Search

Backgrounds: A soluble guanylyl cyclase stimulator vericiguat has been shown to reduce cardiovascular mortality or hospitalization for heart failure in patients with worsening heart failure in the VICTORIA study. However, little is known about the effects of vericiguat on biventricular structure and function., Methods and Results: A retrospective analysis of 63 consecutive patients with heart failure with reduced ejection fraction (HFrEF) who were treated with vericiguat was performed. Clinical data and echocardiographic parameters were compared between baseline and follow-up after the initiation of vericiguat. The median follow-up duration was 266 days. Treatment with vericiguat significantly reduced the plasma BNP levels (log-transformed) compared to baseline (2.46 ± 0.51 vs. 2.14 ± 0.58, p < 0.0001). Left ventricular end-diastolic volume index and left ventricular end-systolic volume index were significantly reduced (LVEDVI, 113.5 ± 46.3 vs. 103.6 ± 51.0, p = 0.0056; LVESVI, 82.0 ± 41.9 vs. 72.8 ± 44.7, p = 0.0077; respectively). The tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP) ratio, an indicator of right ventricle-pulmonary artery (RV-PA) coupling, increased significantly after the treatment (0.56 ± 0.29 vs. 0.92 ± 1.09, p < 0.0001). Univariate and multivariate analyses showed that the treatment effects of vericiguat on BNP levels, LV reverse remodeling, and RV-PA coupling were not correlated with the achievement of the quadruple therapy with beta-blockers, renin-angiotensin system inhibitors, mineralocorticoid inhibitors, and sodium-glucose cotransporter-2 inhibitors, nor with worsening heart failure (WHF)., Conclusion: Treatment with vericiguat improved adverse LV remodeling and RV-PA uncoupling in HFrEF patients. These effects were independent of WHF and achieving the quadruple therapy. Patients with HFrEF may benefit from early initiation of vericiguat to prevent biventricular adverse remodeling., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: Vascular endothelial growth factor is a signaling protein created by cells performing important bodily functions. Vascular endothelial growth factor is abundant in the lung, and plasma levels are elevated in patients with severe pulmonary arterial hypertension. An association between soluble urokinase plasminogen activator receptor, an inflammatory biomarker, and soluble urokinase plasminogen activator receptor levels and interstitial pulmonary and vascular involvement (e.g., development of pulmonary hypertension) has been shown in SSc patients. The tricuspid annular plane systolic excursion/systolic pulmonary artery pressure ratio, which has been recommended as a useful diagnostic tool in the last guideline, is one of the additional echocardiographic signs suggestive of pulmonary hypertension. We aimed to examine whether these biomarkers contribute to the diagnosis and management of pulmonary hypertension., Methods: Patients with group E chronic obstructive lung disease were included in this prospective study. Demographic data, echocardiographic signs about the right ventricle (right atrium area, tricuspid annular plane systolic excursion/systolic pulmonary artery pressure, fractional area change, and right ventricular outflow tract), and peripheral blood analysis were examined and recorded., Results: A total of 70 patients, 12 of whom were female, were analyzed in the study. The mean age was 66.6±8.7 years. The mean vascular endothelial growth factor-A and soluble urokinase plasminogen activator receptor were 91.05±70.7 and 955.8±571.1, and their Pearson correlation coefficients between vascular endothelial growth factor-A and tricuspid annular plane systolic excursion/systolic pulmonary artery pressure, and soluble urokinase plasminogen activator receptor and tricuspid annular plane systolic excursion/systolic pulmonary artery pressure ratio were 0.341 (p=0.004) and -0.045 (p=0.70), respectively. The linear regression model included four variables with significant correlation (vascular endothelial growth factor-A, right atrium area, fractional area change, and right ventricular outflow tract). Three steps were performed, and adjusted r2 was 0.22, 0.22, 0.20, and p<0.001 for each step. Vascular endothelial growth factor-A and right ventricular outflow tract remained in the last step. It was detected a standardized coefficient beta of 0.322 (p=0.004) and a 95%CI 0.000-0.001 for vascular endothelial growth factor-A., Conclusion: Vascular endothelial growth factor-A is correlated with the tricuspid annular plane systolic excursion/systolic pulmonary artery pressure ratio and not with soluble urokinase plasminogen activator receptor.

Background: Endurance training enhances exercise capacity and triggers cardiovascular adaptations in both males and females. We investigated the relationship between the dimensions of great vessels and exercise capacity in amateur cyclists while considering sex differences., Methods: Using resting transthoracic echocardiography, we measured the dimensions of the main pulmonary artery (PA), aorta, and inferior vena cava (IVC) in 190 participants, who subsequently underwent a cardiopulmonary exercise test (CPET) until exhaustion., Results: The mean age of study participants was 30 years. Males (71%) exhibited a larger aortic annulus (approximately 3.5 mm, p<0.0001) and PA diameter (2.4 mm, p<0.0001) than females. No significant sex differences were found in expiratory or inspiratory IVC diameters. Males achieved greater peak exercise capacity, including workload, O2 consumption (VO2), and O2 pulse. Aortic and PA dimensions showed strong correlations with energy expenditure, workload, VO2, and O2 pulse. However, these correlations weakened when analyzed separately by sex. Multivariate linear regression revealed associations between CPET results, vessels size, and sex, with sex differences observed only in the intercepts-not in interactions between sex and vessels size. Despite males having better CPET results and larger vessels, the relationships between peak exercise capacity parameters and vessel dimensions were similar in both sexes., Conclusion: Larger vessel dimensions (of the aorta, PA, and IVC) were associated with greater peak exercise capacity in amateur cyclists, with no significant sex differences in these associations., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: This study and the Open Access article publication charges was partially funded by the budget for the Project "Development of the University Centre for Sports and Medical Studies in Poznan, Poland" (Number: NdS/544750/2021/2022) with Principal Investigator Prof. Przemysław Guzik. The Ministry of Education and Science, Warsaw, Poland, funded the Project within the "Science for Society" Program. The funding for this scientific work was partially provided by the budget for the science of The Polish Ministry of Science and Higher Education as a research project of the program "Diamond Grant" (0184/DIA/2020/49). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ’Author Contributions’ Section. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Pytka et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: The ratio between tricuspid annular plane systolic excursion (TAPSE) and estimated pulmonary artery systolic pressure (PASP) has been shown to be a reliable, non-invasive surrogate of the right ventricular-pulmonary artery (RV-PA) coupling. The present study analysed the association between TAPSE/PASP and response to cardiac resynchronization therapy (CRT) and the prognostic role of RV-PA in patients undergoing CRT implantation. The primary endpoints were: the association between baseline TAPSE/PASP and CRT response/cardiovascular and all-cause death., Methods and Results: All patients having undergone CRT implantation in our Center from 2016 to 2020 were included in our retrospective analysis. The RV-PA coupling was assessed by echocardiography at baseline and 1 year follow up in CRT recipients. The cut-off value of TAPSE/PASP resulted from ROC curve analysis (i.e.<0.33 mm/mmHg). A total of 229 patients (age 69.9 ± 10.1 years; 77.7% men) were included. During a mean follow-up of 44.2 ± 17.9 months, 40 (17.5%) patients died. The baseline value of TAPSE/PASP was not significantly associated with CRT response. Patients with a more impaired TAPSE/PASP ratio had significantly worse survival rates. On multivariate Cox regression, only TAPSE/PASP ratio and estimated glomerular filtration rate were independently associated with all-cause death. Finally, the TAPSE/PASP ratio significantly increased after CRT implantation in the group of "responders" whereas it did not change in 'non-responders'., Conclusions: The baseline value of TAPSE/PASP ratio was not associated with CRT response. However, the TAPSE/PASP ratio was a strong predictor of both all-cause and cardiovascular death in CRT recipients., Competing Interests: Declarations Competing interests The authors report no relationships that could be construed as a conflict of interest., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Objectives: To investigate the short-term/long-term impact of pulmonary artery intramural hematoma (PA-IMH) in patients with acute Stanford type A aortic dissection (ATAAD) following surgical repair., Materials and Methods: Consecutive patients with ATAAD who received surgical repair at Beijing and Yunnan Fuwai Hospital in 2010-2021 were retrospectively reviewed. Patients with hemorrhage extending along the PA were identified as the PA-IMH group. Multivariable logistics regression was used to obtain the odds ratio (OR), and the Kaplan-Meier method was used to estimate the survival rate., Results: Of the 2046 ATAAD patients, 324 (15.8%) patients were identified with PA-IMH, and 1722 (84.2%) were without PA-IMH. PA-IMH had a higher prevalence in patients with older age, female gender, aortic IMH, and type II aortic dissection. PA-IMH patients incurred excess early mortality compared with non-PA-IMH patients (9.3% vs. 5.6%, OR = 1.86, 95%CI 1.19-2.91, p = 0.006). The results were stable in the subgroup analysis, with an increased risk in older (> 70 years) or DeBakey type II ATAAD patients. Notably, an increase in the degree and extent of PA-IMH exacerbated the risk of early mortality. However, after landmark analysis at 30-day postsurgery, no significant difference was noted in the long-term outcomes between PA-IMH and non-PA-IMH groups (p = 0.440). The 5-year survival rates were 87.1% (95%CI: 83.3%, 91.1%) and 90.1% (95%CI: 88.5%, 91.7%), respectively., Conclusions: The presence of PA-IMH in ATAAD patients is common and is independently associated with increased early mortality after surgical repair, especially in those with older age (> 70) or type II dissection. However, such detrimental effects do not persist in the long-term follow-up among patients who survived hospital discharge., Clinical Relevance Statement: We confirmed that PA-IMH significantly increases early postoperative mortality in patients with acute type A aortic dissection, especially in older patients or DeBakey type II dissection. This should prompt further investigation of the incremental role of PA-IMH in this pathology., Key Points: Acute type A aortic dissection mortality gets worse when pulmonary artery intramural hematoma is present. Pulmonary artery-intramural hematoma increased the risk of early mortality but not affect long-term prognosis. Further research should investigate the effects of pulmonary artery intramural thrombus on aortic dissection., (© 2024. The Author(s), under exclusive licence to European Society of Radiology.)

