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Quantitative Dual-Energy Computed Tomography Predicts Regional Perfusion Heterogeneity in a Model of Acute Lung Injury. J Comput Assist Tomogr 2018; 42:866-872. [PMID: 30371620 PMCID: PMC6250290 DOI: 10.1097/rct.0000000000000815] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objective The aims of this study were to investigate the ability of contrast-enhanced dual-energy computed tomography (DECT) for assessing regional perfusion in a model of acute lung injury, using dynamic first-pass perfusion CT (DynCT) as the criterion standard and to evaluate if changes in lung perfusion caused by prone ventilation are similarly demonstrated by DECT and DynCT. Methods This was an institutional review board–approved study, compliant with guidelines for humane care of laboratory animals. A ventilator-induced lung injury protocol was applied to 6 landrace pigs. Perfused blood volume (PBV) and pulmonary blood flow (PBF) were respectively quantified by DECT and DynCT, in supine and prone positions. The lungs were segmented in equally sized regions of interest, namely, dorsal, middle, and ventral. Perfused blood volume and PBF values were normalized by lung density. Regional air fraction (AF) was assessed by triple-material decomposition DECT. Per-animal correlation between PBV and PBF was assessed with Pearson R. Regional differences in PBV, PBF, and AF were evaluated with 1-way analysis of variance and post hoc linear trend analysis (α = 5%). Results Mean correlation coefficient between PBV and PBF was 0.70 (range, 0.55–0.98). Higher PBV and PBF values were observed in dorsal versus ventral regions. Dorsal-to-ventral linear trend slopes were −10.24 mL/100 g per zone for PBV (P < 0.001) and −223.0 mL/100 g per minute per zone for PBF (P < 0.001). Prone ventilation also revealed higher PBV and PBF in dorsal versus ventral regions. Dorsal-to-ventral linear trend slopes were −16.16 mL/100 g per zone for PBV (P < 0.001) and −108.2 mL/100 g per minute per zone for PBF (P < 0.001). By contrast, AF was lower in dorsal versus ventral regions in supine position, with dorsal-to-ventral linear trend slope of +5.77%/zone (P < 0.05). Prone ventilation was associated with homogenization of AF distribution among different regions (P = 0.74). Conclusions Dual-energy computed tomography PBV is correlated with DynCT-PBF in a model of acute lung injury, and able to demonstrate regional differences in pulmonary perfusion. Perfusion was higher in the dorsal regions, irrespectively to decubitus, with more homogeneous lung aeration in prone position.
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Aoki T, Sugimura K, Tatebe S, Miura M, Yamamoto S, Yaoita N, Suzuki H, Sato H, Kozu K, Konno R, Miyata S, Nochioka K, Satoh K, Shimokawa H. Comprehensive evaluation of the effectiveness and safety of balloon pulmonary angioplasty for inoperable chronic thrombo-embolic pulmonary hypertension: long-term effects and procedure-related complications. Eur Heart J 2018; 38:3152-3159. [PMID: 29029023 DOI: 10.1093/eurheartj/ehx530] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 09/12/2017] [Indexed: 12/21/2022] Open
Abstract
Aims Although balloon pulmonary angioplasty (BPA) improves haemodynamics and short-term prognosis in patients with inoperable chronic thrombo-embolic pulmonary hypertension (CTEPH), the long-term effects of BPA, and procedure-related complications remain to be fully elucidated. Methods and results From July 2009 to October 2016, we performed a total of 424 BPA sessions in 84 consecutive patients with inoperable CTEPH. We used 3D reconstructed computed tomography to determine target lesions of pulmonary arteries and optical computed tomography to select balloon size, if needed. In 77 patients (92%) who completed the BPA treatment [65 ± 14 (SD) years-old, male/female 14/63], haemodynamics and exercise capacity were examined at 6 months after last BPA and in the chronic phase [>12 months after first BPA, 31 (20, 41) months]. The BPA treatment significantly improved mean pulmonary arterial pressure (38 ± 10 to 25 ± 6 mmHg), pulmonary vascular resistance (7.3 ± 3.2 to 3.8 ± 1.0 Wood units), and 6-minute walk distance (380 ± 138 to 486 ± 112 m) (all P < 0.01), and the improvements persisted throughout the follow-up period (43 ± 27 months) (N = 53). In the 424 sessions, haemoptysis was noted in 60 sessions (14%), and non-invasive positive pressure ventilation (NPPV) was used to treat haemoptysis and/or hypoxemia in 33 sessions (8%). Furthermore, 5-year survival was 98.4% (only one patient died of colon cancer) with no peri-procedural death. Conclusion These results indicate that BPA improves haemodynamics and exercise capacity in inoperable CTEPH patients with acceptable complication rate and that the beneficial haemodynamic effects of BPA persist for years with resultant good long-term prognosis.
