Clinical 4D flow MRI assessment in aortopathy - what the clinician needs to know

Sep 30, 2026

Interval cross-sectional imaging plays an important role in aortopathy surveillance. Often, cardiac MRI is used over CT for repeated follow-up because it avoids radiation and enables additional hemodynamic assessment. Assessment primarily measures aortic dimensions orthogonally in 3D anatomy. Four-dimensional (4D) flow MRI is increasingly used since it can be acquired in 1–5 minutes. Beyond standard flow quantification, it provides advanced hemodynamic biomarkers such as helical flow, wall shear stress, flow displacement, and systolic flow reversal ratio. The review highlights parameters available on commercial post-processing platforms for clinical centers, including clinical relevance to bicuspid aortic valve disease, HFpEF, chronic aortic dissection, and flow evaluation after valve replacement.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages6

Reading Time15 min

AccessFree to download

Introduction

Anatomical imaging

4D flow MRI

Visual assessment

Clinical 4D flow MRI assessment in aortopathy—what the clinician needs to know Malenka M. Bissell1^, Pankaj Garg2^ 1Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, UK; 2Norwich Medical School, University of East Anglia, Norwich, UK Contributions: (I) Conception and design: Both authors; (II) Administrative support: Both authors; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: None; (V) Data analysis and interpretation: None; (VI) Manuscript writing: Both authors; (VII) Final approval of manuscript: Both authors. Correspondence to: Malenka M. Bissell, DPhil, MD, BM, MRCPCH, FSCMR. Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Clarendon Way, Leeds, LS2 9NL, [UK. Email: m.m.bissell@leeds.ac.uk](UK. Email: m.m.bissell@leeds.ac.uk). Abstract: Interval cross-sectional imaging plays an important role in aortopathy surveillance. Often, cardiac magnetic resonance imaging (MRI) is used over computed tomography (CT) due to the lack of radiation in repeated surveillance and the option of additional hemodynamic assessment. Primarily, assessment includes the orthogonal measurement of aortic dimensions in a three-dimensional (3D) structure. Lately, four-dimensional (4D) flow MRI is becoming more widespread as it can be acquired within 1–5 minutes using advanced techniques. In addition to standard flow quantification, 4D flow MRI offers advanced hemodynamic quantification. This review discusses important advanced imaging biomarkers, including helical flow pattern, wall shear stress (WSS), flow displacement and systolic flow reversal ratio (sFRR) . It focuses on those parameters that can be analyzed using commercially available post-processing platforms and are accessible for clinical centers without the need for research setup and collaboration. WSSplays a role in the assessment of bicuspid aortic valve disease. Here it is elevated even without the presence of stenosis. Flow displacement is also of value in bicuspid aortic valve disease and is abnormal in heart failure with preserved ejection fraction (HFpEF) as well as chronic aortic dissection. 4D flow MRI is also useful in understanding and assessing flow changes in aortic valve replacement. Keywords: Four-dimensional flow magnetic resonance imaging (4D flow MRI); aortopathy; bicuspid aortic valve Submitted Sep 23, 2024. Accepted for publication Oct 21, 2025. Published online Dec 24, 2025. doi: 10.21037/cdt-24-478 View this article at: [https://dx.doi.org/10.21037/cdt-24-478](https://dx.doi.org/10.21037/cdt-24-478) Introduction Interval cross-sectional imaging for aortopathy has become standard practice, with the recent American College of Cardiology (ACC)/American Heart Association (AHA) aortic disease guidelines detailing recommended measurement techniques and imaging planes (1) . Anatomical imaging Three-dimensional (3D) imaging ensures the measurement is orthogonal to the dilated vessel and reduces overestimation of diameters, which can happen on echocardiography due to oblique imaging in the more difficult-to-image ascending aorta. The guideline suggests ^ ORCID: Malenka M. Bissell, 0000-0002-1282-2859; Pankaj Garg, 0000-0002-5483-169X. © AME Publishing Company. Cardiovasc Diagn Ther 2025;15(6):1206-1211 | [https://dx.doi.org/10.21037/cdt-24-478](https://dx.doi.org/10.21037/cdt-24-478) Cardiovascular Diagnosis and Therapy, Vol 15, No 6 December 2025 1207 measuring aortic sinus to sinus on computed tomography (CT)/magnetic resonance imaging (MRI) (rather than commissure to sinus) as these measurements correlate better with surveillance echocardiographic measures (1) . In the adult population, measures are often indexed to body surface area (BSA), but the increased incidence of obesity has posed the question, whether indexing to hei

FAQs

Why is interval cross-sectional imaging important in aortopathy surveillance?

It supports routine monitoring of disease progression over time. The article notes that recommended measurement techniques and imaging planes are detailed in major guidelines.

What advantages does 4D flow MRI offer compared with standard imaging approaches?

4D flow MRI can be acquired in about 1–5 minutes and provides advanced hemodynamic quantification beyond standard flow measurements, including multiple imaging biomarkers.

Which 4D flow MRI biomarkers are highlighted as clinically relevant?

The review focuses on helical flow patterns, wall shear stress (WSS), flow displacement, and systolic flow reversal ratio (sFRR), discussing their roles in conditions such as bicuspid aortic valve disease, HFpEF, and chronic aortic dissection.

Sep 30, 2026

Upload by Margaret