Fetal Flow Quantification in Great Vessels Using Motion-Corrected Radial Phase Contrast MRI: Comparison With Cartesian

Third trimester fetal 4D flow MRI with motion correction

PURPOSE

To correct maternal breathing and fetal bulk motion during fetal 4D flow MRI.

METHODS

A Doppler-ultrasound fetal cardiac-gated free-running 4D flow acquisition was corrected post hoc for maternal respiratory and fetal bulk motion in separate automated steps, with optional manual intervention to assess and limit fetal motion artifacts. Compressed-sensing reconstruction with a data outlier rejection algorithm was adapted from previous work. Pre- and post-motion correction comparison included qualitative visibility of vasculature on phase-contrast MR angiograms (five-point Likert scale), conservation of mass of the aortic isthmus, ductus arteriosus, and descending aorta, and coefficient of variation of flow along the descending aorta.

RESULTS

Twenty-nine third trimester acquisitions were performed for 15 healthy fetuses and two patients with postnatally confirmed aortic coarctation during a single examination for each participant. Only 15/27 (56%) of all volunteers and 1/2 (50%) of all patient precorrection acquisitions were suitable for flow analysis. Motion correction recovered eight "failed" acquisitions, including one patient, with 24/29 (83%) suitable for flow analysis. In the 15 viable uncorrected volunteer acquisitions, motion correction improved phase-contrast MR angiograms visibility significantly in the ductus arteriosus (from 4.0 to 4.3, p = 0.04) and aortic arch (3.7 to 4.0, p = 0.03). Motion correction improved conservation of mass to a median (interquartile range) percent difference of 5% (9%) from 14% (24%) with improvement shown in 14/15 acquisitions (p = 0.002), whereas coefficient of variation changes were not significantly different (uncorrected: 0.15 (0.09), corrected: 0.11 (0.09), p = 0.3).

CONCLUSIONS

Motion correction compensated for maternal and fetal motion in fetal 4D flow MRI data, improving image quality and conservation of mass.

Feasibility of fetal cardiac output measurement by phase contrast magnetic resonance imaging using Doppler ultrasound gating increases with gestational age

BACKGROUND

Fetal magnetic resonance imaging (MRI) is a valuable tool for assessing fetal blood flow; however, its use has primarily been focused on near-term pregnancies. This study aimed to evaluate the feasibility of Doppler ultrasound-gated 2D phase-contrast cardiac MRI of the human fetus in the early, mid, and late third trimester.

METHODS

A total of 100 fetal MRI scans were performed at gestational age (GA) 28, 32 and 38 weeks in 38 fetuses with (n=13) and without (n=25) congenital heart defects. Combined ventricular output was measured by Doppler ultrasound gated 2D phase contrast MRI in the ascending aorta and main pulmonary artery. Success rate of acquisition, repeatability of phase contrast-measurements and intra-/interobserver agreement were assessed at each GA.

RESULTS

Combined ventricular output was obtained in 76/100 (76%) scans. The success rate of acquisition improved with increasing GA from 15/34 (44%) at GA 28 weeks to 31/35 (89%) at GA 32 weeks (p <0.001 compared to 28 weeks) and 30/31 (97%) at GA 38 weeks (p <0.001 compared to 28 weeks). Repeatability of phase contrast measurements demonstrated a moderate to strong correlation (r = 0.63 - 0.82, p = 0.002), with no significant bias but wide limits of agreement. The mean difference ±95% limits of agreement were 7.3±245mL/min, -13.0±260mL/min, and -3.9±326mL/min at 28, 32, and 38 weeks, respectively.

CONCLUSION

Feasibility of fetal cardiac MRI improves with increasing GA. While Doppler-gated 2D phase contrast MRI can effectively assess fetal combined ventricular output and allows for in-group comparisons, the precision may still be insufficient for clinical application.

