Assessing pulmonary hypertension in COPD. Is there a role for computed tomography?

Figures & data

Figure 1 Reconstructed chest CT scan in COPD patient. This image was acquired with high-spatial-frequency algorithm reconstruction using fully automated Pulmo3D software (Siemens, Munich, Germany). Low attenuation area (LAA%) was derived from the voxel frequency distribution histogram and represented the percentage of lung voxels less than −950 HU. In this COPD patient, LAA value was 23%.

Abbreviations: COPD, chronic obstructive pulmonary disease; CT, computed tomography.

Figure 2 Bronchi segmentation. (A) Frontal view of a propagation algorithm to obtain a skeleton binary volume based on bi-thresholding. Arrow shows bronchi in which measurements were assessed. (B) Peripheral bronchus is designated (arrow) on a native transverse thin-section CT. (C) Thin-section CT scan used to obtain measurements. (D) A Laplacian of Gaussian algorithm was assessed to segment the designed airway and measure bronchial thickness.

Abbreviation: CT, computed tomography.

Figure 3 Pulmonary artery and aorta measurements. Ratio measurement obtained in a COPD patient in a transverse CT section.

Abbreviations: COPD, chronic obstructive pulmonary disease; CT, computed tomography.

Figure 4 Measurement of cross-sectional areas (CSA) of small pulmonary vessels using Image J free-software. (A) CT image segmented within the threshold values from −500 to −1024 HU of lung field. (B) Segmented image segmented into binary images. (C) Mask image for the particle analysis after setting circularity within [0.9–1.0] and vessel size within [0–5] mm^2.

Abbreviation: CT, computed tomography.

