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Radiologie up2date 2012; 12(02): 143-159
DOI: 10.1055/s-0032-1308903
Pulmonale und kardiovaskuläre Radiologie
© Georg Thieme Verlag KG Stuttgart · New York

Pulmonale Hypertonie – radiologische Diagnostik im klinischen Kontext

Pulmonary hypertension – radiological diagnostics in the clinical context
S. Ley
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Publication Date:
12 June 2012 (online)

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Zusammenfassung

Eine pulmonale Hypertonie kann zahlreiche Ursachen haben, wobei der radiologischen Diagnostik die Aufgabe zukommt, zugrunde liegende Pathologien zu erkennen oder auszuschließen. Da eine pulmonale Hypertonie insgesamt selten ist und ihre klinischen Symptome unspezifisch sind, wird diese Erkrankung häufig spät diagnostiziert. In den radiologischen Untersuchungsmodalitäten, vor allem Thoraxröntgen und CT, gibt es allerdings spezifische Hinweise auf eine pulmonale Hypertonie, die nicht übersehen werden sollten. Um eine pulmonale Hypertonie zu verifizieren, ist allerdings nach wie vor eine invasive Druckmessung mittels Rechtsherzkatheter erforderlich, auch wenn es vielversprechende Ansätze gibt, dies nichtinvasiv mittels MRT zu bestimmen.

Abstract

Pulmonary hypertension (PH) has a broad differential and the radiological task is to define and characterize the pathophysiological background. The first part of the review is focused on the clinical categorization and specific features of the various groups of PH. Overall, PH is a rare disease and the clinical symptoms are non specific. Therefore, the disease is usually detected delayed. Each radiological technique, especially chest x-ray and CT, do show specific findings suggestive of PH, which will be discussed. Verification of the severity of PH is still a domain of invasive right heart catheterization. However, there are promising approaches using MRI to determine the pulmonary arterial pressure non-invasively.

Kernaussagen

  • Eine pulmonale Hypertonie begegnet dem Radiologen entweder als Zufallsbefund oder im Rahmen der systematischen Abklärung.

  • Die relative Häufigkeit von Patienten mit Linksherzerkrankungen und Lungenerkrankungen bedingt auch den relativ häufigen Zufallsbefund einer pulmonalen Hypertonie. Hierbei ist die zugrunde liegende Erkrankung bereits radiologisch gesichert und es erfolgt eine weitere gezielte kardiologisch/pulmonologische Abklärung.

  • Zur systematischen Abklärung einer pulmonalarteriellen Hypertonie (PAH) gibt es klare Leitlinien für die radiologische Kaskade. Die aktuelle Literaturlage weist allerdings darauf hin, dass eine CTA bei adäquater CT-Ausstattung die bisher empfohlene V/Q-Szintigrafie und die DSA verzichtbar machen.

Keywords

Pulmonary hypertension - diagnostic - computed tomography - x-ray - magnetic resonance tomography
 