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Affiliation(s)
- Tatsuo Aoki
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Koichiro Sugimura
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Shunsuke Tatebe
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Masanobu Miura
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Saori Yamamoto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Nobuhiro Yaoita
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Hideaki Suzuki
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Haruka Sato
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Katsuya Kozu
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Ryo Konno
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Satoshi Miyata
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Kotaro Nochioka
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Kimio Satoh
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
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Kandathil A, Kay F, Batra K, Saboo SS, Rajiah P. Advances in Computed Tomography in Thoracic Imaging. Semin Roentgenol 2018; 53:157-170. [PMID: 29861007 DOI: 10.1053/j.ro.2018.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Asha Kandathil
- Cardiothoracic Imaging, Radiology Department, UT Southwestern Medical Center, Dallas, TX
| | - Fernando Kay
- Cardiothoracic Imaging, Radiology Department, UT Southwestern Medical Center, Dallas, TX
| | - Kiran Batra
- Cardiothoracic Imaging, Radiology Department, UT Southwestern Medical Center, Dallas, TX
| | - Sachin S Saboo
- Cardiothoracic Imaging, Radiology Department, UT Southwestern Medical Center, Dallas, TX
| | - Prabhakar Rajiah
- Cardiothoracic Imaging, Radiology Department, UT Southwestern Medical Center, Dallas, TX.
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Masy M, Giordano J, Petyt G, Hossein-Foucher C, Duhamel A, Kyheng M, De Groote P, Fertin M, Lamblin N, Bervar JF, Remy J, Remy-Jardin M. Dual-energy CT (DECT) lung perfusion in pulmonary hypertension: concordance rate with V/Q scintigraphy in diagnosing chronic thromboembolic pulmonary hypertension (CTEPH). Eur Radiol 2018; 28:5100-5110. [PMID: 29846802 DOI: 10.1007/s00330-018-5467-2] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 03/29/2018] [Accepted: 04/09/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To evaluate the concordance between DECT perfusion and ventilation/perfusion (V/Q) scintigraphy in diagnosing chronic thromboembolic pulmonary hypertension (CTEPH). METHODS Eighty patients underwent V/Q scintigraphy and DECT perfusion on a 2nd- and 3rd-generation dual-source CT system. The imaging criteria for diagnosing CTEPH relied on at least one segmental triangular perfusion defect on DECT perfusion studies and V/Q mismatch on scintigraphy examinations. RESULTS Based on multidisciplinary expert decisions that did not include DECT perfusion, 36 patients were diagnosed with CTEPH and 44 patients with other aetiologies of PH. On DECT perfusion studies, there were 35 true positives, 6 false positives and 1 false negative (sensitivity 0.97, specificity 0.86, PPV 0.85, NPV 0.97). On V/Q scans, there were 35 true positives and 1 false negative (sensitivity 0.97, specificity 1, PPV 1, NPV 0.98). There was excellent agreement between CT perfusion and scintigraphy in diagnosing CTEPH (kappa value 0.80). Combined information from DECT perfusion and CT angiographic images enabled correct reclassification of the 6 false positives and the unique false negative case of DECT perfusion. CONCLUSION There is excellent agreement between DECT perfusion and V/Q scintigraphy in diagnosing CTEPH. The diagnostic accuracy of DECT perfusion is reinforced by the morpho-functional analysis of data sets. KEY POINTS • Chronic thromboembolic pulmonary hypertension (CTEPH) is potentially curable by surgery. • The triage of patients with pulmonary hypertension currently relies on scintigraphy. • Dual-energy CT (DECT) can provide standard diagnostic information and lung perfusion from a single acquisition. • There is excellent agreement between DECT perfusion and scintigraphy in separating CTEPH and non-CTEPH patients.
