Four-dimensional flow cardiovascular magnetic resonance in tetralogy of Fallot: a systematic review

Abstract Background Patients with repaired Tetralogy of Fallot (rTOF) often develop cardiovascular dysfunction and require regular imaging to evaluate deterioration and time interventions such as pulmonary valve replacement. Four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) enables detailed assessment of flow characteristics in all chambers and great vessels. We performed a systematic review of intra-cardiac 4D flow applications in rTOF patients, to examine clinical utility and highlight optimal methods for evaluating rTOF patients. Methods A comprehensive literature search was undertaken in March 2020 on Google Scholar and Scopus. A modified version of the Critical Appraisal Skills Programme (CASP) tool was used to assess and score the applicability of each study. Important clinical outcomes were assessed including similarities and differences. Results Of the 635 articles identified, 26 studies met eligibility for systematic review. None of these were below 59% applicability on the modified CASP score. Studies could be broadly classified into four groups: (i) pilot studies, (ii) development of new acquisition methods, (iii) validation and (vi) identification of novel flow features. Quantitative comparison with other modalities included 2D phase contrast CMR (13 studies) and echocardiography (4 studies). The 4D flow study applications included stroke volume (18/26;69%), regurgitant fraction (16/26;62%), relative branch pulmonary artery flow(4/26;15%), systolic peak velocity (9/26;35%), systemic/pulmonary total flow ratio (6/26;23%), end diastolic and end systolic volume (5/26;19%), kinetic energy (5/26;19%) and vorticity (2/26;8%). Conclusions 4D flow CMR shows potential in rTOF assessment, particularly in retrospective valve tracking for flow evaluation, velocity profiling, intra-cardiac kinetic energy quantification, and vortex visualization. Protocols should be targeted to pathology. Prospective, randomized, multi-centered studies are required to validate these new characteristics and establish their clinical use.

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Left Ventricular Blood Flow Kinetic Energy Assessment by 4D Flow Cardiovascular Magnetic Resonance: A Systematic Review of the Clinical Relevance

Journal of Cardiovascular Development and Disease ◽

10.3390/jcdd7030037 ◽

2020 ◽

Vol 7 (3) ◽

pp. 37

Author(s):

Harjinder Kaur ◽

Hosamadin Assadi ◽

Samer Alabed ◽

Donnie Cameron ◽

Vassilios S. Vassiliou ◽

...

Keyword(s):

Systematic Review ◽

Blood Flow ◽

Cardiovascular Magnetic Resonance ◽

Heart Disease ◽

Magnetic Resonance ◽

Kinetic Energy ◽

Left Ventricular ◽

4D Flow ◽

Hemodynamic Assessment ◽

Lv Diastolic Function

Background: There is an emerging body of evidence that supports the potential clinical value of left ventricular (LV) intracavity blood flow kinetic energy (KE) assessment using four-dimensional flow cardiovascular magnetic resonance imaging (4D flow CMR). The aim of this systematic review is to summarize studies evaluating LV intracavity blood flow KE quantification methods and its potential clinical significance. Methods: A systematic review search was carried out on Medline, Pubmed, EMBASE and CINAHL. Results: Of the 677 articles screened, 16 studies met eligibility. These included six (37%) studies on LV diastolic function, another six (37%) studies on heart failure or cardiomyopathies, three (19%) studies on ischemic heart disease or myocardial infarction and finally, one (6%) study on valvular heart disease, namely, mitral regurgitation. One of the main strengths identified by these studies is high reproducibility of LV blood flow KE hemodynamic assessment (mean coefficient of variability = 6 ± 2%) for the evaluation of LV diastolic function. Conclusions: The evidence gathered in this systematic review suggests that LV blood flow KE has great promise for LV hemodynamic assessment. Studies showed increased diagnostic confidence at no cost of additional time. Results were highly reproducible with low intraobserver variability.

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P872Temporal and spatial distribution of wall shear stress in the main pulmonary artery in tetralogy of Fallot patients using four dimensional flow cardiovascular magnetic resonance

European Heart Journal ◽

10.1093/eurheartj/ehy564.p872 ◽

2018 ◽

Vol 39 (suppl_1) ◽

Author(s):

J Rizk ◽

H Latus ◽

J Zimmermann ◽

N Mkrtchyan ◽

S Martinoff ◽

...