To preliminarily verify the feasibility of a deep-learning (DL) artificial intelligence (AI) model to localize pulmonary embolism (PE) on unenhanced chest-CT by comparison with pulmonary artery (PA) CT angiography (CTA). In a monocentric study, we retrospectively reviewed 99 oncological patients (median age in years: 64 (range: 28-92 years); percentage of female: 39.4%) who received unenhanced and contrast-enhanced chest CT examinations in one session between January 2020 and October 2022 and who were diagnosed incidentally with PE. Findings in the unenhanced images were correlated with the contrast-enhanced images, which were considered the gold standard for central, segmental and subsegmental PE. The new algorithm was trained and tested based on the 99 unenhanced chest-CT image data sets. Based on them, candidate boxes, which were output by the model, were post-processed by evaluating whether the predicted box intersects with the patient's lung segmentation at any position. The AI-based algorithm proved to have an overall sensitivity of 54.5% for central, of 81.9% for segmental and 80.0% for subsegmental PE if taking n = 20 candidate boxes into account. Depending on the localization of the pulmonary embolism, the detection rate for only one box was: 18.1% central, 34.7% segmental and 0.0% subsegmental. The median volume of the clots differed significantly between the three subgroups and was 846.5 mm 3 (IQR:591.1-964.8) in central, 201.3 mm 3 (IQR:98.3-390.9) in segmental and 110.6 mm 3 (IQR:94.3-128.0) in subsegmental PA (p < 0.05). The new algorithm proved to have high sensitivity in detecting PE in particular in segmental/subsegmental localization and may guide to decide whether a second contrast enhanced CT is necessary., Competing Interests: Declarations Competing interests Linda Vorberg, Florian Thamm and Hendrik Ditt are/were employees of Siemens Healthcare., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Assessment of the pattern of the RV outflow tract Doppler provides insights into the hemodynamics of chronic thromboembolic pulmonary hypertension (CTEPH). We studied whether pre-operative assessment of timing of the pulmonary flow systolic notch by Doppler echocardiography is associated with long-term survival after pulmonary endarterectomy (PEA) for CTEPH., Methods: Fifty-nine out of 61 consecutive CETPH patients (mean age 53 ± 14 years, 34% male) whom underwent PEA between June 2002 and June 2005 were studied. Clinical, echocardiographic and hemodynamic variables were assessed pre-operatively and repeat echocardiography was performed 3 months after PEA. Notch ratio (NR) was assessed with pulsed Doppler and calculated as the time from onset of pulmonary flow until notch divided by the time from notch until end of pulmonary flow. Long-term follow-up was obtained between May 2021 and February 2022., Results: Pre-operative mean pulmonary artery pressure (mPAP) was 45 ± 15 mmHg and pulmonary vascular resistance (PVR) was 646 ± 454 dynes.s.cm-5. Echocardiography before PEA showed that 7 patients had no notch, 33 had a NR < 1.0 and 19 had a NR > 1.0. Three months after PEA, echocardiography revealed a significant decrease in sPAP in long-term survivors with a NR < 1.0 and a NR > 1.0, while a significant increase in TAPSE/sPAP was only observed in the NR < 1.0 group. Mean long-term clinical follow-up was 14 ± 6 years. NR was significantly different between survivors and non-survivors (0.73 ± 0.25 vs. 1.1 ± 0.44, p < 0.001) but no significant differences were observed in mPAP or PVR. Long-term survival at 14 years was significantly better in patients with a NR < 1.0 compared to patients with a NR > 1.0 (83% vs. 37%, p =  < 0.001)., Conclusion: Pre-operative assessment of NR is a predictor of long-term survival in CTEPH patients undergoing PEA, with low mortality risk in patients with NR < 1.0. Long-term survivors with a NR < 1.0 and NR > 1.0 had a significant decrease in sPAP after PEA. However, the TAPSE/sPAP only significantly increased in the NR < 1.0 group. In the NR < 1.0 group, the 6-min walk test increased significantly between pre-operative and at 1-year post-operative follow-up. NR is a simple echocardiographic parameter that can be used in clinical decision-making for PEA., (© 2024. The Author(s).)

Objectives: To investigate the potential utility of [ 18 F]fibroblast activation protein inhibitor (FAPI) positron emission tomography/computed tomography (PET/CT) for evaluating pulmonary artery (PA) masses, and compare it with [ 18 F]fluorodeoxyglucose (FDG) PET/CT., Methods: Participants with clinically suspected PA malignancy were prospectively enrolled and underwent dual-tracer PET/CT ([ 18 F]FAPI-42 and [ 18 F]FDG) imaging. Visual analysis and semi-quantitative parameters were compared between the two types of radiotracers. The tissue specimen underwent immunohistochemical staining to verify FAP expression in the tissue., Results: Thirty-three patients (18 males/15 females; mean age 53.1 ± 15.4 years) were enrolled. All 21 patients with malignant PA masses were FDG-positive (100%), whereas 20 out of 21 patients were FAPI-positive (95.2%). All 12 patients with benign PA masses were both negative in FDG and FAPI PET. The mean maximum standardized uptake value (SUVmax) and target-to-background ratio (TBR) of FAPI and FDG in malignant PA masses were significantly higher than those of benign masses. Although there was no significant difference in SUVmax between FDG and FAPI in malignant PA masses (11.36 vs. 9.18, p = 0.175), the TBR (liver) and TBR (left ventricle) were more favorable for FAPI than for FDG (13.04 vs. 5.17, p < 0.001); (median: 7.75 vs. 2.75, p = 0.007). Immunohistochemical analysis (n = 16) validated that the level of FAP expression corresponded strongly to the uptake of FAPI in PET/CT scans (r s  = 0.712, p = 0.002). For clinical management, FAPI PET found more metastatic lesions than FDG PET in 4 patients, with 2 patients upgrading and 1 patient changing treatment decisions., Conclusions: FAPI PET/CT is feasible in the diagnosis of PA masses. Although not superior to FDG PET/CT, FAPI PET/CT showed better target-to-background contrast., Clinical Relevance Statement: This study found that FAPI PET/CT is not superior to FDG PET/CT in diagnosing PA masses, but FAPI PET/CT displays better target-to-background contrast and more positive lesions, which may help improve disease management., Key Points: Pulmonary malignancies lack specificity in clinical manifestations, laboratory tests, and routine imaging examinations. FAPI PET/CT is not diagnostically better than FDG PET/CT but displays better target-to-background contrast and more positive lesions. Dual-tracer PET/CT ([ 18 F]FAPI-42 and [ 18 F]FDG) imaging improves clinical management of pulmonary artery masses., (© 2024. The Author(s), under exclusive licence to European Society of Radiology.)

Rationale: Quantitative interstitial abnormalities (QIAs) are a computed tomography (CT) measure of early parenchymal lung disease associated with worse clinical outcomes, including exercise capacity and symptoms. The presence of pulmonary vasculopathy in QIAs and its role in the QIA-outcome relationship is unknown. Objectives: To quantify radiographic pulmonary vasculopathy in QIAs and determine whether this vasculopathy mediates the QIA-outcome relationship. Methods: Ever-smokers with QIAs, outcomes, and pulmonary vascular mediator data were identified from the Genetic Epidemiology of COPD (COPDGene) study cohort. CT-based vascular mediators were right ventricle-to-left ventricle ratio, pulmonary artery-to-aorta ratio, and preacinar intraparenchymal arterial dilation (pulmonary artery volume, 5-20 mm 2 in cross-sectional area, normalized to total arterial volume). Outcomes were 6-minute walk distance and a modified Medical Council Research Council Dyspnea Scale score of 2 or higher. Adjusted causal mediation analyses were used to determine whether the pulmonary vasculature mediated the QIA effect on outcomes. Associations of preacinar arterial dilation with select plasma biomarkers of pulmonary vascular dysfunction were examined. Measurements and Main Results: Among 8,200 participants, QIA burden correlated positively with vascular damage measures, including preacinar arterial dilation. Preacinar arterial dilation mediated 79.6% of the detrimental impact of QIA on 6-minute walk distance (56.2-100%; P  < 0.001). Pulmonary artery-to-aorta ratio was a weak mediator, and right ventricle-to-left ventricle ratio was a suppressor. Similar results were observed in the relationship between QIA and modified Medical Council Research Council dyspnea score. Preacinar arterial dilation correlated with increased pulmonary vascular dysfunction biomarker levels, including angiopoietin-2 and N-terminal brain natriuretic peptide. Conclusions: Parenchymal QIAs deleteriously impact outcomes primarily through pulmonary vasculopathy. Preacinar arterial dilation may be a novel marker of pulmonary vasculopathy in QIAs.

