Commentary
Catheterization plays a central role in the diagnostic evaluation of patients with intracardiac shunts, complex congenital heart disease, pulmonary vascular disease, cardiomyopathy, cor pulmonale, and heart failure. Elevated pulmonary arterial pressure is a hemodynamic fi nding common to all these disease processes. Establishing the cause of pulmonary hypertension requires complex diagnostic algorithms involving numerous noninvasive and invasive tests. Today, catheterization remains the best available investigative tool for confi rming diagnosis, quantifying severity of disease, and determining treatment. Guidelines 1-3 recommend catheterization be performed in all patients with symptoms and echocardiographic suspicion of pulmonary hypertension or prior to initiation of therapy.Hemodynamic parameters shown to be associated with an increased risk of death include increased mean pulmonary artery pressure, increased mean right atrial pressure, and decreased cardiac index. 4 Most guidelines defi ne pulmonary hypertension based on elevated mean pulmonary artery pressure alone. However, with disease progression, mean pulmonary artery pressure may actually fall as the right ventricle fails. For this reason, pulmonary vascular resistance is a more compelling standard for the diagnosis of pulmonary hypertension because it takes into account both pressure and fl ow. Resistance measurement has not entered guideline care because accurate measurement of pulmonary fl ow is not possible in the presence of tricuspid regurgitation, typical in these patients, using conventional thermodilution techniques. It is important to consider that the cause of elevated pulmonary pressure is not always pulmonary vascular pathology. For example, in patients with high transpulmonary fl ow, such as in pregnant women or in patients with anemia, sepsis, thyrotoxicosis, or intracardiac shunt, pulmonary pressure can be elevated in the presence of normal pulmonary vascular resistance. Provocative testing with vasodilators, such as inhaled nitric oxide plus 100% oxy gen, is recommended because vasoreactivity predicts responsiveness to prostacyclin analogs, endothelin-receptor antagonists, or phosphodiesterase Diagnosis and prognostication in patients with complex cardiopulmonary disease can be a clinical challenge. A new procedure, MRI catheterization, involves invasive right-sided heart catheterization performed inside the MRI scanner using MRI instead of traditional radiographic fl uoroscopic guidance. MRI catheterization combines simultaneous invasive hemodynamic and MRI functional assessment in a single radiation-free procedure. By combining both modalities, the many individual limitations of invasive catheterization and noninvasive imaging can be overcome, and additional clinical questions can be addressed. Today, MRI catheterization is a clinical reality in specialist centers in the United States and Europe. Advances in medical device design for the MRI environment will enable not only diagnostic but also interventional MRI procedure...