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Ait Ali L, Martini N, Listo E, Valenti E, Sotelo J, Salvadori S, Passino C, Monteleone A, Stagnaro N, Trocchio G, Marrone C, Raimondi F, Catapano G, Festa P. Impact of 4D-Flow CMR Parameters on Functional Evaluation of Fontan Circulation. Pediatr Cardiol 2024; 45:998-1006. [PMID: 38519622 PMCID: PMC11056328 DOI: 10.1007/s00246-024-03446-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/06/2024] [Indexed: 03/25/2024]
Abstract
We sought to evaluate the potential clinical role of 4D-flow cardiac magnetic resonance (CMR)-derived energetics and flow parameters in a cohort of patients' post-Fontan palliation. In patients with Fontan circulation who underwent 4D-Flow CMR, streamlines distribution was evaluated, as well a 4D-flow CMR-derived energetics parameters as kinetic energy (KE) and energy loss (EL) normalized by volume. EL/KE index as a marker of flow efficiency was also calculated. Cardiopulmonary exercise test (CPET) was also performed in a subgroup of patients. The population study included 55 patients (mean age 22 ± 11 years). The analysis of the streamlines revealed a preferential distribution of the right superior vena cava flow for the right pulmonary artery (62.5 ± 35.4%) and a mild preferential flow for the left pulmonary artery (52.3 ± 40.6%) of the inferior vena cave-pulmonary arteries (IVC-PA) conduit. Patients with heart failure (HF) presented lower IVC/PA-conduit flow (0.75 ± 0.5 vs 1.3 ± 0.5 l/min/m2, p = 0.004) and a higher mean flow-jet angle of the IVC-PA conduit (39.2 ± 22.8 vs 15.2 ± 8.9, p < 0.001) than the remaining patients. EL/KE index correlates inversely with VO2/kg/min: R: - 0.45, p = 0.01 peak, minute ventilation (VE) R: - 0.466, p < 0.01, maximal voluntary ventilation: R:0.44, p = 0.001 and positively with the physiological dead space to the tidal volume ratio (VD/VT) peak: R: 0.58, p < 0.01. From our data, lower blood flow in IVC/PA conduit and eccentric flow was associated with HF whereas higher EL/KE index was associated with reduced functional capacity and impaired lung function. Larger studies are needed to confirm our results and to further improve the prognostic role of the 4D-Flow CMR in this challenging population.
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Affiliation(s)
- Lamia Ait Ali
- Institute of Clinical Physiology, National Research Council, Via Aurelia Sud, 54100, Massa, Pisa, Italy.
- Gabriele Monasterio Foundation, Pisa, Massa, Italy.
| | | | - Elisa Listo
- Azienda Ospedaliera ASL, 3-Ospedale Villascassi, Genoa, Italy
| | - Elisa Valenti
- Institute of Clinical Physiology, National Research Council, Via Aurelia Sud, 54100, Massa, Pisa, Italy
| | - Julio Sotelo
- Departamento de Informática, Universidad Técnica Federico Santa María, Santiago, Chile
| | - Stefano Salvadori
- Institute of Clinical Physiology, National Research Council, Via Aurelia Sud, 54100, Massa, Pisa, Italy
| | | | | | | | - Gianluca Trocchio
- ASST Ospedale Papa Giovanni XXIII, Piazza OMS, 1, 24127, Bergamo BG, Bergamo, Italy
| | | | - Francesca Raimondi
- ASST Ospedale Papa Giovanni XXIII, Piazza OMS, 1, 24127, Bergamo BG, Bergamo, Italy.