This brief report reviews the clinical, procedural, and imaging data of 7 patients with p.Arg4810Lys variant of the ring finger protein 213 (RNF213) gene-related peripheral pulmonary arterial stenosis who underwent percutaneous transluminal pulmonary angioplasties (PTPAs) for demographics, clinical presentation, indications for angioplasty, and procedural and clinical outcomes. During median follow-up of 64.4 months since the first confirmed diagnosis, PTPA was performed for 62 segmental pulmonary arteries with 38 sessions of the procedure in 7 patients. Vascular stent placement because of resistance to balloon dilation and immediate elastic recoil was performed in 48 of 62 procedures (77%). Except for 1 death, 6 patients showed an improvement in dyspnea and 5 patients showed a decrease in mean pulmonary arterial pressure (mean, 55.5-42.7 mm Hg) and increase in 6-minute walk distance (mean, 415.5-484.3 m). Reperfusion edema occurred in 4 of 7 patients (57%), which was 6 of 38 sessions (16%)., (Copyright © 2024. Published by Elsevier Inc.)

Background: Pulse wave velocity (PWV) in the pulmonary arteries (PA) is a marker of vascular stiffening. Currently, only phase-contrast (PC) MRI-based options exist to measure PA-PWV., Purpose: To test feasibility, repeatability, and correlation to clinical data of Phase-Resolved Functional Lung (PREFUL) MRI-based calculation of PA-PWV., Study Type: Retrospective., Subjects: 79 (26 female) healthy subjects (age range 19-78), 58 (24 female) patients with chronic obstructive pulmonary disease (COPD, age range 40-77), 60 (33 female) patients with suspected pulmonary hypertension (PH, age range 28-85)., Sequence: 2D spoiled gradient echo, 1.5T., Assessment: PA-PWV was measured from PREFUL-derived cardiac cycles based on the determination of temporal and spatial distance between lung vasculature voxels using a simplified (sPWV) method and a more comprehensive (cPWV) method including more elaborate distance calculation. For 135 individuals, PC MRI-based PWV (PWV-QA) was measured., Statistical Tests: Intraclass-correlation-coefficient (ICC) and coefficient of variation (CoV) were used to test repeatability. Nonparametric tests were used to compare cohorts. Correlation of sPWV/cPWV, PWV-QA, forced expiratory volume in 1 sec (FEV 1 ) %predicted, residual volume (RV) %predicted, age, and right heart catheterization (RHC) data were tested. Significance level α = 0.05 was used., Results: sPWV and cPWV showed no significant differences between repeated measurements (P-range 0.10-0.92). CoV was generally lower than 15%. COPD and PH patients had significantly higher sPWV and cPWV than healthy subjects. Significant correlation was found between sPWV or cPWV and FEV 1 %pred. (R = -0.36 and R = -0.44), but not with RHC (P-range -0.11 - 0.91) or age (P-range 0.23-0.89). Correlation to RV%pred. was significant for cPWV (R = 0.42) but not for sPWV (R = 0.34, P = 0.055). For all cohorts, sPWV and cPWV were significantly correlated with PWV-QA (R = -0.41 and R = 0.48)., Data Conclusion: PREFUL-derived PWV is feasible and repeatable. PWV is increased in COPD and PH patients and correlates to airway obstruction and hyperinflation., Level of Evidence: 3 TECHNICAL EFFICACY: Stage 2., (© 2024 The Authors. Journal of Magnetic Resonance Imaging published by Wiley Periodicals LLC on behalf of International Society for Magnetic Resonance in Medicine.)

Background: According to the most recent pulmonary hypertension (PH) guidelines, a main pulmonary artery (MPA) diameter > 25 mm on transthoracic echocardiography supports the diagnosis of PH. However, the size of the pulmonary artery (PA) may vary according to body size, age, and cardiac phases., Research Question: (1) What are the reference limits for PA size on transthoracic echocardiography, considering differences in body size, sex, and age? (2) What is the diagnostic value of the PA size for classifying PH? (3) How does the selection of different reference groups (healthy volunteers vs patients referred for right heart catheterization [RHC]) influence the diagnostic OR (DOR)?, Study Design and Methods: The study included a reference cohort of 248 healthy individuals as control patients, 693 patients with PH proven by RHC, and 156 patients without PH proven by RHC. In the PH cohort, 300 had group 1 PH, 207 had group 2 PH, and 186 had group 3 PH. MPA and right PA diameters and areas were measured in the upper sternal short-axis and suprasternal notch views. Reference limits (5th-95th percentile) were based on absolute values and height-indexed measures. Quantile regression analysis was used to derive median and 95th quantile reference equations for the PA measures. DORs and probability diagnostic plots for PH were then determined using healthy control and non-PH cohorts., Results: The 95th percentile for indexed MPA diameter was 15 mm/m in diastole and 19 mm/m in systole in both sexes. Quantile regression analysis revealed a weak age effect (pseudo-R 2 of 0.08-0.10 for MPA diameters). Among measures, the MPA size in diastole had the highest DOR (156.2; 95% CI, 68.3-357.5) for detection of group 1 PH. Similarly, the DORs were also high for groups 2 and 3 PH when compared with the control cohort but significantly lower compared with the non-PH cohort., Interpretation: This study presents novel reference limits for MPA based on height indexing and quantile regression., Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: F. H. received funding from Janssen Inc to conduct the research. None declared (S. P. B., B. E. C., E. J. S., M. S., K. C. N., A. J. S., R. T. Z.)., (Published by Elsevier Inc.)

Pulmonary hypertension (PH) remains a challenging condition to diagnose, classify and treat. Current approaches to the assessment of PH include echocardiography, ventilation/perfusion scintigraphy, cross-sectional imaging using computed tomography and magnetic resonance imaging, and right heart catheterisation. However, these approaches only provide an indirect readout of the primary pathology of the disease: abnormal vascular remodelling in the pulmonary circulation. With the advent of newer imaging techniques, there is a shift toward increased utilisation of noninvasive high-resolution modalities that offer a more comprehensive cardiopulmonary assessment and improved visualisation of the different components of the pulmonary circulation. In this review, we explore advances in imaging of the pulmonary vasculature and their potential clinical translation. These include advances in diagnosis and assessing treatment response, as well as strategies that allow reduced radiation exposure and implementation of artificial intelligence technology. These emerging modalities hold the promise of developing a deeper understanding of pulmonary vascular disease and the impact of comorbidities. They also have the potential to improve patient outcomes by reducing time to diagnosis, refining classification, monitoring treatment response and improving our understanding of disease mechanisms., Competing Interests: Conflict of interest: S. Rajagopal reports grants from United Therapeutics, Merck, Janssen and Gossamer Bio, royalties or licences from Polarean, consultancy fees from AERAMI Therapeutics, Liquidia, Gossamer Bio, Merck, Insmed, Polarean, Janssen and Visterra, payment or honoraria for lectures, presentations, manuscript writing or educational events from TotalCME, participation on a data safety monitoring board or advisory board with Aerami Therapeutics, and stock (or stock options) with APIE Therapeutics. H.J. Bogaard reports grants from Janssen, MSD, Novartis and Ferrer. M.S.M. Elbaz reports grants from NIH/NHLBI, support for attending meetings from the World Symposium of Pulmonary Hypertension (WSPH), patents planned, issued or pending (US Patent Application number 17/309,246: noninvasive quantitative flow mapping using a virtual catheter volume), and is a member of the SCMR Science Committee and task force 6 of the 7th WSPH. B.H. Freed reports grants from Cardiovascular Medical Research and Education Fund, and consultancy fees from Change Healthcare. E.J.R. van Beek reports consultancy fees from Aidence (Deep Health) and Lunit, payment or honoraria for lectures, presentations, manuscript writing or educational events from AstraZeneca, and is founder/owner of QCTIS Ltd. D.G. Kiely reports grants from Janssen Pharmaceuticals, National Institute of Health Research Sheffield Biomedical Research Centre and Ferrer, consultancy fees from Janssen Pharmaceuticals, Ferrer, Altavant, MSD, United Therapeutics and Liquidia, payment or honoraria for lectures, presentations, manuscript writing or educational events from Janssen Pharmaceuticals, Ferrer, Altavant, MSD and United Therapeutics, support for attending meetings from Janssen, Ferrer, MSD and United Therapeutics, participation on a data safety monitoring board or advisory board with Janssen, MSD and Liquidia, and is member of Clinical Reference Group for Specialised Respiratory Medicine (NHS England) and Lead of UK National Audit of Pulmonary Hypertension. The remaining authors have no potential conflicts of interest to disclose., (Copyright ©The authors 2024.)