Reducing clustering of readouts in non-Cartesian cine magnetic resonance imaging

BACKGROUND

Non-Cartesian magnetic resonance imaging trajectories at golden angle increments have the advantage of allowing motion correction and gating using intermediate real-time reconstructions. However, when the acquired data are cardiac binned for cine imaging, trajectories can cluster together at certain heart rates (HR) causing image artifacts. Here, we demonstrate an approach to reduce clustering by inserting additional angular increments within the trajectory, and optimizing them while still allowing for intermediate reconstructions.

METHODS

Three acquisition models were simulated under constant and variable HR: golden angle (Mtrd), random additional angles (Mrnd), and optimized additional angles (Mopt). The standard deviations of trajectory angular differences (STAD) were compared through their interquartile ranges (IQR) and the Kolmogorov-Smirnov test (significance level: p = 0.05). Agreement between an image reconstructed with uniform sampling and images from Mtrd, Mrnd, and Mopt was analyzed using the structural similarity index measure (SSIM). Mtrd and Mopt were compared in three adults at high, low, and no HR variability.

RESULTS

STADs from Mtrd were significantly different (p < 0.05) from Mopt and Mrnd. STAD (IQR × 10-2 rad) showed that Mopt (0.5) and Mrnd (0.5) reduced clustering relative to Mtrd (1.9) at constant HR. For variable HR, Mopt (0.5) and Mrnd (0.5) outperformed Mtrd (0.9). The SSIM (IQR) showed that Mopt (0.011) produced the best image quality, followed by Mrnd (0.014), and Mtrd (0.030). Mopt outperformed Mtrd at reduced HR variability in in-vivo studies. At high HR variability, both models performed well.

CONCLUSION

This approach reduces clustering in k-space and improves image quality.

Fetal cardiovascular blood flow MRI: techniques and applications

Fetal cardiac MRI is challenging due to fetal and maternal movements as well as the need for a reliable cardiac gating signal and high spatiotemporal resolution. Ongoing research and recent technical developments to address these challenges show the potential of MRI as an adjunct to ultrasound for the assessment of the fetal heart and great vessels. MRI measurements of blood flow have enabled the assessment of normal fetal circulation as well as conditions with disrupted circulations, such as congenital heart disease, along with associated organ underdevelopment and hemodynamic instability. This review provides details of the techniques used in fetal cardiovascular blood flow MRI, including single slice and volumetric imaging sequences, post-processing and analysis, along with a summary of applications in human studies and animal models.

Advanced imaging of fetal cardiac function

Over recent decades, a variety of advanced imaging techniques for assessing cardiovascular physiology and cardiac function in adults and children have been applied in the fetus. In many cases, technical development has been required to allow feasibility in the fetus, while an appreciation of the unique physiology of the fetal circulation is required for proper interpretation of the findings. This review will focus on recent advances in fetal echocardiography and cardiovascular magnetic resonance (CMR), providing examples of their application in research and clinical settings. We will also consider future directions for these technologies, including their ongoing technical development and potential clinical value.

Fetal MRI of the heart and brain in congenital heart disease

Antenatal assessment of congenital heart disease and associated anomalies by ultrasound has improved perinatal care. Fetal cardiovascular MRI and fetal brain MRI are rapidly evolving for fetal diagnostic testing of congenital heart disease. We give an overview on the use of fetal cardiovascular MRI and fetal brain MRI in congenital heart disease, focusing on the current applications and diagnostic yield of structural and functional imaging during pregnancy. Fetal cardiovascular MRI in congenital heart disease is a promising supplementary imaging method to echocardiography for the diagnosis of antenatal congenital heart disease in weeks 30-40 of pregnancy. Concomitant fetal brain MRI is superior to brain ultrasound to show the complex relationship between fetal haemodynamics in congenital heart disease and brain development.

Fetal Cardiovascular MRI - A Systemic Review of the Literature: Challenges, New Technical Developments, and Perspectives

BACKGROUND

Fetal magnetic resonance imaging (MRI) has become a valuable adjunct to ultrasound in the prenatal diagnosis of congenital pathologies of the central nervous system, thorax, and abdomen. Fetal cardiovascular magnetic resonance (CMR) was limited, mainly by the lack of cardiac gating, and has only recently evolved due to technical developments.

