research article assessment of pulmonary artery pulsatility by...

Hindawi Publishing CorporationISRN PulmonologyVolume 2013 Article ID 808615 9 pageshttpdxdoiorg1011552013808615

Research ArticleAssessment of Pulmonary Artery Pulsatility byMultidetector Computed Tomography in PatientsAffected by Chronic Obstructive Pulmonary Diseaseand Pulmonary Hypertension Preliminary Data

Anna Grazia DrsquoAgostino1 Giuseppe Valerio2 Pierluigi Bracciale2 and Fabio Valerio2

1 U O di Radiodiagnostica Ospedale ldquoA Perrinordquo Via Appia 246 72100 Brindisi Italy2 Divisione di Pneumologia ldquoAntonio Blasirdquo Ospedale ldquoNinetto Mellirdquo Via Lecce 246 72017 San Pietro Vernotico Italy

Correspondence should be addressed to Anna Grazia DrsquoAgostino pneumotiscaliit

Received 21 November 2012 Accepted 31 December 2012

Academic Editors A Celi and A S Melani

Copyright copy 2013 Anna Grazia DrsquoAgostino et alThis is an open access article distributed under the Creative CommonsAttributionLicense which permits unrestricted use distribution and reproduction in anymedium provided the originalwork is properly cited

The aim was to assess if computed tomography is able to measure pulmonary artery pulsatility in patients affected by chronicobstructive pulmonary disease and to ascertainwhether pulsatility is different in patients with andwithout pulmonary hypertensionand whether it is related to haemodynamics We selected two groups of patients the first one with pulmonary hypertension andthe second one without In patient with hypertension pulmonary artery pressure and resistance were increased with the increaseddiameters (transverse 36 plusmn 5mm and axial 38 plusmn 4mm versus 22 plusmn 3 and 25 plusmn 5 resp) the increased cross-sectional area (10 plusmn08 versus 4 plusmn 1 cm2) and the reduced pulsatility (21 plusmn 7 versus 10 plusmn 5) Arterial stretching was decreased in patients withhypertension (10 plusmn 5 versus 21 plusmn 7) and significantly related to pulmonary vascular resistances and pressure Cardiac outputmeasured by tomography was significantly related to that obtained by Fick method and was not different in the two groups Thediameters allow to identify patients with PH assuming a cut-off of 28mm and assuming a pulsatility of right branch of 26 aswell These preliminary observations indicate tomography as a suitable technique being able to measure the pulsatility and thedimensions of the arteries and the right ventricular functional parameters

1 Introduction

The assessment of pulmonary hypertension (PH) during thechronic obstructive pulmonary disease (COPD) is importantsince PH worsens quality of life prognosis effort toleranceand outcome in acute respiratory failure [1ndash3] PrecapillaryPH can be seen in 30 to 43 of patients affected byCOPD reaching values higher than 45mmHg in 5 [1ndash3]PH is determined by both functional vasoconstriction andvessels remodeling [3ndash5] that determine the right ventricularafterload leading to effort intolerance poor quality of lifecardiac failure and reduced life expectancy The assessmentof pulsatility (Puls) of pulmonary artery (PA) in PH looks likea promising tool since it looks related to severity progressionof disease functional capacity prognosis and survival [6ndash9] The invasive right heart catheterization (RHC) is the gold

standard for the diagnosis of PH and the assessment ofreversibility of PH with vasodilators the measure of Pulsby intravascular ultrasound (IVU) [10ndash14] The noninvasivecardiac echocardiography (US) allows the measurement ofthe pulmonary artery dimensions the right ventriculareshape the ejection fraction and the noninvasive estima-tion of the systolic pulmonary artery pressure [15ndash18] butthe applicability of US in patients affected by COPD islimited because of the reduced acoustic window [15] dueto pulmonary hyperinflation Within the imaging methodsmagnetic resonance imaging (MRI) is extensively studied andallows the measurement of both morphologic and functionaldata such as Puls and pulmonary blood flow [19ndash21] butit is not widely available Multidetector computer Tomog-raphy (MDCT) and cardiac software imaging are diffuselyemployed and available they allow the detailed examination

2 ISRN Pulmonology

of heart coronary vessels left ventricular function andpulmonary arteries diameters [22ndash28] Our aims are to studywhether MDCT allows the assessment of Puls in COPDwhether Puls is different between patients with and withoutPH and whether it is related to hypertension

2 Methods

21 Selection of Patients All the patients were affected byCOPD (diagnosed according to ATS statement and GOLDcriteria) [29] and they were examined as soon as theyconsecutively come in the ward of pulmonary divisionPatients were assigned to a specific GOLD stage accordingto post bronchodilator FEV1

The inclusion criteria were (a) presence of COPD and (b)the written informed consent and motivation The exclusioncriteria were (a) the significant cardiac diseases such asvalvulopathies or cardiac failure defined by a fraction ejectionof left ventricle lesser than 50 (measured by echocardio-graphy) (b) the presence of other pulmonary diseases aspulmonary fibrosis tuberculosis or chronic embolic disease(already diagnosed by scintigraphy) (c) the allergy to iodinecompounds (d) the recent significant radiation loads dueto isotopic or radiological procedures (e) the psychiatricdisorders as claustrophobia or panic attacks (f) the sleepapnoea syndrome (diagnosed by polysomnography) and (g)the absence of acute relapses All the enrolled patients wereexamined by clinical check pulmonary functional testingblood gas analysis echocardiography six minutes walkingtest (6MWD) RHC in the first day and chest CT examina-tion one day afterThe study started on April 2008 and endedone year later The operator was unaware of the presenceof precapillary PH that was diagnosed under RHC by amean pulmonary artery pressure higher than 25mmHg witha capillary pressure lower than 15mmHg measured duringRHC Within one year only twenty patients with PH wererecruited because of the low prevalence of the disease andthe refuse of the informed consent the enrolled patients werecompared to the first consecutive twenty patients without PH

