Evaluation of 4D flow MRI-based non-invasive pressure assessment in aortic coarctations

Optimizing encoding strategies for 4D Flow MRI of mean and turbulent flow

For 4D Flow MRI of mean and turbulent flow a compromise between spatiotemporal undersampling and velocity encodings needs to be found. Assuming a fixed scan time budget, the impact of trading off spatiotemporal undersampling versus velocity encodings on quantification of velocity and turbulence for aortic 4D Flow MRI was investigated. For this purpose, patient-specific mean and turbulent aortic flow data were generated using computational fluid dynamics which were embedded into the patient-specific background image data to generate synthetic MRI data with corresponding ground truth flow. Cardiac and respiratory motion were included. Using the synthetic MRI data as input, 4D Flow MRI was subsequently simulated with undersampling along pseudo-spiral Golden angle Cartesian trajectories for various velocity encoding schemes. Data were reconstructed using a locally low rank approach to obtain mean and turbulent flow fields to be compared to ground truth. Results show that, for a 15-min scan, velocity magnitudes can be reconstructed with good accuracy relatively independent of the velocity encoding scheme ( S S I M U = 0.938 ± 0.003 ) , good accuracy ( S S I M U ≥ 0.933 ) and with peak velocity errors limited to 10%. Turbulence maps on the other hand suffer from both lower reconstruction quality ( S S I M TKE ≥ 0.323 ) and larger sensitivity to undersampling, motion and velocity encoding strengths ( S S I M TKE = 0.570 ± 0.110 ) when compared to velocity maps. The best compromise to measure unwrapped velocity maps and turbulent kinetic energy given a fixed 15-min scan budget was found to be a 7-point multi- V enc acquisition with a low V enc tuned for best sensitivity to the range of expected intra-voxel standard deviations and a high V enc larger than the expected peak velocity.

Non-invasive Estimation of Pressure Drop Across Aortic Coarctations: Validation of 0D and 3D Computational Models with In Vivo Measurements

Blood pressure gradient ( Δ P ) across an aortic coarctation (CoA) is an important measurement to diagnose CoA severity and gauge treatment efficacy. Invasive cardiac catheterization is currently the gold-standard method for measuring blood pressure. The objective of this study was to evaluate the accuracy of Δ P estimates derived non-invasively using patient-specific 0D and 3D deformable wall simulations. Medical imaging and routine clinical measurements were used to create patient-specific models of patients with CoA (N = 17). 0D simulations were performed first and used to tune boundary conditions and initialize 3D simulations. Δ P across the CoA estimated using both 0D and 3D simulations were compared to invasive catheter-based pressure measurements for validation. The 0D simulations were extremely efficient ( ∼ 15 s computation time) compared to 3D simulations ( ∼ 30 h computation time on a cluster). However, the 0D Δ P estimates, unsurprisingly, had larger mean errors when compared to catheterization than 3D estimates (12.1 ± 9.9 mmHg vs 5.3 ± 5.4 mmHg). In particular, the 0D model performance degraded in cases where the CoA was adjacent to a bifurcation. The 0D model classified patients with severe CoA requiring intervention (defined as Δ P ≥ 20 mmHg) with 76% accuracy and 3D simulations improved this to 88%. Overall, a combined approach, using 0D models to efficiently tune and launch 3D models, offers the best combination of speed and accuracy for non-invasive classification of CoA severity.

Implicit neural representations for unsupervised super-resolution and denoising of 4D flow MRI

BACKGROUND AND OBJECTIVE

4D flow magnetic resonance imaging provides time-resolved blood flow velocity measurements, but suffers from limitations in spatio-temporal resolution and noise. In this study, we investigated the use of sinusoidal representation networks (SIRENs) to improve denoising and super-resolution of velocity fields measured by 4D flow MRI in the thoracic aorta.

METHODS

Efficient training of SIRENs in 4D was achieved by sampling voxel coordinates and enforcing the no-slip condition at the vessel wall. A set of synthetic measurements were generated from computational fluid dynamics simulations, reproducing different noise levels. The influence of SIREN architecture was systematically investigated, and the performance of our method was compared to existing approaches for 4D flow denoising and super-resolution.

RESULTS

Compared to existing techniques, a SIREN with 300 neurons per layer and 20 layers achieved lower errors (up to 50% lower vector normalized root mean square error, 42% lower magnitude normalized root mean square error, and 15% lower direction error) in velocity and wall shear stress fields. Applied to real 4D flow velocity measurements in a patient-specific aortic aneurysm, our method produced denoised and super-resolved velocity fields while maintaining accurate macroscopic flow measurements.

CONCLUSIONS

This study demonstrates the feasibility of using SIRENs for complex blood flow velocity representation from clinical 4D flow, with quick execution and straightforward implementation.

The Role of Multiple Re-Entry Tears in Type B Aortic Dissection Progression: A Longitudinal Study Using a Controlled Swine Model

PURPOSE

False lumen (FL) expansion often occurs in type B aortic dissection (TBAD) and has been associated with the presence of re-entry tears. This longitudinal study aims to elucidate the role of re-entry tears in the progression of TBAD using a controlled swine model, by assessing aortic hemodynamics through combined imaging and computational modeling.

