Pulmonary artery wave reflection and right ventricular function after lung resection

Adam Glass, Philip McCall, Alex Arthur, Kenneth Mangion, Ben Shelley, Adam Glass, Philip McCall, Alex Arthur, Kenneth Mangion, Ben Shelley

Abstract

Background: Lung resection has been shown to impair right ventricular function. Although conventional measures of afterload do not change, surgical ligation of a pulmonary artery branch, as occurs during lobectomy, can create a unilateral proximal reflection site, increasing wave reflection (pulsatile component of afterload) and diverting blood flow through the contralateral pulmonary artery. We present a cardiovascular magnetic resonance imaging (MRI) observational cohort study of changes in wave reflection and right ventricular function after lung resection.

Methods: Twenty-seven patients scheduled for open lobectomy for suspected lung cancer underwent cardiovascular MRI preoperatively, on postoperative Day 2, and at 2 months. Wave reflection was assessed in the left and right pulmonary arteries (operative and non-operative, as appropriate) by wave intensity analysis and calculation of wave reflection index. Pulmonary artery blood flow distribution was calculated as percentage of total blood flow travelling in the non-operative pulmonary artery. Right ventricular function was assessed by ejection fraction and strain analysis.

Results: Operative pulmonary artery wave reflection increased from 4.3 (2.1-8.8) % preoperatively to 9.5 (4.9-14.9) % on postoperative Day 2 and 8.0 (2.3-11.7) % at 2 months (P<0.001) with an associated redistribution of blood flow towards the nonoperative pulmonary artery (r>0.523; P<0.010). On postoperative Day 2, impaired right ventricular ejection fraction was associated with increased operative pulmonary artery wave reflection (r=-0.480; P=0.028) and pulmonary artery blood flow redistribution (r=-0.545; P=0.011). At 2 months, impaired right ventricular ejection fraction and right ventricular strain were associated with pulmonary artery blood flow redistribution (r=-0.634, P=0.002; r=0.540, P=0.017).

Conclusions: Pulsatile afterload increased after lung resection. The unilateral increase in operative pulmonary artery wave reflection resulted in redistribution of blood flow through the nonoperative pulmonary artery and was associated with right ventricular dysfunction.

Clinical trial registration: NCT01892800.

Keywords: afterload; cardiovascular magnetic resonance imaging; lobectomy; lung resection; right ventricle; strain; wave intensity analysis.

Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Figures

Fig 1
Fig 1
Summary of wave intensity analysis methodology. a. Cardiovascular MRI, central image display mapping scan for the left and right (operative and non-operative) pulmonary arteries with cross section of each artery displayed on either side. b. Flow Q and area A plots generated after analysis of pulmonary artery. c. Wave intensity (dQ×dA) is plotted by the blue line with the forward compression wave area (FCW; purple) and backward compression wave area (BCW; green) highlighted with calculation of wave reflection index (WRI) demonstrated. Indicative images from patient in study.
Fig 2
Fig 2
Representative example of the wave intensity analysis changes after lung resection. Wave intensity analysis plots are displayed for the nonoperative (left column) and operative (right column) PAs, preoperatively (top row), on postoperative Day 2 (POD2; middle row), and at 2 months (bottom row). Net wave intensity is plotted by the blue line with the forward compression wave area (FCW; purple) and backward compression wave area (BCW; green) highlighted. Wave reflection index (WRI) and time to peak BCW results from the entire study population are noted on each plot. #Significant difference from preoperative, ¥Significant difference from POD2; both Wilcoxon signed-rank test. llSignificant difference from non-operative PA at same time point; Wilcoxon rank-sum test.

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Source: PubMed

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