Skip to main content

Main menu

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • COVID-19 submission information
    • Peer reviewer login
  • Alerts
  • Podcasts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • COVID-19 submission information
    • Peer reviewer login
  • Alerts
  • Podcasts
  • Subscriptions

Magnetic resonance imaging of pulmonary arterial compliance after pulmonary endarterectomy

Stefano Ghio, Gabriele Crimi, Stefania Guida, Adele Valentini, Anna Celentano, Maurizio Pin, Claudia Raineri, Annalisa Turco, Laura Scelsi, Luigi Oltrona Visconti, Robert Naeije, Andrea Maria D'Armini
European Respiratory Journal 2020 55: 1902171; DOI: 10.1183/13993003.02171-2019
Stefano Ghio
1Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: s.ghio@smatteo.pv.it
Gabriele Crimi
1Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Gabriele Crimi
Stefania Guida
1Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Stefania Guida
Adele Valentini
2Institute of Radiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Anna Celentano
3Division of Cardiac Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Maurizio Pin
3Division of Cardiac Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Claudia Raineri
1Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Annalisa Turco
1Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Laura Scelsi
1Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Luigi Oltrona Visconti
1Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Robert Naeije
4Free University of Brussels, Brussels, Belgium
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Andrea Maria D'Armini
3Division of Cardiac Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
5Dept of Surgical, Clinical, Diagnostic and Pediatric Sciences, University of Pavia School of Medicine, Pavia, Italy
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Abstract

In CTEPH patients who have undergone pulmonary endarterectomy, exercise capacity is better associated with changes in invasively measured pulmonary arterial compliance than with changes in magnetic resonance imaging of pulmonary artery stiffness http://bit.ly/30DAWUj

To the Editor:

Pulmonary endarterectomy (PEA) is the treatment of choice of chronic thromboembolic pulmonary hypertension (CTEPH) [1]. However, successfully operated patients may continue to suffer from dyspnoea and limitation of exercise capacity, despite improvement or even normalisation of pulmonary artery pressure (PAP), cardiac output (CO) and pulmonary vascular resistance (PVR) [2]. This absence of complete symptomatic recovery has been explained by a decreased right ventricular (RV) function reserve due to persistent increased afterload [3, 4], related to decreased pulmonary arterial compliance (PCa) more than to mildly increased PVR [5, 6]. There is therefore interest in assessing PCa in patients during the follow-up of PEA.

Estimation of PCa commonly relies on the invasively measured ratio of stroke volume (SV) and pulse pressure (PP). This approach is limited by the fact that pulmonary circulation is not a closed system and blood leaves through the pulmonary resistive vessels, therefore SV/PP ratio over-estimates PCa considerably [7]. This problem can be addressed by the pulse pressure method (PPM), which calculates PCa from the instantaneous pulmonary artery (PA) flow and a two-element windkessel model with an initial value of SV/PP and PVR [8]. Another approach is to estimate PCa using systolic and diastolic cross sectional area or flow imaging of SV by cardiac magnetic resonance (CMR) in combination or not with the right heart catheterisation (RHC) assessment of PP [9, 10].

We wondered whether CMR imaging of the PA could be a clinically useful addition to RHC determination of PCa for the evaluation of CTEPH patients in the follow-up of successful PEA. We also compared patients with proximal versus distal lesions to better understand the role of anatomical location of the disease in the assessment of PCa.

The present study was a retrospective evaluation of a consecutive cohort of patients who underwent PEA at our institution (Fondazione IRCCS Policlinico San Matteo, Pavia, Italy) and in whom CMR, RHC and a Bruce test were successively performed during the same day, before PEA and 12 months after surgery. All patients signed an informed consent agreement, approved by the institutional review board of Fondazione IRCCS Policlinico San Matteo (Pavia, Italy) for longitudinal, nonpharmacological, non-sponsored studies, which complies with the Italian legislation (Codex on Privacy, D. Lgs. 30 giugno 2003, n. 196).

The anaesthesiological and surgical methods used have been reported previously [11]. RHC was performed as recommended in the guidelines of the European Respiratory Society and European Society of Cardiology [12]. The response variable was exercise capacity assessed using the modified Bruce protocol and expressed in distance achieved in metres. CMR was performed using a 1.5 T scanner (Siemens Synphony, Erlangen, Germany) with a phased array cardiac coil and ECG gating.

