Abstract
Imaging plays a cardinal role in the diagnosis and management of diseases of the pulmonary circulation. Behind the picture itself, every digital image contains a wealth of quantitative data, which are hardly analysed in current routine clinical practice and this is now being transformed by radiomics. Mathematical analyses of these data using novel techniques, such as vascular morphometry (including vascular tortuosity and vascular volumes), blood flow imaging (including quantitative lung perfusion and computational flow dynamics), and artificial intelligence, are opening a window on the complex pathophysiology and structure–function relationships of pulmonary vascular diseases. They have the potential to make dramatic alterations to how clinicians investigate the pulmonary circulation, with the consequences of more rapid diagnosis and a reduction in the need for invasive procedures in the future. Applied to multimodality imaging, they can provide new information to improve disease characterization and increase diagnostic accuracy. These new technologies may be used as sophisticated biomarkers for risk prediction modelling of prognosis and for optimising the long-term management of pulmonary circulatory diseases. These innovative techniques will require evaluation in clinical trials and may in themselves serve as successful surrogate end points in trials in the years to come.
Highlights
The pulmonary circulation is a biologically complex high-flow and low-pressure circuit that works in conjunction with the right ventricle and the various structural components of the lungs to form the cardiopulmonary unit
As malfunction of one or more of these components at any spatial scale can be detrimental to the cardiopulmonary unit as a whole, it is imperative that imaging evaluation of pulmonary vascular diseases moves away from the traditional macroscopic assessment to more sophisticated methodologies that integrate structure–function relationships
First pass pulmonary perfusion can be measured using 13N2-PET imaging, where the local concentration reflects local perfusion [27]. This has been applied in clinical practice to demonstrate spatial heterogeneity of lung perfusion in Chronic Obstructive Pulmonary Disease (COPD) and has the potential to become a vascular biomarker in airways disease [28]
Summary
The pulmonary circulation is a biologically complex high-flow and low-pressure circuit that works in conjunction with the right ventricle and the various structural components of the lungs to form the cardiopulmonary unit. These subsystems have inherent individual characteristics, they are intractably linked and form an integrated metabolic unit that act in concert. As malfunction of one or more of these components at any spatial scale can be detrimental to the cardiopulmonary unit as a whole, it is imperative that imaging evaluation of pulmonary vascular diseases moves away from the traditional macroscopic assessment to more sophisticated methodologies that integrate structure–function relationships. We will discuss the evolving use of morphometric and ML tools in the imaging of the pulmonary circulation
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