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Van den Eynde J, Westenberg JJM, Hazekamp MG, Lamb HJ, Jongbloed MRM, Wentzel JJ, Kenjeres S, Dekkers IA, Van De Bruaene A, Rijnberg FM, Roest AAW. Noninvasive Advanced Cardiovascular Magnetic Resonance-Derived Fontan Hemodynamics Are Associated With Reduced Kidney Function But Not Albuminuria. J Am Heart Assoc 2024; 13:e033122. [PMID: 38293946 PMCID: PMC11056124 DOI: 10.1161/jaha.123.033122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 12/01/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Kidney disease is the most important predictor of death in patients with a Fontan circulation, yet its clinical and hemodynamic correlates have not been well established. METHODS AND RESULTS A total of 53 ambulatory patients with a Fontan circulation (median age, 16.2 years, 52.8% male patients) underwent advanced cardiovascular magnetic resonance assessment, including 4-dimensional flow imaging and computational fluid dynamics. Estimated glomerular filtration rate (eGFR) <90 mL/min per 1.73 m2 was observed in 20.8% and albumin-to-creatinine ratio >3 mg/mmol in 39.6%. The average eGFR decline rate was -1.83 mL/min per 1.73 m2 per year (95% CI, -2.67 to -0.99; P<0.001). Lower eGFR was associated with older age, larger body surface area at examination, longer time since Fontan procedure, and lower systemic ventricular ejection fraction. Higher albumin-to-creatinine ratio was associated with absence of fenestration at the Fontan operation, and older age and lower systemic ventricular ejection fraction at the assessment. Lower cross-sectional area of the Fontan conduit indexed to flow (r=0.32, P=0.038), higher inferior vena cava-conduit velocity mismatch factor (r=-0.35, P=0.022), higher kinetic energy indexed to flow in the total cavopulmonary connection (r=-0.59, P=0.005), and higher total cavopulmonary connection resistance (r=-0.42, P=0.005 at rest; r=-0.43, P=0.004 during exercise) were all associated with lower eGFR but not with albuminuria. CONCLUSIONS Kidney dysfunction and albuminuria are common among clinically well adolescents and young adults with a Fontan circulation. Advanced cardiovascular magnetic resonance-derived metrics indicative of declining Fontan hemodynamics are associated with eGFR and might serve as targets to improve kidney health. Albuminuria might be driven by other factors that need further investigation.
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Affiliation(s)
- Jef Van den Eynde
- Department of Pediatrics, Division of Pediatric CardiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Cardiothoracic SurgeryLeiden University Medical CenterLeidenThe Netherlands
- Congenital and Structural CardiologyUniversity Hospitals LeuvenLeuvenBelgium
- Department of Cardiovascular SciencesCatholic University LeuvenLeuvenBelgium
| | - Jos J. M. Westenberg
- CardioVascular Imaging Group, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Mark G. Hazekamp
- Department of Cardiothoracic SurgeryLeiden University Medical CenterLeidenThe Netherlands
| | - Hildo J. Lamb
- CardioVascular Imaging Group, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Monique R. M. Jongbloed
- Department of CardiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Anatomy & EmbryologyLeiden University Medical CenterLeidenThe Netherlands
| | - Jolanda J. Wentzel
- Department of CardiologyBiomechanical Engineering, Erasmus MCRotterdamThe Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied SciencesDelft University of TechnologyDelftThe Netherlands
- J.M. Burgers Centrum Research School for Fluid MechanicsDelftThe Netherlands
| | - Ilona A. Dekkers
- CardioVascular Imaging Group, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Alexander Van De Bruaene
- Congenital and Structural CardiologyUniversity Hospitals LeuvenLeuvenBelgium
- Department of Cardiovascular SciencesCatholic University LeuvenLeuvenBelgium
| | - Friso M. Rijnberg
- Department of Cardiothoracic SurgeryLeiden University Medical CenterLeidenThe Netherlands
| | - Arno A. W. Roest
- Department of Pediatrics, Division of Pediatric CardiologyLeiden University Medical CenterLeidenThe Netherlands
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Schäfer M, Di Maria MV, Jaggers J, Stone ML, Campbell DN, Ivy DD, Mitchell MB. Hemi-Fontan and bidirectional Glenn operations result in flow-mediated viscous energy loss at the time of stage II palliation. JTCVS OPEN 2023; 16:836-843. [PMID: 38204687 PMCID: PMC10775100 DOI: 10.1016/j.xjon.2023.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/24/2023] [Accepted: 09/08/2023] [Indexed: 01/12/2024]
Abstract
Background Superior cavopulmonary connection (SCPC) for stage II palliation of hypoplastic left heart syndrome (HLHS) is achieved most frequently by either a bidirectional Glenn (BDG) or hemi-Fontan (HF) operation. The comparison of flow hemodynamic efficiency at the region of surgical reconstruction and in proximal pulmonary arteries has been evaluated primarily using computational modeling techniques with conflicting reports. The purpose of this descriptive study was to compare flow hemodynamics following stage II (BDG vs HF) using 4-dimensional flow magnetic resonance imaging (4D-Flow MRI) with particular focus on flow-mediated viscous energy loss (EL') under matched hemodynamic conditions. Methods Patients with hypoplastic left heart syndrome (HLHS) who underwent either HF or BDG as part of stage II palliation underwent pre-Fontan 4D-Flow MRI. Patients were matched by the pulmonary vascular resistance index, net superior vena cava (SVC) flow, right pulmonary artery (RPA) and left pulmonary artery (LPA) size, and age. Maximum EL' throughout the cardiac cycle was calculated along the SVC-RPA and SVC-LPA tracts. Results Eight patients who underwent HF as part of their stage II single ventricle palliation were matched with 8 patients who underwent BDG. There were no differences between the 2 groups in median volumetric indices, including end-diastolic volume (P = .278) and end-systolic volume (P = .213). Moreover, no differences were observed in ejection fraction (P = .091) and cardiac index (P = .324). There also were no differences in peak EL' measured along the SVC-RPA tract (median, 0.05 mW for HF vs 0.04 mW for BDG; P = .365) or along the SVC-LPA tract (median, 0.05 mW vs 0.04 mW; P = .741). Conclusions The second stage of surgical palliation of HLHS using either HF or BDG results in similar flow-mediated viscous energy loss throughout the SCPC junction. 4D-Flow MRI and computational methods should be applied together to investigate flow hemodynamic patterns throughout the Fontan palliation and overall efficiency of the Fontan circuit.
