Hemodynamics assessment using 4D flow CMR before and after balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension: A retrospective observational study

Background The effect of balloon pulmonary angioplasty (BPA) for hemodynamics in chronic thromboembolic pulmonary hypertension (CTEPH), assessed using time-resolved three-dimensional cine phase-contrast cardiac magnetic resonance (4D flow CMR), remains unclear. Therefore, the present study aimed to investigate the hemodynamic features of the pulmonary artery (PA) before and after BPA and the diagnostic performance of 4D flow CMR-derived hemodynamics before BPA to predict the achievement of mean PA pressure (mPAP) < 30 mmHg after BPA. Methods Twenty-one patients with CTEPH who underwent 4D flow CMR before and after BPA were retrospectively enrolled. Regarding 4D flow CMR, the analysis included peak flow volume and velocity at the main PA and peak systolic wall shear stress (WSS). Results Peak flow velocity at the main PA (262.8 ± 52.3 mm/s vs. 298.5 ± 68.3 mm/s, p  = 0.015) and peak WSS (0.61 ± 0.14 Pa vs. 0.76 ± 0.20 Pa, p  = 0.002) both increased after BPA compared to their values before BPA. Receiver operating characteristic analysis was performed to predict mPAP ≥ 30 mmHg after BPA based on peak flow velocity before BPA. The analysis revealed an area under the curve of 0.926 ( p  < 0.001) for peak flow velocity before BPA (sensitivity, 0.765; specificity 0.750; cut-off, < 251 mm/s) and 1.00 ( p  < 0.001) for peak WSS before BPA (sensitivity, 1.00; specificity, 1.00; cut-off, < 0.48 Pa). Conclusions Based on the study results, 4D flow CMR imaging showed improvement in hemodynamics after BPA. Furthermore, peak flow velocity and peak WSS were useful metrics for predicting the achievement of catheter-based BPA goal of mPAP < 30 mmHg with a better prognosis.