Utility of cardiac magnetic resonance feature tracking strain assessment in chronic thromboembolic pulmonary hypertension for prediction of REVEAL 2.0 high risk status

Kai'En Leong; Luke Howard; Francesco Lo Giudice; Rachel Davies; Gulammehdi Haji; Simon Gibbs; Deepa Gopalan

doi:10.1002/pul2.12116

Utility of cardiac magnetic resonance feature tracking strain assessment in chronic thromboembolic pulmonary hypertension for prediction of REVEAL 2.0 high risk status

Pulm Circ. 2023 Feb 22;13(1):e12116. doi: 10.1002/pul2.12116. eCollection 2023 Jan.

Authors

Kai'En Leong^{1

2}, Luke Howard^{3

4}, Francesco Lo Giudice^{3

5}, Rachel Davies³, Gulammehdi Haji³, Simon Gibbs^{4

6}, Deepa Gopalan^{1

6

7}

Affiliations

¹ Department of Radiology Imperial College Healthcare NHS Trust/Hammersmith Hospital London UK.
² Department of Cardiology The Royal Melbourne Hospital Victoria Australia.
³ National Pulmonary Hypertension Service Imperial College Healthcare NHS Trust London UK.
⁴ National Heart & Lung Institute Imperial College London London UK.
⁵ Department of Cardiology Imperial College Healthcare NHS Trust/Hammersmith Hospital London UK.
⁶ Imperial College London London UK.
⁷ Department of Radiology Cambridge University Hospitals NHS Trust Cambridge UK.

Abstract

Chronic thromboembolic pulmonary hypertension may be cured by pulmonary endarterectomy (PEA). Thromboembolic disease distribution/PEA success primarily determines prognosis but risk scoring criteria may be adjunctive. Right ventriculoarterial (RV-PA) and ventriculoatrial (RV-right atrium [RA]) coupling may be evaluated by cardiac MRI (CMR) feature tracking deformation/strain assessment. We characterized biatrial and biventricular CMR feature tracking (FT) strain parameters following PEA and tested the ability of CMR FT to identify REVEAL 2.0 high-risk status. We undertook a retrospective single-center cross-sectional study of patients (n = 57) who underwent PEA (2015-2020). All underwent pre and postoperative catheterization and CMR. Pulmonary arterial hypertension validated risk scores were calculated. Significant postoperative improvements were observed in mean pulmonary artery pressure (mPAP) (pre-op 45 ± 11 mmHg vs. post-op 26 ± 11 mmHg; p < 0.001) and PVR however a large proportion had residual pulmonary hypertension (45%; mPAP ≥25 mmHg). PEA augmented left heart filling with left ventricular end diastolic volume index and left atrial volume index increment. Left ventricular ejection fraction was unchanged postoperatively but LV global longitudinal strain improved (pre-op median -14.2% vs. post-op -16.0%; p < 0.001). Right ventricular (RV) geometry and function also improved with reduction in RV mass. Most had uncoupled RV-PA relationships which recovered (pre-op right ventricular free wall longitudinal strain -13.2 ± 4.8%, RV stroke volume/right ventricular end systolic volume ratio 0.78 ± 0.53 vs. post-op -16.8 ± 4.2%, 1.32 ± 0.55; both p < 0.001). Postoperatively, there were six REVEAL 2.0 high-risk patients, best predicted by impaired RA strain which was superior to traditional volumetric parameters (area under the curve [AUC] 0.99 vs. RVEF AUC 0.88). CMR deformation/strain evaluation can offer insights into coupling recovery; RA strain may be an expeditious surrogate for the more laborious REVEAL 2.0 score.

Keywords: feature tracking (CMR‐FT); pulmonary endarterectomy; strain; ventriculoarterial coupling; ventriculoatrial coupling.