The goal to access the applicability of MDCT in theassessment of Puls was accomplished examining the successrate in the imaging of PA diameters and surface area indiastole and systole The difference of Puls within patientswith and without PH was obtained comparing the mean bya statistical package and observing the relationship betweenPuls and PAP or RVP

22 Physiological Measurements Lung volumes were mea-sured by a whole body chest plethysmography (Pulmobox6200 SensorMedics California USA) Measured volumeswere referred to ERS normal standards [30] Vital capacity(VC) and forced expiratory volume in the 1st second (FEV1)were reported

Blood gas analysis was carried out by radial artery punc-ture (performed at rest whilst breathing air) and automatedanalysis (Rapidlab Bayer FRG) measuring arterial oxygentension (PaO

2) and haemoglobin oxygen saturation (SaO

2)

Mixed venous oxygen tension (PvO2) and saturation (SvO

2)

were obtained by pulmonary artery samplingEffort tolerance was measured by 6MWD [31] and dys-

pnoea by WHO rating scale [32] RHC was performed bycubital vein catheterization according to Seldingerrsquos tech-nique using Swan-Ganz catheters (Baxter USA) [33]

23 Haemodynamic Measurements Pulmonary artery pres-sure (PAP) was assessed both in stable state and under NO(20 ppm) inhalation Cardiac output (1198761015840) was obtained usingFickmethod bymeans of simultaneous pulmonary and radialarteries sampling (to measure oxygen content) together withthe measurement of oxygen consumption (Cortex MetalyzerGermany) Pulmonary wedge pressure (Pw) measurementallowed pulmonary vascular resistances (PVRs) computeddividing pressure drop by cardiac output (PAP minus Pw1198761015840) Allpatients showed Pw lesser than 15mmHg

24 Imaging Measurements Computed tomography wasaccomplished by a 64-detector tomograph (Philips Brilliance64 Germany) A first whole chest scanningwas performed bya low dosage radiation without contrast medium with highresolution technique (100 kV 95mAs 64times 0 625mm 119905 rot0 75 sec pitch 1078) held at functional residual capacity andin forced expiration to check for concomitant pulmonarydiseases or associated conditions A ldquotest bolusrdquo techniquewas used before injecting the contrast medium (Iomeprol400 Bracco Italy) to compute the time necessary for thesimultaneous imaging of both the pulmonary trunk andthe right ventricle choosing as region of interest (ROI) thepulmonary trunk the right atrium and the left ventricleAfterwards the acquisition with contrast medium startedusing cardiac gating (120 kV 350mAs 64times 0 625mm 119905 rot0 4 sec pitch 0299) from the aortic arch to the cardiacbase including the pulmonary arteries up to two centimetresfrom the thoracic cage wall in the reconstruction algorithmThe contrast medium was injected at a flow rate of 4mLsecand at a concentration of 400mgmL by a double lumeninjector according to the sequence 80mL of solution with60mdc and 40 sterile saline followed by 40mL ofcontrast medium and 40mL of sterile saline Two doctorsmeasured the longitudinal and the transverse diameters ofboth pulmonary arteries in CT observed under mediastinalgating choosing a plan perpendicular to the path of vesselsThe measures were obtained at the end-systolic and the end-diastolic frames carefully checking during acquisition thatthe cardiac frequency was in the range of 55 to 85 bpm Theend-systolic frame happens around the 40 of the cardiaccycle and the end-systolic frame around the 70 (Figures 1and 2) The cross-sectional area was measured as well andthe pulsatility of arteries was measured by the ratio betweenthe systolic and the diastolic surface areas By means of adedicated software it was possible to measure the ejectionfraction and the cardiac output of right ventricle

25 Statistical Analysis Biometric data pulmonary functioneffort performance and hemodynamic and radiologic vari-ables of patients with and without pulmonary hypertension

ISRN Pulmonology 3

Figure 1 Assessment of pulmonary diameters inmediastinalwindowat end-diastolic phaseThemeasurement of pulmonary artery diameterswas repeated in end-systolic and end-diastolic phases the ratio allowed the assessment of pulsatility of pulmonary artery

Figure 2 Assessment of cardiac performance Delimitation of region of interest in end-systolic and end-diastolic phases Computer-aidedcalculation of systolic volume and cardiacoutput

were compared by the analysis of the mean with Studentrsquos 119905-test for unpaired data (Tables 1 and 2) by means of computer-aided software (Epistat USA and Graphpad Prism USA)The relationships between pulmonary artery features andhemodynamic variables and between cardiac output assessed

by MDCT and by Fick method were assessed by linear fittingand least square method

The study was approved by the Ethics Committee ofldquoNinetto Mellirdquo Hospital A written informed consent wasobtained from each patient

4 ISRN Pulmonology

3 Results

31 Population Studied Patients showed marked airwayobstruction andmarked dyspnoea (Table 1)Thedegree of air-way obstruction was advanced and most patients belongedto the 3rd stage of the disease in both groups (Table 1) Thefrequency of patients in each stage of COPD was similar inthe two groups The difference between patients with PHand without PH was not significant Hypoxemic hypercap-nic chronic respiratory failure could be observed withoutsignificant difference within patients Patients affected byCOPD and PH showed diminished effort tolerance with asignificantly lower 6MWD and an increased PAP and PVR(Table 1) while cardiac output determined by Fick method(1198761015840Fick) was similar

32 MDCT-Derived PA Diameters and Pulsatility MDCTallowed suitable imaging and effective measurement inevery patient Pulmonary artery (Table 2) was significantlyincreased both in axial and in transversal diameters inpatients with PH with a mean difference of about 14mmbetween COPD and COPD with PH

