Counter-clockwise vortical blood flow in the main pulmonary artery in a patient with patent ductus arteriosus with pulmonary arterial hypertension: a cardiac magnetic resonance imaging case report

Gert Reiter, Ursula Reiter, Gabor Kovacs, Gabriel Adelsmayr, Andreas Greiser, Aurelien F Stalder, Horst Olschewski, Michael Fuchsjäger, Gert Reiter, Ursula Reiter, Gabor Kovacs, Gabriel Adelsmayr, Andreas Greiser, Aurelien F Stalder, Horst Olschewski, Michael Fuchsjäger

Abstract

Background: In patients with pulmonary hypertension (PH), duration of vortical blood flow along the main pulmonary artery enables estimation of the mean pulmonary arterial pressure (mPAP) non-invasively. It remains to date not known, if this method is applicable in patients with pulmonary arterial hypertension (PAH) and abnormal aortic-to-pulmonary shunting.

Case presentation: The present case analyzes the effect of a patent ductus arteriosus (PDA) on pulmonary artery flow patterns in PAH (mPAP from right heart catheterization, 75 mmHg). PH-associated vortical blood flow, which is typically observed rotating in a clockwise direction when viewed in right ventricular outflow tract orientation, was found nested in PDA left-to-right shunting. Even though rotating counter-clockwise, duration of vortical flow translated into correct non-invasive mPAP estimate.

Conclusions: This case indicates that PH-associated vortex rotation is not restricted to clockwise direction, and that vortex-based estimation of elevated mPAP might also be feasible in patients with PAH and PDA.

Trial registration: ClinicalTrials.gov NCT01725763.

Keywords: 4D blood flow; Cardiac magnetic resonance imaging; Patent ductus arteriosus; Pulmonary arterial hypertension.

Figures

Fig. 1
Fig. 1
4D flow evaluation of the PDA. Schematic 3D anatomy (a) of the PDA and surrounding cardiovascular structures based on 3D reconstruction of the anatomical phase contrast images. PDA length and time-averaged cross-sectional area at the center of the PDA were evaluated by multi-planar reformation. Time courses of maximal velocity (b) and net flow rate (c) across the central cross-section of the PDA demonstrate an early systolic and an early diastolic left-to-right peak and small right-to-left flow at end-systole. Velocity-color-encoded streamlines originating from PDA at early systole (d), end-systole (e) and early diastole (f) projected onto multi-planar reformatted anatomical images reflect these bi-phasic PDA flow characteristics. In early systole (d) and diastole (f) there is fast left-to-right flow through the PDA that reverses direction in the main pulmonary artery. In end-systole (e) blood spirals from right-to-left but no streamlines (and particles in Additional file 1: in the online-only Data Supplement) enter the aorta. PDA = patent ductus arteriosus; MPA = main pulmonary artery; RPA = right pulmonary artery; PV = pulmonary valve; AD = aorta descendens; AA = aorta ascendens, LV = left ventricle, RV = right ventricle, LA = left atrium
Fig. 2
Fig. 2
Vortical blood flow in the main pulmonary artery. Velocity-color-encoded streamlines (a, b, c) and 3D velocity vectors (d, e, f) projected onto multi-planar reformatted anatomical images demonstrate counter-clockwise rotating vortical blood flow nested in bi-directional pulmonary flow caused by PDA. This structure is present throughout the entire cardiac cycle (Additional file 2: in the online-only Data Supplement)
Fig. 3
Fig. 3
Typical vortical blood flow in the main pulmonary artery in a patient with pulmonary arterial hypertension (mPAP = 82 mmHg) without PDA. Velocity-color-encoded streamlines (a, b) and 3D velocity vectors (c, d) projected onto multi-planar reformatted anatomical images demonstrate clockwise rotating vortical blood flow and forward flow along the posterior wall of the main pulmonary artery

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