Four-dimensional flow provides incremental diagnostic value over echocardiography in aortic stenosis

Ciaran Grafton-Clarke; Hosamadin Assadi; Rui Li; Zia Mehmood; Rimma Hall; Gareth Matthews; Vasiliki Tsampasian; Samer Alabed; Bahman Kasmai; Laura Staff; John Curtin; Gurung-Koney Yashoda; Julia Sun; Sunil Nair; David Hewson; Kurian Thampi; Jordi Broncano; Fabrizio Ricci; Peter Swoboda; Andrew J Swift; Vassilios S Vassiliou; Rob J van der Geest; Pankaj Garg

doi:10.1136/openhrt-2024-003081

Four-dimensional flow provides incremental diagnostic value over echocardiography in aortic stenosis

Open Heart. 2025 May 7;12(1):e003081. doi: 10.1136/openhrt-2024-003081.

Authors

Ciaran Grafton-Clarke^#^{1

2}, Hosamadin Assadi^#^{1

2}, Rui Li^{1

2}, Zia Mehmood^{1

2}, Rimma Hall¹, Gareth Matthews^{1

2}, Vasiliki Tsampasian^{1

2}, Samer Alabed³, Bahman Kasmai^{1

2}, Laura Staff¹, John Curtin¹, Gurung-Koney Yashoda¹, Julia Sun¹, Sunil Nair¹, David Hewson¹, Kurian Thampi¹, Jordi Broncano⁴, Fabrizio Ricci⁵, Peter Swoboda⁶, Andrew J Swift³, Vassilios S Vassiliou^{1

2}, Rob J van der Geest⁷, Pankaj Garg^{8

2}

Affiliations

¹ Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.
² Department of Cardiovascular and Metabolic Health, University of East Anglia, Norwich, UK.
³ Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.
⁴ Hospital San Juan de Dios, Santa Cruz de Tenerife, Spain.
⁵ Department of Neuroscience, Imaging and Clinical Sciences, Chieti and University Cardiology Division, Chieti, Italy.
⁶ LICAMM, University of Leeds, Leeds, UK.
⁷ Department of Radiology, Division of Image Processing, Leiden University Medical Center (LUMC), Leiden, The Netherlands.
⁸ Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK p.garg@uea.ac.uk.

^# Contributed equally.

Abstract

Aims: Four-dimensional flow cardiovascular MRI (4D flow CMR) has emerged as a promising technique for assessing aortic stenosis (AS). This study aimed to evaluate the agreement between 4D flow CMR and transthoracic echocardiography (TTE) in estimating peak aortic valve (AV) velocities (V_Peak), grading AS severity and predicting AV intervention in a real-world setting.

Methods: Participants from the PREFER-CMR registry who had consecutive TTE and 4D flow CMR were included. AS severity was graded using established protocols using three echocardiographic parameters (V_Peak, AV area and mean pressure gradient) and CMR-derived V_Peak.

Results: The study recruited 30 patients (mean age 75.4 years, 67% male), with 17 undergoing AV intervention. Continuous wave Doppler (CWD) V_Peak (3.4 vs 2.6 m/s, p=0.0025) and 4D flow V_Peak (4.2 vs 2.7 m/s, p<0.0001) were significantly higher in patients going for AV intervention. V_Peak by CWD was significantly lower to 4D flow with a bias of -0.5 (p=0.01) and a correlation of (R=0.55, p=0.002). The Cox-regression analysis reveals that 4D flow V_Peak significantly predicts AV intervention (HR=2.51, p<0.01), while CWD V_Peak (HR=0.54, p=0.76) shows no significant association; overall model fit is significant (χ²=9.5, p=0.02).

Conclusion: 4D flow CMR-derived V_Peak assessment is superior to echocardiographic CWD assessment for predicting timing of AV intervention.

Trial registration number: NCT05114785.

Keywords: Aortic Valve Stenosis; Echocardiography; Magnetic Resonance Imaging.

Publication types

Comparative Study
Observational Study

MeSH terms

Aged
Aged, 80 and over
Aortic Valve Stenosis* / diagnosis
Aortic Valve Stenosis* / diagnostic imaging
Aortic Valve Stenosis* / physiopathology
Aortic Valve Stenosis* / surgery
Aortic Valve* / diagnostic imaging
Aortic Valve* / physiopathology
Blood Flow Velocity
Echocardiography* / methods
Echocardiography, Doppler* / methods
Female
Humans
Magnetic Resonance Imaging, Cine* / methods
Male
Predictive Value of Tests
Registries
Reproducibility of Results
Severity of Illness Index

Associated data

ClinicalTrials.gov/NCT05114785