Table 1 Summary of vessels analyzes in COPD with PH

Publication year	First author	Journal	CT findings	Qualitative /quantitative /Automated /manual	No. of patients	Screened population	Search for
2014	Iyer et al^Citation107	Chest	MAP/AO>1 better than echocardiography to evaluate PH in COPD patients	Quantitative manual	60	Severe COPD	mPAP ≥ 25 mmHg
2017	Iliaz S et al^Citation108	Clin Respir J	MAP/AO correlated with PH, number of exacerbation, not with mortality	Quantitative manual	156	COPD exacerbation	Number of COPD exacerbation 1 year after the first one
2017	Cuttica MJ et al^Citation109	Int J Chron Obstruct Pulmon Dis	MAP/AO associated with pulmonary hemodynamics and right heart structure and function changes	Semi-quantitative manual	88	Mil-to-moderately severe COPD	mPAP ≥ 25 mmHg
2016	Ortaç Ersoy E et al^Citation110	J Crit Care	MAP/AO≥1 associated with pulmonary hypertension, but not with mortality	Quantitative manual	106	COPD	mPAP ≥ 25 mmHg
2016	Coste F et al^Citation86	Thorax	% cross-sectional area of small pulmonary vessels <5 mm^2 (%CSA<5) is negatively correlated to mPAP for moderated PH (25–35 mmHg), and positively correlated to mPAP for severe PH (>35 mmHg)	Quantitative automated	105	COPD	mPAP ≥ 25 mmHg 35 mmHg
2012	Wells JM et al^Citation111	NEJM	MAP/AO>1 associated with severe COPD exacerbation	Quantitative manual	3464	Smokers with COPD	COPD exacerbation
2015	Compton GL et al^Citation112	AJR	Description of technical measurements of MAP/AO in children, threshold is greater than 1, closer to 1.09	Quantitative manual	400	General children population	Threshold of MAP/AO in children
2011	Chan AL et al^Citation21	BMC Med Imaging	Significant predictors of PH: MAP≥ 29 mm, MAP/AO≥ 0.84, MAP/descending aorta≥ 1.29 mm	Quantitative manual	101	Heterogenous diagnoses	mPAP ≥ 25 mmHg
1998	Tan RT et al^Citation113	Chest	MAP≥ 29 mm. Artery to bronchus ratio ≥1 in 3 or 4 lobes	Quantitative manual	28	Parenchymal lung disease	mPAP ≥ 20 mmHg
2012	Truong QA et al^Citation114	Circ Cardiovasc Imaging	MAP≥ 29 mm in men, MAP≥ 27 mm in women, MAP/AO≥ 0.9	Quantitative manual	3171	Asymptomatic community-based population	90^th percentile
2014	Shin S et al^Citation115	Repir Med	MAP/AO>1 associated with PH in patients with COPD, independent predictor of mortality	Quantitative manual	65	Advanced COPD	mPAP ≥ 25 mmHg survival
2016	Mohamed Hoesein FA et al^Citation116	Lung	MAP≥ 30 mm and MAP/AO> 1 associated with PH	Quantitative manual	92	COPD	mPAP ≥ 25 mmHg
2016	Wells JM et al^Citation117	Chest	MAP/AO>1 predict exacerbation of COPD	Quantitative manual	134	Patient with acute exacerbation of COPD	Predict clinical outcome with MAP/AO
2015	Wells JM et al^Citation118	Circ Cardiovasc Imaging	Intraparenchymal pulmonary blood vessel volume and the volume of distal vessels with cross-sectional area (CSA) of <5 mm^2 negatively correlated with MAP/AO. MAP/AO, MAP negatively correlated with 6MWT	Quantitative automated	24	Non severe COPD	MAP/AO>1
2017	Terzikhan N et al^Citation119	Eur Respir J	In general population, MAP/AO >1 not associated with mortality. In COPD population, MAP/AO >1 associated with mortality	Quantitative manual	2197	General and COPD populations	Pronostic information of MAP/AO
2009	Revel MP et al^Citation120	Radiology	Decreased pulmonary arterial distensibility in PH, ECG-gated CT	Quantitative manual	45	Different group 1, 2 etiology of PH	mPAP ≥ 25 mmHg
2014	Pienn M et al^Citation123	Eur Radiol	Reduced bolus propagation speed and time differences between contrast material peaks in PH patients, using dynamic-contrast-enhanced CT	Quantitative semi-automated	33	Different potential etiology of PH, notably lung disease, and control patients	mPAP ≥ 25 mmHg
2010	Devaraj A et al^Citation124	Radiology	MAP/AO and Artery to bronchus ratio correlated with mPAP	Quantitative manual	77	Spectrum of disease associated with PH (Groups 1, 3, 4,5)	mPAP ≥ 25 mmHg 34 mmHg
			Size of segmental arterial diameter correlated positively with mPAP
2010	Matsuoka S et al^Citation44	Am J Respir Crit Care Med	% cross-sectional area of small pulmonary vessels <5 mm^2 (%CSA<5) is negatively correlated to mPAP for moderated PH, in severe emphysema population	Quantitative automated	79	COPD	Correlation with mPAP
2015	Ando K et al^Citation79	Lung	%CSA<5 used to assess pulmonary vasodilators longitudinal evaluation	Quantitative automated	42	COPD	Effect of pulmonary vasodilators in COPD-PH patients
2017	Ma J et al^Citation78	J Xray Sci Technol	3D tool able to detect the mean lumen area that was negatively correlated with MAP, and mean number of vessels negatively correlated with emphysema (LAA%, −950 HU)	Quantitative automated	102	Heavy smokers	Computerized scheme to detect pulmonary vessels
2011	Matsuoka S et al^Citation76	Acad. Radiol.	Negative correlation between %CSA<5 and LAA%	Quantitative automated	191	Smoking history	Evaluate correlation small vessels- emphysema
2011	Uejima I et al^Citation128	Jpn J Radiol	Positive correlation between %CSA<5 and FEV1/FVC	Quantitative automated	30	Non smokers	Evaluate correlation small vessels- PFTs
2013	Park S et al^Citation129	Med Phys	Assessing volumetric technic allowing pulmonary artery/vein separation	Quantitative automated	10	COPD	Evaluate volumetric technic allowing pulmonary artery/vein separation
2016	Iyer S et al^Citation130	Am J Respir Crit Care Med	After sildenafil arterial CSA and perfused blood volume decreased only in centriacinar emphysema patients, using dual-energy CT perfused blood volume	Quantitative automated	17	Current smokers	Effect of sildenafil on vascular perfusion
2016	Payer C et al^Citation131	Med Image Anal	Assessing 3D technic allowing pulmonary artery/vein separation	Quantitative automated	25	Lung vascular disease	Evaluate 3D technic allowing pulmonary artery/vein separation
2016	Charbonnier JP et al^Citation132	IEEE Trans Med Imaging	Automatic separation and classification of pulmonary arteries and veins using CT with an accuracy of 0.89	Quantitative automated	55	Lung cancer	Evaluate separation and classification of pulmonary arteries/veins
2019	Coste F et al^Citation102	Int J Chron Obstruct Pulmon Dis	% cross-sectional area of small pulmonary vessels <5 mm^2 (%CSA<5) is positively correlated to mPAP for severe PH (>35 mmHg)	Quantitative automated	24	COPD	mPAP ≥35 mmHg

