Differential Branch Pulmonary Artery
Regurgitant Fraction Is a Function of
Differential Pulmonary Arterial Anatomy
and Pulmonary Vascular Resistance
Matthew A. Harris, MD,*† Kevin K. Whitehead, MD, PHD,*† Matthew J. Gillespie, MD,*†
Timothy Y. Liu, BS,† Michael T. Cosulich, BS,† David C. Shin, BA,†
Elizabeth Goldmuntz, MD,*† Paul M. Weinberg, MD,*† Mark A. Fogel, MD*†
O B J E C T I V E S We sought to investigate whether differential branch pulmonary artery (BPA)
regurgitation correlates with differences in BPA anatomy and physiology.
B A C K G R O U N D Patients with repaired conotruncal anomalies such as Tetralogy of Fallot fre-
quently have residual BPA stenosis or BPA size differences. Previous reports have demonstrated an
increased left pulmonary artery (LPA) regurgitant fraction (RF) in these patients.
M E T H O D S We retrospectively reviewed 76 consecutive cardiac magnetic resonance (CMR) studies
for BPA size and phase-contrast magnetic resonance data, including 13 consecutive patients who
underwent both CMR and catheterization.
R E S U L T S Thirty of the 76 patients had either BPA stenosis or significant size discrepancy. Whereas
previous studies had shown an increased RF in the LPA, patients with BPA stenosis or size discrepancy
showed no significant difference between right and left BPA RF (30% vs. 30%, p ? 0.985). However, there
was a significantly increased RF of the larger versus smaller BPA (39% vs. 21%, p ? 0.001), resulting in
an insignificant deviation from normal fractional flow distribution (RPA 63% vs. LPA 37%; normal net
fractional flow distribution RPA 55% vs. LPA 45%). Retrospective review of patients who underwent both
CMR and catheterization provides support for the preceding findings and validates differential BPA RF
as strongly correlating with differential pulmonary vascular resistance (PVR) (r ? 0.8364, p ? 0.001).
C O N C L U S I O N S BPA RF is a function of the relative PVR and the presence of BPA stenosis or size
discrepancy. Contrary to prior reports, the LPA RF is only elevated in patients with relatively equal sized
BPAs. In the setting of BPA stenosis or size discrepancy the larger BPA has a relatively increased RF and
PVR. Therefore, the differential RF is an important tool for screening patients with unilateral stenosis for
contralateral increases in PVR that cannot be identified with net flows alone. This can affect the
indication and timing for BPA intervention. (J Am Coll Cardiol Img 2011;4:506–13) © 2011 by the
American College of Cardiology Foundation
From the *University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; and the †Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania. This research was supported by a grant from the National Heart, Lung, and Blood
Institute (P50 HL74731) to Drs. Fogel and Goldmuntz. All authors report that they have no relationships to disclose. Drs.
Fogel and Whitehead are joint senior authors of this work.
Manuscript received November 28, 2010; revised manuscript received January 12, 2011, accepted January 19, 2011.
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Key Words: differential branch
pulmonary regurgitation y
pulmonary vascular disease y
right ventricular dilation y
tetralogy of Fallot.
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Differential Branch Pulmonary Regurgitation