Abstract
Pulmonary hypertension (PH) is a clinical condition characterized by progressive elevations in mean pulmonary artery pressures and right ventricular dysfunction, associated with significant morbidity and mortality. For resting PH to develop, ~50–70% of the pulmonary vasculature must be affected, suggesting that even mild hemodynamic abnormalities are representative of advanced pulmonary vascular disease. The definitive diagnosis of PH is based upon hemodynamics measured by right heart catheterization; however this is an invasive and resource intense study. Early identification of pulmonary vascular disease offers the opportunity to improve outcomes by instituting therapies that slow, reverse, or potentially prevent this devastating disease. Multimodality imaging, including non-invasive modalities such as echocardiography, computed tomography, ventilation perfusion scans, and cardiac magnetic resonance imaging, has emerged as an integral tool for screening, classifying, prognosticating, and monitoring response to therapy in PH. Additionally, novel imaging modalities such as echocardiographic strain imaging, 3D echocardiography, dual energy CT, FDG-PET, and 4D flow MRI are actively being investigated to assess the severity of right ventricular dysfunction in PH. In this review, we will describe the utility and clinical application of multimodality imaging techniques across PH subtypes as it pertains to screening and monitoring of PH.
Highlights
Pulmonary hypertension (PH) is an insidious, highly morbid, and heterogeneous disease that is characterized by elevations in pulmonary arterial pressures and is classified into five groups based on etiology [1,2,3]
We identified 46 articles on echocardiography, 19 on computerized tomography, 7 on nuclear medicine techniques including scintigraphy, and 45 on magnetic resonance imaging in PH
Screening for Pulmonary Hypertension Screening for PH using conventional transthoracic echocardiogram (TTE) primarily relies upon assessment of the right ventricular systolic pressure (RVSP), which is measured from the tricuspid regurgitant (TR) jet velocity and size/collapsibility of the inferior vena cava (IVC) to estimate right atrial pressure (RAP) [12]
Summary
Pulmonary hypertension (PH) is an insidious, highly morbid, and heterogeneous disease that is characterized by elevations in pulmonary arterial pressures and is classified into five groups based on etiology [1,2,3]. PH is exclusively diagnosed using confirmatory invasive right heart catheterization (RHC) to measure mean pulmonary artery pressure (mPAP), pulmonary capillary wedge pressure (PCWP), and pulmonary vascular resistance (PVR) [7]. PH is defined by a mPAP >20 mmHg, a threshold which was recently decreased from ≥25 mmHg based on epidemiologic data demonstrating the distribution of mPAP among healthy individuals and the significant impact of mildly elevated pulmonary pressures on morbidity and mortality [8]. While RHC is the only method to directly measure pulmonary and right heart pressures, it is invasive, resource intensive, and carries procedural risk [9]. This review seeks to describe the current imaging modalities used in diagnosing and monitoring the various forms of PH along with several novel imaging modalities that may soon be incorporated into clinical practice
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