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. 2021 Apr 1;3(2):e200446.
doi: 10.1148/ryct.2021200446. eCollection 2021 Apr.

4D Flow MRI Quantification of Congenital Shunts: Comparison to Invasive Catheterization

Michael J Horowitz  1 , Daniel F Kupsky  1 , Howaida G El-Said  1 , Laith Alshawabkeh  1 , Seth J Kligerman  1 , Albert Hsiao  1
Affiliations

4D Flow MRI Quantification of Congenital Shunts: Comparison to Invasive Catheterization

Michael J Horowitz et al. Radiol Cardiothorac Imaging. .

Abstract

Purpose: To compare invasive right heart catheterization with four-dimensional (4D) flow MRI for estimating shunt fraction in patients with intracardiac and extracardiac shunts.

Materials and methods: In this retrospective study, patients who underwent 4D flow MRI and invasive right heart catheterization with a shunt run between August 2015 and November 2018 were included. The primary objective was comparison of estimated shunt fraction (ratio of pulmonary-to-systemic flow, Qp/Qs) at 4D flow and catheterization. Secondary objectives included comparison of the right ventricular-to-left ventricular stroke volume ratio (RVSV/LVSV) to shunt fraction (for those with applicable shunts) and comparison of cardiac output between 4D flow and catheterization. Statistical analysis included Pearson correlation and Bland-Altman plots.

Results: A total of 33 patients met inclusion criteria (mean age, 49 years ± 16 [standard deviation]; 24 women). 4D flow measurements of Qp/Qs strongly correlated with those at catheterization (r = 0.938), and there was no bias. RVSV/LVSV correlated strongly with Qp/Qs from 4D flow (r = 0.852) and catheterization (r = 0.842). Measurements of left ventricle (Qs) and right ventricle (QP) cardiac output from 4D flow and catheterization (Fick) correlated moderately overall (r = 0.673 [Qp] and r = 0.750 [Qs]).

Conclusion: Shunt fraction measurement using 4D flow MRI compares well with that using invasive cardiac catheterization.Supplemental material is available for this article.© RSNA, 2021.

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Conflict of interest statement

Disclosures of Conflicts of Interest: M.J.H. disclosed no relevant relationships. D.F.K. disclosed no relevant relationships. H.G.E. disclosed no relevant relationships. L.A. disclosed no relevant relationships. S.J.K. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: author is deputy editor of Radiology: Cardiothoracic Imaging. Other relationships: disclosed no relevant relationships. A.H. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: author is founder, shareholder, and consultant for Arterys; consultant for GE Healthcare; received travel accommodations from GE Healthcare and Arterys; institution received grant from GE Healthcare. Other relationships: institution (Stanford University) has issued and licensed patents; author/institution receives royalties from patents.

