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The aim of this study was to evaluate the role of wall shear stress (WSS) as a predictor of ascending aorta (AAo) growth at 5 years or greater follow-up.Aortic 4-dimensional flow cardiac magnetic resonance (CMR) can quantify regions exposed to high WSS, a known stimulus for arterial wall dysfunction. However, its association with longitudinal changes in aortic dilation in patients with bicuspid aortic valve (BAV) is unknown.This retrospective study identified 72 patients with BAV (age 45 ± 12 years) who underwent CMR for surveillance of aortic dilation at baseline and ≥5 years of follow-up. Four-dimensional flow CMR analysis included the calculation of WSS heat maps to compare regional WSS in individual patients with population averages of healthy age- and sex-matched subjects (database of 136 controls). The relative areas of the AAo and aorta (in %) exposed to elevated WSS (outside the 95% CI of healthy population averages) were quantified.At a median follow-up duration of 6.0 years, the mean AAo growth rate was 0.24 ± 0.20 mm/y. The fraction of the AAo exposed to elevated WSS at baseline was increased for patients with higher growth rates (0.24 mm/y, n = 32) compared with those with growth rates 0.24 mm/y (19.9% [IQR: 10.2%-25.5%] vs 5.7% [IQR: 1.5%-21.3%]; P = 0.008). Larger areas of elevated WSS in the AAo and entire aorta were associated with higher rates of AAo dilation0.24 mm/y (odds ratio: 1.51; 95% CI: 1.05-2.17; P = 0.026 and odds ratio: 1.70; 95% CI: 1.01-3.15; P = 0.046, respectively).The area of elevated AAo WSS as assessed by 4-dimensional flow CMR identified BAV patients with higher rates of aortic dilation and thus might determine which patients require closer follow-up.

BACKGROUND Cardiac magnetic resonance imaging (MRI) is becoming an alternative to right heart catheterization (RHC) for evaluating pulmonary hypertension (PH). A need exists to further evaluate cardiac MRI's ability to characterize PH. PURPOSE To evaluate the potential for four-dimensional (4D) flow MRI-derived pulmonary artery velocities to characterize PH. STUDY TYPE Prospective case-control. POPULATION Fifty-four PH patients (56% female); 25 controls (36% female). FIELD STRENGTH/SEQUENCE 1.5 T; gradient recalled echo 4D flow and balanced steady-state free precession cardiac cine. ASSESSMENT RHC was used to derive patients' pulmonary vascular resistance (PVR). 4D flow measured blood velocities at the main, left, and right pulmonary arteries (MPA, LPA, and RPA); cine measured ejection fraction, end diastolic, and end systolic volumes (EF, EDV, and ESV). EDV and ESV were normalized (indexed) to body surface area (ESVI and EDVI). Parameters were evaluated between, and within, PH subgroups: pulmonary arterial hypertension (PAH); PH due to left heart disease (PH-LHD)/chronic lung disease (PH-CLD)/or chronic thrombo-emboli (CTE-PH). STATISTICAL TESTS Analysis of variance and Kruskal-Wallis tests compared parameters between subgroups. Pearson's r assessed velocity, PVR, and volume correlations. Significance definition: P

To noninvasively assess left atrial (LA) kinetic energy (KE) in hypertrophic cardiomyopathy (HCM) patients using 4D flow MRI and evaluate coupling associations with mitral regurgitation (MR) and left ventricular outflow tract (LVOT) obstruction. Twenty-nine retrospectively identified patients with HCM underwent 4D flow MRI. MRI-estimated peak LVOT pressure gradient (∆PMRI) was used to classify patients into non-obstructive and obstructive HCM. Time-resolved volumetric LA kinetic energy (KELA) was computed throughout systole. Average systolic (KELA-avg) and peak systolic (KELA-peak) KELA were compared between non-obstructive and obstructive HCM groups, and associations to MR severity and LVOT ∆PMRI were tested.The study included 15 patients with non-obstructive HCM (58.6 [45.9, 65.2] years, 7 females) and 14 patients with obstructive HCM (51.9 [47.6, 62.6] years, 6 females). Obstructive HCM patients demonstrated significantly elevated instantaneous KELA over all systolic time-points compared to non-obstructive HCM (P