The diastolic diameters were about 2mm less than thesystolic ones Right PA diameters are about 6mm lower thanthose of themain PA Left PAbranches were slightly narrowerthan right ones in both series

Two patients with PH had a PA diameter between 30mmand 28mm the remaining had a diameter larger than 30mmwhile two patients without PH showed a PA diameter largerthan 30mm Assuming a cut-off of 28mm a sensitivity of90 specificity of 85 a positive predictive power of 85and a negative predictive power of 89 could be obtainedCross-sectional area of right and left arteries was about 40smaller than PA area with narrower values in the left side Itwas significantly increased in patients with PH (Table 2)

The Puls of PA is about 20 in the PA and in the leftbranch of COPD patients right PA showed increased values(38plusmn 5) (Table 2) The Puls was significantly diminished(mean 10) in patients with PH both in PA and in branchesmainly in the left side (2) It was not possible to choosea threshold for the Puls of the main pulmonary artery todiagnose the presence of PH because of the large transvari-ance of the distributions between patients with and withoutPH Since the stretching of right PA looks enhanced and thedifference looks wider assuming as a threshold the lowerlimit of right PA Puls (mean minus two standard deviations)a cut-off of 26 is associated with a sensitivity of 90 aspecificity of 85 a positive predictive power of 90 and anegative predictive power of 85 could be obtained Left sidewas not useful to avoid bias in reading the frames due to verylow values

Aorta diameters were normal in both patient sets (trans-verse diameter 29plusmn 8mm axial diameter 29plusmn 5mm and area264plusmn 4 cm2 in patients with PH and 30plusmn 3mm 30 + 3mmand 286plusmn 5 cm2 in patients without PH resp) and pul-monary arteryaorta ratio was significantly increased inpatients with PH (12plusmn 2 in patients with PH and 8plusmn 2 inpatients without PH resp)

80

70

60

50

40

30

20

10

0

PAPx

(mm

Hg)

0 10 20 30 40 50 60

PA diameter (mm)

Figure 3 Scatter plot of the relationship between pulmonary arterypressure and pulmonary artery Diameter

0 10 20 30 40

PA pulsatility ()

PVR

dyne

s sec

(cm

5 )

650

600

550

500

450

400

350

300

250

200

150

100

50

0

Figure 4 The relationship between pulmonary vascular resistanceand pulsatility of pulmonary artery

33 The Relationship with Haemodynamics The Puls wassignificantly inversely related to PVR (PVR= 458 ndash 753 pul-satility plusmn95 1199032 = 274 119875 = 0177) (Figure 4) and PAP(PAP= 38 ndash 25 pulsatility plusmn5 1199032 = 219 119875 = 0371)(Figure 5) PA diameter was related to PH level (Figure 3)(systolic PA diameter =minus61+114 PAPplusmn 38 1199032 = 33 119875 =0075 diastolic PA diameter =minus10 + 132 PAP plusmn34 1199032 =38 119875 = 0018) By grouping of patients according to theWHO staging of PH PA diameter reached an average valueof 32plusmn 3mm in the 1st stage of PH (PAP lt 25 at rest but

ISRN Pulmonology 5

Table 1 Functional values observed in patients affected by COPD with PH under stable state

Units COPD+PH COPD 119875

Age Years old 66 plusmn 9 65 plusmn 10 nsHeight cm 165 plusmn 8 167 plusmn 10 nsWeight kgms 75 plusmn 13 73 plusmn 9 nsGOLD st II 25 20GOLD st III 55 50GOLD st IV 20 30FVC 49 plusmn 18 53 plusmn 15 nsFEV1 37 plusmn 18 39 plusmn 17 nsPaO2 mmHg 57 plusmn 10 58 plusmn 9 nsPaCO2 mmHg 46 plusmn 8 46 plusmn 9 nsPAP mmHg 37 plusmn 5 18 plusmn 5 lt1 times 10minus6

1198761015840 Fick Lm 49 plusmn 14 51 plusmn 12 ns1198761015840 radiol Lm 41plusmn 10 42 plusmn 14 ns

PVR Dynes secminus1 cmminus5 442 plusmn 192 120 plusmn 70 lt1 times 10minus6

6MWD Mt 257 plusmn 118 370 plusmn 150 lt02246Dyspnoea WHO stage IIIplusmn I IIIplusmn I ns119873 119899 20 20FVC forced vital capacity as percentage of predicted values FEV1 forced expired volume in the 1 second as percentage of predicted values PaO2 arterialoxygen tension PaCO2 arterial carbon dioxide tension PAP mean pulmonary artery pressure 1198761015840 cardiac output measured by radiologic method (radiol)and Fick method (Fick) PVR pulmonary vascular resistance 6MWD six minutes walking distance WHO dyspnoea rating according to WHO stages andGOLD st II-III and IV of patients belonging to GOLD stages II III and IV Values are expressed as mean plusmn standard deviation119873 number of observations

Table 2 Pulmonary artery features in COPD

COPD + PH COPD Units 119875

Main pulmonary arteryTransverse systolic 119889 36 plusmn 5 22 plusmn 3 Mm lt1 times 10minus6

Axial systolic 119889 38 plusmn 4 25 plusmn 5 Mm lt1 times 10minus6

Systolic Area 108 plusmn 2 43 plusmn 1 cm2lt1 times 10minus6

Transverse diastolic 119889 34 plusmn 2 20 plusmn 5 mm lt1 times 10minus6

Axial diastolic 119889 36 plusmn 3 22 plusmn 4 mm lt1 times 10minus6

Diastolic area 96 plusmn 1 34 plusmn 1 cm2lt1 times 10minus6

Pulsatility 10 plusmn 05 21 plusmn 07 lt1 times 10minus6

Right pulmonary arteryTransverse Systolic 119889 30 plusmn 1 21 plusmn 8 mm lt1 times 10minus6