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Affiliation(s)
- Michal Schäfer
- Division of Cardiothoracic Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colo
| | - Michael V. Di Maria
- Division of Pediatric Cardiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colo
| | - James Jaggers
- Division of Cardiothoracic Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colo
| | - Matthew L. Stone
- Division of Cardiothoracic Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colo
| | - David N. Campbell
- Division of Cardiothoracic Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colo
| | - D. Dunbar Ivy
- Division of Pediatric Cardiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colo
| | - Max B. Mitchell
- Division of Cardiothoracic Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colo
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Hut T, Roest A, Gaillard D, Hazekamp M, van den Boogaard P, Lamb H, Kroft L, Jongbloed M, Westenberg J, Wentzel J, Rijnberg F, Kenjeres S. Virtual surgery to predict optimized conduit size for adult Fontan patients with 16-mm conduits. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad126. [PMID: 37522877 PMCID: PMC10686953 DOI: 10.1093/icvts/ivad126] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 06/18/2023] [Accepted: 07/30/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES Recent evidence suggests that conduits implanted in Fontan patients at the age of 2-4 years become undersized for adulthood. The objective of this study is to use computational fluid dynamic models to evaluate the effect of virtual expansion of the Fontan conduit on haemodynamics and energetics of the total cavopulmonary connection (TCPC) under resting conditions and increased flow conditions. METHODS Patient-specific, magnetic resonance imaging-based simulation models of the TCPC were performed during resting and increased flow conditions. The original 16-mm conduits were virtually enlarged to 3 new sizes. The proposed conduit sizes were defined based on magnetic resonance imaging-derived conduit flow in each patient. Flow efficiency was evaluated based on power loss, pressure drop and resistance and thrombosis risk was based on flow stagnation volume and relative residence time (RRT). RESULTS Models of 5 adult patients with a 16-mm extracardiac Fontan connection were simulated and subsequently virtually expanded to 24-32 mm depending on patient-specific conduit flow. Virtual expansion led to a 40-65% decrease in pressure gradient across the TCPC depending on virtual conduit size. Despite improved energetics of the entire TCPC, the pulmonary arteries remained a significant contributor to energy loss (60-73% of total loss) even after virtual surgery. Flow stagnation volume inside the virtual conduit and surface area in case of elevated RRT (>20/Pa) increased after conduit enlargement but remained negligible (flow stagnation <2% of conduit volume in rest, <0.5% with exercise and elevated RRT <3% in rest, <1% with exercise). CONCLUSIONS Virtual expansion of 16-mm conduits to 24-32 mm, depending on patient-specific conduit flow, in Fontan patients significantly improves TCPC efficiency while thrombosis risk presumably remains low.