Figures

Cardiac-gated MR angiography and four-dimensional (4D) flow images from patient 2 with partial anomalous pulmonary venous return (PAPVR) of the right upper lobe. Right ventricular outflow tract views from, A, MR angiography and, B, 4D flow show the connection between the right upper lobe pulmonary vein and superior vena cava. In C, four-chamber view shows an enlarged right atrium (RA) and left-to-right flow through a large secundum atrial septal defect. In D, red and black circles highlight the location of blood flow measurements in the ascending aorta and main pulmonary artery, respectively. LV = left ventricle, RV = right ventricle.
Figure 1:
Cardiac-gated MR angiography and four-dimensional (4D) flow images from patient 2 with partial anomalous pulmonary venous return (PAPVR) of the right upper lobe. Right ventricular outflow tract views from, A, MR angiography and, B, 4D flow show the connection between the right upper lobe pulmonary vein and superior vena cava. In C, four-chamber view shows an enlarged right atrium (RA) and left-to-right flow through a large secundum atrial septal defect. In D, red and black circles highlight the location of blood flow measurements in the ascending aorta and main pulmonary artery, respectively. LV = left ventricle, RV = right ventricle.
Comparison of Qp/Qs between four-dimensional (4D) flow MRI and cardiac catheterization. (Left) Bland-Altman analysis and (right) scatterplots demonstrate minimal bias and strong correlation. Data obtained during initial (routine) clinical care are indicated by blue circles, while orange triangles represent recalculation of 4D flow measurements by an independent observer. Mean difference values are zero (initial data) and 0.04 (recalculated), while Pearson r = 0.938 and 0.905 for initial and recalculated data, respectively. Qp/Qs = ratio of pulmonary-to-systemic flow.
Figure 2:
Comparison of Qp/Qs between four-dimensional (4D) flow MRI and cardiac catheterization. (Left) Bland-Altman analysis and (right) scatterplots demonstrate minimal bias and strong correlation. Data obtained during initial (routine) clinical care are indicated by blue circles, while orange triangles represent recalculation of 4D flow measurements by an independent observer. Mean difference values are zero (initial data) and 0.04 (recalculated), while Pearson r = 0.938 and 0.905 for initial and recalculated data, respectively. Qp/Qs = ratio of pulmonary-to-systemic flow.
Comparison of Qp/Qs by four-dimensional (4D) flow MRI and right ventricular–to–left ventricular stroke volume (RVSV/LVSV) ratio from manual cardiac segmentation of steady-state free precession (SSFP) images. (Left) Bland-Altman analysis and (right) scatterplot demonstrate minimal bias and strong correlation. Data obtained during initial (routine) clinical care are indicated by blue circles, while orange triangles represent recalculation of 4D flow measurements by an independent observer. Mean difference values are −0.05 (initial) and −0.08 L/min (recalculated), while Pearson r = 0.852 and 0.815 for initial and recalculated data, respectively. Qp/Qs = ratio of pulmonary-to-systemic flow.
Figure 3:
Comparison of Qp/Qs by four-dimensional (4D) flow MRI and right ventricular–to–left ventricular stroke volume (RVSV/LVSV) ratio from manual cardiac segmentation of steady-state free precession (SSFP) images. (Left) Bland-Altman analysis and (right) scatterplot demonstrate minimal bias and strong correlation. Data obtained during initial (routine) clinical care are indicated by blue circles, while orange triangles represent recalculation of 4D flow measurements by an independent observer. Mean difference values are −0.05 (initial) and −0.08 L/min (recalculated), while Pearson r = 0.852 and 0.815 for initial and recalculated data, respectively. Qp/Qs = ratio of pulmonary-to-systemic flow.
Comparison of Qp/Qs by catheterization and right ventricular–to–left ventricular stroke volume (RVSV/LVSV) ratio from manual segmentation of steady-state free precession (SSFP) images. (Left) Bland-Altman analysis and (right) scatterplot demonstrate minimal bias (mean difference = −0.05) and strong correlation (r = 0.842). Qp/Qs = ratio of pulmonary-to-systemic flow.
Figure 4:
Comparison of Qp/Qs by catheterization and right ventricular–to–left ventricular stroke volume (RVSV/LVSV) ratio from manual segmentation of steady-state free precession (SSFP) images. (Left) Bland-Altman analysis and (right) scatterplot demonstrate minimal bias (mean difference = −0.05) and strong correlation (r = 0.842). Qp/Qs = ratio of pulmonary-to-systemic flow.
Comparison of systemic (Qs) and pulmonary (Qp) cardiac output measurements by four-dimensional (4D) flow MRI and catheterization. (Left) Bland-Altman analyses and (right) scatterplots show that measurements of, A, systemic and, B, pulmonary cardiac output by 4D flow tend to be higher than catheterization. Data obtained during initial (routine) clinical care are indicated by blue circles, while orange triangles represent recalculation of 4D flow measurements by an independent observer. For Qs, mean difference = −1.19 (initial) and −1.18 L/min (recalculated), respectively, while Pearson r = 0.673, 0.593 (initial, recalculated). For Qp, mean difference = −1.54, −1.72 and Pearson r = 0.750, 0.719 (initial, recalculated).
Figure 5:
Comparison of systemic (Qs) and pulmonary (Qp) cardiac output measurements by four-dimensional (4D) flow MRI and catheterization. (Left) Bland-Altman analyses and (right) scatterplots show that measurements of, A, systemic and, B, pulmonary cardiac output by 4D flow tend to be higher than catheterization. Data obtained during initial (routine) clinical care are indicated by blue circles, while orange triangles represent recalculation of 4D flow measurements by an independent observer. For Qs, mean difference = −1.19 (initial) and −1.18 L/min (recalculated), respectively, while Pearson r = 0.673, 0.593 (initial, recalculated). For Qp, mean difference = −1.54, −1.72 and Pearson r = 0.750, 0.719 (initial, recalculated).
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