Pankaj Garg

University of East Anglia | UEA · Norwich Medical School

Background: Four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) is an emerging non-invasive imaging technology used to visualise and quantify intra-cardiac blood flow. The aim of this systematic review is to assess the literature on the current clinical applications of intra-cardiac 4D flow CMR. Methods: A systematic review was...

Aims- The main aim of this study was to characterise changes in the left ventricular (LV) blood flow kinetic energy (KE) using four-dimensional flow (4D flow) cardiovascular magnetic resonance (CMR) imaging in patients with myocardial infarction (MI) with/without LV thrombus (LVT). Methods- This is a prospective cohort study of 108-subjects (contro...

Background Myocardial infarction (MI) leads to complex changes in left ventricular (LV) haemodynamics that are linked to clinical outcomes. We hypothesize that LV blood flow kinetic energy (KE) is altered in MI and is associated with LV function and infarct characteristics. This study aimed to investigate the intra-cavity LV blood flow KE in contro...

Two-dimensional (2D) methods of assessing mitral inflow velocities are pre-load dependent, limiting their reliability for evaluating diastolic function. Left ventricular (LV) blood flow kinetic energy (KE) derived from four-dimensional flow cardiovascular magnetic resonance imaging (4D flow CMR) may offer improvements. It remains unclear whether 4D...

Aims: Non-invasive imaging is routinely used to estimate left ventricular (LV) filling pressure (LVFP) in heart failure (HF). Cardiovascular magnetic resonance (CMR) is emerging as an important imaging tool for sub-phenotyping HF. However, currently, LVFP cannot be estimated from CMR. This study sought to investigate (i) if CMR can estimate LVFP i...

Introduction Pressure-volume (PV) loops offer a comprehensive evaluation of cardiac function. Impedance catheters enable the acquisition of synchronised intracardiac electrocardiogram (ECG), pressure, and volume data with high temporal resolution. However, current calibration methods are impractical and data interpretation is often inconsistent. Me...

This paper describes the role of cardiovascular magnetic resonance (CMR) imaging in assessing patients with mitral valve disease. Mitral regurgitation (MR) is one of the most prevalent valvular heart diseases. It often progresses without significant symptoms, leading to left ventricular overload, dysfunction, frequent decompensated heart failure ep...

This review describes the evolution and enhanced diagnostic capabilities introduced by four-dimensional (4D) flow cardiac magnetic resonance (CMR) in cardiovascular imaging. It charts the historical advancements from echocardiography through to two-dimensional phase-contrast magnetic resonance imaging (2D-PC MRI), culminating in the adoption of 4D...

Background and Objectives: Coronary sinus oxygen saturation is a useful indicator of health and disease states. However, it is not routinely used in clinical practice. Cardiovascular magnetic resonance imaging (CMR) oximetry can accurately estimate oxygen saturation in the pulmonary artery. This research aimed to provide a method for calculating co...

The following open access data repository demonstrates the numerical differences between the reference methods of CMR for volumes and the clinical standard of fluid filled manometer assessment for pressure, against either beat-by-beat or average loop assessment of PV loop traces from the impedance catheter.

Background Admission with acute heart failure carries a poor prognosis. Multiple predictive risk scores exist in heart failure presentation, however the utility of these scores in acute heart failure setting among older adults is limited. Aim The purpose of this study was to develop a practical risk score to predict 6-month mortality in patients p...

Introduction Cardiac magnetic resonance (CMR) is recommended internationally for tissue characterisation, volumetric assessment and assessment of prior myocardial infarction (1). Patients with left bundle branch block (LBBB) form a significant sub-group of individuals, however, there is limited data available to accurate determine whether LBBB is a...

Background Right atrial pressure (RAP) is a key metric in haemodynamic assessment. Elevated RAP is associated with poor prognosis in heart failure and pulmonary hypertension and physiologically with fluid overload. RAP can be measured invasively or non-invasively, but Cardiac MRI (CMR) currently cannot estimate RAP. Purpose To develop a model to e...

(1) Background and Objectives: Flow assessment using cardiovascular magnetic resonance (CMR) provides important implications in determining physiologic parameters and clinically important markers. However, post-processing of CMR images remains labor- and time-intensive. This study aims to assess the validity and repeatability of fully automated seg...