Keyword(s):

Shear Stress ◽

Spatial Distribution ◽

Cardiovascular Magnetic Resonance ◽

Magnetic Resonance ◽

Wall Shear Stress ◽

Pulmonary Artery ◽

Tetralogy Of Fallot ◽

Main Pulmonary Artery ◽

Dimensional Flow ◽

Wall Shear

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Quantification of regurgitation in mitral valve prolapse with four-dimensional flow cardiovascular magnetic resonance

Journal of Cardiovascular Magnetic Resonance ◽

10.1186/s12968-021-00783-8 ◽

2021 ◽

Vol 23 (1) ◽

Author(s):

Ricardo A. Spampinato ◽

Cosima Jahnke ◽

Gerard Crelier ◽

Frank Lindemann ◽

Florian Fahr ◽

...

Keyword(s):

Cardiovascular Magnetic Resonance ◽

Magnetic Resonance ◽

Mitral Valve ◽

Mitral Valve Prolapse ◽

Ventricular Outflow Tract ◽

Left Ventricular ◽

4D Flow ◽

Proximal Isovelocity Surface Area ◽

4D Flow Cmr ◽

Severity Grading

Abstract Background Four-dimensional cardiovascular magnetic resonance (CMR) flow assessment (4D flow) allows to derive volumetric quantitative parameters in mitral regurgitation (MR) using retrospective valve tracking. However, prior studies have been conducted in functional MR or in patients with congenital heart disease, thus, data regarding the usefulness of 4D flow CMR in case of a valve pathology like mitral valve prolapse (MVP) are scarce. This study aimed to evaluate the clinical utility of cine-guided valve segmentation of 4D flow CMR in assessment of MR in MVP when compared to standardized routine CMR and transthoracic echocardiography (TTE). Methods Six healthy subjects and 54 patients (55 ± 16 years; 47 men) with MVP were studied. TTE severity grading used a multiparametric approach resulting in mild/mild-moderate (n = 12), moderate-severe (n = 12), and severe MR (n = 30). Regurgitant volume (RVol) and regurgitant fraction (RF) were also derived using standard volumetric CMR and 4D flow CMR datasets with direct measurement of regurgitant flow (4DFdirect) and indirect calculation using the formula: mitral valve forward flow - left ventricular outflow tract stroke volume (4DFindirect). Results There was moderate to strong correlation between methods (r = 0.59–0.84, p < 0.001), but TTE proximal isovelocity surface area (PISA) method showed higher RVol as compared with CMR techniques (PISA vs. CMR, mean difference of 15.8 ml [95% CI 9.9–21.6]; PISA vs. 4DFindirect, 17.2 ml [8.4–25.9]; PISA vs. 4DFdirect, 27.9 ml [19.1–36.8]; p < 0.001). Only indirect CMR methods (CMR vs. 4DFindirect) showed moderate to substantial agreement (Lin’s coefficient 0.92–0.97) without significant bias (mean bias 1.05 ± 26 ml [− 50 to 52], p = 0.757). Intra- and inter-observer reliability were good to excellent for all methods (ICC 0.87–0.99), but with numerically lower coefficient of variation for indirect CMR methods (2.5 to 12%). Conclusions In the assessment of patients with MR and MVP, cine-guided valve segmentation 4D flow CMR is feasible and comparable to standard CMR, but with lower RVol when TTE is used as reference. 4DFindirect quantification has higher intra- and inter-technique agreement than 4DFdirect quantification and might be used as an adjunctive technique for cross-checking MR quantification in MVP.

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Reproducibility of left ventricular blood flow kinetic energy measured by four-dimensional flow CMR

BMC Research Notes ◽

10.1186/s13104-021-05697-3 ◽

2021 ◽

Vol 14 (1) ◽

Author(s):

Ciaran Grafton-Clarke ◽

Saul Crandon ◽

Jos J. M. Westenberg ◽

Peter P. Swoboda ◽

John P. Greenwood ◽

...

Keyword(s):

Blood Flow ◽

Kinetic Energy ◽

Healthy Volunteers ◽

Statistical Power ◽

Left Ventricular ◽

Diastolic Filling ◽

4D Flow ◽

Energy Data ◽

Dimensional Flow ◽

4D Flow Cmr

Abstract Objectives Four-dimensional flow CMR allows for a comprehensive assessment of the blood flow kinetic energy of the ventricles of the heart. In comparison to standard two-dimensional image acquisition, 4D flow CMR is felt to offer superior reproducibility, which is important when repeated examinations may be required. The objective was to evaluate the inter-observer and intra-observer reproducibility of blood flow kinetic energy assessment using 4D flow of the left ventricle in 20 healthy volunteers across two centres in the United Kingdom and the Netherlands. Data description This dataset contains 4D flow CMR blood flow kinetic energy data for 20 healthy volunteers with no known cardiovascular disease. Presented is kinetic energy data for the entire cardiac cycle (global), the systolic and diastolic components, in addition to blood flow kinetic energy for both early and late diastolic filling. This data is available for reuse and would be valuable in supporting other research, such as allowing for larger sample sizes with more statistical power for further analysis of these variables.