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Affiliation(s)
- Matthieu Masy
- Department of Thoracic Imaging, Calmette Hospital (EA 2694); CHRU et Université de Lille 2 Nord de France, F-59000, Lille, France
| | - Jessica Giordano
- Department of Thoracic Imaging, Calmette Hospital (EA 2694); CHRU et Université de Lille 2 Nord de France, F-59000, Lille, France
| | - Grégory Petyt
- Department of Nuclear Medicine; Salengro Hospital, University of Lille, CHU Lille, F-59000, Lille, France
| | - Claude Hossein-Foucher
- Department of Nuclear Medicine; Salengro Hospital, University of Lille, CHU Lille, F-59000, Lille, France
| | - Alain Duhamel
- Department of Biostatistics (EA 2694), CHRU et Université de Lille 2 Nord de France, F-59000, Lille, France
| | - Maeva Kyheng
- Department of Biostatistics (EA 2694), CHRU et Université de Lille 2 Nord de France, F-59000, Lille, France
| | - Pascal De Groote
- Department of Cardiology; Cardiology Hospital, University of Lille, CHU Lille, F-59000, Lille, France
- INSERM U1167, Institut Pasteur de Lille, F-59000, Lille, France
| | - Marie Fertin
- Department of Cardiology; Cardiology Hospital, University of Lille, CHU Lille, F-59000, Lille, France
- INSERM U1167, Institut Pasteur de Lille, F-59000, Lille, France
| | - Nicolas Lamblin
- Department of Cardiology; Cardiology Hospital, University of Lille, CHU Lille, F-59000, Lille, France
- INSERM U1167, Institut Pasteur de Lille, F-59000, Lille, France
| | - Jean-François Bervar
- Department of Pulmonology, Calmette Hospital; University of Lille, CHU Lille, F-59000, Lille, France
| | - Jacques Remy
- Department of Thoracic Imaging, Calmette Hospital (EA 2694); CHRU et Université de Lille 2 Nord de France, F-59000, Lille, France
| | - Martine Remy-Jardin
- Department of Thoracic Imaging, Calmette Hospital (EA 2694); CHRU et Université de Lille 2 Nord de France, F-59000, Lille, France.
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Bortz G, Germano NG, Cogo-Moreira H. (Dis)agreement on Sight-Singing Assessment of Undergraduate Musicians. Front Psychol 2018; 9:837. [PMID: 29896144 PMCID: PMC5987045 DOI: 10.3389/fpsyg.2018.00837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/09/2018] [Indexed: 11/25/2022] Open
Abstract
Assessment criteria for sight-singing abilities are similar to those used to judge music performances across music school programs. However, little evidence of agreement among judges has been provided in the literature. Fifty out of 152 participants were randomly selected and blindly assessed by three judges, who evaluated students based on given criteria. Participants were recorded while sight-singing 19 intervals and 10 tonal melodies. Interjudge agreement on melodic sight-singing was tested considering four items in a five-point Likert scale format as follows: (1) Intonation and pitch accuracy; (2) Tonal sense and memory; (3) Rhythmic precision, regularity of pulse and subdivisions; (4) Fluency and music direction. Intervals were scored considering a 3-point Likert scale. Agreement was conducted using weighted kappa. For melodic sight-singing considering the ten tonal melodies, on average, the weighted kappa (κw) were: κ1w = 0.296, κ2w = 0.487, κ3w = 0.224, and κ4w = 0.244, ranging from fair to moderate.. For intervals, the lowest agreement was kappa = 0.406 and the highest was kappa = 0.792 (on average, kappa = 0.637). These findings light up the discussion on the validity and reliability of models that have been taken for granted in assessing music performance in auditions and contests, and illustrate the need to better discuss evaluation criteria.
