Short-Term Effects of Inhaled Nitric Oxide on Right Ventricular Flow Hemodynamics by 4-Dimensional-Flow Magnetic Resonance Imaging in Children With Pulmonary Arterial Hypertension

J Am Heart Assoc. 2021 Apr 20;10(8):e020548. doi: 10.1161/JAHA.120.020548. Epub 2021 Apr 6.


Background Pulmonary arterial hypertension (PAH) manifests with progressive right ventricular (RV) dysfunction, which eventually impairs the left ventricular function. We hypothesized that 4-dimensional-flow magnetic resonance imaging can detect flow hemodynamic changes associated with efficient intracardiac flow during noninvasive inhaled nitric oxide (iNO) challenge in children with PAH. Methods and Results Children with PAH (n=10) underwent 2 same-day separate iNO challenge tests using: (1) 4-dimensional-flow magnetic resonance imaging and (2) standard catheterization hemodynamics. Intracardiac flow was evaluated using the particle tracking 4-flow component analysis technique evaluating the direct flow, retained inflow, delayed ejection flow, and residual volume. Respective flow hemodynamic changes were compared with the corresponding catheterization iNO challenge results. The RV analysis revealed decreased direct flow in patients with PAH when compared with controls (P<0.001) and increase in residual volume (P<0.001). Similarly, the left ventricular analysis revealed decreased direct flow in patients with PAH when compared with controls (P=0.004) and increased proportion of the residual volume (P=0.014). There was an increase in the RV direct flow during iNO delivery (P=0.009), with parallel decrease in the residual volume (P=0.008). Conclusions Children with PAH have abnormal biventricular flow associated with impaired diastolic filling. The flow efficiency is significantly improved in the RV on iNO administration with no change in the left ventricle. The changes in the RV flow have occurred despite the minimal change in catheterization hemodynamics, suggesting that flow hemodynamic evaluation might provide more quantitative insights into vasoreactivity testing in PAH.

Keywords: intracardiac flow; nitric oxide; pulmonary hypertension.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Administration, Inhalation
  • Adolescent
  • Child
  • Child, Preschool
  • Endothelium-Dependent Relaxing Factors / administration & dosage
  • Female
  • Follow-Up Studies
  • Heart Ventricles / diagnostic imaging*
  • Heart Ventricles / physiopathology
  • Hemodynamics / drug effects
  • Humans
  • Image Processing, Computer-Assisted / methods*
  • Infant
  • Magnetic Resonance Imaging, Cine / methods*
  • Male
  • Nitric Oxide / administration & dosage*
  • Prospective Studies
  • Pulmonary Arterial Hypertension / diagnosis
  • Pulmonary Arterial Hypertension / drug therapy*
  • Pulmonary Arterial Hypertension / physiopathology
  • Regional Blood Flow / drug effects*
  • Time Factors
  • Ventricular Function, Right / drug effects*


  • Endothelium-Dependent Relaxing Factors
  • Nitric Oxide