Hypertrophic cardiomyopathy (HCM) is a genetic cardiomyopathy with a wide spectrum of clinical manifestations. Patients can be asymptomatic or suffer major adverse events including sudden cardiac death, ventricular arrhythmias, and heart failure. Identification of individuals with HCM who are at risk for these complications remains challenging. While echocardiography remains the mainstay of diagnostic evaluation, cardiac magnetic resonance imaging (CMR) is an important adjunctive diagnostic modality with emerging applications for risk-stratification of adverse events in the HCM population. Although not included in current guidelines for HCM management, there is increasing evidence to support the use of CMR for routine prognostic assessment of HCM patients. In this review we discuss the use of CMR techniques, including late gadolinium enhancement, T1 mapping, and quantification of extracellular volume fraction, for the risk stratification of three major adverse events in HCM: sudden cardiac death, ventricular arrhythmias, and congestive heart failure.

Introduction: Bicuspid aortic valve (BAV) carries high aortopathy risk, and debate exists about relative contributions of altered wall structure vs. BAV-mediated hemodynamics. Pulse wave velocity (PWV), a surrogate for stiffness, can be quantified from 4D flow MRI. Here we use PWV to study wall stiffness in a large cohort of BAV aortic dilatation patients and two control groups. Hypotheses: 1. abnormal thoracic aortic (Ao) wall biomechanics for BAV patients result in altered PWV compared to controls and 2. PWV correlates with Ao diameter. Methods: This retrospective IRB approved study included 483 subjects: 124 healthy (no known cardiovascular disease), 168 BAV patients with ascending Ao (AAo) dilatation—maximal-area AAo (MAA) or sinus of Valsalva (SOV) diameter ≥4cm—and 191 TAV AAo dilatation (see table). No subjects had valve stenosis or ejection fraction ≤50%. Global PWV was assessed from MRI by cross-correlating flow in 80-100 Ao cutplanes and median AAo diameter by geometric mesh analysis of 3D Ao segmentations. Results: In multivariate regression, older age was the most significant predictor of higher PWV (controls: 0.073 m/s / y; TAV: 0.072 m/s / y; BAV: 0.092 m/s / y; all p Conclusion: Global Ao wall stiffness from PWV in BAV Ao dilatation patients has minimal/no significant difference from non-BAV control PWV, despite genetic factors and different wall structure in BAV patients. This suggests wall tissue differences of BAV patients do not coincide with globally altered Ao stiffness. However, BAV-mediated Ao flow changes manifest regionally, and further study of localized properties would be valuable.

Coronary artery fistulas are uncommon but clinically important entities that may produce symptoms and significant complications such as angina, myocardial infarction, coronary artery aneurysm formation, and congestive heart failure. Multiple fistula types have been recognized, and classification uses factors such as etiology, coronary artery origin, and drainage site. Both invasive and noninvasive imaging play an important role in the management and treatment of these patients, and often times, more than one modality is necessary for comprehensive evaluation of coronary fistulas. Recent advances in both functional and anatomic imaging will likely also play a growing role in fistula evaluation. The purpose of this article is to review the classification, pathophysiology, clinical presentations, imaging findings, treatment, and future imaging directions of coronary artery fistulas.

