Pulmonary Arterial Hypertension: Use of Delayed Contrast-Enhanced Cardiovascular Magnetic Resonance in Risk Assessment

Abstract

BackgroundPulmonary arterial hypertension is a severe and progressive disease. Its early diagnosis is the greatest clinical challenge. ObjectiveTo evaluate the presence and extension of the delayed myocardial contrast-enhanced cardiovascular magnetic resonance, as well as to verify if the percentage of the myocardial fibrosis mass is a severity predictor. MethodsCross-sectional study with 30 patients with pulmonary arterial hypertension of groups I and IV, subjected to clinical, functional and hemodynamic evaluation, and to cardiac magnetic resonance. ResultsThe mean age of patients was 52 years old, with female predominance (77%). Among the patients, 53% had right ventricular failure at diagnosis, and 90% were in functional class II/III. The mean of the 6-minute walk test was 395m. In hemodynamic study with right catheterism, the mean average pulmonary arterial pressure was 53.3mmHg, of the cardiac index of 2.1L/ min.m2, and median right atrial pressure was 13.5 mmHg. Delayed myocardial contrast enhanced cardiovascular magnetic resonance was found in 28 patients. The mean fibrosis mass was 9.9 g and the median percentage of fibrosis mass was 6.17%. The presence of functional class IV, right ventricular failure at diagnosis, 6-minute walk test < 300 meters and right atrial pressure ≥ 15 mmHg, with cardiac index < 2.0 L/ min.m2, there was a relevant association with the increased percentage of myocardial fibrosis. ConclusionThe percentage of the myocardial fibrosis mass indicates a non-invasive marker with promising perspectives in identifying patients with high risk factors for pulmonary hypertension.

Delayed Myocardial Enhancement by Cardiac Magnetic Resonance Imaging in Pulmonary Arterial Hypertension: A Marker of Severity of Disease

“…In experimental studies, these are the areas subjected to maximum stress in normal ventricular contraction, and these areas are also the first to produce natriuretic peptide type A in HP models, reflecting greater mechanical stress. The study of Bessa et al demonstrated that most patients with HP had delayed enhancement and ventricular junction pattern, confirming the literature data 1 . An echocardiographic study in patients with HP of a specific etiology associated with schistosomiasis also demonstrated a relationship of increased pulmonary pressure with disease severity, suggesting that in various etiologies of HP, a delayed enhancement of similar pattern may occur (Armstrong) 11 .…”

“…The study of Bessa et al 1 , published in this issue of Arquivos Brasileiros de Cardiologia , studied 30 patients with pulmonary hypertension (PH) using cardiac magnetic resonance imaging. They evaluated the presence and extent of delayed enhancement in these patients and correlated the percentage of delayed enhancement mass with severity markers in pulmonary hypertension.…”

A Clinical Approach to Multimodality Imaging in Pulmonary Hypertension

“…Delayed enhancement from gadolinium (10–20 mins after injection) is associated with cardiac fibrosis ( 104 ). Delayed enhancement mass at the insertion points of the RV is a sensitive and specific marker for PH ( 105 – 108 ). The extent of delayed enhancement mass into the interventricular septum is associated with worse RV function and clinical outcomes ( 109 – 111 ).…”

Assessment of Right Ventricular Function in Pulmonary Hypertension with Multimodality Imaging

“…The typical pattern of delayed enhancement is seen in anterior and posterior RV insertion sites to the interventricular septum in PH patients 65)66). Total delayed enhancement mass correlates with the degree of RV functional change, which suggests that the degree of RV remodeling increases with increased afterload 67).…”