Bronchopulmonary sequestration is a rare condition characterised by the presence of nonfunctional, dysplastic lung tissue. This tissue receives blood supply from the systemic circulation. In this case report, we document an exceptional presentation of a woman in her 50s where bronchopulmonary sequestration in the right upper lung lobe led to haemoptysis. This sequestration received blood supply from a pulmonary artery branch, which is unusual and contrary to the usual systemic circulation. The patient underwent a right upper lobectomy, which confirmed the diagnosis of pulmonary sequestration on histopathology. The unique vascular supply and location of this case challenge conventional diagnostic and management approaches. It emphasises the necessity for meticulous evaluation and consideration of alternative vascular sources in bronchopulmonary sequestration cases., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Balloon pulmonary angioplasty (BPA) has exhibited substantial progress in the management of chronic thromboembolic pulmonary hypertension (CTEPH). However, nearly one-half of the patients with CTEPH experience persistent pulmonary hypertension after undergoing BPA, emphasizing the need for enhanced therapies., Objectives: The authors sought to investigate the clinical significance of functional assessment-guided dilation of the pulmonary artery (PA) in patients with CTEPH undergoing BPA treatment., Methods: The prospective single-center cohort study enrolled 95 patients who underwent 278 consecutive BPA sessions. Lung parenchymal perfusion was assessed via 2-dimensional perfusion angiography, and pressure catheter measurements were taken to determine the PA pressure ratios. The correlation between lung perfusion and the pressure ratio was analyzed to establish an optimal target pressure ratio. Patients were stratified into 2 groups, a pressure-guided group (n = 28) and an angiographic group (n = 63), to evaluate whether optimizing the pressure ratio led to improvements in residual PH and complications., Results: The pressure ratio and lung perfusion measurements of 141 PA lesions were analyzed. A piecewise linear regression model identified a target pressure ratio of 0.7, associated with significant enhancement in lung perfusion. The pressure-guided strategy achieved a higher rate of mean pulmonary artery pressure <25 mm Hg (92.8% [26/28 patients] vs 60.3% [38/63 patients]; P = 0.001) and a concurrent reduction in BPA relevant complications (3.9% [4/101 sessions] vs 12.9% [23/177 sessions]; P = 0.019)., Conclusions: Functional assessment-guided PA dilation with a target pressure ratio of 0.7 proved beneficial in BPA treatment for patients with CTEPH. This approach improved the residual PH and reduced complications, highlighting its potential to enhance CTEPH management outcomes., Competing Interests: Funding Support and Author Disclosures The present study was supported by Japan Agency for Medical Research and Development under grant number 22ek0210149h0003. Dr S.Y. has received grants support from Takeda Pharmaceutical, Abbott, and Boston Scientific and lecture fees from Daiichi-Sankyo and Bristol Myers Squibb. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the effect of the contrast-enhancement-boost (CE-boost) postprocessing technique on improving the image quality of obese patients in computed tomography pulmonary angiography (CTPA) compared to hybrid iterative reconstruction (HIR) and model-based iterative reconstruction (MBIR) algorithms., Methods: This prospective study was conducted on 100 patients who underwent CTPA for suspected pulmonary embolism. Non-obese patients with a body mass index (BMI) under 25 were designated as group 1, while obese patients (group 2) had a BMI exceeding 25. The CE-boost images were generated by subtracting non-contrast HIR images from contrast-enhanced HIR images to improve the visibility of pulmonary arteries further. The CT value, image noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were quantitatively assessed. Two chest radiologists independently reviewed the CT images (5, best; 1, worst) across three subjective characteristics including diagnostic confidence, subjective image noise, and vascular contrast. The Friedman test and Dunn-Bonferroni correction were used for statistical analysis., Results: The CE-boost had significantly higher CT values than HIR and MBIR in both groups (all p < 0.001). The MBIR yielded the lowest image noise compared with HIR and CE-boost (all p < 0.001). The SNR and CNR of main pulmonary artery (MPA) were significantly higher in CE-boost than in MBIR (all p < 0.05), with HIR showing the lowest values (all p < 0.001). Group 2 MBIR received significantly better subjective image noise scores, while the diagnostic confidence and vascular contrast scored highest with the group 2 CE-boost (all p < 0.05)., Conclusion: Compared to the HIR algorithm, both the CE-boost technique and the MBIR algorithm can improve the image quality of CTPA in obese patients. CE-boost had the greatest potential in increasing the visualization of pulmonary artery and its branches., (© 2024. The Author(s).)

Background: Pulmonary arteriovenous malformation (PAVM) is abnormal arteriovenous shunts between pulmonary artery (PA) and pulmonary vein, and rarely has congenital direct communications with systemic arteries., Case Presentation: A 33-year-old male presented to our hospital with intermittent bloody sputum with no evidence of pulmonary infection, trauma or surgery. Chest computed tomography angiography (CTA) indicated the congenital inferior phrenic artery (IPA)-to-PAVM surrounded by diffuse alveolar hemorrhage located in the lower lobe of right lung. Both the afferent PA and IPA were successfully embolized with coils. Recurrent hemoptysis did not occur during one-year follow up., Conclusions: The congenital communication between IPA and PAVM is rare, and the abnormal direct shunt would induce hemodynamically unstable condition within PAVM. Endovascular embolization of the afferent PA and IPA is a safe and effective method for this abnormal congenital shunt in lung., (© 2024. The Author(s).)

Pulmonary hypertension (PH) is highly prevalent in patients with interstitial lung disease (ILD) and is associated with increased morbidity and mortality. Widely available noninvasive screening tools are warranted to identify patients at risk for PH, especially severe PH, that could be managed at expert centres. This review summarises current evidence on noninvasive diagnostic modalities and prediction models for the timely detection of PH in patients with ILD. It critically evaluates these approaches and discusses future perspectives in the field. A comprehensive literature search was carried out in PubMed and Scopus, identifying 39 articles that fulfilled inclusion criteria. There is currently no single noninvasive test capable of accurately detecting and diagnosing PH in ILD patients. Estimated right ventricular pressure (RVSP) on Doppler echocardiography remains the single most predictive factor of PH, with other indirect echocardiographic markers increasing its diagnostic accuracy. However, RVSP can be difficult to estimate in patients due to suboptimal views from extensive lung disease. The majority of existing composite scores, including variables obtained from chest computed tomography, pulmonary function tests and cardiopulmonary exercise tests, were derived from retrospective studies, whilst lacking validation in external cohorts. Only two available scores, one based on a stepwise echocardiographic approach and the other on functional parameters, predicted the presence of PH with sufficient accuracy and used a validation cohort. Although several methodological limitations prohibit their generalisability, their use may help physicians to detect PH earlier. Further research on the potential of artificial intelligence may guide a more tailored approach, for timely PH diagnosis., Competing Interests: Conflict of interest: A. Arvanitaki, M.A. Gatzoulis and C. McCabe declare no conflicts of interest relevant to this work. ​G.P. Diller has received honoraria and travel grants from Janssen Global. L.C. Price has received consultancy fees from Janssen and educational support and conference support from Janssen and Ferrer. S.J. Wort has received consultancy fees from Janssen, Acceleron, MSD, Ferrer and Bayer, honoraria from Janssen, Acceleron, MSD, Ferrer and Bayer, as well as travel and research grants from Janssen and Ferrer., (Copyright ©The authors 2024.)

Background: Current guidelines recommend intervention for asymptomatic rheumatic mitral stenosis (MS) with mitral valve area ≤1.5 cm 2 based on indicators including pulmonary arterial systolic pressure (PASP) >50 mm Hg and new-onset atrial fibrillation; however, evidence supporting this is lacking., Methods: This single-center retrospective study included patients with rheumatic MS between 2006 and 2022. Pulmonary hypertension was evaluated by using echocardiography to estimate PASP. Primary outcomes were major adverse cardiovascular events (MACE), including all-cause mortality, hospitalization for heart failure, and arterial thromboembolic events for up to 5 years., Results: Overall, 287 patients with severe rheumatic MS were enrolled (mean age, 62.5±11.3 years; 74.6% women). During a median follow-up of 2.52 years, MACE occurred in 99 patients. There were no differences in echocardiographic parameters, such as the mean mitral valve pressure gradient, mitral valve area, and proportion of mitral valve area <1.0 cm 2 , between patients who developed primary outcomes and those who did not. Survival analysis showed a worse prognosis in patients with estimated PASP (ePASP) >50 mm Hg than in those with ePASP ≤50 mm Hg (log-rank P <0.001); however, atrial fibrillation was not a significant prognostic indicator. As a continuous variable, ePASP (mm Hg) was a significant predictor of MACE (adjusted hazard ratio, 1.027 [95% CI, 1.011-1.042]; P <0.001). Receiver operating characteristic analysis revealed an optimal ePASP threshold of >45 mm Hg, which was an independent predictor of MACE in patients with severe rheumatic MS (adjusted hazard ratio, 2.127 [95% CI, 1.424-3.177]; P <0.001). Competing risk analysis considering mitral valve intervention as a competing risk showed similar results., Conclusions: Our study demonstrated the prognostic significance of ePASP, rather than atrial fibrillation, in relation to MACE among patients with severe rheumatic MS. Additionally, we proposed a lower ePASP threshold (>45 mm Hg) as a predictor of an unfavorable prognosis., Competing Interests: None.