Axial Systolic 119889 30 plusmn 1 21 plusmn 7 mm lt1 times 10minus6

Systolic area 71 plusmn 1 36 plusmn 8 cm2lt1 times 10minus6





Left pulmonary arteryTransverse Systolic 119889 28 plusmn 2 18 plusmn 5 mm lt1 times 10minus6







COPD + PH pulmonary artery diameter in patients with COPD and pulmonary hypertension COPD pulmonary artery diameter in patients with COPDand normal pulmonary artery pressure transverse systolic 119889 transverse systolic diameter axial systolic 119889 axial systolic diameter and systolic area sectionalsystolic areaMean plusmn SD 119875 level of probability ns not significant right right pulmonary artery left left pulmonary artery pulsatility ratio between systolic and diastoliccross-sectional areas Number of observations 20 for each set

6 ISRN Pulmonology

0 10 20 30 40

PA pulsatility ()

55

50

45

40

35

30

25

20

15

10

5

0

PAP

(mm

Hg)

Figure 5 The relationship between pulmonary artery pressure andpulsatility of pulmonary artery pressure

gt25mmHg on effort) 34plusmn 3mm in the 2nd one (PAP gt 25and lt35mmHg) 36plusmn 3mm in the 3rd one (PAP gt 35 andlt45) and up to 46plusmn 3mm in the 4th stage (PAPgt 45mmHg)The cardiac output measured by CT (1198761015840 rad = 41plusmn 1 Lm)underscores the blood flow measured by Fick method (1198761015840Fick) The two measurements are significantly related (1198761015840Fick = 14 + 96 1198761015840 rad (+09) 119875 lt 001)

34 Additional Outcomes CT allowed the assessment of pul-monary nodules (2 patients) arteriovenous malformations(one patient) and severe coronary pathology (three cases)The average absorbed dose was 8plusmn 2mSv

4 Discussion

Our study indicates for the first time the chance to apply CTcardiac imaging software in the study of pulmonary vesselsand right ventricular performance This method allows toappreciate significant differences of PA dimensions cross-sectional areas and PA stretching in patients with andwithout PH The measurements are related to physiologicalmeasurements obtained under RHC

The main limitation of the current study is the lownumber of observations due to the low prevalence of thedisease and to the difficulties in the recruitment because ofthe lack of compliance of patients thus the current data canbe regarded just as preliminary outcomes to be confirmed bymulticentric studies

The first outcome is that according to our results MDCTcardiac software imaging technique is able to measure thefeatures of pulmonary arteries as well as the right ventricularperformance and it can be used in every COPD patientwhile US applicability is limited by the reduced acousticwindow and MRI is still not diffuse everywhere and ismore expensive and time consuming MDCT allows as well

an effective imaging of the associated pulmonary such ascoronary diseases and pulmonary emboli The applicabilityis not fully extensible in other pulmonary diseases associatedwith PH such as interstitial lung disease because of the inter-ference of fibrosis upon reading of frames and differences ininvolvement of vessels [34 35]

The second observation is the observation of a dimin-ished arterial Puls in patients with PH The applicability inthe early diagnosis of PH looks limited because the Puls ofmain PA (21plusmn 07 in COPD versus 10plusmn 05 in COPD +PH) cannot play a role because of the large overlap of thedistributions between patients with COPD and COPD withPH although the pulsatility or right PA (38plusmn 05 in COPDversus 10plusmn 05 in COPD + PH) looks as a promising indexto be verified in more extensive studies

MDCT-derived pulsatility fairly agrees with that mea-sured by IVU and MRI [11ndash21] indicating a mean pul-satility of 20plusmn 5 The pulsatility significantly diminishesin patients affected by PH because of arterial remodellingleading to arterial stiffness [16 17]

The relationship between the pulsatility of central arteriesand PVR mainly determined by peripheral vessels canbe explained observing that pathology determines contem-porary structural changes in both central and peripheralvessels The inverse relationship between Puls and PAPdepends on the fact that as peripheral vesselrsquos pathologyworsens determining an increase in PVR and PAP thepulmonary artery dilates according to its elastic modulusand becomes proportionally stiffer with the enlargement ofdiameters together with the lack of progression of elasticwaves into the peripheral units Furthermore as the PAP andthe right ventricular afterload (determined by the vascularimpedance) increase the right ventricular performance isimpaired with the decrease in the systolic volume (the maindeterminant of pulsatility) and the evidence of pulmonaryvalve regurgitation [36ndash38]

The reported value of pulsatility in the prognosis [9]can be explained by the observed relationship betweenPuls and haemodynamics the pulmonary artery stretchingis dependent on the degree of PH but it determines aswell the ventriculararterial coupling Controversial reportsindicate higher values in patients responders to vasodilatorssuggesting a possible role in the evaluation of reversibilityof PH and the selection of patients responders to calciumchannel blockers [39 40]

MDCT allows as well to study the additional featuresof pulmonary arteries such as the diameters According topreliminary reports in the literature [24ndash29] and our resultsthe diameters allow the detection of PH with fairly goodsensitivity and specificity Assuming 28mmas the upper limitof normality (mean + 2SD) of PA a sensitivity of 90 aspecificity of 85 and a positive predictive value of 96can be obtained by our study with outcomes similar to thoseobtained in larger series [24ndash29] The variance observedaround the slope of the relationship between diameters andPAP can be explained by several reasons (1) differencesin the amount of elastic bundles of the main pulmonaryartery tissues (2) dilation determined by previous loads suchas higher PAP peaks preceding the measures heavier than

