMed  Google Scholar 

  22. Suntharalingam J, Goldsmith K, Toshner M et al (2007) Role of NT-proBNP and 6MWD in chronic thromboembolic pulmonary hypertension. Respir Med 101:2254–2262. https://doi.org/10.1016/j.rmed.2007.06.027

    Article  PubMed  Google Scholar 

  23. American College of Cardiology Foundation Task Force on Expert Consensus Documents, Hundley WG, Bluemke DA et al (2010) ACCF/ACR/AHA/NASCI/SCMR 2010 expert consensus document on cardiovascular magnetic resonance: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol 55:2614–2662

  24. Kreitner KF, Kunz RP, Ley S et al (2007) Chronic thromboembolic pulmonary hypertension—assessment by magnetic resonance imaging. Eur Radiol 17:11–21. https://doi.org/10.1007/s00330-006-0327-x

    Article  PubMed  Google Scholar 

  25. Peacock AJ, Vonk Noordegraaf A(2013) Cardiac magnetic resonance imaging in pulmonary arterial hypertension. Eur Respir Rev 22:526–534. https://doi.org/10.1183/09059180.00006313

    Article  PubMed  Google Scholar 

  26. Jenkins D, Mayer E, Screaton N, Madani M (2012) State-of-the-art chronic thromboembolic pulmonary hypertension diagnosis and management. Eur Respir Rev 21:32–39. https://doi.org/10.1183/09059180.00009211

  27. Schoenfeld C, Cebotari S, Hinrichs J et al (2016) MR imaging-derived regional pulmonary parenchymal perfusion and cardiac function for monitoring patients with chronic thromboembolic pulmonary hypertension before and after pulmonary endarterectomy. Radiology 279:925–934. https://doi.org/10.1148/radiol.2015150765

    Article  PubMed  Google Scholar 

  28. Galiè N, Humbert M, Vachiery JL et al (2016) 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J 37:67–119. https://doi.org/10.1093/eurheartj/ehv317

    Article  Google Scholar 

  29. Hinrichs JB, Marquardt S, von Falck C et al (2016) Comparison of C-arm computed tomography and digital subtraction angiography in patients with chronic thromboembolic pulmonary hypertension. Cardiovasc Intervent Radiol 39:53–63. https://doi.org/10.1007/s00270-015-1090-7

    Article  PubMed  Google Scholar 

  30. Rajaram S, Swift AJ, Telfer A et al (2013) 3D contrast-enhanced lung perfusion MRI is an effective screening tool for chronic thromboembolic pulmonary hypertension: results from the ASPIRE Registry. Thorax 68:677–678. https://doi.org/10.1136/thoraxjnl-2012-203020

    Article  PubMed  Google Scholar 

  31. Sourbron S, Dujardin M, Makkat S, Luypaert R (2007) Pixel-by-pixel deconvolution of bolus-tracking data: optimization and implementation. Phys Med Biol 52:429–447. https://doi.org/10.1088/0031-9155/52/2/009

    Article  CAS  PubMed  Google Scholar 

  32. Ingrisch M, Dietrich O, Attenberger UI et al (2010) Quantitative pulmonary perfusion magnetic resonance imaging: influence of temporal resolution and signal-to-noise ratio. Invest Radiol 45:7–14. https://doi.org/10.1097/RLI.0b013e3181bc2d0c

    Article  PubMed  Google Scholar 

  33. Skrok J, Shehata ML, Mathai S et al (2012) Pulmonary arterial hypertension: MR imaging-derived first-pass bolus kinetic parameters are biomarkers for pulmonary hemodynamics, cardiac function, and ventricular remodeling. Radiology 263:678–687. https://doi.org/10.1148/radiol.12111001

    Article  PubMed  PubMed Central  Google Scholar 

  34. Vogel-Claussen J, Finn JP, Gomes AS et al (2006) Left ventricular papillary muscle mass: relationship to left ventricular mass and volumes by magnetic resonance imaging. J Comput Assist Tomogr 30:426–432

    Article  PubMed  Google Scholar 

  35. Ryan T, Petrovic O, Dillon JC, Feigenbaum H, Conley MJ, Armstrong WF (1985) An echocardiographic index for separation of right ventricular volume and pressure overload. J Am Coll Cardiol 5:918–927

  36. Vogel-Claussen J, Shehata ML, Lossnitzer D et al (2011) Increased right ventricular septomarginal trabeculation mass is a novel marker for pulmonary hypertension: comparison with ventricular mass index and right ventricular mass. Invest Radiol 46:567–575. https://doi.org/10.1097/RLI.0b013e31821b7041

    Article  PubMed  PubMed Central  Google Scholar 

  37. Swift AJ, Rajaram S, Hurdman J et al (2013) Noninvasive Estimation of PA Pressure, Flow, and Resistance With CMR Imaging: Derivation and Prospective Validation Study From the ASPIRE Registry. JACC Cardiovasc Imaging 6:1036–1047. https://doi.org/10.1016/j.jcmg.2013.01.013

    Article  PubMed  Google Scholar 

  38. Marra AM, Egenlauf B, Ehlken N et al (2015) Change of right heart size and function by long-term therapy with riociguat in patients with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Int J Cardiol 195:19–26. https://doi.org/10.1016/j.ijcard.2015.05.105

    Article  PubMed  Google Scholar 

  39. Yamasaki Y, Nagao M, Kamitani T et al (2016) Clinical impact of left ventricular eccentricity index using cardiac MRI in assessment of right ventricular hemodynamics and myocardial fibrosis in congenital heart disease. Eur Radiol 26:3617–3625. https://doi.org/10.1007/s00330-015-4199-9

    Article  PubMed  Google Scholar 

  40. Swift AJ, Telfer A, Rajaram S et al (2014) Dynamic contrast-enhanced magnetic resonance imaging in patients with pulmonary arterial hypertension. Pulm Circ 4:61–70. https://doi.org/10.1086/674882

    Article  PubMed  PubMed Central  Google Scholar 

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Funding

This study has received funding from the German Center for Lung Research (DZL).

Author information

Author notes

  1. Christian Schoenfeld and Jan B Hinrichs contributed equally

Authors and Affiliations

  1. Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE 8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany

    Christian Schoenfeld, Jan B. Hinrichs, Martin-Alexander Kuettner, Julius Renne, Till Kaireit, Christoph Czerner, Frank Wacker, Bernhard C. Meyer & Jens Vogel-Claussen

  2. Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany

    Christian Schoenfeld, Jan B. Hinrichs, Karen M. Olsson, Julius Renne, Till Kaireit, Christoph Czerner, Frank Wacker, Marius M. Hoeper, Bernhard C. Meyer & Jens Vogel-Claussen

  3. Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany

    Karen M. Olsson & Marius M. Hoeper

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  1. Christian Schoenfeld
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Corresponding author

Correspondence to Jens Vogel-Claussen.

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Guarantor

The scientific guarantor of this publication is Prof. Dr. Jens Vogel-Claussen.

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The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise.

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Written informed consent was obtained from all subjects (patients) in this study.

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Institutional Review Board approval was obtained.

Methodology

• retrospective

• observational

• performed at one institution

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Schoenfeld, C., Hinrichs, J.B., Olsson, K.M. et al. Cardio-pulmonary MRI for detection of treatment response after a single BPA treatment session in CTEPH patients. Eur Radiol 29, 1693–1702 (2019). https://doi.org/10.1007/s00330-018-5696-4

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