Background: In chronic obstructive pulmonary disease (COPD), vascular alterations have been shown to contribute to hypoxia and pulmonary hypertension, but the independent contribution of small vessel abnormalities to mortality remains unclear., Methods: We quantified artery and vein dimensions on computed tomography (CT) down to 0.2 mm. Small vessel volumes (<1 mmᴓ) were normalized by body surface area. In 7903 current and former smokers of the COPDGene study (53.2% male) the independent contribution of small artery and small vein volume to all-cause mortality was tested in multivariable Cox models. Additionally, we calculated the 95 th percentile of small arteries and veins in 374 never smokers to create two groups: normal and high small artery or vein volume. We describe clinical, physiological and imaging characteristics of subjects with a high small artery and high small vein volume., Findings: Both high small artery and high small vein volumes were independently associated with mortality with an adjusted hazard ratio of 1.07 [1.01, 1.14] and 1.34 [1.21, 1.49] per mL/m 2 increase, respectively. In COPDGene, 447 (5.7%) had high small artery volume and 519 (9.1%) subjects had high small vein volume and both had more emphysema, more air trapping and more severe coronary calcium., Interpretation: In smokers, abnormally high volumes in small arteries and veins are both relevant for mortality, which urges investigations into the aetiology of small pulmonary vessels and cardiac function in smokers., Funding: Award Number U01-HL089897 and U01-HL089856 from the NHLBI. COPD Foundation with contributions from AstraZeneca, Boehringer Ingelheim, Genentech, GlaxoSmithKline, Novartis, Pfizer, Siemens, and Sunovion., Competing Interests: Declaration of interests AK, EA, TV, EP: no conflicts relevant to this manuscript. DL and SH: the department of radiology of National Jewish Health received grant support from the NHLBI. PdJ: The Department of Radiology from the UMC Utrecht receives research support from Philips Healthcare. JPC: employee and shareholder of Thirona. LGE, HT: employee of Thirona., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Neonates with congenital heart disease (CHD) and ductal-dependent pulmonary blood flow (DD-PBF) require early intervention. Historically, this intervention was most often a surgical systemic-to-pulmonary shunt (SPS; e.g., Blalock-Thomas-Taussig shunt). However, over the past two decades an alternative to SPS has emerged in the form of transcatheter ductal artery stenting (DAS). While many reports have indicated safety and durability of the DAS approach, few studies compare outcomes between DAS and SPS. The reports that do exist are comprised primarily of small-cohort single-center reviews. Two multicenter retrospective studies suggest that DAS is associated with similar or superior survival compared to SPS. These studies offer the best evidence to-date, and yet both have important limitations. The authors describe herein the rationale and design of the COMPASS (COmparison of Methods for Pulmonary blood flow Augmentation: Shunt vs. Stent) Trial (NCT05268094, IDE G210212). The COMPASS Trial aims to randomize 236 neonates with DD-PBF to either DAS or SPS across approximately 27 pediatric centers in North America. The goal of this trial is to compare important clinical outcomes between DAS and SPS over the first year of life in a cohort of neonates balanced by randomization to assess whether one method of palliation demonstrates therapeutic superiority., (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

In recent years the diagnostics of pulmonary artery embolisms (PE) has gained significance, with confirmation occurring in only about 15-25 % of suspected cases. Despite technological advances, radiological methods remain problematic due to radiation and contrast medium exposure. Clinical scores play a crucial role in the risk assessment of PE. High-risk situations call for specific measures, while negative D‑dimers can help avoid overdiagnosis. Computed tomographic pulmonary angiography (CTPA) remains the gold standard with high sensitivity and specificity. Treatment requires an interdisciplinary team (pulmonary embolism response team, PERT). Anticoagulation is an option for stable patients, while in unstable or unsuccessful courses, thrombolysis or interventional procedures can be considered. Side effects, especially the risk of bleeding, need to be considered for both forms of treatment., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

The diameter (mPAD) of the main pulmonary artery (pulmonary artery trunk) is a crucial indicator for cardiovascular health and prognoses in various conditions. Its enlargement is associated with increased mortality and severity in COVID-19-related pneumonia. However, its relevance to non-COVID pneumonia remains uncertain. The aim of this study was to establish an association between mPAD and the severity of non-COVID pneumonia. Eligible participants with qualified Chest Computed Tomography scans from November 2019 to February 2023 were recruited to a cross-sectional retrospective study. They were stratified into pneumonia and non-pneumonia cohorts. Exclusion criteria included pulmonary hypertension, polytrauma, lung neoplasia, or a history of pulmonary stenosis repair. The mPAD was measured in both groups, and medical records were reviewed to identify comorbidities. Pulmonary CT data were classified by pattern and severity, and the mPAD was measured perpendicularly to the long axis of the artery at the point of bifurcation on an axial slice. Analysis of 380 CT scans (52.6% men, 47.4% women; mean age 52.88 ± 17.58) revealed a significant difference in mPAD between pneumonia and non-pneumonia cases (mean difference: 1.19 mm, 95% CI [0.46, 1.92], p = 0.001). Age correlated positively with mPAD (r = 0.231, 95% CI [0.028, 0.069], p < 0.0001), and this correlation persisted after adjusting for confounders (r = 0.220, 95% CI [0.019, 0.073], p = 0.001). Ordinal logistic regression indicated 1.28 times higher odds of severe pneumonia with a larger diameter. The study highlights associations between mPAD, pneumonia, and severity, suggesting clinical relevance. Furthermore, the mPAD should be carefully considered in defining severity criteria for adverse outcomes in pneumonia patients. Further research is needed to refine clinical criteria on the basis of these findings., (© 2024 American Association of Clinical Anatomists and British Association of Clinical Anatomists.)

Various surgical approaches address complex heart disease with arch anomalies. Bilateral pulmonary artery banding (bPAB) is a strategy for critically ill patients with complex arch anomalies. Some reports argued the potential effect of bPAB on the growth of the left ventricular outflow tract (LVOT) during inter-stage after bPAB. This study aimed to analyze the LVOT growth for biventricular repair candidates with arch anomaly and systemic ventricular outflow tract (SVOT) for univentricular repair candidates with arch anomaly. This retrospective study analyzed 17 patients undergoing initial bPAB followed by arch repair. The Z-scores of LVOT and SVOT were compared between pre-bPAB and pre-arch repair. Patient characteristics, transthoracic echocardiogram data, and PAB circumferences were reviewed. The diameter of the minimum LVOT for biventricular repair (BVR) candidates, the pulmonary valve (neo-aortic valve, neo-AoV) and the pulmonary trunk (the neo-ascending aorta, neo-AAo) for univentricular repair (UVR) candidates, and the degree of aortic or neo-aortic insufficiency in each candidate was statistically analyzed. 17 patients were divided into the UVR candidates (group U) with 9 patients and the BVR candidates (group B) with 8 patients. In group B, the median value of the Z-score of the minimum LVOT increased from -3.2 (range: - 4.1 ~ - 1.0) at pre-PAB to -2.8 (range: - 3.6 ~ - 0.3) at pre-arch repair with a significant difference (p = 0.012). In group U, the median value of the Z-score of the neo-AoV increased from 0.5 (range: - 1.0 ~ 1.7) at pre-bPAB to 1.2 (range: 0.2 ~ 1.9) at pre-arch repair with a significant difference (p < 0.01). The median value of the Z-score of the neo-AAo was also increased from 3.1 (range: 1.5 ~ 4.6) to 4.3 (range: 3.1 ~ 5.9) with a significant difference (p = 0.028). The growth of the LVOT for BVR candidates and SVOT for UVR candidates during the inter-stage between bPAB and arch repair was observed. These results suggest the potential advantage of bPAB in surgical strategies. Further research is needed to validate these findings and refine surgical approaches., (© 2024. Springer Nature Japan KK, part of Springer Nature.)