PURPOSE: To employ four-dimensional (4D) flow MRI to investigate associations between hemodynamic parameters with systolic anterior motion (SAM), mitral regurgitation (MR), stroke volume, and cardiac mass in patients with hypertrophic cardiomyopathy (HCM). MATERIALS AND METHODS: A total of 13 patients with HCM (51 years ± 16 [standard deviation]; 10 men) and 11 age-matched healthy control subjects (54 years ± 15; eight men) underwent cardiac 4D flow MRI data analysis including calculation of peak systolic and diastolic control-averaged left ventricular (LV) velocity maps to quantify volumes of elevated velocity (EVV) in the left ventricle. Standard-of-care cine imaging was performed in short-axis, LV outflow tract (LVOT), and two-, three-, and four-chamber views on which the presence of SAM, presence of MR, total stroke volume, and cardiac mass were assessed. RESULTS: Systolic EVV in patients with HCM was 7 mL ± 5, which was significantly associated with elevated aortic peak velocity (R = 0.87; P < .001), decreased LVOT diameter (R = 0.68; P = .01), and increased cardiac mass (R = 0.62; P = .02). In addition, EVV differed significantly between patients with and those without SAM (10 mL ± 4.7 vs 3 mL ± 2.3; P = .03) and those with and those without MR (9.9 mL ± 4.8 vs 4.0 mL ± 3.2; P < .05). In the atrial systolic phase, peak diastolic velocity in the LV correlated with septal thickness (R = 0.66; P = .01). CONCLUSION: Quantification and visualization of EVV in the LV is feasible and may provide further insight into the clinical manifestations of altered hemodynamics in HCM. © RSNA, 2020

In patients with bicuspid aortic valve (BAV), beta-blockers (BB) are assumed to slow ascending aorta (AAo) dilation by reducing wall shear stress (WSS) on the aneurysmal segment. The aim of this study was to assess differences in AAo peak velocity and WSS in BAV patients with and without BB therapy. BAV patients receiving BB (BB+, n = 30, age: 47 +/- A 11 years) or not on BB (BB-, n = 30, age: 46 +/- A 13 years) and healthy controls (n = 15, age: 43 +/- A 11 years) underwent 4D flow MRI for the assessment of in vivo aortic 3D blood flow. Peak systolic velocities and 3D WSS were calculated at the anterior and posterior walls of the AAo. Both patient groups had higher maximum and mean WSS relative to the control group (p = 0.001 to p = 0.04). WSS was not reduced in the BB+ group compared to BB- patients in the anterior AAo (maximum: 1.49 +/- A 0.47 vs. 1.38 +/- A 0.49 N/m(2), p = 0.99, mean: 0.76 +/- A 0.2 vs. 0.74 +/- A 0.18 N/m(2), p = 1.00) or posterior AAo (maximum: 1.45 +/- A 0.42 vs. 1.39 +/- A 0.58 N/m(2), p = 1.00; mean: 0.65 +/- A 0.16 vs. 0.63 +/- A 0.16 N/m(2), p = 1.00). AAo peak velocity was elevated in patients compared to controls (p

International audience; Background: Children with bicuspid aortic valve (BAV) are at risk for serious complications including aortic valve stenosis and aortic rupture. Most studies investigating biomarkers predictive of BAV complications are focused on adults.Objective: To investigate whether hemodynamic parameters change over time in children and young adults with BAV by comparing baseline and follow-up four-dimensional (4-D) flow MRI examinations.Materials and methods: We retrospectively included 19 children and young adults with BAV who had serial 4-D flow MRI exams (mean difference in scan dates 1.8±1.0 [range, 0.6-3.4 years]). We compared aortic peak blood flow velocity, three-dimensional (3-D) wall shear stress, aortic root and ascending aortic (AAo) z-scores between baseline and follow-up exams. We generated systolic streamlines for all patients and visually compared their baseline and follow-up exams.Results: The only significant difference between baseline and follow-up exams occurred in AAo z-scores (3.12±2.62 vs. 3.59±2.76, P

