European Radiology

, Volume 28, Issue 11, pp 4643–4653 | Cite as

Pulmonary hypertension due to left heart disease: diagnostic and prognostic value of CT in chronic systolic heart failure

  • Geoffrey C. ColinEmail author
  • Bernhard L. Gerber
  • Christophe de Meester de Ravenstein
  • David Byl
  • Anna Dietz
  • Michele Kamga
  • Agnes Pasquet
  • David Vancraeynest
  • Jean-Louis Vanoverschelde
  • Anne-Marie D’Hondt
  • Benoit Ghaye
  • Anne-Catherine Pouleur



To evaluate the ability of chest computed tomography (CT) to predict pulmonary hypertension (PH) and outcome in chronic heart failure with reduced ejection fraction (HFrEF).


We reviewed 119 consecutive patients with HFrEF by CT, transthoracic echocardiography (TTE) and right heart catheterization (RHC). CT-derived pulmonary artery (PA) diameter and PA to ascending aorta diameter ratio (PA:A ratio), left atrial, right atrial, right ventricular (RV) and left ventricular volumes were correlated with RHC mean pulmonary arterial pressure (mPAP) . Diagnostic accuracy to predict PH and ability to predict primary composite endpoint of all-cause mortality and HF events were evaluated.


RV volume was significantly higher in 81 patients with PH compared to 38 patients without PH (133 ml/m2 vs. 79 ml/m2, p < 0.001) and was moderately correlated with mPAP (r=0.55, p < 0.001). Also, RV volume had higher ability to predict PH (area under the curve: 0.88) than PA diameter (0.79), PA:A ratio (0.76) by CT and tricuspid regurgitation gradient (0.83) and RV basal diameter by TTE (0.84, all p < 0.001). During the follow-up period (median: 3.4 years), 51 patients (43%) had HF events or died. After correction for important clinical, TTE and RHC parameters, RV volume (adjusted hazard ratio [HR]: 1.71, 95% CI 1.31–2.23, p < 0.001) and PA diameter (HR: 1.61, 95% CI 1.18–2.22, p = 0.003) were independent predictors of the primary endpoint.


In patients with HFrEF, measurement of RV volume and PA diameter on ungated CT are non-invasive markers of PH and may help to predict the patient outcome.

Key Points

• Right ventricular (RV) volume measured by chest CT has good ability to identify pulmonary hypertension (PH) in patients with chronic heart failure (HF) and reduced ejection fraction (HFrEF).

• The accuracy of pulmonary artery (PA) diameter and PA to ascending aorta diameter ratio (PA:A ratio) to predict PH was similar to previous studies, however, with lower cut-offs (28.1 mm and 0.92, respectively).

• Chest CT-derived PA diameter and RV volume independently predict all-cause mortality and HF events and improve outcome prediction in patients with advanced HFrEF.


Pulmonary hypertension Dilated cardiomyopathy Ischemic heart disease Pulmonary artery Prognosis 



Area under the curve


Body surface area


Confidence interval


Fractional area change


Heart failure with reduced injection fraction


Ischemic heart disease


Interquartile range


Left atrium


Left ventricular or ventricle


Left ventricular ejection fraction


Nonischemic dilated cardiomyopathy


Mean pulmonary artery pressure


Pulmonary artery


Pulmonary artery pressure


Pulmonary artery wedge pressure


Pulmonary hypertension


Pulmonary hypertension due to left heart disease


Pulmonary vascular resistance


Right atrium


Receiving operating curve


Right heart catheterization


Right ventricular or right ventricle


Tricuspid regurgitation


Transthoracic echocardiography



The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Anne-Catherine Pouleur, MD, PhD

Conflict of interest

Pr Pouleur is Clinical Master Specialist of the Fondation Nationale de la Recherche Scientifique of the Belgian Government, FRSM.

The other authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

Christophe de Meester kindly provided statistical advice for this manuscript and has significant statistical expertise.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.