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Affiliation(s)
- Tjerry Hut
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers Centrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Arno Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Duco Gaillard
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers Centrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Mark Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Hildo Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Lucia Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Monique Jongbloed
- Department of Cardiology and Anatomy & Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jolanda Wentzel
- Department of Cardiology, Biomechanical Engineering, Erasmus MC, Rotterdam, Netherlands
| | - Friso Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers Centrum Research School for Fluid Mechanics, Delft, Netherlands
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Impact of pulmonary artery flow distribution on Fontan hemodynamics and flow energetics. Pediatr Radiol 2023; 53:900-909. [PMID: 36879047 PMCID: PMC10156799 DOI: 10.1007/s00247-023-05591-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/15/2022] [Accepted: 01/10/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND With improved life expectancy following Fontan palliation, there is an increasing population of patients with a total cavopulmonary connection. However, there is a poor understanding of which patients will experience Fontan failure and when. 4D flow MRI has identified several metrics of clinical interest, but longitudinal studies investigating hemodynamics in Fontan patients are lacking. OBJECTIVE We aimed to investigate the relationship between flow distribution to the pulmonary arteries and regional hemodynamic metrics in a unique cohort with follow-up 4D flow MRI. MATERIALS AND METHODS Patients with > 6 months of 4D flow MRI follow-up were included. Flow distribution from the caval veins to pulmonary arteries was measured in addition to regional measures of peak velocity, viscous energy loss (ELmean and ELtot), and kinetic energy. RESULTS Ten patients with total cavopulmonary connection (17.7 ± 8.8 years at baseline, follow-up: 4.4 ± 2.6 years) were included. Five subjects had unequal flow distribution from the IVC to the pulmonary arteries at baseline. Over time, these subjects tended to have larger increases in peak velocity (39.2% vs 6.6%), ELmean (11.6% vs -38.3%), ELtot (9.5% vs -36.2%), and kinetic energy (96.1% vs 36.3%) in the IVC. However, these differences were statistically insignificant. We found that changes in ELmean and ELtot were significantly associated with changes in peak velocity in the caval veins (R2 > 0.5, P < 0.001). CONCLUSION Unequal flow distribution from the IVC may drive increasing peak velocities and viscous energy losses, which have been associated with worse clinical outcomes. Changes in peak velocity may serve as a surrogate measure for changes in viscous energy loss.
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Roos PR, Rijnberg FM, Westenberg JJM, Lamb HJ. Particle Tracing Based on
4D
Flow Magnetic Resonance Imaging: A Systematic Review into Methods, Applications, and Current Developments. J Magn Reson Imaging 2022; 57:1320-1339. [PMID: 36484213 DOI: 10.1002/jmri.28540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Particle tracing based on 4D Flow MRI has been applied as a quantitative and qualitative postprocessing technique to study temporally evolving blood flow patterns. PURPOSE To systematically review the various methods to perform 4D Flow MRI-based particle tracing, as well as the clinical value, clinical applications, and current developments of the technique. STUDY TYPE The study type is systematic review. SUBJECTS Patients with cardiovascular disease (such as Marfan, Fontan, Tetralogy of Fallot), healthy controls, and cardiovascular phantoms that received 4D Flow MRI with particle tracing. FIELD STRENGTH/SEQUENCE Three-dimensional three-directional cine phase-contrast MRI, at 1.5 T and 3 T. ASSESSMENT Two systematic searches were performed on the PubMed database using Boolean operators and the relevant key terms covering 4D Flow MRI and particle tracing. One systematic search was focused on particle tracing methods, whereas the other on applications. Additional articles from other sources were sought out and included after a similar inspection. Particle tracing methods, clinical applications, clinical value, and current developments were extracted. STATISTICAL TESTS The main results of the included studies are summarized, without additional statistical analysis. RESULTS Of 127 unique articles retrieved from the initial search, 56 were included (28 for methods and 54 for applications). Most articles that described particle tracing methods used an adaptive timestep, a fourth order Runge-Kutta integration method, and linear interpolation in the time dimension. Particle tracing was applied in heart chambers, aorta, venae cavae, Fontan circulation, pulmonary arteries, abdominal vasculature, peripheral arteries, carotid arteries, and cerebral vasculature. Applications were grouped as intravascular, intracardiac, flow stasis, and research. DATA CONCLUSIONS Particle tracing based on 4D Flow MRI gives unique insight into blood flow in several cardiovascular diseases, but the quality depends heavily on the MRI data quality. Further studies are required to evaluate the clinical value of the technique for different cardiovascular diseases. EVIDENCE LEVEL 5. TECHNICAL EFFICACY Stage 1.