RHC PCa was calculated as (SV/PP divided by 1.76)+0.1, in conformance to the PPM model [8]. CMR-derived estimates included: relative cross-sectional relative area change (RAC) of the PA (RAC=((maxA–minA)/minA)×100), area compliance calculated as absolute change in lumen area for a given change in pressure ((maxA–minA)/PP), area distensibility calculated as the ratio of RAC and PP, vessel wall stiffness (β) calculated as (ln (PAPs/PAPd))/(2 RAC) and CMR compliance as the ratio of CMR flow imaging SV (SVCMR) and PP.

Data were described as mean±sd and compared between the groups (proximal-mid versus distal disease) with the t-test. Haemodynamic and CMR parameters before and after surgery, were compared within individual subjects, by fitting a mixed model for repeated measure, response was defined as total distance at Bruce test. Time (surgery) effect was explored between the groups (proximal versus distal CTEPH) by including the group and interaction term time × group in the model; other covariates were included into the model to assess independent predictive impact on response. Post hoc comparisons were adjusted by the Tukey honest significant difference correction; a two-sided probability value ≤0.05 was considered significant. Data were analysed in R version 3.5.3.

The study included 86 patients, aged 61±13 years, 46 with proximal and 41 with distal CTEPH, with a WHO functional class III or IV in 60 of them. PEA was associated with improvement in the Bruce test distance from 181±201 to 544±286 m.

At RHC, cardiac index improved after PEA from 2.3±0.7 to 2.7±0.5 L·min−1·m−2, mean PAP from 42±12 to 19±6 mmHg, PVR from 776±378 to 216±105 dyne·s·cm−5 and SV/PP from 1.2±0.7 to 3.1±1.1 mL·mmHg−1 (all p<001). The time constant PVR × PCa remained unchanged in both proximal and distal CTEPH patients. At CMR, area compliance increased after PEA from 4.0±3.6 to 6.8±4.4 mm2·mmHg−1, SVCMR/PP from 1.3±0.6 to 3.2±1.2 mL·mmHg−1, RAC from 23±18 to 25±17% and RAC/PP from 0.5±0.5 to 1.2±0.91%·mmHg−1 while vessel wall stiffness decreased from 703±1832 to 167±214 arbitrary units (all p<0.001, except for vessel wall stiffness p=0.18 and RAC p=0.24). All the RHC and CMR changes after PEA were similar and not significantly different in patients with proximal or distal lesions. This is illustrated by PEA-related changes in PCa and Bruce test in figure 1.

FIGURE 1
  • Download figure
  • Open in new tab
  • Download powerpoint
FIGURE 1

Changes in a) pulmonary arterial compliance calculated at right heart catheterisation (RHC) and b) metres walked at Bruce test from baseline to post surgery in patients with Jamieson type 1–2 disease (red line and circles) and in patients with Jamieson type 3 disease (blue line and circles). Post pulmonary endarterectomy Jamieson type 1–2 versus distal Jamieson type 3 casts are illustrated in the upper part of the figure. Data were analysed in a mixed multivariable model for repeated measure, class effect, time (surgery) effect and the interaction between class and time were included as covariates. Statistical significance as follows. a) Jamieson class effect p=0.193; time effect p<0.001; Jamieson class×time p=0.018. b) Jamieson class effect p=0.710; time effect p<0.001; Jamieson class×time p=0.050.

PCa was the only independent haemodynamic parameter associated with improvement in exercise capacity by Bruce exercise test before/after PEA in a multivariable model (p=0.018), while mean PAP and PVR were nonsignificant predictors (p=0.692 and 0.095, respectively). When CMR-based indices of PA structure and function were incorporated in a multivariable model, only SVCMR/PP independently predicted exercise capacity but with borderline significance (p=0.051). However, RHC-derived assessment of PCa but not SVCMR/PP was independently associated with improvement in exercise capacity when both were included in a bivariable model (p<0.001 and p=0.588, respectively).

The observation that the anatomical location of vascular obstruction and relief by PEA surgery did not affect the time constant of the pulmonary circulation is in keeping with previous demonstration [13]. RV afterload is determined by a dynamic interplay between pulmonary vascular resistance, compliance and wave reflection [14]. Therefore the present results suggest a negligible contribution of wave reflection as PCa is tightly related to PVR and, thus, RV hydraulic load is essentially predicted by PCa and PVR only, with a hyperbolic relationship so that PCa predominates in the presence of normal or only mildly increased PAP [15]. On the other hand, CMR imaging of PA stiffness is necessarily limited to the proximal part of the pulmonary arterial tree, so that proximal PA compliance contributes to no more than 20% of the total compliance of the pulmonary vascular bed [13]. This explains why CMR imaging of PA stiffness did not predict exercise capacity in the present study.