ISRN Pulmonology 7

the actual measured PAP (3) differences in cardiac output(4) different body surface area since cross-sectional areaof PA and left branch corrected by body surface area weresignificantly related to PAP and (5) time of measurementreferred to the natural history of disease since pulmonaryartery progressively increases even in case of reductionof PVR by vasodilators due to intrinsic vessel propertiesindependent of pressure and flow changes Other relevantfindings in the literature are the arterialbronchial ratio gt 11in lobar arteries and the ratio PAAorta higher than 1 andclose to 12plusmn 3 as found in our patients as well [24ndash29]

In conclusion MDCT could be applied in every COPDpatient allowing the measurement of PA pulsatility lesserin patients affected by PH and closely related to the haemo-dynamic variables Pulsatility can contribute to raise thesuspicion of the existence of PH together with the mea-surement of diameters MDCT allows as well an insight into the performance of RV by means of the assessment ofthe cardiac output related to the hemodynamic measuresand it offers the chance to verify additional thoracic orcardiac lesions justifying the radiation dose absorbed Thesefindings are relevant not only as scientific outcomes but aswell in clinical practice because they offer a suitable and alsoavailable technique to be applied once in primary health carewhen the suspect of PH is raised

5 Summary

The aim was to assess if multidetector computed tomography(MDCT) is able tomeasure pulmonary artery (PA) pulsatility(Puls) in patients affected by chronic obstructive pulmonarydisease (COPD) and to ascertain whether Puls is different inpatients with and without pulmonary hypertension (PH) andwhether it is related to haemodynamics Statistical analysisby Studentrsquos 119905 test allowed the comparison of data betweenpatients with and without PH The linear fitting and the leastsquare method allowed to assess a significant relationshipbetween haemodynamics and imaging MDCT allowed theimaging and the measurement of PA features in all thepatients We selected two groups of COPD patients thefirst one with PH and the second one without PH Inpatients with COPD and PH PAP and PVR were increased(PAP 37plusmn 18 versus 18plusmn 5mmHg PVR 442plusmn 192 versus120plusmn 70 dynes sminus1 cmminus5) and PA showed increased diameters(transverse 36plusmn 5mm axial 38plusmn 4mm versus 22plusmn 3 and25plusmn 5 resp) increased cross-sectional area (10plusmn 08 versus4plusmn 1 cm2) and reduced pulsatility (21plusmn 7 versus 10plusmn 5)Arterial stretching was decreased in patients with PH(10plusmn 5 versus 21plusmn 7 in non-PH) and significantly relatedto pulmonary vascular resistances (PVRs) (PVR= 458 ndash 753pulsatility plusmn95 1199032 = 274 119875 = 0177) and pulmonaryartery pressure (PAP) PAP= 38 ndash 25 pulsatility plusmn5 1199032 =219 119875 = 0371) Cardiac output measured by MDCT wassignificantly related to that obtained by Fick method (41 plusmn10 Lm versus 49plusmn 14 resp) and was not different in thetwo groups The diameters of PA allow to identify patientswith PHwith a confident specificity and sensitivity assuminga cut-off of 28mm for the diameter of PA it was possible to

diagnose pulmonary hypertension with a sensitivity of 90a specificity of 85 a positive predictive power of 85 anda negative predictive power of 89 While the distributionof PA Puls was overlapping the Puls of right PA assuminga cut off of 26 allowed to diagnose PH with a specificityof 85 a positive predictive power of 90 and a negativepredictive power of 85 These preliminary observations tobe confirmed in multicentric and more extensive studiesindicate MDCT as a suitable technique in COPD able tomeasure the Puls and the dimensions of pulmonary arteriesas well as the right ventricular functional parameters

Abbreviations

Puls PulsatilityMDCT Multidetector tomographyPH Pulmonary hypertensionPAP Pulmonary artery pressurePA Pulmonary arteryPVRs Pulmonary vascular resistances1198761015840 Cardiac output

COPD Chronic obstructive pulmonary diseaseRHC Right heart catheterization

Conflict of Interest

Theauthors declare that they have no conflict of interests andthe study was supported by no grant

References

[1] G Simonneau N Galiersquo and L Rubin ldquoClinical classificationof pulmonary arterial hypertensionrdquo Journal of the AmericanCollege of Cardiology vol 43 no 12 supplement pp s5ndashs122004

[2] R Kessler M Faller EWeitzenblum et al ldquoldquoNatural historyrdquo ofpulmonary hypertension in a series of 131 patients with chronicobstructive lung diseaserdquo American Journal of Respiratory andCritical Care Medicine vol 164 no 2 pp 219ndash224 2001

[3] R Naejie and A Barbera ldquoPulmonary hypertension associatedwith COPDrdquo Critical Care vol 5 pp 286ndash291 2001

[4] O Fira-Mladinescu L Vasile C Suciu et al ldquoSome aspects ofpulmonary vascular remodelling in smokers and patients withmild COPDrdquo Pneumologia vol 57 no 1 pp 7ndash16 2008

[5] S Santos V I Peinado J Ramirez et al ldquoChracterizationof pulmonary vascular remodelling in smokersrdquo EuropeanRespiratory Journal vol 19 no 4 pp 632ndash638 2002

[6] K W Kang H J Chang Y J Kim B W Choi et al ldquoCardiacmagnetic resonance imaging-derived pulmonary artery disten-sibility index correlates with pulmonary artery stiffness andpredicts functional capacity in patients with pulmonary arterialhypertensionrdquo Circulation Journal vol 75 no 9 pp 2244ndash22512011

[7] Y Fukumoto ldquoPulmonary artery distensibility index is a non-invasive useful marker of pulmonary arterial hypertensionprogressionrdquo Circulation Journal vol 75 no 9 pp 2058ndash20592011

[8] A J Swift S Rajaram R Condliffe D Capener et al ldquoPul-monary artery relative area change detects mild elevations inpulmonary vascular resistance and predicts adverse outcome

8 ISRN Pulmonology

in pulmonary hypertensionrdquo Investigative Radiology vol 47 no10 pp 571ndash577 2012