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Affiliation(s)
- Paul R. Roos
- Department of Radiology Leiden University Medical Center Leiden The Netherlands
| | - Friso M. Rijnberg
- Department of Cardiothoracic Surgery Leiden University Medical Center Leiden The Netherlands
| | | | - Hildo J. Lamb
- Department of Radiology Leiden University Medical Center Leiden The Netherlands
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Puricelli F, Voges I, Gatehouse P, Rigby M, Izgi C, Pennell DJ, Krupickova S. Performance of Cardiac MRI in Pediatric and Adult Patients with Fontan Circulation. Radiol Cardiothorac Imaging 2022; 4:e210235. [PMID: 35833165 PMCID: PMC9274315 DOI: 10.1148/ryct.210235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 04/11/2022] [Accepted: 04/18/2022] [Indexed: 06/15/2023]
Abstract
Cardiac MRI has become a widely accepted standard for anatomic and functional assessment of complex Fontan physiology, because it is noninvasive and suitable for comprehensive follow-up evaluation after Fontan completion. The use of cardiac MRI in pediatric and adult patients after completion of the Fontan procedure are described, and a practical and experience-based cardiac MRI protocol for evaluating these patients is provided. The current approach and study protocol in use at the authors' institution are presented, which address technical considerations concerning sequences, planning, and optimal image acquisition in patients with Fontan circulation. Additionally, for each sequence, the information that can be obtained and guidance on how to integrate it into clinical decision-making is discussed. Keywords: Pediatrics, MRI, MRI Functional Imaging, Heart, Congenital © RSNA, 2022.
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Rijnberg FM, Westenberg JJM, van Assen HC, Juffermans JF, Kroft LJM, van den Boogaard PJ, Terol Espinosa de Los Monteros C, Warmerdam EG, Leiner T, Grotenhuis HB, Jongbloed MRM, Hazekamp MG, Roest AAW, Lamb HJ. 4D flow cardiovascular magnetic resonance derived energetics in the Fontan circulation correlate with exercise capacity and CMR-derived liver fibrosis/congestion. J Cardiovasc Magn Reson 2022; 24:21. [PMID: 35346249 PMCID: PMC8962091 DOI: 10.1186/s12968-022-00854-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/15/2022] [Indexed: 12/12/2022] Open
Abstract
AIM This study explores the relationship between in vivo 4D flow cardiovascular magnetic resonance (CMR) derived blood flow energetics in the total cavopulmonary connection (TCPC), exercise capacity and CMR-derived liver fibrosis/congestion. BACKGROUND The Fontan circulation, in which both caval veins are directly connected with the pulmonary arteries (i.e. the TCPC) is the palliative approach for single ventricle patients. Blood flow efficiency in the TCPC has been associated with exercise capacity and liver fibrosis using computational fluid dynamic modelling. 4D flow CMR allows for assessment of in vivo blood flow energetics, including kinetic energy (KE) and viscous energy loss rate (EL). METHODS Fontan patients were prospectively evaluated between 2018 and 2021 using a comprehensive cardiovascular and liver CMR protocol, including 4D flow imaging of the TCPC. Peak oxygen consumption (VO2) was determined using cardiopulmonary exercise testing (CPET). Iron-corrected whole liver T1 (cT1) mapping was performed as a marker of liver fibrosis/congestion. KE and EL in the TCPC were computed from 4D flow CMR and normalized for inflow. Furthermore, blood flow energetics were compared between standardized segments of the TCPC. RESULTS Sixty-two Fontan patients were included (53% male, 17.3 ± 5.1 years). Maximal effort CPET was obtained in 50 patients (peak VO2 27.1 ± 6.2 ml/kg/min, 56 ± 12% of predicted). Both KE and EL in the entire TCPC (n = 28) were significantly correlated with cT1 (r = 0.50, p = 0.006 and r = 0.39, p = 0.04, respectively), peak VO2 (r = - 0.61, p = 0.003 and r = - 0.54, p = 0.009, respectively) and % predicted peak VO2 (r = - 0.44, p = 0.04 and r = - 0.46, p = 0.03, respectively). Segmental analysis indicated that the most adverse flow energetics were found in the Fontan tunnel and left pulmonary artery. CONCLUSIONS Adverse 4D flow CMR derived KE and EL in the TCPC correlate with decreased exercise capacity and increased levels of liver fibrosis/congestion. 4D flow CMR is promising as a non-invasive screening tool for identification of patients with adverse TCPC flow efficiency.
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Affiliation(s)
- Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands.