METHOD

A literature search was performed on PubMed, focusing on technical advancements to perform fetal CMR. In total, 20 publications on cardiac gating techniques in the human fetus were analyzed.

RESULTS

Fetal MRI is a safe imaging method with no developmental impairments found to be associated with in utero exposure to MRI. Fetal CMR is challenging due to general drawbacks (e. g., fetal motion) and specific limitations such as the difficulty to generate a cardiac gating signal to achieve high spatiotemporal resolution. Promising technical advancements include new methods for fetal cardiac gating, based on novel post-processing approaches and an external hardware device, as well as motion compensation and acceleration techniques.

CONCLUSION

Newly developed direct and indirect gating approaches were successfully applied to achieve high-quality morphologic and functional imaging as well as quantitative assessment of fetal hemodynamics in research settings. In cases when prenatal echocardiography is limited, e. g., by an unfavorable fetal position in utero, or when its results are inconclusive, fetal CMR could potentially serve as a valuable adjunct in the prenatal assessment of congenital cardiovascular malformations. However, sufficient data on the diagnostic performance and clinical benefit of new fetal CMR techniques is still lacking.

KEY POINTS

· New fetal cardiac gating methods allow high-quality fetal CMR.. · Motion compensation and acceleration techniques allow for improvement of image quality.. · Fetal CMR could potentially serve as an adjunct to fetal echocardiography in the future..

CITATION FORMAT

· Knapp J, Tavares de Sousa M, Schönnagel BP. Fetal Cardiovascular MRI - A Systemic Review of the Literature: Challenges, New Technical Developments, and Perspectives. Fortschr Röntgenstr 2022; 194: 841 - 851.

Structured analysis of the impact of fetal motion on phase-contrast MRI flow measurements with metric optimized gating

The impact of fetal motion on phase contrast magnetic resonance imaging (PC-MRI) with metric optimized gating (MOG) remains unknown, despite being a known limitation to prenatal MRI. This study aims to describe the effect of motion on fetal flow-measurements using PC-MRI with MOG and to generate a scoring-system that could be used to predict motion-corrupted datasets at the time of acquisition. Ten adult volunteers underwent PC-MRI with MOG using a motion-device to simulate reproducible in-plane motion encountered in fetuses. PC-MRI data were acquired on ten fetuses. All ungated images were rated on their quality from 0 (no motion) to 2 (severe motion). There was no significant difference in measured flows with in-plane motion during the first and last third of sequence acquisition. Movement in the middle section of acquisition produced a significant difference while all referring ungated images were rated with a score of 2. Intra-Class-Correlation (ICC) for flow-measurements in adult and fetal datasets was lower for datasets with scores of 2. For fetal applications, the use of a simple three-point scoring system reliably identifies motion-corrupted sequences from unprocessed data at the time of acquisition, with a high score corresponding to significant underestimation of flow values and increased interobserver variability.

Cerebral Blood Flow Monitoring in High-Risk Fetal and Neonatal Populations

Cerebrovascular pressure autoregulation promotes stable cerebral blood flow (CBF) across a range of arterial blood pressures. Cerebral autoregulation (CA) is a developmental process that reaches maturity around term gestation and can be monitored prenatally with both Doppler ultrasound and magnetic resonance imaging (MRI) techniques. Postnatally, there are key advantages and limitations to assessing CA with Doppler ultrasound, MRI, and near-infrared spectroscopy. Here we review these CBF monitoring techniques as well as their application to both fetal and neonatal populations at risk of perturbations in CBF. Specifically, we discuss CBF monitoring in fetuses with intrauterine growth restriction, anemia, congenital heart disease, neonates born preterm and those with hypoxic-ischemic encephalopathy. We conclude the review with insights into the future directions in this field with an emphasis on collaborative science and precision medicine approaches.