MATERIALS AND METHODS

A TBAD swine model with a primary entry tear at 7 cm distal to the left subclavian artery was created in a previous study. In the current study, reintervention was carried out in this swine model to induce 2 additional re-entry tears of approximately 5 mm in diameter. Computed tomography (CT) and 4-dimensional (4D) flow magnetic resonance imaging (MRI) scans were taken at multiple follow-ups before and after reintervention. Changes in aortic volume were measured on CT scans, and hemodynamic parameters were evaluated based on dynamic data acquired with 4D-flow MRI and computational fluid dynamics simulations incorporating all available in vivo data.

RESULTS

Morphological analysis showed FL growth of 20% following the initial TBAD-growth stabilized after the creation of additional tears and eventually FL volume reduced by 6%. Increasing the number of re-entry tears from 1 to 2 caused flow redistribution, with the percentage of true lumen (TL) flow increasing from 56% to 78%; altered local velocities; reduced wall shear stress surrounding the tears; and led to a reduction in FL pressure and pressure difference between the 2 lumina.

CONCLUSION

This study combined extensive in vivo imaging data with sophisticated computational methods to show that additional re-entry tears can alter dissection hemodynamics through redistribution of flow between the TL and FL. This helps to reduce FL pressure, which could potentially stabilize aortic growth and lead to reversal of FL expansion. This work provides a starting point for further study into the use of fenestration in controlling undesirable FL expansion.

CLINICAL IMPACT

Aortic growth and false lumen (FL) patency are associated with the presence of re-entry tears in type B aortic dissection (TBAD) patients. Guidelines on how to treat re-entry tears are lacking, especially with regards to the control and prevention of FL expansion. Through a combined imagining and computational hemodynamics study of a controlled swine model, we found that increasing the number of re-entry tears reduced FL pressure and cross lumen pressure difference, potentially stabilising aortic growth and leading to FL reduction. Our findings provide a starting point for further study into the use of fenestration in controlling undesirable FL expansion.

Fluid-Structure Interaction Within Models of Patient-Specific Arteries: Computational Simulations and Experimental Validations

Cardiovascular disease (CVD) is the leading cause of mortality worldwide and its incidence is rising due to an aging population. The development and progression of CVD is directly linked to adverse vascular hemodynamics and biomechanics, whose in-vivo measurement remains challenging but can be simulated numerically and experimentally. The ability to evaluate these parameters in patient-specific CVD cases is crucial to better predict future disease progression, risk of adverse events, and treatment efficacy. While significant progress has been made toward patient-specific hemodynamic simulations, blood vessels are often assumed to be rigid, which does not consider the compliant mechanical properties of vessels whose malfunction is implicated in disease. In an effort to simulate the biomechanics of flexible vessels, fluid-structure interaction (FSI) simulations have emerged as promising tools for the characterization of hemodynamics within patient-specific cardiovascular anatomies. Since FSI simulations combine the blood's fluid domain with the arterial structural domain, they pose novel challenges for their experimental validation. This paper reviews the scientific work related to FSI simulations for patient-specific arterial geometries and the current standard of FSI model validation including the use of compliant arterial phantoms, which offer novel potential for the experimental validation of FSI results.

Fast Approximate Quantification of Endovascular Stent Graft Displacement Forces in the Bovine Aortic Arch Variant

PURPOSE

Displacement forces (DFs) identify hostile landing zones for stent graft deployment in thoracic endovascular aortic repair (TEVAR). However, their use in TEVAR planning is hampered by the need for time-expensive computational fluid dynamics (CFD). We propose a novel fast-approximate computation of DFs merely exploiting aortic arch anatomy, as derived from the computed tomography (CT) and a measure of central aortic pressure.

MATERIALS AND METHODS

We tested the fast-approximate approach against CFD gold-standard in 34 subjects with the "bovine" aortic arch variant. For each dataset, a 3-dimensional (3D) model of the aortic arch lumen was reconstructed from computed tomography angiography and CFD then employed to compute DFs within the aortic proximal landing zones. To quantify fast-approximate DFs, the wall shear stress contribution to the DF was neglected and blood pressure space-distribution was averaged on the entire aortic wall to reliably approximate the patient-specific central blood pressure. Also, DF values were normalized on the corresponding proximal landing zone area to obtain the equivalent surface traction (EST).

RESULTS

Fast-approximate approach consistently reflected (r2=0.99, p<0.0001) the DF pattern obtained by CFD, with a -1.1% and 0.7° bias in DFs magnitude and orientation, respectively. The normalized EST progressively increased (p<0.0001) from zone 0 to zone 3 regardless of the type of arch, with proximal landing zone 3 showing significantly greater forces than zone 2 (p<0.0001). Upon DF normalization to the corresponding aortic surface, fast-approximate EST was decoupled in blood pressure and a dimensionless shape vector (S) reflecting aortic arch morphology. S showed a zone-specific pattern of orientation and proved a valid biomechanical blueprint of DF impact on the thoracic aortic wall.

CONCLUSION

Requiring only a few seconds and quantifying clinically relevant biomechanical parameters of proximal landing zones for arch TEVAR, our method suits the real preoperative decision-making process. It paves the way toward analyzing large population of patients and hence to define threshold values for a future patient-specific preoperative TEVAR planning.

Non-invasive estimation of pressure drop across aortic coarctations: validation of 0D and 3D computational models with in vivo measurements

Purpose

Blood pressure gradient (Δ P ) across an aortic coarctation (CoA) is an important measurement to diagnose CoA severity and gauge treatment efficacy. Invasive cardiac catheterization is currently the gold-standard method for measuring blood pressure. The objective of this study was to evaluate the accuracy of Δ P estimates derived non-invasively using patient-specific 0 D and 3 D deformable wall simulations.