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Cardiovascular magnetic resonance imaging: emerging techniques and applications

Heart ◽

10.1136/heartjnl-2019-315669 ◽

2021 ◽

pp. heartjnl-2019-315669

Author(s):

Amrit Chowdhary ◽

Pankaj Garg ◽

Arka Das ◽

Muhummad Sohaib Nazir ◽

Sven Plein

Keyword(s):

Cardiovascular Magnetic Resonance ◽

Magnetic Resonance ◽

Diffusion Tensor ◽

Three Dimensional ◽

Molecular Water ◽

Contrast Imaging ◽

4D Flow ◽

Data Set ◽

Quantitative Pet ◽

4D Flow Cmr

This review gives examples of emerging cardiovascular magnetic resonance (CMR) techniques and applications that have the potential to transition from research to clinical application in the near future. Four-dimensional flow CMR (4D-flow CMR) allows time-resolved three-directional, three-dimensional (3D) velocity-encoded phase-contrast imaging for 3D visualisation and quantification of valvular or intracavity flow. Acquisition times of under 10 min are achievable for a whole heart multidirectional data set and commercial software packages are now available for data analysis, making 4D-flow CMR feasible for inclusion in clinical imaging protocols. Diffusion tensor imaging (DTI) is based on the measurement of molecular water diffusion and uses contrasting behaviour in the presence and absence of boundaries to infer tissue structure. Cardiac DTI is capable of non-invasively phenotyping the 3D micro-architecture within a few minutes, facilitating transition of the method to clinical protocols. Hybrid positron emission tomography-magnetic resonance (PET-MR) provides quantitative PET measures of biological and pathological processes of the heart combined with anatomical, morphological and functional CMR imaging. Cardiac PET-MR offers opportunities in ischaemic, inflammatory and infiltrative heart disease.

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Left ventricular fluid kinetic energy time curves in heart failure from cardiovascular magnetic resonance 4D flow data

Journal of Cardiovascular Magnetic Resonance ◽

10.1186/s12968-015-0211-4 ◽

2015 ◽

Vol 17 (1) ◽

Cited By ~ 42

Author(s):

Mikael Kanski ◽

Per M. Arvidsson ◽

Johannes Töger ◽

Rasmus Borgquist ◽

Einar Heiberg ◽

...

Keyword(s):

Heart Failure ◽

Cardiovascular Magnetic Resonance ◽

Magnetic Resonance ◽

Kinetic Energy ◽

Left Ventricular ◽

Flow Data ◽

4D Flow

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False lumen pressure estimation in type B aortic dissection using 4D flow cardiovascular magnetic resonance: comparisons with aortic growth

Journal of Cardiovascular Magnetic Resonance ◽

10.1186/s12968-021-00741-4 ◽

2021 ◽

Vol 23 (1) ◽

Author(s):

David Marlevi ◽

Julio A. Sotelo ◽

Ross Grogan-Kaylor ◽

Yunus Ahmed ◽

Sergio Uribe ◽

...

Keyword(s):