Abbreviations: COPD, chronic obstructive pulmonary disease; CT, computed tomography; PH, pulmonary hypertension.

Table 2 Summary of scores built in order to diagnose PH or severe PH in lung disease or COPD

Publication year	First author	Journal	Score	CT metrics	No. of patients	Screened population	Search for	Sens. Spe.	PPV NPV
1998	Tan RT et al^Citation113	Chest	MAP ≥29 mm + artery to bronchus ratio ≥1 in 3 or 4 lobes	MAP+A/B	28	Parenchymal lung disease	mPAP≥ 20 mmHg	NA 1.00	NA
2010	Devaraj A et al^Citation124	Radiology	MAP/AO + Right ventricular systolic pressure (echocardiography)	MAP/AO	77	Spectrum of disease associated with PH (Groups 1, 3, 4, 5)	mPAP≥ 25 mmHg 34 mmHg	0.96 0.59 0.73 0.88	NA
2016	Coste F et al^Citation86	Thorax	“Paw score”: %cross-sectional area of small pulmonary vessels <5 mm^2+ bronchial wall thickening + PaO2	%CSA<5+ WT	105	COPD	mPAP≥ 35 mmHg	0.75 0.80	0.36 0.96
2019	Coste F et al^Citation102	Int J Chron Obstruct Pulmon Dis	“Paw score”: %cross-sectional area of small pulmonary vessels <5 mm^2+ bronchial wall thickening + PaO2	%CSA<5+ WT	24	COPD	mPAP≥ 35 mmHg	0.88 NA	NA NA
2018	Johns CS et al^Citation133	Eur. Radio.	“CMR-RV”: RV mass + septal angle		102	COPD	mPAP≥ 25 mmHg	0.90 0.79	0.96 0.58
			“CMR-PA/RV”: RV mass + septal angle + MAP measurement	MAP measurement				0.92 0.80	0.96 0.63
			“α-index”: RV ejection fraction + minimal MAP size	Minimal MAP size				1.00 0.13	0.87 1.00

Abbreviations: COPD, chronic obstructive pulmonary disease; CT, computed tomography; NA, not attributed; NPV, negative predictive value; PPV, predictive positive value; PH, pulmonary hypertension.

Iyer AS, Wells JM, Vishin S, Bhatt SP, Wille KM, Dransfield MT. CT scan-measured pulmonary artery to aorta ratio and echocardiography for detecting pulmonary hypertension in severe COPD. Chest. 2014;145(4):824–832. doi:10.1378/chest.13-142224114440

 PubMed Web of Science ®Google Scholar

Iliaz S, Tanriverdio E, Chousein EGU, et al. Importance of pulmonary artery to ascending aorta ratio in chronic obstructive pulmonary disease. Clin Respir J. 2018;12(3):961–965. doi:10.1111/crj.1261228085229

 PubMed Web of Science ®Google Scholar

Cuttica MJ, Bhatt SP, Rosenberg SR, et al. Pulmonary artery to aorta ratio is associated with cardiac structure and functional changes in mild-to-moderate COPD. Int J Chron Obstruct Pulmon Dis. 2017;12:1439–1446. doi:10.2147/COPD.S13141328553096

 PubMed Web of Science ®Google Scholar

Ortac Ersoy E, Durusu Tanriover M, Ocal S, Gulsun Akpinar M, Topeli A. Measurement of pulmonary artery to aorta ratio in computed tomography is correlated with pulmonary artery pressure in critically ill chronic obstructive pulmonary disease patients. J Crit Care. 2016;33:42–46. doi:10.1016/j.jcrc.2016.01.02026936041