Methods

Medical imaging and routine clinical measurements were used to create patient-specific models of patients with CoA (N = 17 ). 0 D simulations were performed first and used to tune boundary conditions and initialize 3 D simulations. Δ P across the CoA estimated using both 0 D and 3 D simulations were compared to invasive catheter-based pressure measurements for validation.

Results

The 0 D simulations were extremely efficient (~15 secs computation time) compared to 3 D simulations (~30 hrs computation time on a cluster). However, the 0 D Δ P estimates, unsurprisingly, had larger mean errors when compared to catheterization than 3 D estimates (12.1 ± 9.9 mmHg vs 5.3 ± 5.4 mmHg). In particular, the 0 D model performance degraded in cases where the CoA was adjacent to a bifurcation. The 0 D model classified patients with severe CoA requiring intervention (defined as Δ P ≥ 20 mmHg) with 76% accuracy and 3 D simulations improved this to 88%.

Conclusion

Overall, a combined approach, using 0 D models to efficiently tune and launch 3 D models, offers the best combination of speed and accuracy for non-invasive classification of CoA severity.

Irregular anatomical features can alter hemodynamics in Takayasu arteritis

Objective

Takayasu arteritis (TA) is a difficult disease to deal with because there are neither reliable clinical signs, laboratory biomarkers, nor a single noninvasive imaging technique that can be used for early diagnosis and disease activity monitoring. Knowledge of aortic hemodynamics in TA is lacking. This study aimed to fill this gap by assessing hemodynamics in patients with TA using image-based computational fluid dynamics (CFD) simulations.

Methods

Eleven patients with TA were included in the present study. Patient-specific geometries were reconstructed from either clinical aortic computed tomography angiography or magnetic resonance angiography studies and coupled with physiological boundary conditions for CFD simulations. Key anatomical and hemodynamic parameters were compared with a control group consisting of 18 age- and sex-matched adults without TA who had healthy aortas.

Results

Compared with controls, patients with TA had significantly higher aortic velocities (0.9 m/s [0.7, 1.1 m/s] vs 0.6 m/s [0.5, 0.7 m/s]; P = .002), maximum time-averaged wall shear stress (14.2 Pa [9.8, 20.9 Pa] vs 8.0 Pa [6.2, 10.3 Pa]; P = .004), and maximum pressure drops between the ascending and descending aorta (36.9 mm Hg [29.0, 49.3 mm Hg] vs 28.5 mm Hg [25.8, 31.5 mm Hg]; P = .004). These significant hemodynamic alterations in patients with TA might result from abnormal anatomical features including smaller arch diameter (20.0 mm [13.8, 23.3 mm] vs 25.2 mm [23.3, 26.8 mm]; P = .003), supra-aortic branch diameters (21.9 mm [18.5, 24.6 mm] vs 25.7 mm [24.3, 28.3 mm]; P = .003) and descending aorta diameter (14.7 mm [12.2, 16.8 mm] vs 22.5 mm [19.8, 24.0 mm]; P < .001).

Conclusions

CFD analysis reveals hemodynamic changes in the aorta of patients with TA. The applicability of CFD technique coupled with standard imaging assessments in predicting disease progression of such patients will be explored in future studies. Future large cohort study with outcome correlation is also warranted.

Clinical Relevance

Based on patient-specific computational fluid dynamics simulations, the present retrospective study revealed significant difference in aortic hemodynamics between the patients with and without Takayasu arteritis (TA). To the best of our knowledge, this study is the first to evaluate hemodynamic conditions within TA, demonstrating the potential of computational flow modeling in capturing abnormal hemodynamic forces, such as high wall shear stress, resulted from irregular morphological changes. In the future, assessing the hemodynamic parameters within patients with TA during the prestenotic period, together with longitudinal computational fluid dynamics studies may allow better monitoring and management of TA.

A Vector Fitting Approach for the Automated Estimation of Lumped Boundary Conditions of 1D Circulation Models

PURPOSE

The choice of appropriate boundary conditions is a crucial step in the development of cardiovascular models for blood flow simulations. The three-element Windkessel model is usually employed as a lumped boundary condition, providing a reduced order representation of the peripheral circulation. However, the systematic estimation of the Windkessel parameters remains an open problem. Moreover, the Windkessel model is not always adequate to model blood flow dynamics, which often require more elaborate boundary conditions. In this study, we propose a method for the estimation of the parameters of high order boundary conditions, including the Windkessel model, from pressure and flow rate waveforms at the truncation point. Moreover, we investigate the effect of adopting higher order boundary conditions, corresponding to equivalent circuits with more than one storage element, on the accuracy of the model.

METHOD

The proposed technique is based on Time-Domain Vector Fitting, a modeling algorithm that, given samples of the input and output of a system, such as pressure and flow waveforms, can derive a differential equation approximating their relation.

RESULTS

The capabilities of the proposed method are tested on a 1D circulation model consisting of the 55 largest human systemic arteries, to demonstrate its accuracy and its usefulness to estimate boundary conditions with order higher than the traditional Windkessel models. The proposed method is compared to other common estimation techniques, and its robustness in parameter estimation is verified in presence of noisy data and of physiological changes of aortic flow rate induced by mental stress.

