Robustness of 4D flow MRI derived aortic wall shear stress and pulse wave velocity across different protocols in healthy controls and in patients with bicuspid aortic valve

Purpose: To evaluate the reproducibility of important biomarkers like wall shear stress (WSS), pulse wave velocity (PWV), and net flow across two 4D flow MRI imaging protocols with different coverages: aorta-targeted 4D flow MRI (AT4D) and whole-heart 4D flow (WH4D) protocols. Methods: Thirty-eight control subjects (43.2 +/- 10.1 years old; 22 males) and ten patients (45.7 +/- 8.9 years old; 7 males) with bicuspid aortic valve (BAV) were included. Each subject underwent AT4D and WH4D scans. Absolute WSS, PWV, and net flow were assessed for each patient across both protocols and compared using Bland-Altman analysis. Areas of elevated WSS were assessed for BAV patients across different WSS thresholds that define WSS to be elevated compared to a normal population average. A sensitivity analysis was conducted to determine the best WSS threshold at which WH4D-derived areas most closely resemble AT4D-derived areas. Inter-rater reproducibility was evaluated in twenty-four subjects. Results: AT4D and WH4D PWV and WSS estimates demonstrated good agreement (PWV: -0.12 +/- 1.84 m/s, p = 0.4; Median WSS: 0.06 +/- 0.13 Pa, p < 0.01; Maximum WSS: 0.04 +/- 0.27 Pa, p = 0.07). Good agreement was also found for AAo net flow (8.14 +/- 24.86 mL/cycle, p < 0.01). PWV correlated with age across protocols (AT4D: r = 0.68, p < 0.01; WH4D: r = 0.72, p < 0.01). Sensitivity analysis identified a WSS threshold where WH4D-derived areas of elevated WSS most closely resembled AT4D-derived areas. Inter-rater assessment of the tested parameters resulted in a small mean difference percentage of < 3%. Data conclusion: PWV, WSS, and net flow demonstrated good agreement across protocols. The WSS threshold should be adjusted for WH4D estimates to optimally match AT4D-derived output. Reproducibility analysis showed good test-retest agreement. This study demonstrates the reproducibility of certain hemodynamic parameters across two 4D flow MRI protocol.