CT derived left atrial size identifies left heart disease in suspected pulmonary hypertension: Derivation and validation of predictive thresholds

Background Patients with pulmonary hypertension due to left heart disease (PH-LHD) have overlapping clinical features with pulmonary arterial hypertension making diagnosis reliant on right heart catheterization (RHC). This study aimed to investigate computed tomography pulmonary angiography (CTPA) derived cardiopulmonary structural metrics, in comparison to magnetic resonance imaging (MRI) for the diagnosis of left heart disease in patients with suspected pulmonary hypertension. Methods Patients with suspected pulmonary hypertension who underwent CTPA, MRI and RHC were identified. Measurements of the cardiac chambers and vessels were recorded from CTPA and MRI. The diagnostic thresholds of individual measurements to detect elevated pulmonary arterial wedge pressure (PAWP) were identified in a derivation cohort (n = 235). Individual CT and MRI derived metrics were tested in validation cohort (n = 211). Results 446 patients, of which 88 had left heart disease. Left atrial area was a strong predictor of elevated PAWP>15 mm Hg and PAWP>18 mm Hg, area under curve (AUC) 0.854, and AUC 0.873 respectively. Similar accuracy was also identified for MRI derived LA volume, AUC 0.852 and AUC 0.878 for PAWP > 15 and 18 mm Hg, respectively. Left atrial area of 26.8 cm 2 and 30.0 cm 2 were optimal specific thresholds for identification of PAWP > 15 and 18 mm Hg, had sensitivity of 60%/53% and specificity 89%/94%, respectively in a validation cohort. Conclusions CTPA and MRI derived left atrial size identifies left heart disease in suspected pulmonary hypertension with high specificity. The proposed diagnostic thresholds for elevated left atrial area on routine CTPA may be a useful to indicate the diagnosis of left heart disease in suspected pulmonary hypertension.