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans C van Assen
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joe F Juffermans
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | - Tim Leiner
- Department of Radiology, Utrecht Medical Center, Utrecht, The Netherlands
| | - Heynric B Grotenhuis
- Department of Pediatric Cardiology, Utrecht Medical Center, Utrecht, The Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology and Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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Rijnberg FM, van der Woude SFS, Hazekamp MG, van den Boogaard PJ, Lamb HJ, Terol Espinosa de Los Monteros C, Kroft LJM, Kenjeres S, Karim T, Jongbloed MRM, Westenberg JJM, Wentzel JJ, Roest AAW. Extracardiac conduit adequacy along the respiratory cycle in adolescent Fontan patients. Eur J Cardiothorac Surg 2021; 62:6423130. [PMID: 34747442 PMCID: PMC9257669 DOI: 10.1093/ejcts/ezab478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/12/2021] [Accepted: 09/26/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers Centrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Tawab Karim
- Department of Cardiology, Biomechanical Engineering, Erasmus MC, Rotterdam, Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology and Anatomy and Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jolanda J Wentzel
- Department of Cardiology, Biomechanical Engineering, Erasmus MC, Rotterdam, Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
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van der Woude SFS, Rijnberg FM, Hazekamp MG, Jongbloed MRM, Kenjeres S, Lamb HJ, Westenberg JJM, Roest AAW, Wentzel JJ. The Influence of Respiration on Blood Flow in the Fontan Circulation: Insights for Imaging-Based Clinical Evaluation of the Total Cavopulmonary Connection. Front Cardiovasc Med 2021; 8:683849. [PMID: 34422920 PMCID: PMC8374887 DOI: 10.3389/fcvm.2021.683849] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/05/2021] [Indexed: 12/18/2022] Open
Abstract
Congenital heart disease is the most common birth defect and functionally univentricular heart defects represent the most severe end of this spectrum. The Fontan circulation provides an unique solution for single ventricle patients, by connecting both caval veins directly to the pulmonary arteries. As a result, the pulmonary circulation in Fontan palliated patients is characterized by a passive, low-energy circulation that depends on increased systemic venous pressure to drive blood toward the lungs. The absence of a subpulmonary ventricle led to the widely believed concept that respiration, by sucking blood to the pulmonary circulation during inspiration, is of great importance as a driving force for antegrade blood flow in Fontan patients. However, recent studies show that respiration influences pulsatility, but has a limited effect on net forward flow in the Fontan circulation. Importantly, since MRI examination is recommended every 2 years in Fontan patients, clinicians should be aware that most conventional MRI flow sequences do not capture the pulsatility of the blood flow as a result of the respiration. In this review, the unique flow dynamics influenced by the cardiac and respiratory cycle at multiple locations within the Fontan circulation is discussed. The impact of (not) incorporating respiration in different MRI flow sequences on the interpretation of clinical flow parameters will be covered. Finally, the influence of incorporating respiration in advanced computational fluid dynamic modeling will be outlined.
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Affiliation(s)
- Séline F S van der Woude
- Department of Cardiology, Biomedical Engineering, Biomechanics Laboratory, Rotterdam, Netherlands
| | - Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Monique R M Jongbloed
- Department of Anatomy, Embryology and Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J. M. Burgerscentrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jolanda J Wentzel
- Department of Cardiology, Biomedical Engineering, Biomechanics Laboratory, Rotterdam, Netherlands
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11
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Rijnberg FM, Juffermans JF, Hazekamp MG, Helbing WA, Lamb HJ, Roest AAW, Westenberg JJM, van Assen HC. Segmental assessment of blood flow efficiency in the total cavopulmonary connection using four-dimensional flow magnetic resonance imaging: vortical flow is associated with increased viscous energy loss rate. EUROPEAN HEART JOURNAL OPEN 2021; 1:oeab018. [PMID: 35919267 PMCID: PMC9241567 DOI: 10.1093/ehjopen/oeab018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/19/2021] [Accepted: 08/06/2021] [Indexed: 11/12/2022]
Abstract
Aims To study flow-related energetics in multiple anatomical segments of the total cavopulmonary connection (TCPC) in Fontan patients from four-dimensional (4D) flow magnetic resonance imaging (MRI), and to study the relationship between adverse flow patterns and segment-specific energetics. Methods and results Twenty-six extracardiac Fontan patients underwent 4D flow MRI of the TCPC. A segmentation of the TCPC was automatically divided into five anatomical segments [conduit, superior vena cava (SVC), right/left pulmonary artery (LPA), and the Fontan confluence]. The presence of vortical flow in the pulmonary arteries or Fontan confluence was qualitatively scored. Kinetic energy (KE), viscous energy loss rate, and vorticity were calculated from the 4D flow MRI velocity field and normalized for segment length and/or inflow. Energetics were compared between segments and the relationship between vortical flow and segment cross-sectional area (CSA) with segment-specific energetics was determined. Vortical flow in the LPA (n = 6) and Fontan confluence (n = 12) were associated with significantly higher vorticity (P = 0.001 and P = 0.015, respectively) and viscous energy loss rate (P = 0.046 and P = 0.04, respectively) compared to patients without vortical flow. The LPA and conduit segments showed the highest KE and viscous energy loss rate, while most favourable energetics were observed in the SVC. Conduit CSA inversely correlated with KE (r = −0.614, P = 0.019) and viscous energy loss rate (r = −0.652, P = 0.011). Conclusions Vortical flow in the Fontan confluence and LPA associated with significantly increased viscous energy loss rate. Four-dimensional flow MRI-derived energetics may be used as a screening tool for direct, MRI-based assessment of flow efficiency in the TCPC.
