Evaluation of elevated mean pulmonary arterial pressure based on magnetic resonance 4D velocity mapping: comparison of visualization techniques

Ursula Reiter, Gert Reiter, Gabor Kovacs, Aurelien F Stalder, Mehmet A Gulsun, Andreas Greiser, Horst Olschewski, Michael Fuchsjäger, Ursula Reiter, Gert Reiter, Gabor Kovacs, Aurelien F Stalder, Mehmet A Gulsun, Andreas Greiser, Horst Olschewski, Michael Fuchsjäger

Abstract

Purpose: Three-dimensional (3D) magnetic resonance phase contrast imaging (PC-MRI) allows non-invasive diagnosis of pulmonary hypertension (PH) and estimation of elevated mean pulmonary arterial pressure (mPAP) based on vortical motion of blood in the main pulmonary artery. The purpose of the present study was to compare the presence and duration of PH-associated vortices derived from different flow visualization techniques with special respect to their performance for non-invasive assessment of elevated mPAP and diagnosis of PH.

Methods: Fifty patients with suspected PH (23 patients with and 27 without PH) were investigated by right heart catheterization and time-resolved PC-MRI of the main pulmonary artery. PC-MRI data were visualized with dedicated prototype software, providing 3D vector, multi-planar reformatted (MPR) 2D vector, streamline, and particle trace representation of flow patterns. Persistence of PH-associated vortical blood flow (tvortex) was evaluated with all visualization techniques. Dependencies of tvortex on visualization techniques were analyzed by means of correlation and receiver operating characteristic (ROC) curve analysis.

Results: tvortex values from 3D vector visualization correlated strongly with those from other visualization techniques (r = 0.98, 0.98 and 0.97 for MPR, streamline and particle trace visualization, respectively). Areas under ROC curves for diagnosis of PH based on tvortex did not differ significantly and were 0.998 for 3D vector, MPR vector and particle trace visualization and 0.999 for streamline visualization. Correlations between elevated mPAP and tvortex in patients with PH were r = 0.96, 0.93, 0.95 and 0.92 for 3D vector, MPR vector, streamline and particle trace visualization, respectively. Corresponding standard deviations from the linear regression lines ranged between 3 and 4 mmHg.

Conclusion: 3D vector, MPR vector, streamline as well as particle trace visualization of time-resolved 3D PC-MRI data of the main pulmonary artery can be employed for accurate vortex-based diagnosis of PH and estimation of elevated mPAP.

Conflict of interest statement

Competing Interests: GR, AFS, and AG are employed by Siemens Healthcare, MAG is employee of Siemens Medical Cooperate Research. This does not alter the authors’ adherence to all the PLOS ONE policies on sharing data and materials. All authors have declared that no competing interests exist.

Figures

Figure 1. PH-associated vortical blood flow in…
Figure 1. PH-associated vortical blood flow in the main pulmonary artery (MPA) in 3D vector (A), MPR vector (B), streamline (C) and particle trace (D) visualization together with schematic drawings of identification criteria of this flow pattern in 3D vector (E), MPR vector (F), streamline (G) and particle trace (H) visualization.
PV: pulmonary valve, RV: right ventricle.
Figure 2. Bland-Altman plots of vortex duration…
Figure 2. Bland-Altman plots of vortex duration (tvortex) determined from MPR vector (A), streamline (B) and particle trace (C) visualization compared to tvortex determined by 3D vector visualization for all patients (n = 50).
SD denotes standard deviation of measurement differences.
Figure 3. ROC curves for the diagnosis…
Figure 3. ROC curves for the diagnosis of manifest PH employing vortex duration (tvortex) determined from 3D vector, MPR vector, streamline and particle trace visualization.
Figure 4. Scatter plot and linear regression…
Figure 4. Scatter plot and linear regression lines of mPAP and vortex duration (tvortex) determined from 3D vector (A), MPR vector (B), streamline (C) and particle trace (D) visualization for patients with PH (n = 23).
Regression equations are to be understood in mmHg. SD denotes standard deviation from regression line.
Figure 5. Helical blood flow in the…
Figure 5. Helical blood flow in the main pulmonary artery mimicking PH-associated vortical blood flow in MPR vector representation (A).
The same perspective in 3D vector visualization is not interpreted as showing a PH-associated vortex (B). Rotation of perspective (C) indicates the helical character of the blood flow. RV: right ventricle, PV: pulmonary valve, MPA: main pulmonary artery.
Figure 6. Blood flow patterns in the…
Figure 6. Blood flow patterns in the main pulmonary artery of a patient with PH in streamline (A, B) and 3D vector visualization (C, D) in two consecutive systolic cardiac phases.
Onset of vertical blood flow tstart is defined later in streamline (B) than in 3D vector visualization (C). RV: right ventricle, PV: pulmonary valve, MPA: main pulmonary artery.

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