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Affiliation(s)
- Graziela Bortz
- Department of Music, Universidade Estadual Paulista Júlio de Mesquita Filho, São Paulo, Brazil
| | - Nayana G. Germano
- Department of Music, Universidade Estadual Paulista Júlio de Mesquita Filho, São Paulo, Brazil
| | - Hugo Cogo-Moreira
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
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Treatment Effect of Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Hypertension Quantified by Automatic Comparative Imaging in Computed Tomography Pulmonary Angiography. Invest Radiol 2018; 53:286-292. [DOI: 10.1097/rli.0000000000000441] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Li M, Wang S, Lin W, Li J, Wang C, Chen H, Lu W, Yang K, Wang J, Zeng Q. Cardiovascular parameters of chest CT scan in estimating pulmonary arterial pressure in patients with pulmonary hypertension. THE CLINICAL RESPIRATORY JOURNAL 2018; 12:572-579. [PMID: 27696745 DOI: 10.1111/crj.12564] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 09/03/2016] [Accepted: 09/17/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To develop a formula to compute mean pulmonary arterial pressure (MPAP) by chest computerized tomography (CT), and to verify its accuracy and reliability. METHODS Eighty-five patients who had taken chest CT and right heart catheterization (RHC) were recruited. The pulmonary arterial systolic pressure (PASP), pulmonary arterial diastolic pressure (PADP), and MPAP of each subject were measured and recorded by RHC. The diameters of the ascending aorta (dAA), descending aorta (dDA) and main pulmonary artery (dMPA), Cobb angle, diameters of right ventricle (dRV), diameters of left ventricle (dLV) were measured by means of chest CT scans. Systolic blood pressure (SBP) was measured by using electronic sphygmomanometer. A linear regression equation was generated in 56 patients to estimate PAP based on chest CT values, 29 patients were used to test the accuracy of the formula. RESULTS The computed equation for analyzing MPAP is: MPAP = 9.011 + 34.195 × dMPA/dAA - 0.319 × SBP + 0.402 × Cobb angle. AUC of equation with three variables (dMPA/dAA, SBP, and Cobb angle) was 0.923 with 95% CI (0.863-0.982). The mean ± SD of predicted values and RHC values had no statistical difference. CONCLUSIONS Ratio of dMAP/dAA, Cobb angle, and SBP can be reliably used to estimate MPAP and predict severity of PH.