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Affiliation(s)
- Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Joe F Juffermans
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Willem A Helbing
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus University Medical Center, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands
- Department of Pediatrics, Division of Pediatric Cardiology, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Hans C van Assen
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands
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12
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Rijnberg FM, van der Woude SFS, van Assen HC, Juffermans JF, Hazekamp MG, Jongbloed MRM, Kenjeres S, Lamb HJ, Westenberg JJM, Wentzel JJ, Roest AAW. Non-uniform mixing of hepatic venous flow and inferior vena cava flow in the Fontan conduit. J R Soc Interface 2021; 18:20201027. [PMID: 33823607 PMCID: PMC8086942 DOI: 10.1098/rsif.2020.1027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Fontan patients require a balanced hepatic blood flow distribution (HFD) to prevent pulmonary arteriovenous malformations. Currently, HFD is quantified by tracking Fontan conduit flow, assuming hepatic venous (HV) flow to be uniformly distributed within the Fontan conduit. However, this assumption may be unvalid leading to inaccuracies in HFD quantification with potential clinical impact. The aim of this study was to (i) assess the mixing of HV flow and inferior vena caval (IVC) flow within the Fontan conduit and (ii) quantify HFD by directly tracking HV flow and quantitatively comparing results with the conventional approach. Patient-specific, time-resolved computational fluid dynamic models of 15 total cavopulmonary connections were generated, including the HV and subhepatic IVC. Mixing of HV and IVC flow, on a scale between 0 (no mixing) and 1 (perfect mixing), was assessed at the caudal and cranial Fontan conduit. HFD was quantified by tracking particles from the caudal (HFDcaudal conduit) and cranial (HFDcranial conduit) conduit and from the hepatic veins (HFDHV). HV flow was non-uniformly distributed at both the caudal (mean mixing 0.66 ± 0.13) and cranial (mean 0.79 ± 0.11) level within the Fontan conduit. On a cohort level, differences in HFD between methods were significant but small; HFDHV (51.0 ± 20.6%) versus HFDcaudal conduit (48.2 ± 21.9%, p = 0.033) or HFDcranial conduit (48.0 ± 21.9%, p = 0.044). However, individual absolute differences of 8.2–14.9% in HFD were observed in 4/15 patients. HV flow is non-uniformly distributed within the Fontan conduit. Substantial individual inaccuracies in HFD quantification were observed in a subset of patients with potential clinical impact.
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Affiliation(s)
- Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Hans C van Assen
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joe F Juffermans
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology and Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J. M. Burgerscentrum Research School for Fluid Mechanics, Delft, The Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jolanda J Wentzel
- Department of Cardiology, Biomedical Engineering, Erasmus MC, Rotterdam, The Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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13
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Reduced scan time and superior image quality with 3D flow MRI compared to 4D flow MRI for hemodynamic evaluation of the Fontan pathway. Sci Rep 2021; 11:6507. [PMID: 33753790 PMCID: PMC7985309 DOI: 10.1038/s41598-021-85936-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/03/2021] [Indexed: 12/14/2022] Open
Abstract
Long scan times prohibit a widespread clinical applicability of 4D flow MRI in Fontan patients. As pulsatility in the Fontan pathway is minimal during the cardiac cycle, acquiring non-ECG gated 3D flow MRI may result in a reduction of scan time while accurately obtaining time-averaged clinical parameters in comparison with 2D and 4D flow MRI. Thirty-two Fontan patients prospectively underwent 2D (reference), 3D and 4D flow MRI of the Fontan pathway. Multiple clinical parameters were assessed from time-averaged flow rates, including the right-to-left pulmonary flow distribution (main endpoint) and systemic-to-pulmonary collateral flow (SPCF). A ten-fold reduction in scan time was achieved [4D flow 15.9 min (SD 2.7 min) and 3D flow 1.6 min (SD 7.8 s), p < 0.001] with a superior signal-to-noise ratio [mean ratio of SNRs 1.7 (0.8), p < 0.001] and vessel sharpness [mean ratio 1.2 (0.4), p = 0.01] with 3D flow. Compared to 2D flow, good–excellent agreement was shown for mean flow rates (ICC 0.82–0.96) and right-to-left pulmonary flow distribution (ICC 0.97). SPCF derived from 3D flow showed good agreement with that from 4D flow (ICC 0.86). 3D flow MRI allows for obtaining time-averaged flow rates and derived clinical parameters in the Fontan pathway with good–excellent agreement with 2D and 4D flow, but with a tenfold reduction in scan time and significantly improved image quality compared to 4D flow.
