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Four-dimensional flow cardiovascular magnetic resonance in tetralogy of Fallot: a systematic review

Research output: Contribution to journalReview articlepeer-review

Ayah Elsayed, Kathleen Gilbert, Miriam Scadeng, Brett R. Cowan, Kuberan Pushparajah, Alistair A. Young

Original languageEnglish
Article number59
JournalJournal of Cardiovascular Magnetic Resonance
Issue number1
PublishedDec 2021

Bibliographical note

Funding Information: This work was funded by the New Zealand Heart Foundation. AY acknowledges the support of the Health Research Council of New Zealand grants 17/234 and 17/608 and NIH R01HL121754 from the National Heart, Lung, and Blood Institute. Publisher Copyright: © 2021, The Author(s). Copyright: Copyright 2021 Elsevier B.V., All rights reserved.

King's Authors


Background: Patients with repaired Tetralogy of Fallot (rTOF) often develop cardiovascular dysfunction and require regular imaging to evaluate deterioration and time interventions such as pulmonary valve replacement. Four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) enables detailed assessment of flow characteristics in all chambers and great vessels. We performed a systematic review of intra-cardiac 4D flow applications in rTOF patients, to examine clinical utility and highlight optimal methods for evaluating rTOF patients. Methods: A comprehensive literature search was undertaken in March 2020 on Google Scholar and Scopus. A modified version of the Critical Appraisal Skills Programme (CASP) tool was used to assess and score the applicability of each study. Important clinical outcomes were assessed including similarities and differences. Results: Of the 635 articles identified, 26 studies met eligibility for systematic review. None of these were below 59% applicability on the modified CASP score. Studies could be broadly classified into four groups: (i) pilot studies, (ii) development of new acquisition methods, (iii) validation and (vi) identification of novel flow features. Quantitative comparison with other modalities included 2D phase contrast CMR (13 studies) and echocardiography (4 studies). The 4D flow study applications included stroke volume (18/26;69%), regurgitant fraction (16/26;62%), relative branch pulmonary artery flow(4/26;15%), systolic peak velocity (9/26;35%), systemic/pulmonary total flow ratio (6/26;23%), end diastolic and end systolic volume (5/26;19%), kinetic energy (5/26;19%) and vorticity (2/26;8%). Conclusions: 4D flow CMR shows potential in rTOF assessment, particularly in retrospective valve tracking for flow evaluation, velocity profiling, intra-cardiac kinetic energy quantification, and vortex visualization. Protocols should be targeted to pathology. Prospective, randomized, multi-centered studies are required to validate these new characteristics and establish their clinical use.

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