Απεικόνιση στην πνεσμονική σπέρταση

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1 Αττικό Νοσοκομείο Απεικόνιση στην πνεσμονική σπέρταση Ηρακλής Τσαγκάρης Πνεσμονολόγος - Εντατικολόγος Επίκοσρος Καθηγητής Εντατικής Θεραπείας

2 Goal of imaging to establish (?) the diagnosis and to identify disease subsets to follow up disease

3 Chest Radiography Echocardiography Ventilation / Perfusion lung scan Computed Tomography ( HRCT, CTPA ) Pulmonary Angiography Cardiac MRI

7 Pulmonary venous hypertension interstitial edema with interlobular septal thickening, centrilobular nodular opacities and/or pleural effusions

8 Υπερητογράυημα

9 Chest Radiography Echocardiography Ventilation / Perfusion lung scan Computed Tomography ( HRCT, CTPA ) Pulmonary Angiography Cardiac MRI

10 Galie N, Hoeper MM, Humbert M, et al. Guidelines for the diagnosis and treatment of pulmonary hypertension: The Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT) Eur Resp J 2009; 34: Eur Heart J 2009; 30:

13 Scanning ipah CTEPH

14 New CTs The current generation of 64-slice (and higher) multidetector CT (MDCT) scanners allow for better spatial (versus CMR) and temporal (versus older scanners) resolution, shorter scanning times and breath-holds, and electrocardiogram (ECG)- gated acquisition for detailed cardiac structural analysis.

Όηαν η πνεσμονική αρηηρία > 29 mm και ο λόγος διαμέηροσ ημημαηικής αρηηρίας/ βρόγτο είναι > 1 ζε 3 από ηοσς 4 πνεσμονικούς λοβούς,

16 ημεία πνεσμονικής σπέρηαζης MDCTPA Διάμετρος > 29 mm PPV 97%, sens 87%, spec 89%. ΠΡΟΟΧΗ!! Διάμεηρος κύριας πνεσμονικής αρηηρίας < 29 mm ΔΕΝ ΑΠΟΚΛΕΙΕΙ πιθανή παροσζία πνεσμονικής σπέρηαζης. Όηαν η πνεσμονική αρηηρία > 29 mm και ο λόγος διαμέηροσ ημημαηικής αρηηρίας/ βρόγτο είναι > 1 ζε 3 από ηοσς 4 πνεσμονικούς λοβούς, ειδικόηηηα 100% για παροσζία πνεσμονικής σπέρηαζης. Διάμετρος > 29 mm Διάμετρος ΠΑ > διάμετρο ΑΑ Διάμετρος ΠΑ > διάμετρο ΑΑ Πνεσμονική αρηηρία > ανιούζα θωρακική αορηή: PPV 96%, spec 92%, ειδικά ζε αζθενείς < 50 εηών.

17 ημεία πνεσμονικής σπέρηαζης MDCTPA + περικαρδιακή ζσλλογή ΚΑΚΟ προγνωζηικό ζημείο

18 55 yo,, ipah

19 37yo,, ipah

20 36 yo,, CTEPH

24 ημεία πνεσμονικής αρηηριακής σπέρηαζης MDCTPA

25 ημεία πνεσμονικής σπέρηαζης MDCTPA Decrease in right pulmonary artery distensibility Revel MP et al. Pulmonary hypertension: ECG-gated 64-section CT angiographic evaluation of new functional parameters as diagnostic criteria. Radiology 2009;250(2):

26 Pulmonary Veno-Occlusive Disease Septal lines Ground glass opacities Mediastinal lymphadenopathy 100% spec, 66% sens Resten et al. AJR 2004;183:65-70

27 PVOD in a 20-year-old man

28 56 yo, PVOD

HRCT is the investigation of choice Galie N, Hoeper MM, Humbert M, et al.

30 Pulmonary Veno-Occlusive Disease Vasodilators and especially prostanoids must be used with great caution because of the high risk of pulmonary edema. HRCT is the investigation of choice Galie N, Hoeper MM, Humbert M, et al. Eur Resp J 2009; 34: Montani Det al. Medicine 2008;87: Montani D et al. Eur Resp J2009;33: A. A. Frazier et al. Radiographics 2007;27:

31 Normal PVOD

32 Normal PCH

34 Interstitial lung disease A C E B D F

38 CMR CMR is the current gold standard for structural and functional assessment of the right heart and it allows for simultaneous evaluation of the lungs and pulmonary circulation. Studies show minimal intra- or inter-observer variability, providing an accurate and reproducible testing modality.

39 Cardiac MR This technique allows wall motion abnormalities, ventricular volumes, ejection fraction and myocardial mass to be assessed for either ventricle in the short axis or transverse plane.

40 Cardiac MRI Multiplanar anatomy Non invasive angiography contrast enhanced MRA and time resolved MRA Cine assessment of ventricular global and regional systolic function, volumes and mass Velocity and flow assessment by PC sequences Myocardial enhancement (viability) studies

41 Despite suggestion that the inter-study reproducibility of the RV is less than for the LV, CMR is still considered a reliable method for the assessment of RV morphology and function, with a large RV volume and a low stroke volume being independent predictors of mortality and treatment failure.

42 VOLUMETRIC PARAMETERS van Wolferen SA, et al. European Heart Journal 2007;282:

43 Right ventricular end-diastolic wall thickness has been shown to correlate well with MPAP in IPAH and some cases of secondary PAH. A linear relationship has also been described between right ventricular mass and MPAP in IPAH.

44 Cine images also demonstrate the dynamic distortion of the normal shape of the interventricular septum. With raised right ventricular pressures, the interventricular septum flattens and bows towards the left ventricle, with systolic pressures being proportional to septal curvature in patients with PH.

45 Right ventricular delayed hyper-enhancement can be identified in patients with PH and has been shown to correlate with right ventricular dysfunction The enhancement pattern involves the RV septal insertion points and the interventricular septum with septal enhancement being associated with septal bowing. However, delayed enhancement in the RV insertion point is a non-specific sign.

46 Cardiac MRI

47 Cardiac MRI

48 MRI pulmonary perfusion studies IPAH CTEPH Ley S, et al. Computed Tomography and Magnetic Resonance Imaging of Pulmonary Hypertension: Pulmonary Vessels and Right Ventricle. JMRI 2010; 32:

49 Cardiac MRI MRI permits safe and reproducible evaluation of morphology, volume and flow parameters in pts with CHD MR flow assessment provides estimators of PVR and mpap; they cannot, however, replace catheterization at present in routine clinical practice MRI may be used to monitor treatment results with assessment of biventricular mass and volumes Baseline RVEF, SVI, RVEDVI, LVEDVI are predictors of survival PA stiffness evaluation may permit early detection of PH changes and has prognostic role

50 Galie N, Hoeper MM, Humbert M, et al. Eur Resp J 2009; 34: Torbicki A Eur Heart J 2007;28:

51 VOLUMETRIC PARAMETERS Pts with decreased PVR after therapy Mariëlle C. van de Veerdonk,, et al. JACC 2011;58:

55 Future challenges Accurate visualization of complex RV anatomies by advanced imaging techniques and precise measurement of blood volumes and flow may obviate invasive procedures in the future (??).

56 Future Pathological remodeling occurs at the level of the pulmonary resistance vessels measuring approximately 100 μm in diameter. If one were able to visualize these small vessels, recognize occlusions, and ultimately also identify hypertrophy of the smooth muscle cell layer, one might be able to predict the development of pulmonary hypertension at early stages when hemodynamics are still normal.

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