CONCLUSION

Results suggest that the proposed method is able to accurately estimate boundary conditions of arbitrary order. Higher order boundary conditions can improve the accuracy of cardiovascular simulations, and Time-Domain Vector Fitting can automatically estimate them.

A clinician's guide to understanding aortic 4D flow MRI

Four-dimensional flow magnetic resonance imaging is an emerging technique which may play a role in diagnosis and risk-stratification of aortic disease. Some knowledge of flow dynamics and related parameters is necessary to understand and apply this technique in clinical workflows. The purpose of the current review is to provide a guide for clinicians to the basics of flow imaging, frequently used flow-related parameters, and their relevance in the context of aortic disease.Clinical relevance statement Understanding normal and abnormal aortic flow could improve clinical care in patients with aortic disease.

Geometry and flow in ascending aortic aneurysms are influenced by left ventricular outflow tract orientation: Detecting increased wall shear stress on the outer curve of proximal aortic aneurysms

BACKGROUND

The geometrical characterization of ascending thoracic aortic aneurysms in clinical practice is limited to diameter measurements. Despite growing interest in hemodynamic assessment, its relationship with ascending thoracic aortic aneurysm pathogenesis is poorly understood. This study examines the relationship between geometry of the ventriculo-aortic junction and blood flow patterns in ascending thoracic aortic aneurysm disease.

METHODS

Thirty-three patients with ascending thoracic aortic aneurysms (exclusions: bicuspid aortic valves, connective tissue disease) underwent 4-dimensional flow magnetic resonance imaging. After image segmentation, geometrical parameters were measured, including aortic curvature, tortuosity, length, and diameter. A unique angular measurement made by the trajectory of the left ventricular outflow tract axis and the proximal aorta was also conducted. Velocity profiles were quantitatively and qualitatively analyzed. In addition, 11 patients (33%) underwent wall shear stress mapping of the ascending thoracic aortic aneurysm region using computational fluid dynamics simulation.

RESULTS

Greater left ventricular outflow tract aortic angles were associated with larger aortic diameters at the levels of the sinus (coefficient = 0.387, P = .014) and ascending aorta (coefficient = 0.284, P = .031). Patients with left ventricular outflow tract aortic angles greater than 60° had marked asymmetric flow acceleration on the outer curvature in the proximal aorta, ascertained from 4-dimensional flow analysis. For patients undergoing computational fluid dynamics assessment, regression analysis found that higher left ventricular outflow tract aortic angles were associated with significantly higher wall shear stress values in the outer curve of the aorta (coefficient 0.07, 95% confidence interval 0.04-0.11, P = .002): Angles greater than 50° yielded time-averaged wall shear stress values greater than 2.5 Pa, exhibiting a linear relationship.

CONCLUSIONS

Our findings strengthen the hypothesis of flow-mediated ascending thoracic aortic aneurysm disease progression and that left ventricular outflow tract aortic angle may be a predictor of disease severity.

Aortic haemodynamics and wall stress analysis following arch aneurysm repair using a single-branched endograft

Introduction

Thoracic endovascular aortic repair (TEVAR) of the arch is challenging given its complex geometry and the involvement of supra-aortic arteries. Different branched endografts have been designed for use in this region, but their haemodynamic performance and the risk for post-intervention complications are not yet clear. This study aims to examine aortic haemodynamics and biomechanical conditions following TVAR treatment of an aortic arch aneurysm with a two-component single-branched endograft.

Methods

Computational fluid dynamics and finite element analysis were applied to a patient-specific case at different stages: pre-intervention, post-intervention and follow-up. Physiologically accurate boundary conditions were used based on available clinical information.

Results

Computational results obtained from the post-intervention model confirmed technical success of the procedure in restoring normal flow to the arch. Simulations of the follow-up model, where boundary conditions were modified to reflect change in supra-aortic vessel perfusion observed on the follow-up scan, predicted normal flow patterns but high levels of wall stress (up to 1.3M MPa) and increased displacement forces in regions at risk of compromising device stability. This might have contributed to the suspected endoleaks or device migration identified at the final follow up.

Discussion

Our study demonstrated that detailed haemodynamic and biomechanical analysis can help identify possible causes for post-TEVAR complications in a patient-specific setting. Further refinement and validation of the computational workflow will allow personalised assessment to aid in surgical planning and clinical decision making.

Validation of the Reduced Unified Continuum Formulation Against In Vitro 4D-Flow MRI

We previously introduced and verified the reduced unified continuum formulation for vascular fluid-structure interaction (FSI) against Womersley's deformable wall theory. Our present work seeks to investigate its performance in a patient-specific aortic setting in which assumptions of idealized geometries and velocity profiles are invalid. Specifically, we leveraged 2D magnetic resonance imaging (MRI) and 4D-flow MRI to extract high-resolution anatomical and hemodynamic information from an in vitro flow circuit embedding a compliant 3D-printed aortic phantom. To accurately reflect experimental conditions, we numerically implemented viscoelastic external tissue support, vascular tissue prestressing, and skew boundary conditions enabling in-plane vascular motion at each inlet and outlet. Validation of our formulation is achieved through close quantitative agreement in pressures, lumen area changes, pulse wave velocity, and early systolic velocities, as well as qualitative agreement in late systolic flow structures. Our validated suite of FSI techniques offers a computationally efficient approach for numerical simulation of vascular hemodynamics. This study is among the first to validate a cardiovascular FSI formulation against an in vitro flow circuit involving a compliant vascular phantom of complex patient-specific anatomy.