[9] C T J Gan J W Lankhaar N Westerhof et al ldquoNoninvasivelyassessed pulmonary artery stiffness predicts mortality in pul-monary arterial hypertensionrdquo Chest vol 132 no 6 pp 1906ndash1912 2007

[10] J Rodes-Cabau E Domingo A Roman et al ldquoIntravascularultrasound of the elastic pulmonary arteries a new approachfor the evaluation of primary pulmonary hypertensionrdquo Heartvol 89 no 3 pp 311ndash315 2003

[11] A C Borges R Wensel C Opitz U Bauer G Baumann andF X Kleber ldquoRelationship between haemodynamics and mor-phology in pulmonary hypertension A quantitative intravascu-lar ultrasound studyrdquo EuropeanHeart Journal vol 18 no 12 pp1988ndash1994 1997

[12] C E Weinberg and J R Hertzberg ldquoUse of intravascular ultra-sound to measure local compliance of the pediatric pulmonaryartery in vitro studiesrdquo Journal of the American Society ofEchocardiography vol 15 no 12 pp 1507ndash1514 2002

[13] E Domingo R Aguilar M Lopez-Meseguer G Teixido MVazquez and A Roman ldquoNew concepts in the invasive andnon invasive evaluation of remodelling of the right ventricle andpulmonary vasculature in pulmonary arterial hypertensionrdquoOpen Respiratory Medicine Journal vol 3 pp 31ndash37 2009

[14] E M Lau N Iyer R Ilsar B P Bailey M R Adams and DS Celermajer ldquoAbnormal pulmonary artery stiffness in pul-monary arterial hypertension in vivo study with intravascularultrasoundrdquo PLoS ONE vol 7 no 3 Article ID e33331 2012

[15] M R Fisher G J Criner A P Fishman et al ldquoEstimatingpulmonary artery pressures by echocardiography in patientswith emphysemardquo European Respiratory Journal vol 30 no 5pp 914ndash921 2007

[16] S Ghio A S Pazzano C Klersy et al ldquoClinical and prognosticrelevance of echocardiographic evaluation of right ventriculargeometry in patients with idiopathic pulmonary arterial hyper-tensionrdquoAmerican Journal of Cardiology vol 107 no 4 pp 628ndash632 2011

[17] C Ginghina D Muraru A Vladaia et al ldquoDoppler flow pat-terns in the evaluation of pulmonary hypertensionrdquo RomanianJournal of Internal Medicine vol 47 no 2 pp 109ndash121 2009

[18] A Vonk-Noordegraaf J T Marcus S Holverda B Roseboomand P E Postmus ldquoEarly changes of cardiac structure andfunction in COPD patients with mild hypoxemiardquo Chest vol127 no 6 pp 1898ndash1903 2005

[19] R W W Biederman ldquoCardiovascular magnetic resonanceimaging as applied to patients with pulmonary arterial hyper-tensionrdquo International Journal of Clinical Practice vol 63 no162 pp 20ndash35 2009

[20] N Creuze S Hoette and D Chemla ldquoMagnetic resonanceimaging and pulmonary hypertension towards an improvedevaluation of right heart and pulmonary circulationrdquo PresseMedicale vol 40 supplement 1 pp 1S21ndash1S27 2011

[21] C Jardim C E Rochitte M Humbert et al ldquoPulmonary arterydistensibility in pulmonary arterial hypertension an MRI pilotstudyrdquo European Respiratory Journal vol 29 no 3 pp 476ndash4812007

[22] J B A Haimovici B Trotman-Dickenson E F Halpern et alldquoRelationship between pulmonary artery diameter at computedtomography and pulmonary artery pressures at right-sidedheart catheterizationrdquoAcademic Radiology vol 4 no 5 pp 327ndash334 1997

[23] E Abel A Jankowski C Pison J L Bosson H Bouvaistand G R Ferretti ldquoPulmonary artery and right ventricleassessment in pulmonary hypertension correlation betweenfunctional parameters of ECG-gated CT and right-side heartcatheterizationrdquo Acta Radiologica vol 53 no 7 pp 720ndash7272012

[24] B Boerrigter G J Mauritz J T Marcus et al ldquoProgressivedilatation of the main pulmonary artery is a characteristic ofpulmonary arterial hypertension and is not related to changesin pressurerdquo Chest vol 138 no 6 pp 1395ndash1401 2010

[25] R Condliffe M Radon J Hurdman et al ldquoCT pulmonaryangiography combined with echocardiography in suspectedsystemic sclerosis-associated pulmonary arterial hypertensionrdquoRheumatology vol 50 no 8 pp 1480ndash1486 2011

[26] R S Dusaj K C Michelis M Terek et al ldquoEstimation ofright atrial and ventricular hemodynamics by CT coronaryangiographyrdquo Journal of Cardiovascular Computed Tomographyvol 5 no 1 pp 44ndash49 2011

[27] F Y Lin R B Devereux M J Roman et al ldquoThe right sidedgreat vessels by cardiac multidetector computed tomographyNormative reference values among healthy adults free of car-diopulmonary disease hypertension and obesityrdquo AcademicRadiology vol 16 no 8 pp 981ndash987 2009

[28] R T Tan R Kuzo L R Goodman R Siegel G B Haasler andK W Presberg ldquoUtility of CT scan evaluation for predictingpulmonary hypertension in patients with parenchymal lungdiseaserdquo Chest vol 113 no 5 pp 1250ndash1256 1998

[29] R A Pauwels A S Buist P M A Calverley C R Jenkinsand S S Hurd ldquoGlobal strategy for the diagnosis managementand prevention of chronic obstructive pulmonary diseaseNHLBIWHO Global Initiative for Chronic Obstructive LungDisease (GOLD) workshop summaryrdquo American Journal ofRespiratory and Critical Care Medicine vol 163 no 5 pp 1256ndash1276 2001