Aims: Novel echocardiographic parameters of right ventricular (RV) function, including speckle-tracking-derived, three-dimensional, and RV-pulmonary artery coupling parameters, have emerged for the evaluation of pulmonary arterial hypertension (PAH). The relative role of these parameters in the risk stratification of PAH patients is unclear. We compared the performance of multiple RV parameters and sought to establish an optimal model for identifying the risk profile of patients with PAH., Methods and Results: Comprehensive risk assessments were performed for 70 patients with PAH. The risk profile of every patient was determined based on the guideline recommendations. Conventional parameters, including fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE), novel speckle-tracking-derived RV longitudinal strain (RVLS), and three-dimensional RV ejection fraction (3D-RVEF), were used to evaluate RV function. Pressure-strain loops were measured for the assessment of RV myocardial work, including RV global wasted work (RVGWW). RV-pulmonary artery coupling was assessed by indexing RV parameters to the estimated pulmonary artery systolic pressure (PASP). The median age was 34 (30-43) years, and 62 (88.6%) patients were female. Forty-five patients were classified into the low-risk group, while 25 patients were classified into the intermediate-high-risk group. Most RV parameters could be used to determine the risk profile and exhibited significantly improved diagnostic performance after indexing to PASP (including FAC/PASP, TAPSE/PASP, and 3D-RVEF/PASP). RVLS/PASP showed the best performance, with an area under the curve of 0.895. In multivariate analysis (Model 1), only RVGWW (>90.5 mmHg%), RVLS (> -16.7%), and TAPSE (<17.5 mm) remained significant (all P < 0.05). Model 1 outperformed every single RV parameter, with a significantly larger area under the curve (all P < 0.05). With PASP indexing in Model 2, RVLS/PASP > -0.275 [odds ratio (OR) 20.63, 95% confidence interval (CI) 4.62-92.11, P < 0.001] and RVGWW > 90.5 mmHg% (OR 6.17, 95% CI 1.37-27.76, P = 0.018) independently identified a higher risk profile. The addition of RVGWW to two models determined incremental value in identification (continuous net reclassification improvement 1.058, 95% CI 0.639-1.477, P < 0.001)., Conclusions: The combination models for RV function outperformed any single parameter in identifying the risk profile of patients with PAH. Comprehensive assessment of RV-pulmonary artery coupling using multiparametric methods is clinically meaningful in patients with PAH., (© 2024 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Objective: Segmentectomy has been widely performed in clinical practice, which required a comprehensive understanding of anatomical structure. In right lower lobe, studies of superior segment (S 6 ) were relatively small-sized. And only one study focusing on subsuperior segment (S∗) was published, which showed different results with previous ones. As the close relationship between S 6 and S∗, variation types and their prevalence rate were reported, aiming to providing larger-size study of S 6 and showing new evidence on anatomical structure of S∗., Methods: 800 CT imaging data were collected from patients in our hospital. Three-dimensional reconstruction was performed after quality check. All images were screened according to the definition of corresponding segment and anatomical variations were analyzed., Results: The proportion of S 6 variation types in the largest scale (718 patients) was reported with no significant difference compared to previous studies and newly classified subtypes of two-stem V 6 . The prevalence rate for S∗ in right lower lobe reached 28.3 % (203/718) with similar proportion of three types. Variation types and origins of pulmonary artery were analyzed in detail, finding two-stem A∗ only be observed in type III B∗., Conclusions: Through this study, the variation types and incidence rate of S 6 were confirmed, and a different result of S∗ has been provided as well. The feasibility of the current classification standards and proposed new subclassifications were verified. The results would be a supplement to lung segmental anatomy and could advance researches in the future., Competing Interests: Declaration of competing interest None, (Copyright © 2024 Asian Surgical Association and Taiwan Society of Coloproctology. Published by Elsevier B.V. All rights reserved.)

Purpose: To compare the diagnostic approach of acute pulmonary embolism (PE) with photon-counting-detector CT (PCD-CT) and energy-integrating-detector CT (EID-CT)., Materials and Methods: Two cohorts underwent CT angiographic examinations with EID-CT (Group 1; n = 158) and PCD-CT (Group 2; n = 172), (b) with two options in Group 1, dual energy (Group 1a) or single energy (Group 1b) and a single option in Group 2 (spectral imaging with single source)., Results: In Group 2, all patients benefited from spectral imaging, only accessible to 105 patients (66.5%) in Group 1, with a mean acquisition time significantly shorter (0.9 ± 0.1 s vs 4.0 ± 0 .3 s; p < 0.001) and mean values of CTDI vol and DLP reduced by 46.3% and 47.7%, respectively. Comparing the quality of 70 keV (Group 2) and averaged (Group 1a) images: (a) the mean attenuation within pulmonary arteries did not differ (p = 0.13); (b) the image noise was significantly higher (p < 0.001) in Group 2 with no difference in subjective image noise (p = 0.29); and (c) 89% of examinations were devoid of artifacts in Group 2 vs 28.6% in Group 1a. The percentage of diagnostic examinations was 95.2% (100/105; Group 1a), 100% (53/53; Group 1b), and 95.3% (164/172; Group 2). There were 4.8% (5/105; Group 1a) and 4.7% (8/172; Group 2) of non-diagnostic examinations, mainly due to the suboptimal quality of vascular opacification with the restoration of a diagnostic image quality on low-energy images., Conclusion: Compared to EID-CT, morphology and perfusion imaging were available in all patients scanned with PCD-CT, with the radiation dose reduced by 48%., Clinical Relevance Statement: PCD-CT enables scanning patients with the advantages of both spectral imaging, including high-quality morphologic imaging and lung perfusion for all patients, and fast scanning-a combination that is not simultaneously accessible with EID-CT while reducing the radiation dose by almost 50%., (© 2024. The Author(s), under exclusive licence to European Society of Radiology.)

Purpose:  Preoperative evaluation of pulmonary vascular and tracheal routes and variations is of great importance to the surgeon. Three-dimensional computed tomography bronchography and angiography (3D-CTBA) has evolved in recent years with the optimization of 3D reconstruction techniques and artificial intelligence. We aim to apply CT angiography and Exoview 3D reconstruction technology to assess patients' pulmonary arterial tree and its anatomical variants and to try to summarize a set of anatomical typing of the pulmonary arterial tree that is relatively easy and conducive to promoting teaching based on surgical habits of lobectomy., Methods:  A total of 358 patients hospitalized in the Department of Thoracic Surgery of the First Affiliated Hospital of Soochow University between July 2020 and August 2021 were included in this study. We carefully analyzed the site of emanation, alignment, and number of branches of the pulmonary artery according to a uniform classification method in conjunction with the two-dimensional CT images and transformed them into 3D reconstruction models., Results:  Different types of pulmonary artery were observed in 358 cases. We evaluated the complete pulmonary artery tree and counted the number and frequency of major arteries of the pulmonary based on the surgical habits of anatomical lobectomy., Conclusion:  The 3D-CTBA technique enables us to adequately assess the anatomy of the pulmonary arteries. Moreover, we provide a practical classification scheme of pulmonary arterial anatomical patterns based on lobectomy and 3D-CTBA. Our data can be used by clinicians in the teaching of pulmonary artery anatomy and the preoperative preparation for anatomical lobectomy., Competing Interests: None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Competing Interests: None.

The current state of the literature for a bullet embolization to the heart and/or pulmonary vasculature indicates the occurrence is rare but could increase due to the rise in civilian low-kinetic-energy firearm acquisition and use. We present the case of an older teenage male who sustained a gunshot wound to the left flank. The bullet entered the iliac vein, travelled through the heart and lodged in the pulmonary artery. Successful relocation of the bullet to the internal iliac vein was performed by the interventional radiologist. This article highlights the advancement of interventional radiology as a successful non-invasive endovascular technique for bullet embolus removal., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

A 17-year-old male presented to our hospital from an external center with complaints of chest pain and shortness of breath, referred with preliminary diagnoses of pulmonary stenosis and pulmonary artery dilation. Echocardiography revealed moderate pulmonary regurgitation and mild pulmonary stenosis. Coronary computed tomography (CT) angiography showed normal coronary arteries and no presence of a patent ductus arteriosus, but an aneurysmal dilation of up to 4 cm was observed in the pulmonary artery. The patient was found to have a quadricuspid (QPV) pulmonary valve, while the aortic valve appeared normal. No phenotypic anomalies or accompanying aortic or lung abnormalities were detected in this case. Our case represents the first in the pediatric age group diagnosed via CT scan. Our study contributes insights into the relationship between QPV anomaly and pulmonary artery aneurysm, aiding in the diagnosis and management of these rare conditions. Furthermore, our findings highlight the importance of evaluating the possibility of QPV in patients with pulmonary valve stenosis, regurgitation, or artery aneurysm, emphasizing the significance of coronary CT angiography in the diagnostic process., (© 2024 Wiley Periodicals LLC.)

