Hemodynamic Assessment of Structural Heart Disease Using 4D Flow MRI: How We Do It

MRI is an essential diagnostic tool in the anatomic and functional evaluation of cardiovascular disease. In many practices, 2D phase-contrast (2D-PC) MRI has been used for blood flow quantification. Four-dimensional flow MRI is a time-resolved volumetric acquisition that captures the vector field of blood flow along with anatomic images. It also provides a simpler acquisition compared with 2D-PC and facilitates a more accurate and comprehensive hemodynamic assessment. Advancements in accelerated imaging have significantly shortened scanning times for 4D flow MRI while preserving image quality, enabling this technology to transition from the research arena to routine clinical practice. In this article, we review technical optimization based on our more than 10 years of clinical experience with 4D flow MRI. We also present pearls and pitfalls in the practical application of 4D flow MRI, including how to quantify cardiovascular shunts, valvular or vascular stenosis, and valvular regurgitation. As experience increases, and as 4D flow sequences and postprocessing software become more broadly available, 4D flow MRI will likely become an essential component of cardiac imaging in practices involved in the management of congenital and acquired structural heart disease.