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Myocardial scar in pulmonary hypertension: relationship to pulmonary hemodynamics, right ventricular function and remodeling


Right ventricular (RV) functional and structural monitoring is important as a prognostic measure in pulmonary hypertension (PH) patients. Cardiac magnetic resonance (CMR) imaging is the standard of reference for RV anatomical and functional assessment. Using delayed enhancement (DE)-CMR, presence of myocardial scar in association with PH was typically described at the RV septal insertions. However, its etiology in relation to RV remodeling, altered regional mechanics and pulmonary hemodynamics has not been fully assessed.


To identify predictors of scar burden at the RV septal insertions in PH patients.


We prospectively evaluated 38 patients with suspected PH with right heart catheterization (RHC) and CMR. 10 age-matched controls were included for CMR study comparison. Septal DE mass was quantified at the RV insertions. Systolic septal eccentricity index (EI), global RV function and remodeling indices were quantified using cine short axis images. Regional peak systolic circumferential (ECC) and longitudinal (ELL) strain were measured at the DE-corresponding sites using conventional tagged and Fast strain encoding acquisitions respectively.


PH was diagnosed in 32 patients. DE was noted in 31/32 PH patients and 1/6 suspected but absent PH patients (mean DE mass ± SD = 4.6 g ± 3.3 and 0.6 g ± 1.5 for both groups respectively, p = 0.001). No DE was detected in controls. DE was more prevalent at the posterior septal insertion (PSI) compared to the anterior septal insertion (ASI). DE mass correlated with reduced RV function and increased RV remodeling indices. DE mass was associated with reduced ELL at the base (r = 0.6, p < 0.01) (Figure 1, 2). Similarly, it correlated with reduced EI (r = -0.4 for ASI-DE, r = -0.5 for PSI-DE, p < 0.05). Using multivariate regression including RV and LV mass indices, RV ejection fraction, EI and mPAP as parameters, RV mass index was an independent predictor of total DE mass (β = 0.65, p < 0.001). On regional analysis including: mPAP, RV mass index, EI, ELL and ECCas parameters, ELL at the base remained an independent predictor of DE mass at the ASI (β = 0.69, p = 0.002), whereas, elevated mPAP was an independent predictor of DE mass at the PSI (β = 0.4, p = 0.03).

Figure 1

72 yr olf PH patient (mPAP = 53 mmHg). 1A) GRE inversion recovery image deomonstrating areas of LV DE at the basal anterior and posterior RV septal insertions (arrows). 1B) Corresponding peak systolic Fast-SENC image demonstrating reduced ELL at the anterior RV septal insetion (white) compared to posterior septal insertion (red).

Figure 2

59 yr old non PH patient (mPAP = 18 mmHg). 2A) GRE inversion recovery image at the base of LV. 2B) Corresponding peak systlic Fast-SENC image demonstrating normal ELL at both RV attachment sites.


In PH, total scar burden at the RV septal insertions is predicted by measures of RV remodeling in response to increased RV after-load. Local scar mass at the ASI is associated with reduced regional longitudinal contractility at the base of the left ventricle.

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Correspondence to Monda L Shehata.

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Open Access This article is published under license to BioMed Central Ltd. This is an Open Access article is distributed under the terms of the Creative Commons Attribution 2.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Shehata, M.L., Skrok, J., Lossnitzer, D. et al. Myocardial scar in pulmonary hypertension: relationship to pulmonary hemodynamics, right ventricular function and remodeling. J Cardiovasc Magn Reson 12, O51 (2010).

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  • Pulmonary Hypertension
  • Right Ventricular
  • Cardiac Magnetic Resonance
  • Right Ventricular Function
  • Right Ventricular Ejection Fraction