 PubMed Web of Science ®Google Scholar

Coste F, Dournes G, Dromer C, et al. CT evaluation of small pulmonary vessels area in patients with COPD with severe pulmonary hypertension. Thorax. 2016;71(9):830–837. doi:10.1136/thoraxjnl-2015-20769627084957

 PubMed Web of Science ®Google Scholar

Wells JM, Washko GR, Han MK, et al. Pulmonary arterial enlargement and acute exacerbations of COPD. N Engl J Med. 2012;367(10):913–921. doi:10.1056/NEJMoa120383022938715

 PubMed Web of Science ®Google Scholar

Compton GL, Florence J, MacDonald C, Yoo SJ, Humpl T, Manson D. Main pulmonary artery-to-ascending aorta diameter ratio in healthy children on MDCT. AJR Am J Roentgenol. 2015;205(6):1322–1325. doi:10.2214/AJR.15.1430126587940

 PubMed Web of Science ®Google Scholar

Chan AL, Juarez MM, Shelton DK, et al. Novel computed tomographic chest metrics to detect pulmonary hypertension. BMC Med Imaging. 2011;11:7. doi:10.1186/1471-2342-11-721447184

 PubMed Web of Science ®Google Scholar

Tan RT, Kuzo R, Goodman LR, Siegel R, Haasler GB, Presberg KW. Utility of CT scan evaluation for predicting pulmonary hypertension in patients with parenchymal lung disease. Medical college of wisconsin lung transplant group. Chest. 1998;113(5):1250–1256. doi:10.1378/chest.113.5.12509596302

 PubMed Web of Science ®Google Scholar

Truong QA, Massaro JM, Rogers IS, et al. Reference values for normal pulmonary artery dimensions by noncontrast cardiac computed tomography: the Framingham Heart Study. Circ Cardiovasc Imaging. 2012;5(1):147–154. doi:10.1161/CIRCIMAGING.111.96861022178898

 PubMed Web of Science ®Google Scholar

Shin S, King CS, Brown AW, et al. Pulmonary artery size as a predictor of pulmonary hypertension and outcomes in patients with chronic obstructive pulmonary disease. Respir Med. 2014;108(11):1626–1632. doi:10.1016/j.rmed.2014.08.00925225149

 PubMed Web of Science ®Google Scholar

Mohamed Hoesein FA, Besselink T, Pompe E, et al. Accuracy of CT pulmonary artery diameter for pulmonary hypertension in end-stage COPD. Lung. 2016;194(5):813–819. doi:10.1007/s00408-016-9926-827423782

 PubMed Web of Science ®Google Scholar

Wells JM, Morrison JB, Bhatt SP, Nath H, Dransfield MT. Pulmonary artery enlargement is associated with cardiac injury during severe exacerbations of COPD. Chest. 2016;149(5):1197–1204. doi:10.1378/chest.15-150426501747

 PubMed Web of Science ®Google Scholar

Wells JM, Iyer AS, Rahaghi FN, et al. Pulmonary artery enlargement is associated with right ventricular dysfunction and loss of blood volume in small pulmonary vessels in chronic obstructive pulmonary disease. Circ Cardiovasc Imaging. 2015;8(4):e002546. doi:10.1161/CIRCIMAGING.114.00254625855668

 PubMed Web of Science ®Google Scholar

Terzikhan N, Bos D, Lahousse L, et al. Pulmonary artery to aorta ratio and risk of all-cause mortality in the general population: the Rotterdam Study. Eur Respir J. 2017;49(6):1602168. doi:10.1183/13993003.02168-201628619955

 PubMed Web of Science ®Google Scholar

Revel MP, Faivre JB, Remy-Jardin M, Delannoy-Deken V, Duhamel A, Remy J. Pulmonary hypertension: ECG-gated 64-section CT angiographic evaluation of new functional parameters as diagnostic criteria. Radiology. 2009;250(2):558–566. doi:10.1148/radiol.250208031519188324