• retrospective

• diagnostic or prognostic study

• performed at one institution


  1. 1.
    Simonneau G, Gatzoulis MA, Adatia I et al (2013) Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol 62:D34–D41CrossRefGoogle Scholar
  2. 2.
    Galiè N, Humbert M, Vachiery JL et al (2016) 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 37:67–119CrossRefGoogle Scholar
  3. 3.
    Vachiéry JL, Adir Y, Barberà JA et al (2013) Pulmonary hypertension due to left heart diseases. J Am Coll Cardiol 62:D100–D108CrossRefGoogle Scholar
  4. 4.
    Ghio S, Gavazzi A, Campana C et al (2001) Independent and additive prognostic value of right ventricular systolic function and pulmonary artery pressure in patients with chronic heart failure. J Am Coll Cardiol 37:183–188CrossRefGoogle Scholar
  5. 5.
    Grigioni F, Potena L, Galie N et al (2016) Prognostic implications of serial assessments of pulmonary hypertension in severe chronic heart failure. J Heart Lung Transplant 25:1241–1246CrossRefGoogle Scholar
  6. 6.
    Costard-Jäckle A, Fowler MB (1992) Influence of preoperative pulmonary artery pressure on mortality after heart transplantation: testing of potential reversibility of pulmonary hypertension with nitroprusside is useful in defining a high risk group. J Am Coll Cardiol 19:48–54CrossRefGoogle Scholar
  7. 7.
    Butler J, Stankewicz MA, Wu J et al (2005) Pre-transplant reversible pulmonary hypertension predicts higher risk for mortality after cardiac transplantation. J Heart Lung Transplant 24:170–177CrossRefGoogle Scholar
  8. 8.
    Mehra MR, Kobashigawa J, Starling R et al (2006) Listing criteria for heart transplantation: International Society for Heart and Lung Transplantation guidelines for the care of cardiac transplant candidates--2006. J Heart Lung Transplant 25:1024–1042CrossRefGoogle Scholar
  9. 9.
    Gavazzi A, Berzuini C, Campana C et al (1997) Value of right ventricular ejection fraction in predicting short-term prognosis of patients with severe chronic heart failure. J Heart Lung Transplant 16:774–785PubMedGoogle Scholar
  10. 10.
    Ghio S, Temporelli PL, Klersy C et al (2013) Prognostic relevance of a non-invasive evaluation of right ventricular function and pulmonary artery pressure in patients with chronic heart failure. Eur J Heart Fail 15:408–414CrossRefGoogle Scholar
  11. 11.
    Kjaergaard J, Akkan D, Iversen KK, Kober L, Torp-Pedersen C, Hassager C (2007) Right ventricular dysfunction as an independent predictor of short- and long-term mortality in patients with heart failure. Eur J Heart Fail 9:610–616CrossRefGoogle Scholar
  12. 12.
    Bourantas CV, Loh HP, Bragadeesh T et al (2011) Relationship between right ventricular volumes measured by cardiac magnetic resonance imaging and prognosis in patients with chronic heart failure. Eur J Heart Fail 13:52–60CrossRefGoogle Scholar
  13. 13.
    Mehra MR, Canter CE, Hannan MM et al (2016) The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update. J Heart Lung Transplant 35:1–23CrossRefGoogle Scholar
  14. 14.
    Freed BH, Collins JD, François CJ et al (2016) MR and CT Imaging for the Evaluation of Pulmonary Hypertension. JACC Cardiovasc Imaging 9:715–732CrossRefGoogle Scholar
  15. 15.
    Kuriyama K, Gamsu G, Stern RG, Cann CE, Herfkens RJ, Brundage BH (1984) CT-determined pulmonary artery diameters in predicting pulmonary hypertension. Invest Radiol 19:16–22CrossRefGoogle Scholar
  16. 16.
    Karazincir S, Balci A, Seyfeli E et al (2008) CT assessment of main pulmonary artery diameter. Diagn Interv Radiol 14:72–74PubMedGoogle Scholar
  17. 17.
    Ng CS, Wells AU, Padley SP (1999) A CT sign of chronic pulmonary arterial hypertension: the ratio of main pulmonary artery to aortic diameter. J Thorac Imaging 14:270–278CrossRefGoogle Scholar
  18. 18.
    Mahammedi A, Oshmyansky A, Hassoun PM, Thiemann DR, Siegelman SS (2013) Pulmonary artery measurements in pulmonary hypertension: the role of computed tomography. J Thorac Imaging 28:96–103CrossRefGoogle Scholar