Purpose: Hypertrophic cardiomyopathy (HCM) is associated with altered hemodynamics in the left ventricular outflow tract (LVOT) and myocardial tissue abnormalities such as fibrosis. The aim of this study was to quantify changes in LVOT 3D hemodynamics and myocardial extracellular volume fraction (ECV, measure of fibrosis) and to investigate relationships between elevated flow metrics and left ventricular (LV) tissue abnormalities. Materials and Methods: Cardiac magnetic resonance imaging (MRI) including 4D flow (field strength 5 1.5T, resolution 5 2.1–4.0 3 2.1–4.0 3 2.5–3.2 mm 3 ; venc 5 150–250 cm/s; TE/TR/FA 5 2.2–2.5msec/4.6–4.9msec/158) for the in vivo assessment of 3D blood flow velocities with full covera ge of the LVOT was applied in 35 patients with HCM (546 15 years) and 10 age-matched healthy controls (45 6 14 years). In addition, pre- and postcontrast myocardial T1-mapping (resolution 5 2.3 3 1.8 mm, slice thickness 5 8m m, TE/TR-FA5 1.0-1.1msec/2.0-2.2msec/358) of the LV (basal, mid-ventricular, apical short axis) was performed in a subgroup of 23 HCM patients. Analysis included the segmentation of the LVOT and quantification of peak systolic LVOT pressure gradients and rate of viscous energy loss EL 0 as well as left ventricular ECV. Results: HCM patients demonstrated significantly elevated peak systolic LVOT pressure gradients (21 6 16 mmHg vs. 9 6 2 mmHg) and energy loss EL 0 (3.8 6 2.5 mW vs. 1.5 6 0.7 mW, P < 0.005) compared to controls. There was a significant relationship between increased LV fibrosis (ECV) with both elevated pressure gradients (R 2 5 0.44, P < 0.001) and energy loss EL 0 (R 2 5 0.46, P < 0.001). Conclusions: The integration of 4D-flow and T1-mapping-MRI allowed for the evaluation of tissue and flow abnormalities in HCM patients. Our findings suggest a mechanistic link between abnormal LVOT flow, increased LV loading, and adverse myocardial remodeling in HCM. J. Magn. Reson. Imaging 2015;00:000–000. J. MAGN. RESON. IMAGING 2015;00:000–000.

Bicuspid aortic valve (BAV) is the most commonly diagnosed congenital heart defect with a prevalence ranging from 0.5 to 2% of the population1 and is often coincident with other congenital cardiovascular diseases, particularly left-sided obstructive lesions such as coarctation of the aorta.2 Pediatric BAV patients are known to have larger aortic dimensions than children with trileaflet valves, and are prone to progressive ascending aorta (AAo) dilatation.3 As these patients progress into adulthood, they are at increased risk for aortic dissection as a result of the disease4; however, the risk of primary cardiac events in childhood is minimal.5 Nonetheless, when diagnosed at an early age, BAV patients may require surgical intervention to normalize valve function and alter thoracic aorta anatomy in hopes of reducing long term risk.6 Time-resolved, three dimensional (3D) phase contrast (4D flow) MRI is increasingly used to study the role of cardiovascular hemodynamics in BAV.7 Recent studies in adult patients have shown that congenitally abnormal valves are associated with altered ascending aortic blood flow including high velocity outflow jet patterns and deranged helix and vortex type flow.8-12 Moreover, coarctation of the aorta can also result in varied hemodynamics in both the ascending and descending aorta in BAV patients.13 These hemodynamic alterations can result in changes in aortic wall shear stress (WSS) which have been shown to promote endothelial cell dysfunction and may ultimately lead to vascular remodeling.14 Elevated AAo WSS resulting from high velocity, asymmetric outflow jets in BAV patients has been hypothesized to play a role in progressive aortic dilatation in this cohort. Recent studies have demonstrated that adults with BAV have systematically higher and more asymmetric WSS relative to age and aortic size matched controls,9-11,15,16 and recent work by van Ooij et al using 4D flow MRI demonstrated increased volumetric WSS in the ascending aorta of adult BAV patients with aortic valve stenosis.17 Other hemodynamic parameters such as peak velocity, flow jet angle,18 and outflow eccentricity (flow displacement)19 have also been used in an attempt to quantify the impact of valvular heart disease on aortic hemodynamics. In the pediatric population, 4D flow MRI assessment has generally been described in small studies or case reports that have focused on patients with complex congenital heart or vascular defects or on postsurgical hemodynamics such as Fontan circulation.20-23 Truong et al recently used 2D phase contrast of the right pulmonary artery to measure WSS in children with pulmonary artery hypertension.24 However, the impact of BAV on changes in blood flow and the association with age and aortic size is poorly understood. In this pilot study, our aim was to describe the influence of BAV on thoracic aorta hemodynamic parameters in a group of pediatric and young adult patients using 4D flow MRI.