 PubMed Web of Science ®Google Scholar

Pienn M, Kovacs G, Tscherner M, et al. Non-invasive determination of pulmonary hypertension with dynamic contrast-enhanced computed tomography: a pilot study. Eur Radiol. 2014;24(3):668–676. doi:10.1007/s00330-013-3067-824311231

 PubMed Web of Science ®Google Scholar

Devaraj A, Wells AU, Meister MG, Corte TJ, Wort SJ, Hansell DM. Detection of pulmonary hypertension with multidetector CT and echocardiography alone and in combination. Radiology. 2010;254(2):609–616. doi:10.1148/radiol.0909054820093532

 PubMed Web of Science ®Google Scholar

Matsuoka S, Washko GR, Yamashiro T, et al. Pulmonary hypertension and computed tomography measurement of small pulmonary vessels in severe emphysema. Am J Respir Crit Care Med. 2010;181(3):218–225. doi:10.1164/rccm.200908-1189OC19875683

 PubMed Web of Science ®Google Scholar

Ando K, Kuraishi H, Nagaoka T, et al. Potential role of CT metrics in chronic obstructive pulmonary disease with pulmonary hypertension. Lung. 2015;193(6):911–918. doi:10.1007/s00408-015-9813-826453478

 PubMed Web of Science ®Google Scholar

Ma J, Yu N, Shen C, Wang Z, He T, Guo YM. A three-dimensional approach for identifying small pulmonary vessels in smokers. J Xray Sci Technol. 2017;25(3):391–402. doi:10.3233/XST-1621628157121

 PubMed Web of Science ®Google Scholar

Matsuoka S, Yamashiro T, Diaz A, et al. The relationship between small pulmonary vascular alteration and aortic atherosclerosis in chronic obstructive pulmonary disease: quantitative CT analysis. Acad Radiol. 2011;18(1):40–46. doi:10.1016/j.acra.2010.08.01320947389

 PubMed Web of Science ®Google Scholar

Uejima I, Matsuoka S, Yamashiro T, Yagihashi K, Kurihara Y, Nakajima Y. Quantitative computed tomographic measurement of a cross-sectional area of a small pulmonary vessel in nonsmokers without airflow limitation. Jpn J Radiol. 2011;29(4):251–255. doi:10.1007/s11604-010-0551-921607838

 PubMed Web of Science ®Google Scholar

Park S, Lee SM, Kim N, Seo JB, Shin H. Automatic reconstruction of the arterial and venous trees on volumetric chest CT. Med Phys. 2013;40(7):071906. doi:10.1118/1.477196023822443

 PubMed Web of Science ®Google Scholar

Iyer KS, Newell JD Jr, Jin D, et al. Quantitative dual-energy computed tomography supports a vascular etiology of smoking-induced inflammatory lung disease. Am J Respir Crit Care Med. 2016;193(6):652–661. doi:10.1164/rccm.201506-1196OC26569033

 PubMed Web of Science ®Google Scholar

Payer C, Pienn M, Balint Z, et al. Automated integer programming based separation of arteries and veins from thoracic CT images. Med Image Anal. 2016;34:109–122. doi:10.1016/j.media.2016.05.00227189777

 PubMed Web of Science ®Google Scholar

Charbonnier JP, Brink M, Ciompi F, Scholten ET, Schaefer-Prokop CM, van Rikxoort EM. Automatic pulmonary artery-vein separation and classification in computed tomography using tree partitioning and peripheral vessel matching. IEEE Trans Med Imaging. 2016;35(3):882–892. doi:10.1109/TMI.2015.250027926584489

 PubMed Web of Science ®Google Scholar

Coste F, Benlala I, Dournes G, et al. Quantitative CT assessment of bronchial and vascular alterations in severe precapillary pulmonary hypertension. Int J Chron Obstruct Pulmon Dis. 2019;14:381–389. doi:10.2147/COPD.S17763830809092

 PubMed Web of Science ®Google Scholar

Johns CS, Rajaram S, Capener DA, et al. Non-invasive methods for estimating mPAP in COPD using cardiovascular magnetic resonance imaging. Eur Radiol. 2018;28(4):1438–1448. doi:10.1007/s00330-017-5143-y29147768

 PubMed Web of Science ®Google Scholar