  19. 19.
    Devaraj A, Wells AU, Meister MG et al (2008) The Effect of Diffuse Pulmonary Fibrosis on the Reliability of CT Signs of Pulmonary Hypertension. Radiology 249:1042–1049CrossRefGoogle Scholar
  20. 20.
    Alhamad EH, Al-Boukai AA, Al-Kassimi FA et al (2011) Prediction of pulmonary hypertension in patients with or without interstitial lung disease: reliability of CT findings. Radiology 260:875–883CrossRefGoogle Scholar
  21. 21.
    Devaraj A, Loveridge R, Bosanac D et al (2014) Portopulmonary hypertension: improved detection using CT and echocardiography in combination. Eur Radiol 24:2385–2393CrossRefGoogle Scholar
  22. 22.
    Iyer AS, Wells JM, Vishin S, Bhatt SP, Wille KM, Dransfield MT (2014) CT scan-measured pulmonary artery to aorta ratio and echocardiography for detecting pulmonary hypertension in severe COPD. Chest 145:824–832CrossRefGoogle Scholar
  23. 23.
    Shen Y, Wan C, Tian P et al (2014) CT-base pulmonary artery measurement in the detection of pulmonary hypertension: a meta-analysis and systematic review. Medicine (Baltimore) 93:e256CrossRefGoogle Scholar
  24. 24.
    Devaraj A, Wells AU, Meister MG, Corte TJ, Wort SJ, Hansell DM (2010) Detection of pulmonary hypertension with multidetector CT and echocardiography alone and in combination. Radiology 254:609–616CrossRefGoogle Scholar
  25. 25.
    Chan AL, Juarez MM, Shelton DK et al (2011) Novel computed tomographic chest metrics to detect pulmonary hypertension. BMC Med Imaging 11:7CrossRefGoogle Scholar
  26. 26.
    Lang RM, Badano LP, Mor-Avi V et al (2015) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 16:233–270CrossRefGoogle Scholar
  27. 27.
    Puntmann VO, Carr-White G, Jabbour A et al (2016) T1-Mapping and Outcome in Nonischemic Cardiomyopathy: All-Cause Mortality and Heart Failure. JACC Cardiovasc Imaging 9:40–50CrossRefGoogle Scholar
  28. 28.
    Hicks KA, Tcheng JE, Bozkurt B et al (2015) ACC/AHA Key Data Elements and Definitions for Cardiovascular Endpoint Events in Clinical Trials: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Cardiovascular Endpoints Data Standards). J Am Coll Cardiol 66:403–469CrossRefGoogle Scholar
  29. 29.
    Meyer P, Filippatos GS, Ahmed MI et al (2010) Effects of right ventricular ejection fraction on outcomes in chronic systolic heart failure. Circulation 121:252–258CrossRefGoogle Scholar
  30. 30.
    Rahimi K, Bennett D, Conrad N et al (2014) Risk prediction in patients with heart failure: a systematic review and analysis. JACC Heart Fail 2:440–446CrossRefGoogle Scholar
  31. 31.
    Pocock SJ, Ariti CA, McMurray JJ et al (2013) Predicting survival in heart failure: a risk score based on 39 372 patients from 30 studies. Eur Heart J 34:1404–1413CrossRefGoogle Scholar
  32. 32.
    Dzudie A, Kengne AP, Thienemann F, Sliwa K (2014) Predictors of hospitalizations for heart failure and mortality in patients with pulmonary hypertension associated with left heart disease: a systematic review. BMJ Open 4:e004843CrossRefGoogle Scholar
  33. 33.
    Karakus G, Kammerlander AA, Aschauer S et al (2015) Pulmonary artery to aorta ratio for the detection of pulmonary hypertension: cardiovascular magnetic resonance and invasive hemodynamics in heart failure with preserved ejection fraction. J Cardiovasc Magn Reson 17:79CrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  • Geoffrey C. Colin
    • 1
    Email author
  • Bernhard L. Gerber
    • 2
  • Christophe de Meester de Ravenstein
    • 2
  • David Byl
    • 1
  • Anna Dietz
    • 1
  • Michele Kamga
    • 2
  • Agnes Pasquet
    • 2
  • David Vancraeynest
    • 2
  • Jean-Louis Vanoverschelde
    • 2
  • Anne-Marie D’Hondt
    • 2
  • Benoit Ghaye
    • 1
  • Anne-Catherine Pouleur
    • 2
  1. 1.Division of RadiologyCliniques Universitaires Saint-LucBrusselsBelgium
  2. 2.Division of CardiologyCliniques Universitaires Saint-LucBrusselsBelgium

Personalised recommendations