Growth Rate ◽

Cardiovascular Magnetic Resonance ◽

Magnetic Resonance ◽

Aortic Dissection ◽

False Lumen ◽

Relative Pressure ◽

Type B ◽

Type B Aortic Dissection ◽

4D Flow ◽

4D Flow Cmr

Abstract Background Chronic type B aortic dissection (TBAD) is associated with poor long-term outcome, and accurate risk stratification tools remain lacking. Pressurization of the false lumen (FL) has been recognized as central in promoting aortic growth. Several surrogate imaging-based metrics have been proposed to assess FL hemodynamics; however, their relationship to enlarging aortic dimensions remains unclear. We investigated the association between aortic growth and three cardiovascular magnetic resonance (CMR)-derived metrics of FL pressurization: false lumen ejection fraction (FLEF), maximum systolic deceleration rate (MSDR), and FL relative pressure (FL ΔPmax). Methods CMR/CMR angiography was performed in 12 patients with chronic dissection of the descending thoracoabdominal aorta, including contrast-enhanced CMR angiography and time-resolved three-dimensional phase-contrast CMR (4D Flow CMR). Aortic growth rate was calculated as the change in maximal aortic diameter between baseline and follow-up imaging studies over the time interval, with patients categorized as having either ‘stable’ (< 3 mm/year) or ‘enlarging’ (≥ 3 mm/year) growth. Three metrics relating to FL pressurization were defined as: (1) FLEF: the ratio between retrograde and antegrade flow at the TBAD entry tear, (2) MSDR: the absolute difference between maximum and minimum systolic acceleration in the proximal FL, and (3) FL ΔPmax: the difference in absolute pressure between aortic root and distal FL. Results FLEF was higher in enlarging TBAD (49.0 ± 17.9% vs. 10.0 ± 11.9%, p = 0.002), whereas FL ΔPmax was lower (32.2 ± 10.8 vs. 57.2 ± 12.5 mmHg/m, p = 0.017). MSDR and conventional anatomic variables did not differ significantly between groups. FLEF showed positive (r = 0.78, p = 0.003) correlation with aortic growth rate whereas FL ΔPmax showed negative correlation (r = − 0.64, p = 0.026). FLEF and FL ΔPmax remained as independent predictors of aortic growth rate after adjusting for baseline aortic diameter. Conclusion Comparative analysis of three 4D flow CMR metrics of TBAD FL pressurization demonstrated that those that focusing on retrograde flow (FLEF) and relative pressure (FL ΔPmax) independently correlated with growth and differentiated patients with enlarging and stable descending aortic dissections. These results emphasize the highly variable nature of aortic hemodynamics in TBAD patients, and suggest that 4D Flow CMR derived metrics of FL pressurization may be useful to separate patients at highest and lowest risk for progressive aortic growth and complications.

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Accelerated aortic 4D flow cardiovascular magnetic resonance using compressed sensing: applicability, validation and clinical integration

Journal of Cardiovascular Magnetic Resonance ◽

10.1186/s12968-019-0573-0 ◽

2019 ◽

Vol 21 (1) ◽

Cited By ~ 8

Author(s):

Elisabeth Neuhaus ◽

Kilian Weiss ◽

Rene Bastkowski ◽

Jonas Koopmann ◽

David Maintz ◽

...

Keyword(s):

Cardiovascular Magnetic Resonance ◽

Magnetic Resonance ◽

Compressed Sensing ◽

Thoracic Aorta ◽

4D Flow ◽

Particle Trace ◽

4D Flow Cmr ◽

Scan Time ◽

On Line ◽

Mean Differences

Abstract Background Three-dimensional time-resolved phase-contrast cardiovascular magnetic resonance (4D flow CMR) enables the quantification and visualisation of blood flow, but its clinical applicability remains hampered by its long scan time. The aim of this study was to evaluate the use of compressed sensing (CS) with on-line reconstruction to accelerate the acquisition and reconstruction of 4D flow CMR of the thoracic aorta. Methods 4D flow CMR of the thoracic aorta was acquired in 20 healthy subjects using CS with acceleration factors ranging from 4 to 10. As a reference, conventional parallel imaging (SENSE) with acceleration factor 2 was used. Flow curves, net flows, peak flows and peak velocities were extracted from six contours along the aorta. To measure internal data consistency, a quantitative particle trace analysis was performed. Additionally, scan-rescan, inter- and intraobserver reproducibility were assessed. Subsequently, 4D flow CMR with CS factor 6 was acquired in 3 patients with differing aortopathies. The flow patterns resulting from particle trace visualisation were qualitatively analysed. Results All collected data were successfully acquired and reconstructed on-line. The average acquisition time including respiratory navigator efficiency with CS factor 6 was 5:02 ± 2:23 min while reconstruction took approximately 9 min. For CS factors of 8 or less, mean differences in net flow, peak flow and peak velocity as compared to SENSE were below 2.2 ± 7.8 ml/cycle, 4.6 ± 25.2 ml/s and − 7.9 ± 13.0 cm/s, respectively. For a CS factor of 10 differences reached 5.4 ± 8.0 ml/cycle, 14.4 ± 28.3 ml/s and − 4.0 ± 12.2 cm/s. Scan-rescan analysis yielded mean differences in net flow of − 0.7 ± 4.9 ml/cycle for SENSE and − 0.2 ± 8.5 ml/cycle for CS factor of 6. Conclusions A six- to eightfold acceleration of 4D flow CMR using CS is feasible. Up to a CS acceleration rate of 6, no statistically significant differences in measured flow parameters could be observed with respect to the reference technique. Acquisitions in patients with aortopathies confirm the potential to integrate the proposed method in a clinical routine setting, whereby its main benefits are scan-time savings and direct on-line reconstruction.

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