In conclusion, the present results show that CMR imaging of PA dimensions cannot replace RHC and is of no added value to RHC for the determination of PCa before and after successful PEA in CTEPH patients with either proximal or distal thrombotic lesions.

Shareable PDF

Supplementary Material

This one-page PDF can be shared freely online.

Shareable PDF ERJ-02171-2019.Shareable

Footnotes

  • Author contributions: S. Ghio made substantial contributions to conception and to the design of the study and to interpretation of data; drafted the submitted article; and provided final approval of the version to be published. S. Ghio takes responsibility for (is the guarantor of) the content of the manuscript, including the data and analysis. G. Crimi, S. Guida, A. Valentini, A. Celentano, M. Pin, C. Raineri, A. Turco, L. Oltrona Visconti, R. Naeije and A.M. D'Armini have made substantial contributions to conception of the study, to interpretation of data; have revised the manuscript critically for important intellectual content and has provided final approval of the version to be published; G. Crimi has also analysed the data.

  • Conflict of interest: S. Ghio has nothing to disclose.

  • Conflict of interest: G. Crimi has nothing to disclose.

  • Conflict of interest: S. Guida has nothing to disclose.

  • Conflict of interest: A. Valentini has nothing to disclose.

  • Conflict of interest: A. Celentano has nothing to disclose.

  • Conflict of interest: M. Pin has nothing to disclose.

  • Conflict of interest: C. Raineri has nothing to disclose.

  • Conflict of interest: A. Turco has nothing to disclose.

  • Conflict of interest: L. Scelsi has nothing to disclose.

  • Conflict of interest: L. Oltrona Visconti has nothing to disclose.

  • Conflict of interest: R. Naeije has nothing to disclose.

  • Conflict of interest: A.M. D'Armini has nothing to disclose.

  • Received November 8, 2019.
  • Accepted January 12, 2020.
  • Copyright ©ERS 2020
https://www.ersjournals.com/user-licence

