Evaluating the Diagnostic Potential of Four-Dimensional Flow Magnetic Resonance Imaging in Aortic Stenosis Diagnosis: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis evaluates the potential of four-dimensional flow magnetic resonance imaging (4DFM) in assessing aortic stenosis (AS) compared to traditional imaging modalities like two-dimensional phase contrast MRI (2D MRI) and transthoracic echocardiography (TTE). AS is a common and severe valvular heart disease, particularly in older adults, requiring accurate diagnosis for proper clinical management. Conventional imaging methods have limitations in capturing complex flow dynamics, prompting the need for advanced modalities like 4DFM. The objectives of the review were to determine whether 4DFM offers superior diagnostic metrics, including peak aortic jet velocity, transvalvular pressure gradients, and aortic valve area (AVA), and to identify potential advantages of 4DFM in overcoming the limitations of traditional modalities. This review included six cohort studies with 285 participants, examining the diagnostic accuracy of 4DFM in terms of peak aortic jet velocity, transvalvular pressure gradients, and aortic valve area (AVA). Studies were selected from MEDLINE (PubMed), Cochrane Library, and Google Scholar databases between December 2010 and October 2024. The study pool was limited by stringent inclusion criteria focusing on cohort studies that directly compared 4DFM with TTE or 2D MRI for AS assessment. The National Institutes of Health Quality Assessment Tool and Cochrane ROBINS-I tool were used to assess bias. Quantitative results showed that 4DFM typically measured higher AVA values than TTE, with a mean difference of 0.48 cm² (95% CI: -0.16 to 1.12). For mean pressure gradients, 4DFM reported slightly higher measurements in individual studies, but pooled results showed no significant difference compared to TTE (mean difference: 3.32 mmHg, 95% CI: -2.30 to 8.93). In terms of peak aortic jet velocity, 4DFM demonstrated a pooled mean difference of -0.18 m/s (95% CI: -0.44 to 0.08) compared to TTE. High heterogeneity was observed across studies (e.g., I² = 97% for peak velocity, I² = 93% for AVA), likely due to differences in patient populations, imaging protocols, and software for data analysis. 4DFM demonstrates potential as a complementary imaging tool, particularly in complex AS cases where conventional methods like TTE may provide inconclusive results. Its capacity to capture intricate flow dynamics and deliver high spatial resolution could inform clinical decision-making, potentially influencing practice guidelines to integrate 4DFM as a supplementary tool. Limitations such as high costs, specialized training requirements, and access challenges currently restrict widespread adoption. Limitations of this review include small sample sizes, high heterogeneity, and variability in patient populations and imaging protocols. Despite these challenges, 4DFMI demonstrated superior spatial resolution and complex cardiovascular flow assessment, suggesting it could serve as a valuable complement to TTE for more detailed AS evaluation, particularly in complex cases. Future studies should aim to standardize imaging protocols, incorporate larger and more diverse populations, and conduct cost-benefit analyses to support the integration of 4DFM into clinical practice, potentially shaping future diagnostic guidelines.