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. 2025 Sep 1;15(9):8567-8578.
doi: 10.21037/qims-24-2152. Epub 2025 Aug 11.

Noninvasive assessment of pulmonary vascular resistance: a synergistic approach using computed tomography pulmonary angiography and echocardiography in pulmonary hypertension

Junqing Ma #  1   2 , Wenting Li #  1 , Sunan Xu  1 , Ruichen Ren  1 , Xiaopei Cui  3 , Yongze Zheng  4 , Yan Deng  1 , Yongfeng Liang  1 , Yang Zhang  1
Affiliations

Noninvasive assessment of pulmonary vascular resistance: a synergistic approach using computed tomography pulmonary angiography and echocardiography in pulmonary hypertension

Junqing Ma et al. Quant Imaging Med Surg. .

Abstract

Background: Pulmonary vascular resistance (PVR) is essential in managing pulmonary hypertension (PH) and has prompted the search for noninvasive assessment techniques. This study investigates the integration of morphological parameters from computed tomography pulmonary angiography (CTPA) and functional parameters from transthoracic echocardiography (TTE) to develop a noninvasive method for evaluating PVR in patients with PH.

Methods: Data from PH patients who underwent CTPA, TTE, and right heart catheterization (RHC) were analyzed retrospectively. The Cobb angle, defined as the angle between the spine and interventricular septum, was calculated by CTPA. It is assumed that thorax geometry, pericardial morphology, and body surface area (BSA) are factors influencing the Cobb angle measurement, and these factors were adjusted for in the analysis. Multiple linear regression was performed to evaluate the multivariate ability to predict PVR. Multivariate Cox regression analysis assessed the prognostic value of parameters in predicting hospitalization for heart failure.

Results: In total, 78 patients meeting the criteria were enrolled. Among the TTE parameters, the right ventricular outflow tract acceleration time (RVOT-AT) demonstrated the best goodness-of-fit to PVR (R2=0.433, P<0.001). Correcting the Cobb angle by BSA significantly improved its fit to PVR (R2=0.510, P<0.001), compared to the uncorrected angle (R2=0.450, P<0.001). The model combining Cobb angle/BSA and RVOT-AT strongly predicted PVR (r=0.815, R2=0.634, P<0.001) and was effective across different demographics. After multivariable adjustment, the Cobb angle [hazard ratio (HR): 1.057; P<0.001], Cobb angle/BSA (HR: 1.087; P<0.001), tricuspid annular plane systolic excursion (TAPSE) (HR: 0.878; P=0.014), RVOT-AT (HR: 0.968; P=0.030), and right ventricular myocardial performance index (RVMPI) (HR: 5.324; P<0.001) remained significant independent predictors of heart failure.

Conclusions: The integration of BSA-adjusted morphological markers from CTPA with hemodynamic parameters derived from TTE provides a promising noninvasive method for predicting PVR and demonstrates significant prognostic value in evaluating heart failure in PH patients.

Keywords: Cardiovascular; computed tomography pulmonary angiography (CTPA); pulmonary hypertension (PH); pulmonary vascular resistance (PVR); transthoracic echocardiography (TTE).

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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-24-2152/coif). The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Measurements were selected at the level with the largest biventricular area in diastole. (A) Showed the Cobb angle was 70.4°; (B) demonstrated the measurement of the thoracic longitudinal diameter (a) and the thoracic transverse diameter (b); (C) showed the measurement of the pericardial longitudinal diameter (c) and the pericardial transverse diameter (d).
Figure 2
Figure 2
Scatter plot of the relationship between RVOT-AT, LnRVOT-AT and PVR. PVR, pulmonary vascular resistance; RVOT-AT, right ventricular outflow tract acceleration time; WU, Wood Unit.
Figure 3
Figure 3
Cobb angle, Cobb angle/BSA combined with RVOT-AT to evaluate PVR respectively. BSA, body surface area; PVR, pulmonary vascular resistance; RVOT-AT, right ventricular outflow tract acceleration time; WU, Wood Unit.
Figure 4
Figure 4
Bland-Altman analysis shows the consistency of PVR obtained from RHC with predicted values. BSA, body surface area; PVR, pulmonary vascular resistance; RHC, right heart catheterization; RVOT-AT, right ventricular outflow tract acceleration time; WU, Wood Unit.
Figure 5
Figure 5
Kaplan-Meier curves of TTE and CTPA parameters. BSA, body surface area; CTPA, computed tomography pulmonary angiography; RVMPI, right ventricular myocardial performance index; RVOT-AT, right ventricular outflow tract acceleration time; S’, tricuspid annular systolic peak velocity; TAPSE, tricuspid annular plane systolic excursion; TTE, transthoracic echocardiography.
See this image and copyright information in PMC

References

    1. Houston BA, Brittain EL, Tedford RJ. Right Ventricular Failure. N Engl J Med 2023;388:1111-25. 10.1056/NEJMra2207410 - DOI - PubMed
    1. Maron BA, Brittain EL, Hess E, Waldo SW, Barón AE, Huang S, Goldstein RH, Assad T, Wertheim BM, Alba GA, Leopold JA, Olschewski H, Galiè N, Simonneau G, Kovacs G, Tedford RJ, Humbert M, Choudhary G. Pulmonary vascular resistance and clinical outcomes in patients with pulmonary hypertension: a retrospective cohort study. Lancet Respir Med 2020;8:873-84. 10.1016/S2213-2600(20)30317-9 - DOI - PMC - PubMed
    1. Hoeper MM, Lee SH, Voswinckel R, Palazzini M, Jais X, Marinelli A, Barst RJ, Ghofrani HA, Jing ZC, Opitz C, Seyfarth HJ, Halank M, McLaughlin V, Oudiz RJ, Ewert R, Wilkens H, Kluge S, Bremer HC, Baroke E, Rubin LJ. Complications of right heart catheterization procedures in patients with pulmonary hypertension in experienced centers. J Am Coll Cardiol 2006;48:2546-52. 10.1016/j.jacc.2006.07.061 - DOI - PubMed
    1. Hull JV, Padkins MR, El Hajj S, Al-Hijji MA, Kanwar A, Crusan DJ, Gulati R, El Sabbagh A, Park JY, Lennon RJ, Behfar A, Rihal CS, Singh M. Risks of Right Heart Catheterization and Right Ventricular Biopsy: A 12-year, Single-Center Experience. Mayo Clin Proc 2023;98:419-31. 10.1016/j.mayocp.2022.07.025 - DOI - PubMed
    1. Al-Hijji MA, Lennon RJ, Gulati R, El Sabbagh A, Park JY, Crusan D, Kanwar A, Behfar A, Lerman A, Holmes DR, Bell M, Singh M. Safety and Risk of Major Complications With Diagnostic Cardiac Catheterization. Circ Cardiovasc Interv 2019;12:e007791. 10.1161/CIRCINTERVENTIONS.119.007791 - DOI - PubMed