References

  1. ↵
    1. Kim NH,
    2. Delcroix M,
    3. Jais X, et al.
    Chronic thromboembolic pulmonary hypertension. Eur Respir J 2019; 53: 1801915. doi:10.1183/13993003.01915-2018
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Lang IM M
    . Update on chronic thromboembolic pulmonary hypertension. Circulation 2014; 130: 508–518. doi:10.1161/CIRCULATIONAHA.114.009309
    OpenUrlFREE Full Text
  3. ↵
    1. Bonderman D,
    2. Martischnig AM,
    3. Vonbank K, et al.
    Right ventricular load at exercise is a cause of persistent exercise limitation in patients with normal resting pulmonary vascular resistance after pulmonary endarterectomy. Chest 2011; 139: 122–127. doi:10.1378/chest.10-0348
    OpenUrlCrossRefPubMedWeb of Science
  4. ↵
    1. Claessen G,
    2. La Gerche A,
    3. Dymarkowski S, et al.
    Pulmonary vascular and right ventricular reserve in patients with normalized resting haemodynamics after pulmonary endarterectomy. J Am Heart Assoc 2015; 4: e001602. doi:10.1161/JAHA.114.001602
    OpenUrlAbstract/FREE Full Text
  5. ↵
    1. Ghio S,
    2. Morsolini M,
    3. Corsico A, et al.
    Pulmonary arterial compliance and exercise capacity after pulmonary endarterectomy. Eur Respir J 2014; 43: 1403–1409. doi:10.1183/09031936.00195313
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Corsico AG,
    2. D'Armini AM,
    3. Conio V, et al.
    Persistent exercise limitation after successful pulmonary endoarterectomy: frequency and determinants. Respir Res 2019; 20: 34. doi:10.1186/s12931-019-1002-5
    OpenUrl
  7. ↵
    1. Stergiopulos N,
    2. Meister JJ,
    3. Westerhof N
    . Evaluation of methods for estimation of total arterial compliance. Am J Physiol 1995; 268: H1540–H1548.
    OpenUrl
  8. ↵
    1. Segers P,
    2. Brimioulle S,
    3. Stergiopulos N, et al.
    Pulmonary arterial compliance in dogs and pigs: the three-element windkessel model revisited. Am J Physiol 1999; 277: H725–H723.
    OpenUrl
  9. ↵
    1. Gan CT,
    2. Lankhaar JW,
    3. Westerhof N, et al.
    Noninvasively assessed pulmonary artery stiffness predicts mortality in pulmonary arterial hypertension. Chest 2007; 132: 1906–1912. doi:10.1378/chest.07-1246
    OpenUrlCrossRefPubMedWeb of Science
  10. ↵
    1. Stevens GR,
    2. Garcia-Alvarez A,
    3. Sahni S, et al.
    RV dysfunction in pulmonary hypertension is independently related to pulmonary artery stiffness. JACC Cardiovasc Imaging 2012; 5: 378–387. doi:10.1016/j.jcmg.2011.11.020
    OpenUrlAbstract/FREE Full Text
  11. ↵
    1. Morsolini M,
    2. Nicolardi S,
    3. Milanesi E, et al.
    Evolving surgical techniques for pulmonary endarterectomy according to the changing features of chronic thromboembolic pulmonary hypertension patients during 17-year single center experience. J Thorac Cardiovasc Surg 2012; 144: 100–107. doi:10.1016/j.jtcvs.2011.11.041
    OpenUrlCrossRefPubMedWeb of Science
  12. ↵
    1. Galiè N,
    2. Humbert M,
    3. Vachiery JL, et al.
    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). Eur Respir J 2015; 46: 903–975. doi:10.1183/13993003.01032-2015
    OpenUrlAbstract/FREE Full Text
  13. ↵
    1. Saouti N,
    2. Westerhof N,
    3. Helderman F, et al.
    RC time constant of single lung equals that of both lungs together: a study in chronic thromboembolic pulmonary hypertension. Am J Physiol Heart Circ Physiol 2009; 297: H2154–H2160. doi:10.1152/ajpheart.00694.2009
    OpenUrlCrossRefPubMed
  14. ↵
    1. Sniderman AD,
    2. Fitchett DH
    . Vasodilators and pulmonary arterial hypertension: the paradox of therapeutic success and clinical failure. Int J Cardiol 1988; 20: 173–181. doi:10.1016/0167-5273(88)90261-6
    OpenUrlCrossRefPubMedWeb of Science
  15. ↵
    1. Saouti N,
    2. Westerhof N,
    3. Helderman F, et al.
    Right ventricular oscillatory power is a constant fraction of total power irrespective of pulmonary artery pressure. Am J Respir Crit Care Med 2010; 182: 1315–1320. doi:10.1164/rccm.200910-1643OC
    OpenUrlCrossRefPubMedWeb of Science
PreviousNext
Back to top
View this article with LENS
Vol 55 Issue 5 Table of Contents
European Respiratory Journal: 55 (5)
  • Table of Contents
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Magnetic resonance imaging of pulmonary arterial compliance after pulmonary endarterectomy
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
Magnetic resonance imaging of pulmonary arterial compliance after pulmonary endarterectomy
Stefano Ghio, Gabriele Crimi, Stefania Guida, Adele Valentini, Anna Celentano, Maurizio Pin, Claudia Raineri, Annalisa Turco, Laura Scelsi, Luigi Oltrona Visconti, Robert Naeije, Andrea Maria D'Armini
European Respiratory Journal May 2020, 55 (5) 1902171; DOI: 10.1183/13993003.02171-2019

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Magnetic resonance imaging of pulmonary arterial compliance after pulmonary endarterectomy
Stefano Ghio, Gabriele Crimi, Stefania Guida, Adele Valentini, Anna Celentano, Maurizio Pin, Claudia Raineri, Annalisa Turco, Laura Scelsi, Luigi Oltrona Visconti, Robert Naeije, Andrea Maria D'Armini
European Respiratory Journal May 2020, 55 (5) 1902171; DOI: 10.1183/13993003.02171-2019
del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Abstract
    • Shareable PDF
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • PDF
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

Agora

  • Dupilumab in patients with asthma and blood eosinophils ≥500 cells·µL−1
  • NTM-PD incidence among elderly patients with bronchiectasis
  • Inaccuracy of pulse oximetry in darker skinned patients unchanged across 32 years
Show more Agora

Research letters

  • Dupilumab in patients with asthma and blood eosinophils ≥500 cells·µL−1
  • NTM-PD incidence among elderly patients with bronchiectasis
  • G-protein coupled receptor 87 as a basal cell marker in IPF
Show more Research letters

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About the ERJ

  • Journal information
  • Editorial board
  • Reviewers
  • Press
  • Permissions and reprints
  • Advertising

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Instructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • Podcasts
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN:  0903-1936
Online ISSN: 1399-3003

Copyright © 2022 by the European Respiratory Society