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Journal of Cardiovascular Magnetic Resonance

Open Access

Analysis of right heart flow patterns in repaired Tetralogy of Fallot with 4D flow-sensitive MRI

  • Christopher J Francois1,
  • Shardha Srinivasan1,
  • Benjamin R Landgraf1,
  • Eric Niespodzany1,
  • Oliver Wieben1 and
  • Alex Frydrychowicz1
Journal of Cardiovascular Magnetic Resonance201113(Suppl 1):P206

Published: 2 February 2011


Right VentricleInferior Vena CavaRight VentricleSuperior Vena CavaRight Atrium


Cardiac MRI (CMR) is used to follow patients after TOF repair to assess pulmonary regurgitation (PR), pulmonary stenosis (PS) and right ventricular (RV) function. 4D flow-sensitive MRI techniques enable visualization of complex flow patterns [1],[2]. With the ability to simultaneously acquire morphology and hemodynamics for visualization and quantification, they may improve evaluation of functional outcomes following surgery for complex CHD.


Analyze flow patterns in superior vena cava (SVC), inferior vena cava (IVC), right atrium (RA), right ventricle (RV), and main, right and left pulmonary arteries (MPA, RPA, and LPA) using 3D radially-undersampled, 4D flow-sensitive MRI.


This HIPAA-compliant study was performed in 11 patients with TOF (5M/6F; 20.1±12.4 years) on 1.5T and 3.0T clinical systems (GE Healthcare, Waukesha, WI) after IRB-approval and obtaining consent. 4D flow-sensitive MRI data were acquired with a radially undersampled phase contrast (PC) sequence, PC VIPR [2] with: 320mm3 volume, 1.0-1.25mm3 acquired isotropic spatial resolution, and VENC of 50-200cm/s. Scan time was approximately 8-12min using an adaptive respiratory bellows reading and 50% efficiency. Retrospective ECG-triggered cardiac gating was used with datasets reconstructed into 20 time frames. Flow visualization and analysis (Table 1) was performed using Ensight (CEI, Apex, NC) with particle trace emitter planes placed in SVC, IVC, tricuspid valve, and MPA.
Table 1

Grading system for evaluation of right heart flow patterns



S wave > D wave



D wave > S wave



normal, single clockwise vortex



increased vortices

RV diastole


normal right-handed helix through TV



increased helicity and vorticity

RV systole


uniform, laminar flow toward RVOT



non-uniform outflow



uniform, laminar flow



helical or vortical flow


SVC and IVC flow was greater during diastole than systole in 8/11. Increased RA vortices were present in 7/11. RV diastolic flow was normal in 1/11. RV systolic flow was normal in 9/11. MPA, RPA, and LPA flow was helical or vortical in 6/11, 10/11, and 10/11, respectively. PR and PS were present in 10/11 and 6/11, respectively.


Flow patterns in the right heart of patients with repaired TOF are altered compared to previously reported flow patterns in normal subjects [3],[4]. These alterations may help explain the increased symptoms during exercise in the repaired heart. An additional benefit of acquiring 4D flow-sensitive MRI data is that flow analysis can be performed post priori through any area of interest.
Figure 1

Right atrial and ventricular particle tracings. (A) A second RA vortex (closed arrow) was present during diastole in 7/11. (B) RV inflow was directed toward the RV apex (open arrow) in patients with PR (closed arrow). (C) RV outflow was normal in 9/11.

Authors’ Affiliations

University of Wisconsin, Madison, USA


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© Francois et al; licensee BioMed Central Ltd. 2011

This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.