Harm Bogaard, MD - phaware® interview 456

Harm Bogaard, MD, Ph.D., FAHA is a pulmonologist at the Amsterdam UMC. In this episode, he discusses the use of magnetic resonance imaging (MRI) in monitoring pulmonary hypertension patients. Dr. Bogaard explains that MRI is a valuable tool for assessing the function and structure of the right heart, which is crucial in determining the prognosis and long-term outcomes of patients with pulmonary hypertension.

My name is Harm Bogaard. I'm a pulmonologist here in Amsterdam in the Netherlands. I work at the National Expert Center for pulmonary hypertension patients. We have a clinic, obviously, with patients mainly with idiopathic and hereditary PAH. We also have a chronic thromboembolic pulmonary hypertension (CTEPH) program with diagnostics, surgeries, balloon pulmonary angioplasty. In addition to my clinical work, we have a translational lab to find out more about different forms of pulmonary hypertension and its treatment.

Today, I would like to tell you a little bit about how we use magnetic resonance imaging in the Netherlands to monitor our pulmonary hypertension patients. We started doing this 20 years ago to use non-invasive imaging by magnetic resonance imaging or MRI to basically follow the function and structure of the right heart in our patients. It's been known for quite some time that the prognosis and the long-term outcomes in patients with pulmonary hypertension are really determined by the capacity of the right heart to adapt to the high load. Exercise testing, like the six-minute walk test, provides some indirect information about the functioning of the right heart. NT-proBNP does the same thing. Echocardiography also gives you some clue as to how well the right heart adapts, but the right heart is quite difficult to understand and also to image by echocardiography. We've found some 20 years ago already that MRI is really a fantastic tool to get a really good grip on the adaptation of the right heart.

We started following our patients (around 2,000) with MRI. We did a lot of research, so we showed that MRI gives very valuable prognostic information. We also learned a lot about how physiologically the right heart adapts to high pressure. Now, we've really adopted the use of MRI in our routine follow-up. So, it basically means that we hardly ever do a repeat right heart catheterization in our patients. We used to do many. We used to do like four months after initiation of treatment, and then after one year, after two years, after three years, we did a lot of right heart catheterizations. But now, we've gathered so much data with MRI, we really know that we can get very similar or sometimes even better information by doing a non-invasive MRI.

The setting in our hospital is quite unique because the hospital is devoted to imaging and we get some really good deals basically by the hospital or administration to do this in a very cheap way and to get the personnel to do this. I know that it's difficult in many other hospitals. There's limited time available for MRI scanning, it's expensive. I wish the situation would be better because I really feel that this is a great way for patients to be followed.

The only downside is that some patients are claustrophobic. It is a tight space. Fortunately, the more modern MRIs are a little bit bigger, so it doesn't feel so cramped anymore, but some people do have some problems with getting into this tube. Fortunately, it's only a small minority and most of our patients we can follow really well by doing MRI.

We can even do some more sophisticated testing. We have the possibility to do exercise in the MRI, so patients are on a recumbent bike. They can stress their heart and we can look at how the heart adapts to exercise, which gives a ton of additional information. By using different techniques, we can look at the development of scar tissue in the heart, which is also important prognostic information development fibrosis in the right heart. We can look at how well the heart readjusts when given treatment. We can easily look at basically how much treatment you need to give to get a really good response in the right heart. We make great use of it and we hope that the technique can be implemented in a much larger scale. Maybe in clinical management of patients, but also as an endpoint in trials MRI could be really useful.

In many countries, right heart catheterization is still considered the best way to diagnose your patients in the first place and also to follow your patients. I think for a proper diagnosis, I fully agree, a right heart catheterization is still necessary, because right heart catheterization gives you the only real means by which you can make a distinction between real pulmonary vascular disease or other causes of pulmonary hypertension. Even though there are definitely developments in imaging, if we still see it the same in 10 or 15 years, I think then we probably (will) get rid of a right heart catheterization altogether. But right now, for diagnosis, I still have to agree that the right heart catheterization is what you need to do. But for follow-up, by now, we really know which parameters that you get from a right heart catheterization, which are informative; which is basically stroke volume, which is the most informative value from a right heart catheterization. We can derive this perfectly with MRI.

In the follow-up of your patients, I don’t think there's a real need to do a repeat right heart catheterization unless maybe you do still have some doubt as to whether you have the diagnosis righ. Maybe that's still a reason to do it. But in general, I think all of the important prognostic parameters that you can get from right heart catheterization, you get from MRI.

Of course, I can recommend to ask for an MRI. But yeah, if the local situation is as such that is not available, then, yeah, there's maybe not much that you can do other than using the techniques that are available. I'm not saying that you can only follow your patient right with MRI, because there are alternatives you can do a right heart catheterization and be informed in that way. So, it's not that you're not getting the right treatment, but it's a little bit more non-invasive of course, if you can do an MRI. So, if it is reimbursed, if there are possibilities, then go for it. Ask your doctor to get an MRI.

So here in the Netherlands, we are in a situation that we can use MRI and I'm really grateful for it and it's really helpful. I'm not saying that you cannot follow your patient in a proper way if you don't use MRI. There are definitely other ways to do an excellent monitoring and provide the best care to your patients, but I do know that MRI makes it a little bit easier. To be able to do this in a non-invasive way is very comfortable for the patient friendly. So, I hope the technique will become more widely available.

I'm Harm Bogaard and I'm aware that my patients are rare.

Learn more about pulmonary hypertension trials at www.phaware.global/clinicaltrials. Follow us on social @phaware Engage for a cure: www.phaware.global/donate #phaware
Share your story: [email protected] #phawareMD