Synthesis of patient-specific multipoint 4D flow MRI data of turbulent aortic flow downstream of stenotic valves

We propose to synthesize patient-specific 4D flow MRI datasets of turbulent flow paired with ground truth flow data to support training of inference methods. Turbulent blood flow is computed based on the Navier-Stokes equations with moving domains using realistic boundary conditions for aortic shapes, wall displacements and inlet velocities obtained from patient data. From the simulated flow, synthetic multipoint 4D flow MRI data is generated with user-defined spatiotemporal resolutions and reconstructed with a Bayesian approach to compute time-varying velocity and turbulence maps. For MRI data synthesis, a fixed hypothetical scan time budget is assumed and accordingly, changes to spatial resolution and time averaging result in corresponding scaling of signal-to-noise ratios (SNR). In this work, we focused on aortic stenotic flow and quantification of turbulent kinetic energy (TKE). Our results show that for spatial resolutions of 1.5 and 2.5 mm and time averaging of 5 ms as encountered in 4D flow MRI in practice, peak total turbulent kinetic energy downstream of a 50, 75 and 90% stenosis is overestimated by as much as 23, 15 and 14% (1.5 mm) and 38, 24 and 23% (2.5 mm), demonstrating the importance of paired ground truth and 4D flow MRI data for assessing accuracy and precision of turbulent flow inference using 4D flow MRI exams.

A Parametric Study of Flushing Conditions for Improvement of Angioscopy Visibility

During an angioscopy operation, a transparent liquid called dextran is sprayed out from a catheter to flush the blood away from the space between the camera and target. Medical doctors usually inject dextran at a constant flow rate. However, they often cannot obtain clear angioscopy visibility because the flushing out of the blood is insufficient. Good flushing conditions producing clear angioscopy visibility will increase the rate of success of angioscopy operations. This study aimed to determine a way to improve the clarity for angioscopy under different values for the parameters of the injection waveform, endoscope position, and catheter angle. We also determined the effect of a stepwise waveform for injecting the dextran only during systole while synchronizing the waveform to the cardiac cycle. To evaluate the visibility of the blood-vessel walls, we performed a computational fluid dynamics (CFD) simulation and calculated the visible area ratio (VAR), representing the ratio of the visible wall area to the total area of the wall at each point in time. Additionally, the normalized integration of the VAR called the area ratio (ARVAR) represents the ratio of the visible wall area as a function of the dextran injection period. The results demonstrate that the ARVAR with a stepped waveform, bottom endoscope, and three-degree-angle catheter results in the highest visibility, around 25 times larger than that under the control conditions: a constant waveform, a center endoscope, and 0 degrees. This set of conditions can improve angioscopy visibility.

Personalized Pre- and Post-Operative Hemodynamic Assessment of Aortic Coarctation from 3D Rotational Angiography

PURPOSE

Coarctation of Aorta (CoA) is a congenital disease consisting of a narrowing that obstructs the systemic blood flow. This proof-of-concept study aimed to develop a framework for automatically and robustly personalizing aortic hemodynamic computations for the assessment of pre- and post-intervention CoA patients from 3D rotational angiography (3DRA) data.

METHODS

We propose a framework that combines hemodynamic modelling and machine learning (ML) based techniques, and rely on 3DRA data for non-invasive pressure computation in CoA patients. The key features of our framework are a parameter estimation method for calibrating inlet and outlet boundary conditions, and regional mechanical wall properties, to ensure that the computational results match the patient-specific measurements, and an improved ML based pressure drop model capable of predicting the instantaneous pressure drop for a wide range of flow conditions and anatomical CoA variations.

RESULTS

We evaluated the framework by investigating 6 patient datasets, under pre- and post-operative setting, and, since all calibration procedures converged successfully, the proposed approach is deemed robust. We compared the peak-to-peak and the cycle-averaged pressure drop computed using the reduced-order hemodynamic model with the catheter based measurements, before and after virtual and actual stenting. The mean absolute error for the peak-to-peak pressure drop, which is the most relevant measure for clinical decision making, was 2.98 mmHg for the pre- and 2.11 mmHg for the post-operative setting. Moreover, the proposed method is computationally efficient: the average execution time was of only [Formula: see text] minutes on a standard hardware configuration.

CONCLUSION

The use of 3DRA for hemodynamic modelling could allow for a complete hemodynamic assessment, as well as virtual interventions or surgeries and predictive modeling. However, before such an approach can be used routinely, significant advancements are required for automating the workflow.

Comparison of Four-Dimensional Magnetic Resonance Imaging Analysis of Left Ventricular Fluid Dynamics and Energetics in Ischemic and Restrictive Cardiomyopathies

Background

Time‐resolved three‐directional velocity‐encoded (4D flow) magnetic resonance imaging (MRI) enables the quantification of left ventricular (LV) intracavitary fluid dynamics and energetics, providing mechanistic insight into LV dysfunctions. Before becoming a support to diagnosis and patient stratification, this analysis should prove capable of discriminating between clearly different LV derangements.

Purpose

To investigate the potential of 4D flow in identifying fluid dynamic and energetics derangements in ischemic and restrictive LV cardiomyopathies.

