Pulmonary hypertension and the role of MRI flow assessment: a systematic review

Abstract Objectives Cardiac magnetic resonance imaging (CMR) plays an increasingly important role in non-invasive assessment of pulmonary hypertension (PH). This systematic review aimed to assess the utility, accuracy, and clinical applications of CMR flow techniques in evaluating pulmonary arterial blood flow in patients with suspected or confirmed PH. Methods MEDLINE and EMBASE databases were searched on December 10, 2024, utilizing the following key terms: “cardiac MRI,” “flow,” and “pulmonary hypertension.” Eligible studies were screened, and data extraction included study design, cohort characteristics, CMR flow techniques and outcomes. Risk of bias was assessed using the Newcastle-Ottawa scale. Results Thirty-eight studies (mean sample size: 30 [20-57]) published between 2012 and 2024 were included. These utilized 2D flow (19 studies), 4D flow (15 studies), black blood imaging (1 study) and combined flow techniques (3 studies). Vortex duration derived by 4D flow demonstrated the strongest correlation (r = 0.96) with mean pulmonary artery pressure and the highest diagnostic accuracy in identifying PH patients (area under the curve, 0.99). Risk of bias rated 14 studies as good/very good and 13 as unsatisfactory, with none justifying their sample size selection. Conclusion CMR flow parameters correlate strongly with right heart catheterization measurements and demonstrate high diagnostic accuracy in identifying patients with PH, with 4D flow potentially adding greater value. This systematic review reinforces the potential benefit of CMR flow techniques in the investigation, prognostication, and monitoring of PH patients. Advances in knowledge This systematic review is the first to evaluate the role of CMR flow techniques in PH and should inform guidelines on flow assessment in PH.