  • Literatur

  • 1 Lu MT, Cai T, Ersoy H et al. Comparison of ECG-gated versus non-gated CT ventricular measurements in thirty patients with acute pulmonary embolism. Int J Cardiovasc Imaging 2009; 25: 101-107
    CrossrefPubMedGoogle Scholar
  • 2 Haddad F, Hunt SA, Rosenthal DN et al. Right ventricular function in cardiovascular disease, part I: Anatomy, physiology, aging, and functional assessment of the right ventricle. Circulation 2008; 117: 1436-1448
    CrossrefPubMedGoogle Scholar
  • 3 Wintersperger BJ, Stäbler A, Seemann M et al. Beurteilung der Rechtsherzbelastung in der Spiral-CT bei Patienten mit akuter Lungenembolie. Fortschr Röntgenstr 1999; 170: 542-549
    PubMedGoogle Scholar
  • 4 Karazincir S, Balci A, Seyfeli E et al. CT assessment of main pulmonary artery diameter. Diagn Interv Radiol 2008; 14: 72-74
    PubMedGoogle Scholar
  • 5 Arcasoy SM, Christie JD, Ferrari VA et al. Echocardiographic assessment of pulmonary hypertension in patients with advanced lung disease. Am J Respir Crit Care Med 2003; 167: 735-740
    CrossrefPubMedGoogle Scholar
  • 6 Simonneau G, Robbins IM, Beghetti M et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol 2009; 54: 43-54
    CrossrefPubMedGoogle Scholar
  • 7 Rich S, Dantzker DR, Ayres SM et al. Primary pulmonary hypertension. A national prospective study. Ann Intern Med 1987; 107: 216-223
    CrossrefPubMedGoogle Scholar
  • 8 Olschewski H. Diagnosis and treatment of pulmonary hypertension. Dtsch Med Wochenschr 2006; 131: 635-638
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 McLaughlin VV, Archer SL, Badesch DB et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College of Chest Physicians, American Thoracic Society, Inc. and the Pulmonary Hypertension Association. Circulation 2009; 119: 2250-2294
    CrossrefPubMedGoogle Scholar
  • 10 Pengo V, Lensing AW, Prins MH et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 2004; 350: 2257-2264
    CrossrefPubMedGoogle Scholar
  • 11 Ghofrani HA, Distler O, Gerhardt F et al. Treatment of pulmonary arterial hypertension (PAH): recommendations of the Cologne Consensus Conference 2010. Dtsch Med Wochenschr 2010; 135 (Suppl. 03) 87-101
    Article in Thieme ConnectPubMedGoogle Scholar
  • 12 Galie N, Hoeper MM, Humbert M et al. Guidelines for the diagnosis and treatment of pulmonary hypertension: The Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J 2009; 30: 2493-2537
    CrossrefPubMedGoogle Scholar
  • 13 Grunig E, Barner A, Bell M et al. Non-invasive diagnosis of pulmonary hypertension: ESC/ERS Guidelines with commentary of the Cologne Consensus Conference 2010. Dtsch Med Wochenschr 2010; 135 (Suppl. 03) 67-77
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Meyer FJ, Ley S, Borst MM. Diagnostik der pulmonalen Hypertonie. Pneumologe 2004; 1: 83-94
    CrossrefPubMedGoogle Scholar
  • 15 Henk CB, Gabriel H, Fleischmann D et al. Pulmonary hypertension and cor pulmonale. Radiologe 1997; 37: 388-401
    CrossrefPubMedGoogle Scholar
  • 16 Woodruff WW, Hoeck BE, Chitwood WR et al. Radiographic Findings in Pulmonary Hypertension from Unresolved Embolism. AJR Am J Roentgenol 1985; 144: 681-686
    CrossrefPubMedGoogle Scholar
  • 17 Schmidt HC, Kauczor HU, Schild HH et al. Pulmonary hypertension in patients with chronic pulmonary thromboembolism: chest radiograph and CT evaluation before and after surgery. Eur Radiol 1996; 6: 817-825
    PubMedGoogle Scholar
  • 18 Seferian A, Helal B, Jais X et al. Ventilation perfusion lung scan in pulmonary veno-occlusive disease. Eur Respir J 2011; doi:10.1183/09031936.00097911
    PubMedGoogle Scholar
  • 19 Bugnone AN, Viamonte Jr M, Garcia H. Imaging findings in human immunodeficiency virus-related pulmonary hypertension: report of five cases and review of the literature. Radiology 2002; 223 (Suppl. 03) 820-827
    CrossrefPubMedGoogle Scholar
  • 20 Resten A, Maitre S, Humbert M et al. Pulmonary Arterial Hypertension: Thin-Section CT Predictors of Epoprostenol Therapy Failure. Radiology 2002; 222: 782-788
    CrossrefPubMedGoogle Scholar
  • 21 Chaouat A, Naeije R, Weitzenblum E. Pulmonary hypertension in COPD. Eur Respir J 2008; 32: 1371-1385
    CrossrefPubMedGoogle Scholar
  • 22 Hoeper MM, Andreas S, Bastian A et al. Pulmonary hypertension due to chronic lung disease. Recommendations of the Cologne Consensus Conference 2010. Dtsch Med Wochenschr 2010; 135 (Suppl. 03) 115-124
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Han MK, McLaughlin VV, Criner GJ et al. Pulmonary diseases and the heart. Circulation 2007; 116: 2992-3005
    CrossrefPubMedGoogle Scholar
  • 24 Mayer E. Surgical and post-operative treatment of chronic thromboembolic pulmonary hypertension. European Respiratory Journal 2010; 19: 64-67
    CrossrefPubMedGoogle Scholar
  • 25 Ley S, Ley-Zaporozhan J, Pitton MB et al. Diagnostic performance of state-of-the-art imaging techniques for morphological assessment of vascular abnormalities in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Eur Radiol 2012; 22: 607-616