Purpose: To evaluate the correlation between clot burden and pulmonary artery pressures in patients undergoing suction thromboembolectomy for high-risk and intermediate-high-risk pulmonary embolism with secondary outcomes of 30-day mortality and intensive care unit (ICU) length of stay., Materials and Methods: Institutional review board (IRB) exemption was granted for this retrospective study. The charts of 120 consecutive patients who underwent mechanical thromboembolectomy using the Flowtriever system (Inari Medical, Irvine, California) between February 2020 and August 2022 were retrospectively reviewed, and the following data were collected: (a) preprocedural B-type natriuretic peptide and creatinine levels, (b) echocardiographic findings, (c) preprocedural and postprocedural pulmonary artery pressures, (d) ICU length of stay, and (e) 30-day mortality. Clot burden was scored using Qanadli and Miller indices and correlated with the clinical outcomes., Results: Of the 120 patients who underwent thromboembolectomy, pulmonary artery pressures and diagnostic-quality angiograms were available in 109 patients. In the 109 patients with adequate data, Qanadli, preprocedural Miller, and postprocedural Miller scores correlated with pulmonary artery pressures. Neither was independently associated with ICU length of stay. Freedom from 30-day mortality was 91%, and embolism-specific mortality was 92%. All-risk and high-risk patients who survived demonstrated a significantly lower preprocedural and postprocedural Miller score, respectively., Conclusions: Thrombus burden as measured by the Qanadli and Miller scores appeared to be correlated with pulmonary artery pressures. Furthermore, catheter-directed thromboembolectomy led to a reduction in Miller scores, which appeared to be correlated with a reduction in pulmonary pressures. In high-risk patients, a reduced postprocedural Miller score and pulmonary pressure demonstrated improved 30-day survival. Further investigation into the association between Miller scores and patient mortality is warranted to stratify patients who would benefit from emergency intervention., (Copyright © 2024 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate effectiveness of pulmonary arteriovenous malformation (PAVM) embolization using dual-energy computed tomography (CT) and spectral curve analysis by characterizing contrast enhancement and vascular perfusion as a surrogate of the degree of vascular occlusion after embolotherapy., Materials and Methods: Nine consecutive adult patients underwent embolization for 21 PAVMs (size range, 0.4-2.0 cm; 15/21 simple angioarchitecture) and subsequent postembolization chest dual-energy CT angiography. Twelve PAVMs were treated with vascular plugs with or without coils, whereas 9 PAVMs were treated with coils alone. Virtual spectral curves were generated using dual-energy image postprocessing in order to measure embolization effectiveness., Results: Complete occlusion of target PAVM was achieved in all cases on digital subtraction angiography (DSA) at the end of the embolization procedure. With a median follow-up of 12.7 months, the vascular plug group demonstrated significantly less vascular opacification compared with the coils-only group, as measured by opacification between upstream feeding artery and different downstream vasculature locations (Δslope1: median 79.1 vs 28.6; P = .003; Δslope2: 76.4 vs 28.6; P = .0197; Δslope3: 78.9 vs 28.6; P = .004). Persistence occurred in 3 PAVMs based on size criteria, which demonstrated higher vascular opacification by dual-energy CT (Δslope1: 72 vs 28.6; P = .253; Δslope2: 65.1 vs 32.7; P = .326; Δslope3: 72.9 vs 53.5; P = .733), although statistical significance was not reached., Conclusions: Similar to emerging literature, dual-energy CT showed improved occlusion in PAVMs treated with vascular plugs compared with those treated with coils alone., (Copyright © 2024 SIR. Published by Elsevier Inc. All rights reserved.)

Background: It is crucial to identify factors that can predict the risk of mortality in patients newly diagnosed with interstitial lung disease (ILD). This study sought to develop and assess a composite scoring system for mortality prediction among ILD patients based on cardiovascular parameters, which were previously reported as predictors of survival., Methods: We prospectively enrolled patients with newly diagnosed ILD and monitored their survival status for 24 months. Surviving and deceased patients were compared regarding their baseline characteristics including clinical, pulmonary, and cardiovascular parameters. A system of composite scores was established based on significant cardiovascular parameters and the Gender-Age-Physiology (GAP) score. Receiver operating characteristic curves were generated to identify their optimal cut-off values. Univariate as well as multiple multivariate regression models were built to investigate the mortality prediction of different individual and combined parameters., Results: Ninety-six patients newly diagnosed with ILD underwent cardiovascular evaluation. In univariate analysis, three cardiovascular parameters were identified as significant predictors of mortality risk in ILD patients, either individually or as a combination of composite scores: tricuspid regurgitation velocity > 3.1 m/s; N-terminal pro-B-type natriuretic peptide level > 300 pg/ml and computed tomography pulmonary artery/ascending aorta diameter ratio > 0.9. In multivariate analysis, a composite score of those parameters [hazard ratio (HR) = 2.37 (confidence interval [CI]:1.06-5.33); p = 0.037; Score 1] and GAP score [HR = 1.62 (CI: 1.11-2.36); p = 0.012] were the most significant predictors for mortality among ILD patients. Combination of Score 1 and GAP score (Score 2) can increase the accuracy of survival predictions (area under the curve 0.83; p < 0.001)., Conclusions: A composite score based on cardiovascular parameters and the GAP score can be used to predict the risk of mortality of patients with ILD. Such a score achieved better diagnostic accuracy than the GAP score alone. Nevertheless, further larger-scale randomized controlled trials are required for evaluation of the newly proposed score and confirmation of our results., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Purpose: The purpose of this study was to compare ultra-low dose (ULD) and standard low-dose (SLD) chest computed tomography (CT) in terms of radiation exposure, image quality and diagnostic value for diagnosing pulmonary arteriovenous malformation (AVM) in patients with hereditary hemorrhagic telangiectasia (HHT)., Materials and Methods: In this prospective board-approved study consecutive patients with HHT referred to a reference center for screening and/or follow-up chest CT examination were prospectively included from December 2020 to January 2022. Patients underwent two consecutive non-contrast chest CTs without dose modulation (i.e., one ULD protocol [80 kVp or 100 kVp, CTDIvol of 0.3 mGy or 0.6 mGy] and one SLD protocol [140 kVp, CTDIvol of 1.3 mGy]). Objective image noises measured at the level of tracheal carina were compared between the two protocols. Overall image quality and diagnostic confidence were scored on a 4-point Likert scale (1 = insufficient to 4 = excellent). Sensitivity, specificity, positive predictive value and negative predictive value of ULD CT for diagnosing pulmonary AVM with a feeding artery of over 2 mm in diameter were calculated along with their 95% confidence intervals (CI) using SLD images as the standard of reference., Results: A total of 44 consecutive patients with HHT (31 women; mean age, 42 ± 16 [standard deviation (SD)] years; body mass index, 23.2 ± 4.5 [SD] kg/m 2 ) were included. Thirty-four pulmonary AVMs with a feeding artery of over 2 mm in diameter were found with SLD images versus 35 with ULD images. Sensitivity, specificity, predictive positive value, and predictive negative value of ULD CT for the diagnosis of PAVM were 100% (34/34; 95% CI: 90-100), 96% (18/19; 95% CI: 74-100), 97% (34/35; 95% CI: 85-100) and 100% (18/18; 95% CI: 81-100), respectively. A significant difference in diagnostic confidence scores was found between ULD (3.8 ± 0.4 [SD]) and SLD (3.9 ± 0.1 [SD]) CT images (P = 0.03). No differences in overall image quality scores were found between ULD CT examinations (3.9 ± 0.2 [SD]) and SLD (4 ± 0 [SD]) CT examinations (P = 0.77). Effective radiation dose decreased significantly by 78.8% with ULD protocol, with no significant differences in noise values between ULD CT images (16.7 ± 5.0 [SD] HU) and SLD images (17.7 ± 6.6 [SD] HU) (P = 0.07)., Conclusion: ULD chest CT provides 100% sensitivity and 96% specificity for the diagnosis of treatable pulmonary AVM with a feeding artery of over 2 mm in diameter, leading to a 78.8% dose-saving compared with a standard low-dose protocol., Competing Interests: Declaration of competing interest Hugo Lacombe is an employee of Philips Healthcare. The other authors have no competing interests to disclose in relation with this article., (Copyright © 2024 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