The objective of this study was to evaluate the potential of 4D flow MRI to assess valve effective orifice area (EOA) in patients with aortic stenosis as determined by the jet shear layer detection (JSLD) method.An in-vitro stenosis phantom was used for validation and in-vivo imaging was performed in 10 healthy controls and 40 patients with aortic stenosis. EOA was calculated by the JSLD method using standard 2D phase contrast MRI (PC-MRI) and 4D flow MRI measurements (EOAJSLD-2D and EOAJSLD-4D, respectively). As a reference standard, the continuity equation was used to calculate EOA (EOACE) with the 2D PC-MRI velocity field and compared to the EOAJSLD measurements. The in-vitro results exhibited excellent agreement between flow theory (EOA=0.78cm(2)) and experimental measurement (EOAJSLD-4D=0.78±0.01cm(2)) for peak velocities ranging from 0.9 to 3.7m/s. In-vivo results showed good correlation and agreement between EOAJSLD-2D and EOACE (r=0.91, p0.001; bias: -0.01±0.38cm(2); agreement limits: 0.75 to -0.77cm(2)), and between EOAJSLD-4D and EOACE (r=0.95, p0.001; bias: -0.09±0.26cm(2); limits: 0.43 to -0.62cm(2)).This study demonstrates the feasibility of measuring EOAJSLD using 4D flow MRI. The technique allows for optimization of the EOA measurement position by visualizing the 3D vena contracta, and avoids potential sources of EOACE measurement variability.

Aims The left ventricular outflow tract (LVOT) peak pressure gradient is an important haemodynamic descriptor in patients with hypertrophic cardiomyopathy (HCM); however, secondary alterations in aortic blood flow have not been well described in these patients. Aortic flow derangement is not easily assessed by traditional imaging methods, but may provide unique characterization of this disease. In this study, we demonstrated how four-dimensional (4D) flow MRI can assess LVOT peak pressure gradients in HCM patients and also evaluated the ascending aorta (AAo) haemodynamic derangement associated with HCM. Methods and results Obstructive ( n = 12) and non-obstructive ( n = 18) HCM patients were included in the study along with 10 normal volunteers. 4D flow MRI was used to visualize three-dimensional (3D) blood flow patterns within the LVOT and AAo, which were graded for the presence of helical flow as a marker of flow derangement (absent = 0, mild/moderate = 1, and severe = 2). MRI-estimated pressure gradient (Δ P MRI) was calculated from the peak systolic 3D blood velocity profile within the LVOT. There was higher grade helical flow in obstructive HCM patients compared with non-obstructive patients ( P = 0.04) and volunteers ( P < 0.001). Non-obstructive patients also had higher helix grade than volunteers ( P = 0.002). There was a significant correlation between helical grade and increasing Δ P MRI ( r S = 0.69, P < 0.001). Systolic anterior motion (SAM) of the mitral valve was associated with both increasing helix grade ( P < 0.001) and Δ P MRI ( P = 0.006). Conclusions Ascending aorta flow derangement occurs in both obstructive and non-obstructive HCM patients and can be identified using 4D flow MRI. The degree of flow derangement correlates with LVOT gradient, SAM, and outflow tract geometry.

Purpose To compute cohort-averaged wall shear stress (WSS) maps in the thoracic aorta of patients with aortic dilatation or valvular stenosis and to detect abnormal regional WSS. Methods Systolic WSS vectors, estimated from four-dimensional flow MRI data, were calculated along the thoracic aorta lumen in 10 controls, 10 patients with dilated aortas, and 10 patients with aortic valve stenosis. Three-dimensional segmentations of each aorta were coregistered by group and used to create a cohort-specific aortic geometry. The WSS vectors of each subject were interpolated onto the corresponding cohort-specific geometry to create cohort-averaged WSS maps. A Wilcoxon rank sum test was used to generate aortic P-value maps (P