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14
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Kamphuis VP, Roest AAW, van den Boogaard PJ, Kroft LJM, Lamb HJ, Helbing WA, Blom NA, Westenberg JJM, Elbaz MSM. Hemodynamic interplay of vorticity, viscous energy loss, and kinetic energy from 4D Flow MRI and link to cardiac function in healthy subjects and Fontan patients. Am J Physiol Heart Circ Physiol 2021; 320:H1687-H1698. [PMID: 33635164 DOI: 10.1152/ajpheart.00806.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The purpose of this study was to directly assess (patho)physiology of intraventricular hemodynamic interplay between four-dimensional flow cardiovascular magnetic resonance imaging (4D Flow MRI)-derived vorticity with kinetic energy (KE) and viscous energy loss (EL) over the cardiac cycle and their association to ejection fraction (EF) and stroke volume (SV). Fifteen healthy subjects and thirty Fontan patients underwent whole heart 4D Flow MRI. Ventricular vorticity, KE, and EL were computed over systole (vorticity_volavg systole, KEavg systole, and ELavg systole) and diastole (vorticity_volavg diastole, KEavg diastole, and ELavg diastole). The association between vorticity_vol and KE and EL was tested by Spearman correlation. Fontan patients were grouped to normal and impaired EF groups. A significant correlation was found between SV and vorticity in healthy subjects (systolic: ρ = 0.84, P < 0.001; diastolic: ρ = 0.81, P < 0.001) and in Fontan patients (systolic: ρ = 0.61, P < 0.001; diastolic: ρ = 0.54, P = 0.002). Healthy subjects showed positive correlation between vorticity_vol versus KE (systole: ρ = 0.96, P < 0.001; diastole: ρ = 0.90, P < 0.001) and EL (systole: ρ = 0.85, P < 0.001; diastole: ρ = 0.84, P < 0.001). Fontan patients showed significantly elevated vorticity_vol compared with healthy subjects (vorticity_volavg systole: 3.1 [2.3-3.9] vs. 1.7 [1.3-2.4] L/s, P < 0.001; vorticity_volavg diastole: 3.1 [2.0-3.7] vs. 2.1 [1.6-2.8] L/s, P = 0.002). This elevated vorticity in Fontan patients showed strong association with KE (systole: ρ = 0.91, P < 0.001; diastole: ρ = 0.85, P < 0.001) and EL (systole: ρ = 0.82, P < 0.001; diastole: ρ = 0.89, P < 0.001). Fontan patients with normal EF showed significantly higher vorticity_volavg systole and ELavg systole, but significantly decreased KE avg diastole, in the presence of normal SV, compared with healthy subjects. Healthy subjects show strong physiological hemodynamic interplay between vorticity with KE and EL. Fontan patients demonstrate a pathophysiological hemodynamic interplay characterized by correlation of elevated vorticity with KE and EL in the presence of maintained normal stroke volume. Altered vorticity and energetic hemodynamics are found in the presence of normal EF in Fontan patients.NEW & NOTEWORTHY Physiologic intraventricular hemodynamic interplay/coupling is present in the healthy left ventricle between vorticity versus viscous energy loss and kinetic energy from four-dimensional flow cardiovascular magnetic resonance imaging (4D Flow MRI). Conversely, Fontan patients present compensatory pathophysiologic hemodynamic coupling by an increase in intraventricular vorticity that positively correlates to viscous energy loss and kinetic energy levels in the presence of maintained normal stroke volume. Altered vorticity and energetics are found in the presence of normal ejection fraction in Fontan patients.
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Affiliation(s)
- Vivian P Kamphuis
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands.,Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Arno A W Roest
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem A Helbing
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.,Division of Pediatric Cardiology, Department of Pediatrics, Academic Medical Center, Amsterdam, The Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mohammed S M Elbaz
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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15
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Rizk J. 4D flow MRI applications in congenital heart disease. Eur Radiol 2020; 31:1160-1174. [PMID: 32870392 DOI: 10.1007/s00330-020-07210-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 07/04/2020] [Accepted: 08/19/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Judy Rizk
- Department of Cardiology, Faculty of Medicine, Alexandria University, El-Khartoum Square, Alexandria, 21521, Egypt.
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