There is limited experience in evaluating abnormal ductus arteriosus (DA) insertion pattern by contrast-enhanced cardiac computed tomography (cardiac CT) in patients with right-sided obstructive cardiac defects. Retrospective review of 38 infants with right-sided obstructive cardiac defects who underwent a preoperative cardiac CT between 2016 and 2021. We reviewed the types of cardiac lesions, patterns of ductal insertion, frequency of pulmonary artery (PA) stenosis requiring intervention, total dose length product (DLP), and effective radiation dose. Of 38 infants, 45% were female, the median gestational age and weight were 37 (range 34-40) weeks and 2.95 (range 2-4) kg. The most common pathologies were pulmonary atresia with ventricular septal defect (24%) and tetralogy of Fallot (24%). The abnormal ductal insertion patterns were DA inserting into the left PA in 39%, DA bifurcating into branch PA in 32%, and DA inserting into the right PA in 13%. Of the 38 infants, 76% developed branch PA stenosis requiring intervention. Among patients with abnormal DA insertion, 44% required branch PA arterioplasty during their index surgery compared to 17% without abnormal DA insertion. Regardless of the type of abnormal DA insertion, 67% developed bilateral branch PA stenosis over time. The mean DLP was 8 mGy-cm and the mean calculated effective radiation dose was 0.312 mSv. The utilization of contrast-enhanced cardiac CT in infants with right-sided obstructive heart defects can offer crucial insights into abnormal ductus arteriosus insertion patterns. This information is valuable for effective procedure planning and for monitoring the development of branch pulmonary artery stenosis., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: European and U.S. clinical guidelines diverge regarding pulmonary hypertension (PHTN) in degenerative mitral regurgitation (DMR). Gaps in knowledge underpinning these divergences affect risk assessment and management recommendations attached to systolic pulmonary pressure (SPAP) in DMR., Objectives: This study sought to define PHTN links to DMR severity, prognostic thresholds, and independent outcome impact in a large quantitative DMR registry., Methods: This study gathered a large multicentric registry of consecutive patients with isolated moderate-to-severe DMR, with DMR and SPAP quantified prospectively at diagnosis., Results: In 3,712 patients (age 67 ± 15 years, 36% women) with ≥ moderate-to-severe DMR, effective regurgitant orifice (ERO) was 0.42 ± 0.19 cm 2 , regurgitant volume 66 ± 327 mL/beat and SPAP 41 ± 16 mm Hg. Spline-curve analysis showed excess mortality under medical management emerging around SPAP 35 mm Hg and doubling around SPAP 50 mm Hg. Accordingly, severe pulmonary hypertension (sPHTN) (SPAP ≥50 mm Hg) was detected in 916 patients, moderate pulmonary hypertension (mPHTN) (SPAP 35-49 mm Hg) in 1,128, and no-PHTN (SPAP <35 mm Hg) in 1,668. Whereas SPAP was strongly associated with DMR-ERO, nevertheless excess mortality with sPHTN (adjusted HR: 1.65; 95% CI: 1.24-2.20) and mPHTN (adjusted HR: 1.44; 95% CI: 1.11-1.85; both P ≤ 0.005) was observed independently of ERO and all baseline characteristics and in all patient subsets. Nested models demonstrated incremental prognostic value of mPHTN and sPHTN (all P < 0.0001). Despite higher operative risk with mPHTN and sPHTN, DMR surgical correction was followed by higher survival in all PHTN ranges with strong survival benefit of early surgery (<3 months). Postoperatively, excess mortality was abolished (P ≥ 0.30) in mPHTN, but only abated in sPHTN., Conclusions: This large international registry, with prospectively quantified DMR and SPAP, demonstrates a Doppler-defined PHTN impact on mortality, independent of DMR severity. Crucially, it defines objectively the new and frequent mPHTN range, independently linked to excess mortality under medical management, which is abolished by DMR correction. Thus, at DMR diagnosis, Doppler-SPAP measurement defining these new PHTN ranges, is crucial to guiding DMR management., Competing Interests: Funding Support and Author Disclosures This study was supported by the Mayo Foundation, French Ministry of Health “PHRC-I 2012” (Dr Le Tourneau, API12/N/019), Fédération Française de Cardiologie (Dr Le Tourneau, 2015), and Fondation Cœur et Recherche (Dr Le Tourneau, 2015). The Department of Cardiology of the Leiden University Medical Center received research grants from Abbott Vascular, Bioventrix, Medtronic, Biotronik, Boston Scientific, GE Healthcare, and Edwards Lifesciences. Drs Bax and Ajmone Marsan have received speaker fees from Abbott Vascular. Dr Enriquez-Sarano has received consulting fees from Edwards LLC, Cryolife Inc, ChemImage, and HighLife Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Tracheobronchial or esophageal fistula after aortic surgery has been reported sporadically in the literature, however, reports of an aortopulmonary fistula associated with a post-operative aortic pseudoaneurysm are rare. We experienced a case of refractory heart failure due to an aortopulmonary fistula associated with a post-operative aortic pseudoaneurysm. A 60-year-old man who had undergone aortic surgery 2 years earlier was hospitalized for congestive heart failure. He was diagnosed with refractory heart failure after 10 days of diuretic therapy failed to improve his condition. He underwent a contrast-enhanced computed tomography (CT) scan and was suspected to have pulmonary artery perforation of an aortic pseudoaneurysm at the anastomotic site of the ascending aortic surgery. Transesophageal echocardiography showed shunt blood flow from the aortic aneurysm into the right pulmonary artery, leading to a definitive diagnosis of aortopulmonary fistula with post-operative aortic pseudoaneurysm. Computed tomography angiography is commonly used to diagnose an aortic fistula; however, diagnosis is often difficult because of the subtle imaging findings. We highlight the usefulness of transesophageal echocardiography in providing a definitive diagnosis and detailed morphologic information on this pathophysiology.

Right-to-left shunt (RLS) caused by patent foramen ovale (PFO) and pulmonary arteriovenous malformations (PAVM) have been associated with a variety of diseases, and reliable techniques for detecting RLS are essential for diagnosis. This study aimed to compare the diagnostic accuracy of multimodal ultrasound imaging, including transthoracic echocardiography (TTE) plus contrast transthoracic echocardiography (CTTE) and transesophageal echocardiography (TEE) plus contrast transesophageal echocardiography (CTEE) for PFO and PAVM in patients with cryptogenic stroke or migraine. This prospective study enrolled patients with cryptogenic stroke or migraine admitted to First Hospital of Shanxi Medical University between July 2018 and April 2023. The TTE + CTTE + TEE + CTEE multimodal ultrasound imaging was defined as the gold standard. A total of 230 patients with cryptogenic stroke (108) or migraine (122) were enrolled. The TEE + CTEE generated a better area under the receiver operator characteristic (ROC) curves (AUC) than TTE + CTTE [0.995 (0.988-1.000) vs 0.975 (0.767-0.984), P < .001], indicating better identification of PFO and PAVM. The sensitivity and specificity of the TTE + CTTE were 89.4% and 85.7%, respectively, whereas the sensitivity and specificity of TEE + CTEE were 99.1% and 100%, respectively. The missed diagnosis rate of TTE + CTTE and TEE + CTEE was 65.7 % and 12.5%, respectively. The combination of TEE + CTEE may be a more reliable and sensitive tool to detect PFO and PAVM than TTE + CTTE in patients with cryptogenic stroke or migraine., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Identifying and understanding the microstructural changes within the wall of the pulmonary artery (PA) is crucial for elucidating disease mechanisms and guiding treatment strategies. We assessed the utility of optical coherence tomography (OCT) in identifying such changes within segmental/subsegmental PAs and compared the morphological variations in WHO group 4 pulmonary hypertension associated with Behcet Disease (BD), Takayasu arteritis (TA) and chronic thromboembolic pulmonary hypertension (CTEPH). Idiopathic pulmonary arterial hypertension (IPAH) patients served as controls.Methods and Results: A total of 197 cross-sectional images were analyzed from 20 consecutive patients. BD patients exhibited lower %wall area and mean wall thickness (MWT) compared with CTEPH, TA and, IPAH patients. TA patients showed a notably higher %wall area, which was significant in IPAH and BD patients. Variations in %wall area measurements were observed across distinct cross-sectional segments of the PA within individual patients (22% in CTEPH, 19% in BD, 16% in TA, 23% in IPAH patients). Intravascular webs, bands, and thrombi were observed in BD and CTEPH patients. OCT provided clear delineation of vascular wall calcifications and adventitial vasa vasorum. No procedure-related complications were observed., Conclusions: PA involvement differs among the various etiologies of PH, with the PA being heterogeneously affected. OCT offers promise in elucidating microstructural vascular wall changes and providing insights into disease mechanisms and treatment effects.

Competing Interests: Conflict of interest: none declared.

An aortopulmonary window is a rare disorder that occurs in 0.1–0.2% of all congenital disorders. Our patient was a 1-month-old boy weighing 4180 g. The patient had heart failure associated with an aortopulmonary window. We used 3-dimensional computer graphic software (Viewtify, SCIEMENT) for diagnosis based on DICOM data from contrast-enhanced computed tomography. This made it easy to identify anatomical landmarks and findings and select the most suitable approach. We avoided stenosis of the right pulmonary artery and aorta. We encountered a case of an aortopulmonary window in which 3-dimensional computer graphic software was helpful in selecting the surgical technique. We report this case using 3-dimensional computer graphic images and present a review of the literature., (© The Author 2024. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Takayasu's arteritis-pulmonary artery involvement (TA-PAI) is a chronic, progressive, inflammatory disease affecting the pulmonary artery and its branches. Patients typically present with non-specific respiratory symptoms, such as fever, dyspnea, and chest pain, leading to a high rate of misdiagnosis. The diagnosis of TA-PAI is currently based on the diagnostic criteria of aortitis and imaging evidence of pulmonary artery involvement. However, pulmonary artery involvement is not typically included in the diagnostic criteria for aortitis, which may lead to a significant underestimation of the diagnostic rate of TA-PAI, particularly in cases where pulmonary artery involvement is the only manifestation. This article reports the case of a 26-year-old female patient who presented with recurrent chest pain and fever. She was initially diagnosed with pneumonia in a foreign hospital but did not show significant improvement after four months of treatment. Eventually, she was diagnosed with pulmonary artery involvement in aortitis and was stabilized with hormones, immunosuppressive drugs, and pulmonary vascular intervention. By analyzing the clinical features and diagnostic and therapeutic approaches of this case, and reviewing the relevant literature, clinicians can improve their understanding of TA-PAI.