Objectives To assess the prognostic value of right ventricular (RV) remodelling defined with artificial intelligence (AI) derived RV volumetric and mass measurements on cardiac magnetic resonance (CMR) imaging in patients with pulmonary arterial hypertension (PAH). Methods Consecutive PAH patients underwent CMR assessment analysed using deep learn...

Background Aortic conduit and reservoir functions can be directly measured by four-dimensional flow (4D flow) cardiovascular magnetic resonance (CMR). Methods Twenty healthy controls (10 young and 10 age-gender-matched old controls) and 20 patients with heart failure with preserved ejection fraction (HFpEF) were recruited. All had 4D flow CMR. Flo...

Background Cardiovascular magnetic resonance (CMR) imaging shows promise in estimating pulmonary capillary wedge pressure (PCWP) non‐invasively. At the population level, the prognostic role of CMR‐modelled PCWP remains unknown. Furthermore, the relationship between CMR‐modelled PCWP and established risk factors for cardiovascular disease has not be...

Background Patients with diabetes mellitus (DM) and heart failure (HF) have worse outcomes than normoglycemic HF patients. Cardiovascular magnetic resonance (CMR) can identify ischemic heart disease (IHD) and quantify coronary microvascular dysfunction (CMD) using myocardial perfusion reserve (MPR). We aimed to quantify the extent of silent IHD and...

Background Cardiac magnetic resonance (CMR) in the four-chamber plane offers comprehensive insight into the volumetrics of the heart. We aimed to develop an artificial intelligence (AI) model of time-resolved segmentation using the four-chamber cine. Methods A fully automated deep learning algorithm was trained using retrospective multicentre and m...

Background Pulmonary transit time (PTT) can be measured automatically from arterial input function (AIF) images of dual sequence first-pass perfusion imaging. PTT has been validated against invasive cardiac catheterisation correlating with both cardiac output and left ventricular filling pressure (both important prognostic markers in heart failure)...

Introduction: Diffuse myocardial fibrosis is a negative CV prognostic marker. We employed advanced cardiac MRI (CMR) techniques for detailed left ventricular myocardial tissue characterization people with type 1 diabetes (PwT1D) and high CV risk. Methods: Quantitative native T1 mapping (T1) and extracellular volume fraction (ECV) calculation of the...

Background Right atrial pressure (RAP) corresponds to fluid status and preload and is also important in prognostication for patients with heart failure and pulmonary hypertension. RAP can be measured invasively or non-invasively, but cannot currently be estimated by cardiac MRI (CMR). This study used paired CMR and invasive right heart catheter (RH...

Introduction Admission with acute heart failure carries a poor prognosis. Multiple predictive risk scores exist in heart failure presentation however the utility of these scores in acute heart failure setting among older adults is limited.The purpose of this study was to develop a practical risk score to predict 6-month mortality in patients presen...

Aims We aimed to identify the distinctive cardiovascular magnetic resonance (CMR) features of patients with left bundle branch block (LBBB) and heart failure with reduced ejection fraction (HFrEF) of presumed non-ischaemic aetiology. The secondary aim was to determine whether these individuals exhibit characteristics that could potentially serve as...

Aims Heart failure (HF) with preserved ejection fraction disproportionately affects women. There are no validated sex-specific tools for HF diagnosis despite widely reported differences in cardiac structure. This study investigates whether sex, as assigned at birth, influences cardiac magnetic resonance (CMR) assessment of left ventricular filling...

Introduction Heart failure (HF) incidence is increasing in older adults with high hospitalisation and mortality rates. Treatment is complicated by side effects and comorbidities. We investigated the clinical characteristics of octogenarians presenting to the HF clinic. Methods Data were collected on octogenarians (80–89 years) referred to the HF c...

Background Chronic pulmonary embolism (PE) may result in pulmonary hypertension (CTEPH). Automated CT pulmonary angiography (CTPA) interpretation using artificial intelligence (AI) tools has the potential for improving diagnostic accuracy, reducing delays to diagnosis and yielding novel information of clinical value in CTEPH. This systematic review...