[30] P Quanjer ldquoERS official statement on lung volumes and expira-tory flowsrdquo European Respiratory Journal vol 6 supplement 16pp 5ndash40 1993

[31] R O Crapo R Casaburi A L Coates et al ldquoATS statementguidelines for the six-minute walk testrdquo American Journal ofRespiratory and Critical Care Medicine vol 166 no 1 pp 111ndash117 2002

[32] DAMahler andAHarveyDyspnea in FishmanAPPulmonaryRehabilitation Marcel Dekker New York NY USA 1996

[33] N Buchbinder and W Ganz ldquoHemodynamic monitoringinvasive techniquesrdquo Anesthesiology vol 45 no 2 pp 146ndash1551976

[34] D A Zisman A S Karlamangla D J Ross et al ldquoHigh-resolution chest CT findings do not predict the presence ofpulmonary hypertension in advanced idiopathic pulmonaryfibrosisrdquo Chest vol 132 no 3 pp 773ndash779 2007

[35] E H Alhamad A A Al-Boukai F A Al-Kassimi et alldquoPrediction of pulmonary hypertension in patients with orwithout interstitial lung disease reliability of CT findingsrdquoRadiology vol 260 pp 875ndash883 2011

[36] M Remy-Jardin D Delhaye A Teisseire C Hossein-FoucherA Duhamel and J Remy ldquoMDCT of right ventricular functionimpact ofmethodologic approach in estimation of right ventric-ular ejection fractionrdquo American Journal of Roentgenology vol187 no 6 pp 1605ndash1609 2006

[37] P J Kilner R Balossino G Dubini et al ldquoPulmonary regurgi-tation the effects of varying pulmonary artery compliance and

ISRN Pulmonology 9

of increased resistance proximal or distal to the compliancerdquoInternational Journal of Cardiology vol 133 no 2 pp 157ndash1662009

[38] G R Stevens and A Garcia-Alvarez ldquoRV dysfunction inpulmonary hypertension is independently related to pulmonaryartery stiffnessrdquo JACC Cardiovascular Imaging vol 5 no 4 pp378ndash387 2012

[39] D D Ivy S R Neish O A Knudson et al ldquoIntravascularultrasonic characteristics and vasoreactivity of the pulmonaryvasculature in children with pulmonary hypertensionrdquo Ameri-can Journal of Cardiology vol 81 no 6 pp 740ndash748 1998

[40] J C Grignola E Domingo R Aguilar et al ldquoAcute absolutevasodilatation is associated with a lower vascular wall stiffnessin pulmonary arterial hypertensionrdquo International Journal ofCardiology 2011

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of



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OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

2 ISRN Pulmonology

of heart coronary vessels left ventricular function andpulmonary arteries diameters [22ndash28] Our aims are to studywhether MDCT allows the assessment of Puls in COPDwhether Puls is different between patients with and withoutPH and whether it is related to hypertension

2 Methods

21 Selection of Patients All the patients were affected byCOPD (diagnosed according to ATS statement and GOLDcriteria) [29] and they were examined as soon as theyconsecutively come in the ward of pulmonary divisionPatients were assigned to a specific GOLD stage accordingto post bronchodilator FEV1

The inclusion criteria were (a) presence of COPD and (b)the written informed consent and motivation The exclusioncriteria were (a) the significant cardiac diseases such asvalvulopathies or cardiac failure defined by a fraction ejectionof left ventricle lesser than 50 (measured by echocardio-graphy) (b) the presence of other pulmonary diseases aspulmonary fibrosis tuberculosis or chronic embolic disease(already diagnosed by scintigraphy) (c) the allergy to iodinecompounds (d) the recent significant radiation loads dueto isotopic or radiological procedures (e) the psychiatricdisorders as claustrophobia or panic attacks (f) the sleepapnoea syndrome (diagnosed by polysomnography) and (g)the absence of acute relapses All the enrolled patients wereexamined by clinical check pulmonary functional testingblood gas analysis echocardiography six minutes walkingtest (6MWD) RHC in the first day and chest CT examina-tion one day afterThe study started on April 2008 and endedone year later The operator was unaware of the presenceof precapillary PH that was diagnosed under RHC by amean pulmonary artery pressure higher than 25mmHg witha capillary pressure lower than 15mmHg measured duringRHC Within one year only twenty patients with PH wererecruited because of the low prevalence of the disease andthe refuse of the informed consent the enrolled patients werecompared to the first consecutive twenty patients without PH

The goal to access the applicability of MDCT in theassessment of Puls was accomplished examining the successrate in the imaging of PA diameters and surface area indiastole and systole The difference of Puls within patientswith and without PH was obtained comparing the mean bya statistical package and observing the relationship betweenPuls and PAP or RVP

22 Physiological Measurements Lung volumes were mea-sured by a whole body chest plethysmography (Pulmobox6200 SensorMedics California USA) Measured volumeswere referred to ERS normal standards [30] Vital capacity(VC) and forced expiratory volume in the 1st second (FEV1)were reported

Blood gas analysis was carried out by radial artery punc-ture (performed at rest whilst breathing air) and automatedanalysis (Rapidlab Bayer FRG) measuring arterial oxygentension (PaO

2) and haemoglobin oxygen saturation (SaO

2)

Mixed venous oxygen tension (PvO2) and saturation (SvO

2)

were obtained by pulmonary artery samplingEffort tolerance was measured by 6MWD [31] and dys-

pnoea by WHO rating scale [32] RHC was performed bycubital vein catheterization according to Seldingerrsquos tech-nique using Swan-Ganz catheters (Baxter USA) [33]