OBJECTIVE: To provide a more complete characterization of aortic blood flow in patients following valve-sparing aortic root replacement (VSARR) compared with presurgical cohorts matched by tricuspid and bicuspid valve morphology, age and presurgical aorta size. METHODS: Four-dimensional (4D) flow magnetic resonance imaging (MRI) was performed to analyse three-dimensional (3D) blood flow in the thoracic aorta of n= 13 patients after VSARR with reimplantation of native tricuspid aortic valve (TAV, n= 6) and bicuspid aortic valve (BAV, n= 7). Results were compared with presurgical age and aortic size-matched control cohorts with TAV (n= 10) and BAV (n= 10). Preand post-surgical aortic flow was evaluated using time-resolved 3D pathlines using a blinded grading system (0–2, 0 = small, 1 = moderate and 2 = prominent) analysing ascending aortic (AAo) helical flow. Systolic flow profile uniformity in the aortic root, proximal and mid-AAo was evaluated using a four-quadrant model. Further analysis in nine analysis planes distributed along the thoracic aorta quantified peak systolic velocity, retrograde fraction and peak systolic flow acceleration. RESULTS: Pronounced AAo helical flow in presurgical control subjects (both BAV and TAV: helix grading = 1.8 ± 0.4) was significantly reduced (0.2 ± 0.4, P< 0.001) in cohorts after VSARR independent of aortic valve morphology. Presurgical AAo flow was highly eccentric for BAV patients but more uniform for TAV. VSARR resulted in less eccentric flow profiles. Systolic peak velocities were significantly (P< 0.05) increased in post-root repair BAV patients throughout the aorta (six of nine analysis planes) and to a lesser extent in TAV patients (three of nine analysis planes). BAV reimplantation resulted in significantly increased peak velocities in the proximal AAo compared with root repair with TAV (2.3 ± 0.6 vs 1.6 ± 0.4 m/s, P= 0.017). Post-surgical patients showed a non-significant trend towards higher systolic flow acceleration as a surrogate measure of reduced aortic compliance. CONCLUSIONS: VSARR restored a cohesive flow pattern independent of native valve morphology but resulted in increased peak velocities throughout the aorta. 4D flow MRI methods can assessthe clinical implications of altered aortic flow dynamics in patients undergoing VSARR.

Background Cardiotoxicity is a major limiting factor preventing dose-effective use of multiple cytotoxic agents in cancer treatment. Current cardiotoxicity diagnosis is based on functional changes that occur late in the course of the disease. In this pre-clinical pilot study, we hypothesize myocardial T1 and T2 mapping will identify mice at risk of death secondary to doxorubicin-induced cardiotoxicity prior to cardiac function deterioration. Methods Eleven healthy, 10-week-old C57BL/6 female mice were included in the study. All procedures are in accordance with an Institutional Animal Care and Use Committee approved protocol. Doxorubicin-induced cardiotoxicity was generated by giving 8 mg/kg of doxorubicin via intraperitoneal (IP) injection weekly for 4 weeks in n = 8 randomly selected mice. A control group of n = 3 mice was given a weekly volume equivalent dose of IP normal saline. Each mouse underwent ECG-gated CMR on a 7T small animal scanner (ClinScan, Bruker, Billerica, MA) prior to treatment, at 2 weeks, and post-treatment. Steady-state free precession images were acquired at the left ventricular base, mid-ventricle, and apex and ejection fraction (EF) was calculated (Figure 1). Gadopentetate Dimeglumine contrast was injected via the tail vein at a dose of 1 mL/kg. Myocardial T1 and T2 maps were generated using dedicated offline software to calculate the pixel-wise relaxation

Methods Right-left coronary leaflet fusion BAV patients on b-blockers (BB+) (n = 30, M:F = 23:7, age: 46 ± 14 years) and not on b-blockers (BB-) (n=30, M:F = 23:7, age: 46 ± 13 years) and healthy controls (n=15, age:43±11 years) underwent time-resolved, 3D phase contrast (4D flow) MRI. Patient groups were matched by systolic blood pressure (SBP), degree of aortic stenosis (AS), and AAo diameter (3.9 ± 0.7 vs. 3.9 ± 0.6 cm, p = 0.70). A 3D segmentation of the thoracic aorta was performed (MIMICS, Materlise, Belgium). Systolic 3D WSS was calculated in the thoracic aorta from 4D flow velocity acquisition and a sagittal maximum intensity projection (MIP) of WSS was generated.