Citation: Assadi, H.; Sawh, N.; Bailey, C.; Matthews, G.; Li, R.; Grafton-Clarke, C.; Mehmood, Z.; Kasmai, B.; Swoboda, P.P.; Swift, A.J.; et al. Validation of Left Atrial Volume Correction for Single Plane Method on Four-Chamber Cine Cardiac MRI. Tomography 2024, 10, 459-470. Abstract: Background: Left atrial (LA) assessment is an important marker...

Introduction Non-invasive imaging is routinely used to estimate left ventricular (LV) filling pressure (LVFP) in heart failure (HF). Cardiovascular magnetic resonance (CMR) is emerging as an important imaging tool for sub-phenotyping HF and estimating pulmonary capillary wedge pressure (PCWP), a surrogate for LVFP.¹ This research sought to investig...

Introduction Mortality from heart failure (HF) remains unacceptably high.¹ Left ventricular (LV) ejection fraction (EF) is a flawed, surrogate marker of function.² Pressure- Volume (PV) loops permit comprehensive study of myocardial energetics, stiffness and loading conditions. PV-loops can be assessed invasively but this is laborious and carries r...

Purpose: The main objective of this study was to develop two-dimensional (2D) phase contrast (PC) methods to quantify the helicity and vorticity of blood flow in the aortic root. Methods: This proof-of-concept study used four-dimensional (4D) flow cardiovascular MR (4D flow CMR) data of five healthy controls, five patients with heart failure with...

Aims Turbulent aortic flow makes the cardiovascular system less effective. It remains unknown if patients with heart failure with preserved ejection fraction (HFpEF) have disturbed aortic flow. This study sought to investigate advanced markers of aortic flow disturbances in HFpEF. Methods This case-controlled observational study used four-dimensio...

Background Four‐dimensional‐flow cardiac MR (4DF‐MR) offers advantages in primary mitral regurgitation. The relationship between 4DF‐MR‐derived mitral regurgitant volume (MR‐Rvol) and the post‐operative left ventricular (LV) reverse remodeling has not yet been established. Purpose To ascertain if the 4DF‐MR‐derived MR‐Rvol correlates with the LV r...

Background Segmentation of cardiac structures is an important step in evaluation of the heart on imaging. There has been growing interest in how artificial intelligence (AI) methods—particularly deep learning (DL)—can be used to automate this process. Existing AI approaches to cardiac segmentation have mostly focused on cardiac MRI. This systematic...

Aims Turbulent aortic flow makes the cardiovascular system less effective. It remains unknown if patients with heart failure with preserved ejection fraction (HFpEF) have disturbed aortic flow. This study sought to investigate advanced markers of aortic flow disturbances in HFpEF. Methods This case-controlled observational study used two-dimensiona...

BACKGROUND Stress perfusion cardiovascular magnetic resonance can be performed without rest perfusion for the quantification of ischemia burden. However, the optimal method of analysis is uncertain. METHODS We identified 666 patients from CE-MARC (Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease) with complete stress per...

Aims Blood pressure (BP) is a crucial factor in cardiovascular health and can affect cardiac imaging assessments. However, standard outpatient cardiovascular MR (CMR) imaging procedures do not typically include BP measurements prior to image acquisition. This study proposes that brachial systolic BP (SBP) and diastolic BP (DBP) can be modelled usin...

Background Blood flow eccentricity, as determined by phase contrast (PC) CMR-assessed peak systolic flow displacement, has been linked to future aortic enlargement in patients with bicuspid aortic valve and thoracic aortic aneurysm. Its presence, extent and functional consequence in healthy adults are unknown. Purpose We quantified aortic flow ecc...

Introduction: Right ventricular restrictive physiology (RVRP) is common after repair of Tetralogy of Fallot (rTOF), especially with residual pulmonary regurgitation. Four-dimensional (4D) flow cardiovascular magnetic resonance (CMR) quantitates biventricular blood flow components and kinetic energy (KE) parameters, but their association with RVRP i...

Background and objectives: Evaluating left ventricular filling pressure (LVFP) plays a crucial role in diagnosing and managing heart failure (HF). While traditional assessment methods involve multi-parametric transthoracic echocardiography (TTE) or right heart catheterisation (RHC), cardiovascular magnetic resonance (CMR) has emerged as a valuable...