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Affiliation(s)
- Mengxi Li
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
- Ningbo Yinzhou Peoples' Hospital (The Affiliated Yinzhou Hospital of School of Medicine of Ningbo University), Ningbo, Zhejiang, China
| | - Shouyang Wang
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
- The first affiliated hospital of Shantou University Medical College, Shantou, China
| | - Weiquan Lin
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
- Guangzhou Center for Disease Control and Prevention, Guangzhou, Guangdong, China
| | - Jinhui Li
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
- The Affiliated Hospital of School of Medicine of Ningbo University, Ningbo, Zhejiang, China
| | - Chunyang Wang
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
- The first affiliated hospital of Shantou University Medical College, Shantou, China
| | - Huai Chen
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Wenju Lu
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Kai Yang
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
- State Key Laboratory of Protein and Plant Gene Research, School of Life Sciences, Peking University, Beijing, China
| | - Jian Wang
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
- Department of Medicine/Pulmonary, Johns Hopkins University, Baltimore, Maryland, USA
| | - Qingsi Zeng
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
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Ota H, Higuchi S, Sun W, Ueda T, Takase K, Tamura H. Four-Dimensional Flow Magnetic Resonance Imaging for Cardiovascular Imaging: from Basic Concept to Clinical Application. ACTA ACUST UNITED AC 2018. [DOI: 10.22468/cvia.2018.00045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Hideki Ota
- Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan
| | - Satoshi Higuchi
- Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan
| | - Wenyu Sun
- Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan
| | - Takuya Ueda
- Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan
| | - Kei Takase
- Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan
| | - Hajime Tamura
- Division of Medical Physics, Tohoku University Graduate School of Medicine, Sendai, Japan
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is one of the potentially curable causes of pulmonary hypertension and is definitively treated with pulmonary thromboendartectomy. CTEPH can be overlooked, as its symptoms are nonspecific and can be mimicked by a wide range of diseases that can cause pulmonary hypertension. Early diagnosis of CTEPH and prompt evaluation for surgical candidacy are paramount factors in determining future outcomes. Imaging plays a central role in the diagnosis of CTEPH and patient selection for pulmonary thromboendartectomy and balloon pulmonary angioplasty. Currently, various imaging tools are used in concert, with techniques such as computed tomography (CT) and conventional pulmonary angiography providing detailed structural information, tests such as ventilation-perfusion (V/Q) scanning providing functional data, and magnetic resonance imaging providing a combination of morphologic and functional information. Emerging techniques such as dual-energy CT and single photon emission computed tomography-CT V/Q scanning promise to provide both anatomic and functional information in a single test and may change the way we image these patients in the near future. In this review, we discuss the roles of various imaging techniques and discuss their merits, limitations, and relative strengths in depicting the structural and functional changes of CTEPH. We also explore newer imaging techniques and the potential value they may offer.
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Gopalan D, Delcroix M, Held M. Diagnosis of chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2017; 26:26/143/160108. [PMID: 28298387 DOI: 10.1183/16000617.0108-2016] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 01/10/2017] [Indexed: 12/19/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is the only potentially curable form of pulmonary hypertension. Rapid and accurate diagnosis is pivotal for successful treatment. Clinical signs and symptoms can be nonspecific and risk factors such as history of venous thromboembolism may not always be present. Echocardiography is the recommended first diagnostic step. Cardiopulmonary exercise testing is a complementary tool that can help to identify patients with milder abnormalities and chronic thromboembolic disease, triggering the need for further investigation. Ventilation/perfusion (V'/Q') scintigraphy is the imaging methodology of choice to exclude CTEPH. Single photon emission computed tomography V'/Q' is gaining popularity over planar imaging. Assessment of pulmonary haemodynamics by right heart catheterisation is mandatory, although there is increasing interest in noninvasive haemodynamic evaluation. Despite the status of digital subtraction angiography as the gold standard, techniques such as computed tomography (CT) and magnetic resonance imaging are increasingly used for characterising the pulmonary vasculature and assessment of operability. Promising new tools include dual-energy CT, combination of rotational angiography and cone beam CT, and positron emission tomography. These innovative procedures not only minimise misdiagnosis, but also provide additional vascular information relevant to treatment planning. Further research is needed to determine how these modalities will fit into the diagnostic algorithm for CTEPH.
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Affiliation(s)
- Deepa Gopalan
- Imperial College Hospitals, London, UK.,Cambridge University Hospital, Cambridge, UK
| | | | - Matthias Held
- Medical Mission Hospital, Dept of Internal Medicine, Center for Pulmonary Hypertension and Pulmonary Vascular Disease, Academic Teaching Hospital, Julius-Maximilian University of Würzburg, Würzburg, Germany
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