23 Haemodynamic Measurements Pulmonary artery pres-sure (PAP) was assessed both in stable state and under NO(20 ppm) inhalation Cardiac output (1198761015840) was obtained usingFickmethod bymeans of simultaneous pulmonary and radialarteries sampling (to measure oxygen content) together withthe measurement of oxygen consumption (Cortex MetalyzerGermany) Pulmonary wedge pressure (Pw) measurementallowed pulmonary vascular resistances (PVRs) computeddividing pressure drop by cardiac output (PAP minus Pw1198761015840) Allpatients showed Pw lesser than 15mmHg

24 Imaging Measurements Computed tomography wasaccomplished by a 64-detector tomograph (Philips Brilliance64 Germany) A first whole chest scanningwas performed bya low dosage radiation without contrast medium with highresolution technique (100 kV 95mAs 64times 0 625mm 119905 rot0 75 sec pitch 1078) held at functional residual capacity andin forced expiration to check for concomitant pulmonarydiseases or associated conditions A ldquotest bolusrdquo techniquewas used before injecting the contrast medium (Iomeprol400 Bracco Italy) to compute the time necessary for thesimultaneous imaging of both the pulmonary trunk andthe right ventricle choosing as region of interest (ROI) thepulmonary trunk the right atrium and the left ventricleAfterwards the acquisition with contrast medium startedusing cardiac gating (120 kV 350mAs 64times 0 625mm 119905 rot0 4 sec pitch 0299) from the aortic arch to the cardiacbase including the pulmonary arteries up to two centimetresfrom the thoracic cage wall in the reconstruction algorithmThe contrast medium was injected at a flow rate of 4mLsecand at a concentration of 400mgmL by a double lumeninjector according to the sequence 80mL of solution with60mdc and 40 sterile saline followed by 40mL ofcontrast medium and 40mL of sterile saline Two doctorsmeasured the longitudinal and the transverse diameters ofboth pulmonary arteries in CT observed under mediastinalgating choosing a plan perpendicular to the path of vesselsThe measures were obtained at the end-systolic and the end-diastolic frames carefully checking during acquisition thatthe cardiac frequency was in the range of 55 to 85 bpm Theend-systolic frame happens around the 40 of the cardiaccycle and the end-systolic frame around the 70 (Figures 1and 2) The cross-sectional area was measured as well andthe pulsatility of arteries was measured by the ratio betweenthe systolic and the diastolic surface areas By means of adedicated software it was possible to measure the ejectionfraction and the cardiac output of right ventricle

25 Statistical Analysis Biometric data pulmonary functioneffort performance and hemodynamic and radiologic vari-ables of patients with and without pulmonary hypertension

ISRN Pulmonology 3






4 ISRN Pulmonology

3 Results







80

70

60

50

40

30

20

10

0

PAPx

(mm

Hg)

0 10 20 30 40 50 60

PA diameter (mm)


0 10 20 30 40

PA pulsatility ()

PVR

dyne

s sec

(cm

5 )

650

600

550

500

450

400

350

300

250

200

150

100

50

0



ISRN Pulmonology 5































6 ISRN Pulmonology

0 10 20 30 40

PA pulsatility ()

55

50

45

40

35

30

25

20

15

10

5

0

PAP

(mm

Hg)




4 Discussion










ISRN Pulmonology 7



5 Summary



Abbreviations





References









8 ISRN Pulmonology































ISRN Pulmonology 9










of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















ISRN Pulmonology 3






4 ISRN Pulmonology

3 Results







80

70

60

50

40

30

20

10

0

PAPx

(mm

Hg)

0 10 20 30 40 50 60

PA diameter (mm)


0 10 20 30 40

PA pulsatility ()

PVR

dyne

s sec

(cm

5 )

650

600

550

500

450

400

350

300

250

200

150

100

50

0



ISRN Pulmonology 5































6 ISRN Pulmonology

0 10 20 30 40

PA pulsatility ()

55

50

45

40

35

30

25

20

15

10

5

0

PAP

(mm

Hg)




4 Discussion










ISRN Pulmonology 7



5 Summary



Abbreviations





References









8 ISRN Pulmonology































ISRN Pulmonology 9










of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















4 ISRN Pulmonology

3 Results







80

70

60

50

40

30

20

10

0

PAPx

(mm

Hg)

0 10 20 30 40 50 60

PA diameter (mm)


0 10 20 30 40

PA pulsatility ()

PVR

dyne

s sec

(cm

5 )

650

600

550

500

450

400

350

300

250

200

150

100

50

0



ISRN Pulmonology 5































6 ISRN Pulmonology

0 10 20 30 40

PA pulsatility ()

55

50

45

40

35

30

25

20

15

10

5

0

PAP

(mm

Hg)




4 Discussion










ISRN Pulmonology 7



5 Summary



Abbreviations





References









8 ISRN Pulmonology































ISRN Pulmonology 9










of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















ISRN Pulmonology 5































6 ISRN Pulmonology

0 10 20 30 40

PA pulsatility ()

55

50

45

40

35

30

25

20

15

10

5

0

PAP

(mm

Hg)




4 Discussion










ISRN Pulmonology 7



5 Summary



Abbreviations





References









8 ISRN Pulmonology































ISRN Pulmonology 9










of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















6 ISRN Pulmonology

0 10 20 30 40

PA pulsatility ()

55

50

45

40

35

30

25

20

15

10

5

0

PAP

(mm

Hg)




4 Discussion










ISRN Pulmonology 7



5 Summary



Abbreviations





References









8 ISRN Pulmonology































ISRN Pulmonology 9










of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















ISRN Pulmonology 7



5 Summary



Abbreviations





References









8 ISRN Pulmonology































ISRN Pulmonology 9










of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















8 ISRN Pulmonology































ISRN Pulmonology 9










of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















ISRN Pulmonology 9










of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















research article assessment of pulmonary artery pulsatility by...

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