Background Beta-blockers are the recommended medical treatment for slowing ascending aorta (AAo) dilation in patients with bicuspid aortic valve (BAV). Wall shear stress (WSS) has been shown to promote endothelial cell dysfunction [1] and AAo WSS may play a role in aortic aneurysm growth. Time-resolved 3D phase contrast (4D flow) MRI allows for the quantification of 3D WSS regionally in the thoracic aorta. The aim of this study was to assess changes in thoracic aorta WSS associated with b-blocker therapy in BAV patients.

Background A key determinant of cardiac pump function is the complex interplay between the heart and the arterial system, (i. e. arterio-ventricular coupling). Aging and pathological changes such as atherosclerosis alter elastic properties of the vessel wall, and therefore adversely influence hemodynamic parameters. Mice are commonly used to study cardiovascular disease, but very little has been published on comprehensive blood flow measurements in these models. We therefore sought to establish a compressed sensing (CS) accelerated, phase contrast MR technique (4D flow MRI) for measuring aortic 3D hemodynamics in the mouse.

Background Bicuspid aortic valve (BAV) is a congenital abnormality that is often associated with aortic coarctation. Evidence suggests this combination may increase the risk of secondary aortic complications compared to patients with BAV alone.[1] Altered aortic hemodynamics likely induce vascular remodeling[2] and may contribute to these complications. No study has investigated the impact of aortic coarctation on aortic hemodynamics in pediatric and young adult patients with BAV using time-resolved three-dimensional phase contrast (4D flow) MRI. The aim of this study is to utilize 4D flow MRI to compare thoracic aorta flow patterns in pediatric and young adult patients with BAV with and without aortic coarctation or coarctation repair. Methods In accordance with an IRB-approved protocol, 17 patients with BAV (age = 11.9 +/- 5.3 years) who underwent cardiovascular MRI including 4D flow as part of follow-up care were included. Seven patients had aortic coarctation including 5 patients with coarctation repairs. Images were processed using in-house software for noise reduction, anti-aliasing, and eddy current correction. Flow visualization and quantification were performed in EnSight (CEI, Apex, NC). Aortic root z-scores were calculated from MRI measurements and height and weight at time of scan in EchoIMS (Merge, Chicago, IL). Flow jet pattern and helicity were assessed in the ascending aorta, aortic arch, and descending aorta. Flow jet pattern was determined by the region of peak velocity in systole corresponding to anatomically designated quadrants of

A 41-year-old man with a bicuspid aortic valve (BAV) and coarctation of the aorta, as visualized by 2D phase contrast cardiovascular magnetic resonance imaging (CMR) ( Figure 1D , Supplementary data online, Videos S1 ) and contrast enhanced MR angiography ( Figure 1A ), was referred for evaluation by time-resolved 3D phase contrast (4D flow) CMR to assess the flow velocity through the coarctation and provide aortic flow characterization. Findings of the comprehensive examination demonstrate the complex haemodynamic patterns that emerge throughout the aorta secondary …

