Cardiovascular magnetic resonance pulmonary perfusion for guidance of interventional treatment of pulmonary vein stenosis

Figures

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  Fig. 1. Peri-procedural stratification of the study cohort. Flow chart illustrating the peri-procedural stratification of the study population forming three subgroups considered during the post-interventional follow-up period. Two patients with a non-successful revascularization attempt of a single pulmonary vein (PV) occlusion did not undergo post-interventional follow-up cardiovascular magnetic resonance (CMR) examinations corresponding to 2 PVs “stenosis ≥ 70%, revasc (‒)” and 8 PVs “stenosis < 70%”. PV indicates pulmonary vein; revasc, revascularization

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  Fig. 2. Cine CMR and pulmonary artery flow imaging for depiction of left ventricular (LV) “D-shape” pattern and systolic notching. A, B Systolic still frame of cine short axis view at baseline (A). Systolic flattening of the interventricular septum (“D-shape”) indicated substantial pressure overload of the right ventricle (RV) in the presence of three high-grade ostial PV stenoses. Distinct systolic notching of pulmonary flow curve was present (B). C, D One day after successful stenting of all three PV stenoses, complete reversibility of LV “D-shape” (C) and abolishment of the systolic notch of the pulmonary artery flow curve (D) were noted (Additional file 1: video file 1)

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  Fig. 3. Quantitative analysis of CMR pulmonary perfusion imaging to discriminate ≥ 70% PV stenosis and to determine the gain attributable to successful revascularization. Upper row: ROC analyses were performed to determine the relationship between signal intensity time curve measurements derived from dynamic contrast-enhanced CMR pulmonary perfusion imaging in the presence of ≥ 70% PV luminal diameter stenosis as defined by CMR angiography: time-to-peak enhancement demonstrated the highest discriminatory power resulting in a sensitivity and specificity of 93% and 95%, respectively (cut-off value, 8.0 s). Bottom row: mean change of quantitative measures of pulmonary perfusion at baseline, on day 1 and 3 months after interventional treatment of PV stenosis: for all three quantitative pulmonary perfusion measures, lung lobes with ≥ 70% PV stenosis demonstrated significantly impaired pulmonary perfusion at baseline when compared to non-stenosis dependent lung lobes and successful interventional treatment led to a significant improvement at day 1. In bottom row plots, mean ± standard error of the mean are given. FU 1 indicates follow-up at day 1; FU 2, follow-up at 3 months

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  Fig. 4. Pre- and post-interventional CMR pulmonary perfusion imaging for assessment of the treatment effect after stenting of a severe ostial left superior pulmonary vein (LSPV) stenosis. Upper row (pre-intervention): Invasive X-ray angiography (A, anterior–posterior projection) and pre-interventional CMR angiography (inlay of A, posterior–anterior projectional view) revealed a ≥ 70% ostial stenosis of the LSPV (white arrow). CMR pulmonary perfusion imaging depicted a perfusion deficit of the left upper lung lobe (B, still frame of original dynamic pulmonary perfusion; C, still frame of dynamic pulmonary perfusion after background stationary tissue subtraction; D, corresponding pseudo-colored parametric map of quantitative CMR pulmonary perfusion analysis with time-to-peak enhancement as the quantitative measure). Bottom row (post-intervention): Invasive X-ray angiography (E, anterior–posterior projection) and post-interventional CMR angiography (inlay of E, posterior–anterior projectional view) after successful angioplasty/stenting of PV stenosis with stent-related signal void (white arrow). On post-interventional CMR pulmonary perfusion imaging at day 1, homogenous perfusion of all…

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  Fig. 5. Pre- and post-interventional CMR pulmonary perfusion imaging for assessment of the treatment effect after stenting of multiple severe PV stenoses. A, B Pre-interventional three-dimensional CMR angiography revealed a total occlusion of both, the LSPV and left inferior pulmonary vein (LIPV; A, posterior–anterior view of volume rendering reconstruction) with “late-filling” of large distal pulmonary vein side branches on the second angiographic dynamic scan indicating focal ostial stenosis (B, posterior–anterior view of volume intensity projection). In addition, a ≥ 70% luminal diameter stenosis of the right superior pulmonary vein (RSPV) was present. C–E Pre-interventional CMR pulmonary perfusion imaging revealed corresponding perfusion loss of the entire left lung and hypoperfusion of the right upper lung lobe (C, still frame of original dynamic pulmonary perfusion; D still frame of dynamic pulmonary perfusion after background stationary tissue subtraction; E, pseudo-colored parametric map of quantitative CMR pulmonary perfusion analysis with time-to-peak enhancement as the quantitative measure). F–H Post-interventional CMR pulmonary perfusion imaging at day 1 demonstrated…