Study Type

Prospective observational study.

Population

Ten patients with post‐ischemic cardiomyopathy (ICM), 10 patients with cardiac light‐chain cardiac amyloidosis (AL‐CA), and 10 healthy controls were included.

Field Strength/Sequence

1.5 T/balanced steady‐state free precession cine and 4D flow sequences.

Assessment

Flow was divided into four components: direct flow (DF), retained inflow, delayed ejection flow, and residual volume (RV). Demographics, LV morphology, flow components, global and regional energetics (volume‐normalized kinetic energy [KE_V] and viscous energy loss [EL_V]), and pressure‐derived hemodynamic force (HDF) were compared between the three groups.

Statistical Tests

Intergroup differences in flow components were tested by one‐way analysis of variance (ANOVA); differences in energetic variables and peak HDF were tested by two‐way ANOVA. A P‐value of <0.05 was considered significant.

Results

ICM patients exhibited the following statistically significant alterations vs. controls: reduced KE_V, mostly in the basal region, in systole (−44%) and in diastole (−37%); altered flow components, with reduced DF (−33%) and increased RV (+26%); and reduced basal–apical HDF component on average by 63% at peak systole. AL‐CA patients exhibited the following alterations vs. controls: significantly reduced KE_V at the E‐wave peak in the basal segment (−34%); albeit nonstatistically significant, increased peaks and altered time‐course of the HDF basal–apical component in diastole and slightly reduced HDF components in systole.

Data Conclusion

The analysis of multiple 4D flow‐derived parameters highlighted fluid dynamic alterations associated with systolic and diastolic dysfunctions in ICM and AL‐CA patients, respectively.

Level of Evidence

2

Technical Efficacy Stage

3

Qualitative and Quantitative Assessments of Blood Flow on Tears in Type B Aortic Dissection With Different Morphologies

Objective: The interactions between aortic morphology and hemodynamics play a key role in determining type B aortic dissection (TBAD) progression and remodeling. The study aimed to provide qualitative and quantitative hemodynamic assessment in four different TBAD morphologies based on 4D flow MRI analysis. Materials and Methods: Four patients with different TBAD morphologies underwent CT and 4D flow MRI scans. Qualitative blood flow evaluation was performed by visualizing velocity streamlines and flow directionality near the tears. Quantitative analysis included flow rate, velocity and reverse flow index (RFI) measurements. Statistical analysis was performed to evaluate hemodynamic differences between the true lumen (TL) and false lumen (FL) of patients. Results: Qualitative analysis revealed blood flow splitting near the primary entry tears (PETs), often causing the formation of vortices in the FL. All patients exhibited clear hemodynamic differences between TL and FL, with the TL generally showing higher velocities and flow rates, and lower RFIs. Average velocity magnitude measurements were significantly different for Patient 1 (t = 5.61, p = 0.001), Patient 2 (t = 3.09, p = 0.02) and Patient 4 (t = 2.81, p = 0.03). At follow-up, Patient three suffered from left renal ischemia because of FL collapse. This patient presented a complex morphology with two FLs and marked flow differences between TL and FLs. In Patient 4, left renal artery malperfusion was observed at the 32-months follow-up, due to FL thrombosis growing after PET repair. Conclusion: The study demonstrates the clinical feasibility of using 4D flow MRI in the context of TBAD. Detailed patient-specific hemodynamics assessment before treatment may provide useful insights to better understand this pathology in the future.

A novel MRI-based data fusion methodology for efficient, personalised, compliant simulations of aortic haemodynamics

We present a novel, cost-efficient methodology to simulate aortic haemodynamics in a patient-specific, compliant aorta using an MRI data fusion process. Based on a previously-developed Moving Boundary Method, this technique circumvents the high computational cost and numerous structural modelling assumptions required by traditional Fluid-Structure Interaction techniques. Without the need for Computed Tomography (CT) data, the MRI images required to construct the simulation can be obtained during a single imaging session. Black Blood MR Angiography and 2D Cine-MRI data were used to reconstruct the luminal geometry and calibrate wall movement specifically to each region of the aorta. 4D-Flow MRI and non-invasive pressure measurements informed patient-specific inlet and outlet boundary conditions. Luminal area closely matched 2D Cine-MRI measurements with a mean error of less than 4.6% across the cardiac cycle, while physiological pressure and flow distributions were simulated to within 3.3% of patient-specific targets. Moderate agreement with 4D-Flow MRI velocity data was observed. Despite lower peak velocity, an equivalent rigid-wall simulation predicted a mean Time-Averaged Wall Shear Stress (TAWSS) 13% higher than the compliant simulation. The agreement observed between compliant simulation results and MRI data is testament to the accuracy and efficiency of this MRI-based simulation technique.