Aims Data on the prognosis of heart failure (HF) patients with coronary artery disease (CAD) have been conflicting. We describe the clinical characteristics and mode-specific outcomes of HF patients with reduced ejection fraction (EF) and documented CAD in a large randomized trial. Methods and results EVEREST was a prospective, randomized trial of vasopressin-2 receptor blockade, in addition to standard therapy, in 4133 patients hospitalized with worsening HF and reduced EF. Patients were classified as having CAD based on patient-reported myocardial infarction (MI) or coronary revascularization. We analysed the characteristics and outcomes [all-cause mortality and cardiovascular (CV) mortality/HF hospitalization] of patients with and without documented CAD. All events were centrally adjudicated. Documented CAD was present in 2353 patients (57%). Patients with CAD were older and had more co-morbidities compared with those without CAD. Patients with CAD were more likely to receive a beta-blocker, but less likely to receive an angiotensin-converting enzyme (ACE) inhibitor or aldosterone antagonist (P < 0.01). After risk adjustment, patients with documented CAD had similar mortality [hazard ratio (HR) 1.12, 95% confidence interval (CI) 0.97–1.30], but were at an increased risk for CV mortality/HF hospitalization (HR 1.25, 95% CI 1.12–1.41) due to an increased risk for HF hospitalization (HR 1.26, 95% CI 1.10–1.44). Patients with CAD had increased HF- and MI-related events, but similar rates of sudden cardiac death. Conclusion Documented CAD in patients hospitalized for worsening HF with reduced EF was associated with a higher burden of co-morbidities, lower use of HF therapies (except beta-blockers), and increased HF hospitalization, while all-cause mortality was similar.

Background Alterations in systolic blood flow are a characteristic finding in patients with obstructive hypertrophic cardiomyopathy (HCM). Echocardiography is the gold standard for hemodynamic assessment in HCM, but this technique is generally limited to measurement of the left ventricular outflow tract (LVOT) pressure gradient and may not provide a complete description of the hemodynamic impact of the disease. In this study, we sought to employ time-resolved, three-dimensional phase contrast (4D flow) MRI to visualize and quantify 3D blood flow patterns in the LVOT and ascending aorta (AAo) in patients with obstructive and nonobstructive HCM. Methods Obstructive (n = 12) and non-obstructive (n = 18) HCM patients as well as 10 normal volunteers were included in this IRB-approved study. Obstruction was defined as LVOT pressure gradient > 30 mmHg on patients’ most recent echocardiography study (ΔPecho). Septal thickness, LVOT diameter and septum/free wall ratio were measured on SSFP cine MRI. 4D flow MRI data analysis included correction for eddy currents and velocity aliasing, followed by flow visualization and quantification in dedicated software (EnSight, CEI, Apex, NC). 3D blood flow patterns within the LVOT and AAo were graded for the presence of helical flow (absent = 0, mild/moderate = 1, severe = 2) by two observers blinded to diagnosis, and the results were averaged. MRI-measured pressure gradient (ΔPMRI) was calculated from the peak systolic 3D blood velocity profile within the LVOT using the simplified Bernoulli equation. (Figure 1) The Mann-Whitney U test was used to compare groups and Spearman’ s( rS) or Pearson’s (r) correlations were used as appropriate. Results

Background Cardiac MR is the reference standard for assessing biventricular systolic function and delayed enhancement. However, changes in systolic function as assessed by global parameters such as ventricular ejection fraction are late indicators of adverse structure-function changes. Myocardial strain has shown promise to identify abnormal potentially reversible regional myocardial function, preceding changes in the ejection fraction. Feature tracking cardiac MR is a novel technique to quantitate myocardial function, tracking biventricular myocardial features to generate Lagrangian strain values from existing cine balanced steady state free precession (bSSFP) data. The purpose of this study is to assess the feasibility of retrospective strain analysis in a patient cohort with biopsy-proven non-ischemic cardiomyopathy, comparing to strain data in healthy volunteers. Methods 26 consecutive patients (21 men, avg age 64 years) with a biopsy proven non-ischemic cardiomyopathy (NICM) and 20 healthy volunteers (14 men, avg age 44 years) underwent cardiac MR (CMR) imaging at 1.5T with bSSFP segmented cine imaging with a temporal resolution of 25-40 msec. bSSFP cine images were evaluated by a single observer using prototype software employing deformation field analysis to generate Lagrangian strain values for the left (LV - radial, circumferential, longitudinal) and right ventricles (RV - longitudinal). LV (LVEF) and RV ejection fraction (RVEF) were quantified on a dedicated workstation by a single observer. A twotailed student’s t-test assessed differences in strain values between groups, with an alpha of 0.05 chosen to demarcate statistical significance. Results