    CrossrefPubMedGoogle Scholar
  • 26 Ley S, Kreitner K-F, Fink C et al. Assessment of pulmonary hypertension by CT and MR imaging. Eur Radiol 2004; 14: 359-368
    CrossrefPubMedGoogle Scholar
  • 27 Battal B, Akgun V, Karaman B et al. Normal anatomical features and variations of bronchial arteries: an analysis with 64-detector-row computed tomographic angiography. J Comput Assist Tomogr 2011; 35: 253-259
    CrossrefPubMedGoogle Scholar
  • 28 Ley S, Kreitner K-F, Morgenstern I et al. Bronchopulmonary shunts in patients with Chronic Thromboembolic Pulmonary Hypertension: Evaluation by helical CT and MR imaging. AJR Am J Roentgenol 2002; 179: 1209-1215
    CrossrefPubMedGoogle Scholar
  • 29 Pitton MB, Düber C, Mayer E et al. Hemodynamic effects of nonionic contrast bolus injection and oxygen inhalation during pulmonary angiography in patients with chronic major-vessel thromboembolic pulmonary hypertension. Circulation 1996; 94: 2485-2491
    CrossrefPubMedGoogle Scholar
  • 30 Ley S, Grunig E, Kiely DG et al. Computed tomography and magnetic resonance imaging of pulmonary hypertension: Pulmonary vessels and right ventricle. J Magn Reson Imaging 2010; 32: 1313-1324
    CrossrefPubMedGoogle Scholar
  • 31 Ley S, Kauczor HU. MR imaging/magnetic resonance angiography of the pulmonary arteries and pulmonary thromboembolic disease. Magn Reson Imaging Clin N Am 2008; 16: 263-273
    CrossrefPubMedGoogle Scholar
  • 32 Ley S, Fink C, Zaporozhan J et al. Value of high spatial and high temporal resolution magnetic resonance angiography for differentiation between idiopathic and thromboembolic pulmonary hypertension: initial results. Eur Radiol 2005; 15: 2256-2263
    CrossrefPubMedGoogle Scholar
  • 33 Ohno Y, Hatabu H, Murase K et al. Primary pulmonary hypertension: 3D dynamic perfusion MRI for quantitative analysis of regional pulmonary perfusion. AJR Am J Roentgenol 2007; 188: 48-56
    CrossrefPubMedGoogle Scholar
  • 34 Ley S, Mereles D, Risse F et al. Quantitative 3D pulmonary MR-perfusion in patients with pulmonary arterial hypertension: Correlation with invasive pressure measurements. Eur J Radiol 2007; 61: 251-255
    CrossrefPubMedGoogle Scholar
  • 35 Alfakih K, Plein S, Bloomer T et al. Comparison of right ventricular volume measurements between axial and short axis orientation using steady-state free precession magnetic resonance imaging. J Magn Reson Imaging 2003; 18: 25-32
    CrossrefPubMedGoogle Scholar
  • 36 Ley S, Fink C, Puderbach M et al. MRI Measurement of the hemodynamics of the pulmonary and systemic arterial circulation: influence of breathing maneuvers. AJR Am J Roentgenol 2006; 187: 439-444
    CrossrefPubMedGoogle Scholar
  • 37 Torbicki A. Cardiac magnetic resonance in pulmonary arterial hypertension: a step in the right direction. Eur Heart J 2007; 28: 1187-1189
    CrossrefPubMedGoogle Scholar
  • 38 Abolmaali N, Seitz U, Esmaeili A et al. Evaluation of a resistance-based model for the quantification of pulmonary arterial hypertension using MR flow measurements. J Magn Reson Imaging 2007; 26: 646-653
    CrossrefPubMedGoogle Scholar
  • 39 Sanz J, Kuschnir P, Rius T et al. Pulmonary arterial hypertension: noninvasive detection with phase-contrast MR imaging. Radiology 2007; 243: 70-79
    CrossrefPubMedGoogle Scholar
  • 40 Kreitner KF, Kunz RP, Ley S et al. Chronic thromboembolic pulmonary hypertension - assessment by magnetic resonance imaging. Eur Radiol 2007; 17: 11-21
    CrossrefPubMedGoogle Scholar
  • 41 Ley S, Mereles D, Puderbach M et al. Value of MR phase-contrast flow measurements for functional assessment of pulmonary arterial hypertension. Eur Radiol 2007; 17: 1892-1897
    CrossrefPubMedGoogle Scholar
  • 42 Roeleveld RJ, Marcus JT, Boonstra A et al. A comparison of noninvasive MRI-based methods of estimating pulmonary artery pressure in pulmonary hypertension. J Magn Reson Imaging 2005; 22: 67-72
    CrossrefPubMedGoogle Scholar
  • 43 Reiter G, Reiter U, Kovacs G et al. Magnetic resonance-derived 3-dimensional blood flow patterns in the main pulmonary artery as a marker of pulmonary hypertension and a measure of elevated mean pulmonary arterial pressure. Circ Cardiovasc Imaging 2008; 1: 23-30
    CrossrefPubMedGoogle Scholar
  • 44 Kreitner KF, Ley S, Kauczor HU et al. Chronic Thromboembolic Pulmonary Hypertension: Pre- and Postoperative Assessment with Breath-hold MR Imaging Techniques. Radiology 2004; 232: 535-543
    CrossrefPubMedGoogle Scholar
  • 45 McCann GP, Gan CT, Beek AM et al. Extent of MRI delayed enhancement of myocardial mass is related to right ventricular dysfunction in pulmonary artery hypertension. AJR Am J Roentgenol 2007; 188: 349-355
    CrossrefPubMedGoogle Scholar
  • 46 Bradlow WM, Assomull R, Kilner PJ et al. Understanding late gadolinium enhancement in pulmonary hypertension. Circ Cardiovasc Imaging 2010; 3: 501-503
    CrossrefPubMedGoogle Scholar