Rationale and Objectives
We investigated the feasibility of detecting left ventricular (LV) cardiac magnetic resonance (CMR) strain abnormalities using feature-tracking in patients with pulmonary hypertension (PH).
Materials and Methods
CMR was performed in 16 patients with all groups of PH and in 13 controls. Global and regional peak circumferential strains (%) (which have been shown to be robust by CMR), peak diastolic strain rate (%/s), and dyssynchrony index (ms) were quantified with feature-tracking software. Ventricular function and volumes were calculated from CMR, and right heart pressures were measured with catheterization.
Results
Left ventricular ejection fraction (LVEF) was similar in patients (60.2% ± 11.0%) and controls (61.9% ± 4.5%), P = .150. Global LV peak circumferential strain was significantly different in patients compared to controls, −16.7 ± 2.8% vs −19.9 ± 1.8%, respectively ( P = .001). The greatest difference in strain was seen in the LV septum, −11.6 ± 4.3% in patients vs −16.7 ± 4.0% in controls ( P < .001). There was a significant association between septal strain and right ventricular end-diastolic volume index ( P = .047) in patients with PH; however, there were no associations with pulmonary artery pressures or right ventricular ejection fraction.
Conclusions
Feature-tracking CMR can detect LV strain abnormalities in patients with PH and preserved or mildly depressed LVEF, with greatest abnormality in the septum. The association between septal strain and right ventricular end-diastolic volume index suggests that ventricular interdependence may be a mechanism of LV dysfunction in PH. Feature-tracking CMR may be useful for identification of LV dysfunction before LVEF significantly declines in patients with PH. The feasibility of detecting LV strain abnormalities in patients with PH shown by this study paves the way for a variety of future investigations into the applications of LV strain in this patient population.
Introduction
Pulmonary hypertension (PH) is a progressive, chronic disease characterized by sustained elevation of resting mean pulmonary artery pressure of 25 mmHg or greater. The World Health Organization (WHO) classifies PH into five major groups: pulmonary arterial hypertension (PAH), PH due to left heart disease, due to lung disease or hypoxia, chronic thromboembolic PH, and PH with unclear multifactorial mechanisms . Despite significant progress in medical management of PAH, overall prognosis remains poor, as shown in an analysis of patients with PAH that demonstrated 1-, 3-, 5-, and 7-year survival rates of 85%, 68%, 57%, and 49% .
A major limitation of the current management of patients with PH is the requirement for invasive cardiac catheterization to evaluate pulmonary artery pressures to risk-stratify patients and evaluate treatment response. The invasive tests performed in patients with PH expose the patients to procedural risks and radiation.
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Materials and Methods
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TABLE 1
Demographics, Volumetric, and Functional Parameters in Patients with Pulmonary Hypertension Versus Controls
Controls
n = 13 Patients
n = 16 Unadjusted
P Value Age-adjusted P Value Age—years 35.6 ± 12.0 52.9 ± 16.5 .004 — Male (%) 6/13 (46%) 5/16 (31%) .429 .989 White (%) 6/13 (46%) 10/16 (63%) .397 .173 LVEF (%) 61.9% ± 4.5% 60.2% ± 11.0% .634 .150 RVEF (%) 53.3% ± 5.6% 41.0% ± 15.4% .019 .085 LVEDVI mL/m 2 97.0 ± 36.3 73.0 ± 24.9 .057 .571 RVEDVI mL/m 2 96.6 ± 42.0 111.7 ± 42.55 .377 .177 RBBB — 5/16 (31%) — —
LVEDVI, left ventricular end-diastolic volume index; LVEF, left ventricular ejection fraction; RBBB, right bundle branch block; RVEDVI, right ventricular end-diastolic volume index; RVEF, right ventricular ejection fraction.
Continuous variables are expressed as mean ± standard deviation.
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Image Acquisition
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Image Analysis
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Clinical Parameters
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Statistical Analysis
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Results
Demographics
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CMR Function and Volumetrics
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Echocardiography
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Cardiac Catheterization
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Electrocardiography
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CMR Strain
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TABLE 2
Strain Analyses in Patients with Pulmonary Hypertension Versus Controls
Controls
n = 13 Patients
n = 16 Unadjusted
P Value Age-adjusted P Value Global strain (%) −19.9% ± 1.8% −16.7% ± 2.8% .002 .001 Septal strain (%) −16.7% ± 4.0% −11.6% ± 4.3% .003 <.001 Lateral wall strain (%) −22.9% ± 2.2% −20.5% ± 4.7% .096 .273 Dyssynchrony index (ms) 61.5 ± 7.9 74.4 ± 21.2 .047 .198 Diastolic strain rate (%/s) 121.0 ± 27.2 115.1 ± 42.4 .667 .988
ms, milliseconds; s, seconds.
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Regression Analyses
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Discussion
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Conclusions
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