CTA-Based Non-invasive Estimation of Pressure Gradients Across a CoA: a Validation Against Cardiac Catheterisation

Non-invasive estimation of pressure gradients across a coarctation of the aorta (CoA) can reduce the need for diagnostic cardiac catheterisation. We aimed to validate two novel computational strategies-target-value approaching (TVA) and target-value fixing (TVF)-together with unrefined Doppler estimates, and to compare their diagnostic performance in identifying critical pressure drops for 40 patients. Compared to catheterisation, no statistically significant difference was demonstrated with TVA (P = 0.086), in contrast to TVF (P = 0.005) and unrefined Doppler echocardiography (P < 0.001). TVA manifested the strongest correlation with catheterisation (r = 0.93), compared to TVF (r = 0.83) and echocardiography (r = 0.67) (all P < 0.001). In discriminating pressure gradients greater than 20 mmHg, TVA, TVF, and echocardiography had respective sensitivities of 0.92, 0.88, and 0.80; specificities of 0.93, 0.80, and 0.73; and AUCs of 0.96, 0.89, and 0.80. The TVA strategy may serve as an effective and easily implemented approach to be used in clinical management of patients with CoA. Graphical Abstract Central illustration. Pressure gradients estimated using Doppler echocardiography and two novel computational strategies (TVA and TVF) were compared with cardiac catheterisation for 40 patients. TVA and TVF utilised the CTA images to obtain the CoA anatomy and Doppler echocardiography velocimetry to obtain velocity data for the assignment of CFD boundary conditions.

The role of 4D flow MRI for clinical applications in cardiovascular disease: current status and future perspectives

Magnetic resonance imaging (MRI) four-dimensional (4D) flow is a type of phase-contrast (PC) MRI that uses blood flow encoded in 3 directions, which is resolved relative to 3 spatial and temporal dimensions of cardiac circulation. It can be used to simultaneously quantify and visualize hemodynamics or morphology disorders. 4D flow MRI is more comprehensive and accurate than two-dimensional (2D) PC MRI and echocardiography. 4D flow MRI provides numerous hemodynamic parameters that are not limited to the basic 2D parameters, including wall shear stress (WSS), pulse wave velocity (PWV), kinetic energy, turbulent kinetic energy (TKE), pressure gradient, and flow component analysis. 4D flow MRI is widely used to image many parts of the body, such as the neck, brain, and liver, and has a wide application spectrum to cardiac diseases and large vessels. This present review aims to summarize the hemodynamic parameters of 4D flow MRI technology and generalize their usefulness in clinical practice in relation to the cardiovascular system. In addition, we note the improvements that have been made to 4D flow MRI with the application of new technologies. The application of new technologies can improve the speed of 4D flow, which would benefit clinical applications.

Effects of Uncertainty of Outlet Boundary Conditions in a Patient-Specific Case of Aortic Coarctation

Computational Fluid Dynamics (CFD) simulations of blood flow are widely used to compute a variety of hemodynamic indicators such as velocity, time-varying wall shear stress, pressure drop, and energy losses. One of the major advances of this approach is that it is non-invasive. The accuracy of the cardiovascular simulations depends directly on the level of certainty on input parameters due to the modelling assumptions or computational settings. Physiologically suitable boundary conditions at the inlet and outlet of the computational domain are needed to perform a patient-specific CFD analysis. These conditions are often affected by uncertainties, whose impact can be quantified through a stochastic approach. A methodology based on a full propagation of the uncertainty from clinical data to model results is proposed here. It was possible to estimate the confidence associated with model predictions, differently than by deterministic simulations. We evaluated the effect of using three-element Windkessel models as the outflow boundary conditions of a patient-specific aortic coarctation model. A parameter was introduced to calibrate the resistances of the Windkessel model at the outlets. The generalized Polynomial Chaos method was adopted to perform the stochastic analysis, starting from a few deterministic simulations. Our results show that the uncertainty of the input parameter gave a remarkable variability on the volume flow rate waveform at the systolic peak simulating the conditions before the treatment. The same uncertain parameter had a slighter effect on other quantities of interest, such as the pressure gradient. Furthermore, the results highlight that the fine-tuning of Windkessel resistances is not necessary to simulate the post-stenting scenario.

Aortic hemodynamics assessment prior and after valve sparing reconstruction: A patient-specific 4D flow-based FSI model

INTRODUCTION

Valve-sparing root replacement (VSRR) of the ascending aorta is a life-saving procedure for the treatment of aortic aneurysms, but patients remain at risk for post-operative events involving the downstream native aorta, the mechanism for which is uncertain. It is possible that proximal graft replacement of the ascending aorta induces hemodynamics alterations in the descending aorta, which could trigger adverse events. Herein, we present a fluid-structure interaction (FSI) protocol, based on patient-specific geometry and boundary conditions, to assess impact of proximal aortic grafts on downstream aortic hemodynamics and distensibility.

METHODS

Cardiac magnetic resonance (CMR), including MRA, cine-CMR and 4D flow sequences, was performed prior and after VSRR on one subject. Central blood pressure was non-invasively acquired at the time of the CMR: data were used to reconstruct the pre- and post-VSRR model and derive patient-specific boundary conditions for the FSI and a computational fluid dynamic (CFD) analysis with the same settings. Results were validated comparing the predicted velocity field against 4D flow dataset, over four landmarks along the aorta, and the predicted distensibility against the cine-CMR derived value.

RESULTS

Instantaneous velocity magnitudes extracted from 4D flow and FSI were similar (p > 0.05), while CFD-predicted velocity was significantly higher (p < 0.001), especially in the descending aorta of the pre-VSRR model (v_max was 73 cm/s, 76 cm/s and 99 cm/s, respectively). As measured in cine-CMR, FSI predicted an increase in descending aorta distensibility after grafting (i.e., 4.02 to 5.79 10^-3 mmHg^-1). In the descending aorta, the post-VSRR model showed increased velocity, aortic distensibility, stress and strain and wall shear stress.

