The principal finding from this study is that myocardial oxygenation response to adenosine stress is blunted in patients with PAH compared to healthy controls. The blunted oxygenation response was demonstrated in PAH patients who were stable on pulmonary vasodilator therapy and at an adaptive stage of PAH with non-obstructive epicardial coronaries, and was correlated inversely with RV wall thickness and RHC mPAP. Although we had demonstrated changes to the myocardial interstitium, no clear interaction with myocardial oxygenation was noted. These findings highlight the potential contribution of myocardial ischemia to the pathophysiology of RV dysfunction in PAH, and could subsequently lead to new potential treatment targets, in such patients.
Right ventricular myocardial deoxygenation in PAH
In PAH, RV myocardial ischemia is acknowledged to be a significant contributor to adverse remodelling and progressive RV dysfunction [
4]. Reduced right coronary artery perfusion pressure [
24] and microvascular ischemia leads to progressive RV dysfunction causing RV failure and death. Abnormal pressure gradient between the aorta and the RV due to escalating pulmonary vascular resistance, reduces myocardial blood flow in the RV branch of the right coronary artery causing ischemia [
7,
25]. RV myocardial ischemia is further exacerbated by inadequate compensatory increase in the myocardial vasculature owing to progressive RV hypertrophy (RVH) [
7,
26,
27]. Occlusive microvascular damage and impairment in angiogenesis (known as capillary rarefaction) has been demonstrated in animal models and SScPAH, is thought to cause microvascular ischemia [
5,
28]. Furthermore, a study by Meloche et al. proposes common pathobiology mechanisms between PAH pulmonary vasculature and coronary arteries [
29]. These pathobiology mechanisms trigger coronary vascular remodeling in both the LV and RV leading to microvascular ischemia.
In this study, we have demonstrated a blunted myocardial oxygenation response to vasodilator stress in the inferior RV segment on PAH patients. Specifically our study demonstrates the presence in-vivo myocardial deoxygenation in the adaptive stage of PAH. The findings of in-vivo RV myocardial deoxygenation in PAH are novel because abnormalities in myocardial blood flow or microvascular dysfunction may not necessarily lead to myocardial deoxygenation [
11]. Arnold et al
. had demonstrated that in coronary artery disease, 50% of hypoperfused segments on quantitative myocardial perfusion demonstrate no evidence of deoxygenation [
11]. Furthermore in dilated cardiomyopathy, Dass et al. had demonstrated disassociation between microvascular dysfunction and oxygenation [
30]. Although we had not performed any direct comparison between myocardial blood flow and myocardial oxygenation, these findings provide further mechanistic insight into pathophysiology of myocardial ischemia in the RV in PAH.
The OS-CMR SI changes in the RV had good correlation with global OS-CMR SI changes seen in the LV, an area of myocardium in which there is good validation with the OS-CMR technique. In our study, the OS-CMR technique has demonstrated significant changes in the inferior RV segment. Thinned myocardium (causing partial volume effects), off-resonance artefacts and image artefacts are known limitations of the OS-CMR technique in the RV [
18]. However, these limitations have previously been known to affect the accuracy of OS-CMR SI in LV myocardium [
31]. Consistent voxel-size was applied during OS-CMR imaging, hence the measured inferior RV wall thickness provided sufficient coverage to avert partial volume effects. Additionally, it has been shown that the inferior RV segment has the greatest end-diastolic wall thickness once the afterload, serum biomarkers and RV structural adaptation in pre- and post-capillary pulmonary hypertension have been taken into consideration [
32].
Furthermore, our study has demonstrated a moderate inverse correlation between RV OS-CMR SI and mPAP. The moderate correlation highlights that there are other pathophysiological factors (such as microvascular ischemia) that affect the RV besides elevated mPAP. Patients with microvascular ischemia often present with typical effort-induced angina, but also with atypical symptoms such as dyspnea on exertion [
33]. Exertional limitation is the dominant symptom in PAH, however it is contributed by many factors such as respiratory mechanics/ventilation, cardiovascular response and psychological/emotional aspects [
34]. Even though RHC resting hemodynamic measures such as mPAP and cardiac output correlate with severity of symptoms, there are considerable inter-individual variability that is not explained by RHC hemodynamic severity [
35]. The findings of myocardial deoxygenation provide further mechanistic insights into the pathophysiology of myocardial ischaemia in PAH population.
