Guidelines summarize and evaluate available evidence with the aim of assisting health professionals in proposing the best management strategies for an individual patient with a given condition. Guidelines and their recommendations should facilitate decision making of health professionals in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.
Background Chronic thromboembolic pulmonary hypertension (CTEPH), a complication of acute pulmonary embolism, is a potentially curable form of pulmonary hypertension (PH). CTEPH is under-diagnosed for a number of reasons leading to delayed referral or missed diagnosis; however, the frequency of misdiagnosis of CTEPH findings on computed tomography (CT) is currently unknown. Purpose To evaluate the extent of misdiagnosis of CTEPH on CT. Material and Methods We studied the original CT reports from 35 patients with confirmed CTEPH diagnosis referred to a specialist center for pulmonary endarterectomy during 2011–2016. The patients’ CT reports were assessed according to a standardized form and compared to a consensus reading by two expert radiologists. Results The expert reading identified all CTEPH cases. However, in the original reports, the terminology “CTEPH” was only used in two patients. Another seven descriptive reports picked up the combination of PH and vascular signs of CTEPH without making a definitive diagnosis. Taking these nine cases as positive for CTEPH, the overall sensitivity on a diagnostic level was 26%. Pulmonary arterial abnormalities were described in isolation in 63% with no mention of PH or CTEPH. Signs of PH and mosaic attenuation were documented in 53% and 6% of the original reports, respectively, where it could be seen on the CT examination. Conclusion The study shows that radiologists frequently miss CTEPH findings, leading to a falsely low sensitivity for CT. There was also a notable discrepancy in how the findings were presented in radiology reports.
A compelling body of evidence points to pulmonary thrombosis and thromboembolism as a key feature of COVID-19. As the pandemic spread across the globe over the past few months, a timely call to arms was issued by a team of clinicians to consider the prospect of long-lasting pulmonary fibrotic damage and plan for structured follow-up. However, the component of post-thrombotic sequelae has been less widely considered. Although the long-term outcomes of COVID-19 are not known, should pulmonary vascular sequelae prove to be clinically significant, these have the potential to become a public health problem. In this Personal View, we propose a proactive follow-up strategy to evaluate residual clot burden, small vessel injury, and potential haemodynamic sequelae. A nuanced and physiological approach to follow-up imaging that looks beyond the clot, at the state of perfusion of lung tissue, is proposed as a key triage tool, with the potential to inform therapeutic strategies.
A 52-year-old woman with atopic asthma and a long smoking habit underwent CT pulmonary angiography (CTPA) for investigation of atypical, pleuritic chest pain. There was no history of heart disease or cardiovascular risk factors. As per usual practice for non-cardiac imaging, CTPA was performed without ECG gating. While there was no pulmonary embolism, CT showed an apparent large left atrial filling defect (arrows), demonstrated in axial ( Panel A …
Background: Chronic thromboembolism is an under-recognised cause of pulmonary hypertension but pulmonary endarterectomy (PEA) can be curative. Thromboembolic disease distribution/PEA success primarily determines prognosis but risk scoring criteria may be adjunctive. Right ventriculo-arterial (RV-PA) and ventriculo-atrial (RV-RA) coupling may be evaluated by cardiac MRI (CMR) feature tracking deformation/strain assessment. We characterized biatrial and biventricular CMR FT strain parameters following PEA, and tested the ability of CMR FT to identify REVEAL 2.0 high risk status.Methods: Retrospective single centre cross-sectional study of patients (n=57) who underwent PEA (2015-2020). Patients were arbitrarily dichotomized into good and poor responders by post-operative VO2 peak (> or < 11.4 mL O2/min/kg). Pulmonary arterial hypertension validated risk scores were calculated for all.Results: Pre-operative hemodynamic and imaging parameters were similar between groups. Post-operative LVEF was alike between groups (median 62%; p=0.221) but LV global longitudinal strain/GLS was disparate (good responders -16.5 + 2.8% vs poor responders -13.7 + 3.9%; p=0.003). Biatrial volumes were comparable between groups post-operatively but biatrial peak strain was significantly impaired in poor responders. Poor responders had persistently uncoupled RV-PA (RV strain -14.3 + 4.8%) and RV-RA (RA strain 15.1 + 7.6%) relationships but these recovered in good responders (RV strain -17.8 + 3.6%, RA strain 20.5 + 6.3%; both p < 0.05 vs poor). Post-operatively, there were 6 REVEAL 2.0 high risk patients, best predicted by impaired RA strain (AUC 0.99 vs RVEF AUC 0.88).Conclusion: CMR deformation/strain evaluation may offer insights into coupling recovery and enhance risk stratification beyond volumetric assessment.
A 38-year-old woman with a 6-month history of breathlessness and intermittent central chest pain was referred for an ECG-gated cardiac CT examination. This excluded significant coronary artery disease, but revealed an unexpected extracardiac finding. The left pulmonary artery had an anomalous origin from the right main pulmonary artery and was seen to hook around and compress the right main bronchus before crossing to the left of the midline between the trachea and oesophagus to form a ring (fig 1). In addition, CT showed the proximal oesophagus to be mildly dilated (fig 2). The patient did not report any dysphagia on further questioning. Volume-rendered …
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