Impact of 4D-Flow CMR Parameters on Functional Evaluation of Fontan Circulation

Pediatr Cardiol. 2024 Jun;45(5):998-1006. doi: 10.1007/s00246-024-03446-4. Epub 2024 Mar 22.


We sought to evaluate the potential clinical role of 4D-flow cardiac magnetic resonance (CMR)-derived energetics and flow parameters in a cohort of patients' post-Fontan palliation. In patients with Fontan circulation who underwent 4D-Flow CMR, streamlines distribution was evaluated, as well a 4D-flow CMR-derived energetics parameters as kinetic energy (KE) and energy loss (EL) normalized by volume. EL/KE index as a marker of flow efficiency was also calculated. Cardiopulmonary exercise test (CPET) was also performed in a subgroup of patients. The population study included 55 patients (mean age 22 ± 11 years). The analysis of the streamlines revealed a preferential distribution of the right superior vena cava flow for the right pulmonary artery (62.5 ± 35.4%) and a mild preferential flow for the left pulmonary artery (52.3 ± 40.6%) of the inferior vena cave-pulmonary arteries (IVC-PA) conduit. Patients with heart failure (HF) presented lower IVC/PA-conduit flow (0.75 ± 0.5 vs 1.3 ± 0.5 l/min/m2, p = 0.004) and a higher mean flow-jet angle of the IVC-PA conduit (39.2 ± 22.8 vs 15.2 ± 8.9, p < 0.001) than the remaining patients. EL/KE index correlates inversely with VO2/kg/min: R: - 0.45, p = 0.01 peak, minute ventilation (VE) R: - 0.466, p < 0.01, maximal voluntary ventilation: R:0.44, p = 0.001 and positively with the physiological dead space to the tidal volume ratio (VD/VT) peak: R: 0.58, p < 0.01. From our data, lower blood flow in IVC/PA conduit and eccentric flow was associated with HF whereas higher EL/KE index was associated with reduced functional capacity and impaired lung function. Larger studies are needed to confirm our results and to further improve the prognostic role of the 4D-Flow CMR in this challenging population.

Keywords: 4D-flow CMR; Cardiac magnetic resonance; Energy loss; Fontan flows; Fontan palliation.

MeSH terms

  • Adolescent
  • Adult
  • Blood Flow Velocity / physiology
  • Child
  • Exercise Test* / methods
  • Female
  • Fontan Procedure*
  • Heart Defects, Congenital* / physiopathology
  • Heart Defects, Congenital* / surgery
  • Heart Failure / physiopathology
  • Heart Failure / surgery
  • Humans
  • Magnetic Resonance Imaging, Cine / methods
  • Male
  • Pulmonary Artery* / diagnostic imaging
  • Pulmonary Artery* / physiopathology
  • Vena Cava, Inferior / diagnostic imaging
  • Vena Cava, Superior / diagnostic imaging
  • Young Adult