CONCLUSIONS

Our Results indicate that i) the distensibility of the wall cannot be neglected, and hence the FSI method is necessary to obtain reliable results; ii) graft implantation induces alterations in the hemodynamics and biomechanics along the thoracic aorta, that may trigger adverse vessel remodeling.

Noninvasive imaging assessment of portal hypertension

Portal hypertension (PH) is a spectrum of complications of chronic liver disease (CLD) and cirrhosis, with manifestations including ascites, gastroesophageal varices, splenomegaly, hypersplenism, hepatic hydrothorax, hepatorenal syndrome, hepatopulmonary syndrome and portopulmonary hypertension. PH can vary in severity and is diagnosed via invasive hepatic venous pressure gradient measurement (HVPG), which is considered the reference standard. Accurate diagnosis of PH and assessment of severity are highly relevant as patients with clinically significant portal hypertension (CSPH) are at higher risk for developing acute variceal bleeding and mortality. In this review, we discuss current and upcoming noninvasive imaging methods for diagnosis and assessment of severity of PH.

4D flow MRI applications in congenital heart disease

Advances in the diagnosis and management of congenital heart disease (CHD) have resulted in a growing population of patients surviving well into adulthood and requiring lifelong follow-up. Flow quantification is a central component in the assessment of patients with CHD. 4D flow magnetic resonance imaging (MRI) has emerged as a tool that enables comprehensive study of flow. It involves the acquisition of a three-dimensional time-resolved volume with velocity encoding in all three spatial directions along the cardiac cycle. This allows flow quantification and visualization of blood flow patterns as well as the study of advanced hemodynamic parameters as kinetic energy and wall shear stress. 4D flow MRI-based study of flow has given insight into the altered hemodynamics in CHD particularly in bicuspid aortic valve disease and Fontan circulation. The aim of this review is to discuss the expanding clinical and research applications of 4D flow MRI in CHD as well its limitations.Key Points• Three-dimensional velocity encoding allows not only flow quantification but also the visualization of multidirectional flow patterns and the study of advanced hemodynamic parameters.• 4D flow MRI has added insight into the abnormal hemodynamics involved in congenital heart disease in particular in bicuspid aortic valve and Fontan circulation.• The main limitation of 4D flow MRI in congenital heart disease is the relatively long scan duration required for the complete coverage of the heart and great vessels with adequate spatiotemporal resolution.

Patient-Specific Bicuspid Aortic Valve Biomechanics: A Magnetic Resonance Imaging Integrated Fluid-Structure Interaction Approach

Congenital bicuspid aortic valve (BAV) consists of two fused cusps and represents a major risk factor for calcific valvular stenosis. Herein, a fully coupled fluid-structure interaction (FSI) BAV model was developed from patient-specific magnetic resonance imaging (MRI) and compared against in vivo 4-dimensional flow MRI (4D Flow). FSI simulation compared well with 4D Flow, confirming direction and magnitude of the flow jet impinging onto the aortic wall as well as location and extension of secondary flows and vortices developing at systole: the systolic flow jet originating from an elliptical 1.6 cm² orifice reached a peak velocity of 252.2 cm/s, 0.6% lower than 4D Flow, progressively impinging on the ascending aorta convexity. The FSI model predicted a peak flow rate of 22.4 L/min, 6.7% higher than 4D Flow, and provided BAV leaflets mechanical and flow-induced shear stresses, not directly attainable from MRI. At systole, the ventricular side of the non-fused leaflet revealed the highest wall shear stress (WSS) average magnitude, up to 14.6 Pa along the free margin, with WSS progressively decreasing towards the belly. During diastole, the aortic side of the fused leaflet exhibited the highest diastolic maximum principal stress, up to 322 kPa within the attachment region. Systematic comparison with ground-truth non-invasive MRI can improve the computational model ability to reproduce native BAV hemodynamics and biomechanical response more realistically, and shed light on their role in BAV patients' risk for developing complications; this approach may further contribute to the validation of advanced FSI simulations designed to assess BAV biomechanics.

Emerging 3D technologies and applications within congenital heart disease: teach, predict, plan and guide

3D visualization technologies have evolved to become a mainstay in the management of congenital heart disease (CHD) with a growing presence within multiple facets. Printed and virtual 3D models allow for a more comprehensive approach to educating trainees and care team members. Computational fluid dynamics can take 3D modeling to the next level, by predicting post-procedural outcomes and helping to determine surgical approach. 3D printing and extended reality are developing resources for pre-procedural planning and intra-procedural guidance with the potential to revolutionize decision-making and procedural success. Challenges still remain within existing technologies and their applications to the CHD field. Addressing these gaps, both by those within and outside of CHD, will transform education and patient care within our field.

Four-dimensional-flow Magnetic Resonance Imaging of the Aortic Valve and Thoracic Aorta

Blood flow through the heart and great vessels is sensitive to time and multiple velocity directions. The assessment of its three-dimensional nature has been limited. Recent advances in magnetic resonance imaging (MRI) allow the comprehensive visualization and quantification of in vivo flow dynamics using four-dimensional (4D)-flow MRI. In addition, the technique provides the opportunity to obtain advanced hemodynamic measures. This article introduces 4D-flow MRI as it is currently used for blood flow visualization and quantification of cardiac hemodynamic parameters. It discusses its advantages relative to other flow MRI techniques and describes its potential clinical applications.