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. 2023 Dec 1;13(12):7910-7923.
doi: 10.21037/qims-23-250. Epub 2023 Oct 10.

Comparison of cardiovascular metrics on computed tomography pulmonary angiography of the updated and old diagnostic criteria for pulmonary hypertension in patients with chronic thromboembolic pulmonary hypertension

Wenqing Xu #  1 , Mei Deng #  2 , Linfeng Xi  3 , Anqi Liu  2 , Haoyu Yang  1 , Xincao Tao  2 , Qiang Huang  3 , Jinzhi Wang  4 , Wanmu Xie  3 , Min Liu  5
Affiliations

Comparison of cardiovascular metrics on computed tomography pulmonary angiography of the updated and old diagnostic criteria for pulmonary hypertension in patients with chronic thromboembolic pulmonary hypertension

Wenqing Xu et al. Quant Imaging Med Surg. .

Abstract

Background: In the 2022 European Society of Cardiology (ESC) and the European Respiratory Society (ERS) guidelines, the diagnostic criteria for pulmonary hypertension (PH) included a reduced mean pulmonary artery pressure (mPAP) of 20 mmHg (mPAP >20 mmHg). This study aimed to reassess cardiovascular metrics on computed tomography pulmonary angiography (CTPA) for chronic thromboembolic pulmonary hypertension (CTEPH) to optimize the timely diagnosis of patients with suspected PH.

Methods: Patients with suspected CTEPH who underwent CTPA and right heart catheterization (RHC) between January 2019 and December 2022 in China-Japan Friendship Hospital were retrospectively included. They were grouped into CTEPH and non-PH groups according to the new and old criteria (2022 and 2015 ESC/ERS guidelines) for the diagnosis of PH. Cardiovascular metrics including the main pulmonary artery diameter (MPAd), Cobb angle, and right ventricular free wall thickness (RVWT), among others, were measured. The correlation of these metrics with hemodynamic data was analyzed with Spearman rank correlation analysis, while the differences in cardiovascular metrics between the updated (mPAP >20 mmHg) and old PH criteria (mPAP ≥25 mmHg) were compared with independent samples t-test or the Mann-Whitney test. Receiver operator characteristic (ROC) curve analysis was performed for the prediction model.

Results: The study enrolled 180 patients (males n=86; age 55.5±12.0 years old). According to the old guidelines, 119 patients were placed into the PH group (mPAP ≥25 mmHg) , while according to the new guidelines, 130 patients were placed into the PH group (mPAP >20 mmHg). Cardiovascular metrics on CTPA between the updated and old guidelines were comparable (P>0.05). Compared to other metrics, an MPAd of 30.4 mm exhibited the highest area under the curve (AUC: 0.934±0.021), with a sensitivity of 0.88 and specificity of 0.90. MPAd [odds ratio (OR) =1.271], transverse diameter of the right ventricle (RVtd; OR =1.176), Cobb angle (OR =1.108), and RVWT (OR =3.655) were independent factors for diagnosing CTEPH (P<0.05). Cobb angle, right and left ventricular transverse diameter ratio, and right and left ventricular area ratio moderately correlated with mPAP (r=0.586, r=0.583, r=0.629) and pulmonary vascular resistance (PVR) (r=0.613, r=0.593, r=0.642).

Conclusions: Cardiovascular metrics on CTPA were comparable between the new and old guidelines for CTEPH diagnosis. Cardiovascular metrics on CTPA can noninvasively assess the hemodynamics of patients with CTEPH.

Keywords: Pulmonary hypertension (PH); chronic thromboembolic pulmonary hypertension (CTEPH); computed tomography pulmonary angiography (CTPA); hemodynamics.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-23-250/coif). The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Flowchart detailing participant selection. PH, pulmonary hypertension; RHC, right heart catheterization; CTEPH, chronic thromboembolic PH; CTPA, computed tomography pulmonary angiography; PEA, pulmonary endarterectomy; ESC, European Society of Cardiology; ERS, European Respiratory Society; mPAP, mean pulmonary arterial pressure.
Figure 2
Figure 2
The vascular diameters and Cobb angle measurement from transversal computed tomography pulmonary angiography images. (A) The widest MPAd and the widest AAd at the same level were measured at standard axial images. (B) The Cobb angle, the angle between the interventricular septum and the line connecting the midpoint of the sternum and the thoracic vertebral spinous process, was measured during diastole in the transversal image. MPAd, diameter of the main pulmonary artery; AAd, diameter of the ascending aorta.
Figure 3
Figure 3
Measurements of the diameters and areas in 4-chamber-view computed tomography pulmonary angiography. (A) The longest longitudinal and transverse diameters of the biventricles and right atrium are illustrated for reformatted 4-chamber views. The transverse axis is parallel to the line connecting the heart valves. The ventricle longitudinal line is the midpoint of the heart valve and the line connecting the apex of the heart, and the right atrium longitudinal line is perpendicular to the transverse axis. (B) The longest LAap and the widest LAlr are illustrated for reformatted 4-chamber views. The LAap is the largest straight-line distance connecting the front and back walls of the left atrium, and the LAlr is perpendicular to the LAap. (C) The maximum 4-chamber heart area was measured on the reformatted 4-chamber position. RVtd, transverse diameter of the right ventricle; LVtd, transverse diameter of the left ventricle; RVld, longitudinal diameter of the right ventricle; LVld, longitudinal diameter of the left ventricle; RAld, longitudinal diameter of the right atrium; RAtd, transverse diameter of the right atrium; LAlr, left-right dimension of the left atrium; LAap, anteroposterior dimension of the left atrium; RVa, area of the right ventricle; LVa, area of the left ventricle; RAa, right atrial area; LAa, left atrial area.
Figure 4
Figure 4
Measurement of the RVWT and IVST on the sagittal position obtained through the multiplanar reconstruction method. RVWT, right ventricular free wall thickness; IVST, interventricular septal thickness.
Figure 5
Figure 5
The ROC of cardiovascular metrics and prediction models for diagnosing chronic thromboembolic pulmonary hypertension under both the 2015 and 2022 ESC and the ERS guidelines. (A) ROC of cardiovascular metrics and prediction models for diagnosing CTEPH under the new 2022 criteria (mean pulmonary artery pressure >20 mmHg). (B) ROC of the cardiovascular metrics and prediction models for diagnosing CTEPH under the old 2015 criteria (mPAP ≥25 mmHg). ROC, receiver operating characteristic; ESC, European Society of Cardiology; ERS, European Respiratory Society; mPAP, mean pulmonary artery pressure; AUC, area under the curve; CTEPH, chronic thromboembolic pulmonary hypertension; MPAd, diameter of the main pulmonary artery; RVWT, right ventricular free wall thickness; RVtd, transverse dimension of right ventricle; RAtd, transverse dimension of right atrium.
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