Native T1-values in the right ventricle
In PAH, the RV adaptation extends to the cardiomyocytes and interstitium altering the cardiac structure and function [
8]. Although the initial adaptive changes of myocardial collagen accumulation serve as a favorable response helping the RV withstand higher pressures, over time maladaptive alteration ensues leading to fibrosis and progressive RV dysfunction [
36]. Native CMR T1 parametric mapping has been used as a surrogate for diffuse interstitial fibrosis in the absence of an alternative cause of interstitial expansion (oedema, infiltrations/fibre disarray) [
16]. Previous studies of RV native T1 mapping in PAH using Modified Look-Locker Inversion recovery (MOLLI) sequence has produced varying results [
17,
22,
37]. One possible explanation is that each of these studies have adapted an altered version of the MOLLI sequence thus producing differing results. Utilising the ShMOLLI sequence, our study demonstrated increased native T1-values in the inferior RV wall compared to healthy controls. The native T1-values in the inferior RV wall were comparable to the LV septum and LV free wall in PAH patients, similar to the findings previously demonstrated by Spruijt et al.[
22]. Unexpectedly in our study, we found that the RV native T1-values did not correlate with inferior RV OS-CMR SI changes. This is pertinent in PAH as the pressure overload leads to disruption of the healthy extracellular matrix in the RV due to the excess collagen formation and myocardial interstitial fibrosis. Changes in RV extracellular matrix could potentially disrupt the coronary microvasculature and hence myocardial oxygen supply. However, the lack of association between RV native T1-values and RV OS-CMR SI in our study suggests that the changes in RV extracellular matrix does not directly impact myocardial oxygenation.
Interestingly our study is the first to have demonstrated a significant difference in the native T1-values between the IPAH and SScPAH. We have used the ShMOLLI sequence in contrast to other studies that have used the MOLLI sequence [
17,
22,
38]. The ShMOLLI sequence is heart rate independent [
39] and as such is able to estimate long T1s which is important for assessing oedematous tissue [
40]. Previous ShMOLLI T1 mapping studies of the LV in systemic sclerosis patients suggested the presence of interstitial fibrosis and low-grade inflammation [
41]. Therefore, the higher T1-value SScPAH seen in our study could signify a combination of diffuse interstitial fibrosis and myocardial inflammation, a theory that fits with the pathophysiology of systemic sclerosis.
Study limitations
Our study only performed a single mid-ventricular slice on OS-CMR imaging rather than the entire ventricle hence there was incomplete coverage of the full RV myocardium. This is unlikely to be of major relevance in RV assessment of PAH which is a global process. While our study had demonstrated in-vivo myocardial deoxygenation in the RV of PAH, we had not performed any direct comparison with myocardial blood flow, an area for future studies. Late-gadolinium enhancement or extracellular volume assessment was not performed due to concerns of patient safety and tolerability during CMR research scan. While OS-CMR sequence has been studied in many conditions [
9], to our knowledge it has not been studied in PAH. The multiple breath-hold during rest/stress OS-CMR image acquisitions could potentially be challenging for PAH patients as dyspnoea is a common symptom in this cohort of patients. The number of subjects in the healthy control groups were relatively small especially with female controls, compared to the PAH group. However the control group were age-matched, minimizing any significant bias. This is important, especially in T1-values whereby age is known to influence native myocardial T1-values [
39]. Measuring RV T1 on a curved RV myocardium can be challenging. RV T1 mapping with ShMOLLI sequence at 8 mm slice thickness can be a potential substrate for partial volume effects affecting T1-values. However, every effort was taken to ensure the ROI was drawn in the myocardium. Furthermore the adequate reproducibility and the comparable RV T1-values to the LV T1-values in PAH patients suggest accurate interpretation of RV T1. Although this study was prospective, the PAH patients were stable on pulmonary vasodilator therapy. This could have mitigated against the finding of RV ischemia. A larger study would help to determine the clinical and prognostic utility of these novel CMR techniques in PAH.