Background Permanent pacemaker (PPM) implantation is a well‐established treatment for symptomatic sinus node dysfunction (SND). The optimal timing of this intervention is unclear, with atrioventricular blocks often prioritized in resource stressed waiting lists due to mortality concerns. Methods Mortality data was compared between patients receivi...

Background and Objectives: Cardiovascular magnetic resonance (CMR) is emerging as an important imaging tool for sub-phenotyping and estimating left ventricular (LV) filling pressure (LVFP). The N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) is released from cardiac myocytes in response to mechanical load and wall stress. This study...

Introduction: The purpose of this study was to investigate the differences in pulmonary vascular tree structures between control patients, patients with pulmonary arterial hypertension (PAH) and those with chronic thromboembolic pulmonary hypertension (CTEPH) using computed tomography (CT) pulmonary vessel analysis. Methods: This retrospective st...

Aortic blood flow patterns are closely linked to the morphology and function of the left ventricle, aortic valve and aorta. These flow patterns demonstrate the exceptional adaptability of the cardiovascular system to maintain blood circulation under a broad range of haemodynamic workloads and can be altered in various pathophysiological states. For...

Introduction: There is growing interest in identifying cardiovascular magnetic resonance (CMR) signatures in ageing due to their relevance to cardiovascular health.1 It also remains uncertain whether patients with heart failure with preserved ejection fraction (HFpEF) have disruptions in their aortic flow. This study aimed to explore sophisticated...

STROBE CHECKLIST for “Aortic Flow is abnormal in HFpEF”

Introduction To identify minimally important differences (MIDs) for cardiac MRI metrics based on FDA recommendations for a clinical outcome measure that should reflect how a patient feels, functions or survives. Methods Consecutive treatment-naïve patients with pulmonary arterial hypertension between 2010 and 2022 who had two cardiac MRI scans (at...

Background Advances in four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) have allowed quantification of left ventricular (LV) and right ventricular (RV) blood flow. We aimed to (1) investigate age and sex differences of 4D flow CMR-derived LV and RV relative flow components and kinetic energy (KE) parameters indexed to end-diast...

Trans-thoracic echocardiography (TTE) is the primary imaging modality for diagnosing any left ventricular outflow tract obstruction (LVOTO), estimating hemodynamic severity and timing of surgical intervention1 4 . Multi-parametric cardiac magnetic resonance imaging (CMR) provides additional details on tissue characterisation and cardiac haemodynami...

Aims Increased blood flow eccentricity in the aorta has been associated with aortic (AO) pathology, however, its association with exercise capacity has not been investigated. This study aimed to assess the relationships between flow eccentricity parameters derived from 2-dimensional (2D) phase-contrast (PC) cardiovascular magnetic resonance (CMR) i...

Aims: Left ventricular filling pressure (LVFP) can be estimated from cardiovascular magnetic resonance (CMR). We aimed to investigate whether CMR-derived LVFP is associated with signs, symptoms, and prognosis in patients with recently diagnosed heart failure (HF). Methods and results: This study recruited 454 patients diagnosed with HF who under...

BACKGROUND Stress perfusion cardiovascular magnetic resonance (CMR) is increasingly used without rest perfusion for the quantification of ischemia burden. However, the optimal method of analysis is uncertain. METHODS We identified 666 patients from Clinical Evaluation of MAgnetic Resonance imaging in Coronary heart disease (CE-MARC) with complete...

Hemodynamic assessment is an integral part of the diagnosis and management of cardiovascular disease. Four-dimensional cardiovascular magnetic resonance flow imaging (4D Flow CMR) allows comprehensive and accurate assessment of flow in a single acquisition. This consensus paper is an update from the 2015 '4D Flow CMR Consensus Statement'. We elabor...

Introduction Cardiac MRI (CMR) is the gold standard technique to assess bi-ventricular volumes and function and is increasingly being considered as an endpoint in clinical studies. Currently, with the exception of right ventricle (RV) stroke volume and RV end-diastolic volume, there is only limited data on minimally important differences (MIDs) rep...

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute for Health and Care Research British Cardiovascular Society. Background Cardiovascular magnetic resonance imaging (CMR) can estimate left ventricular filling pressure (LVFP). The relationship between LVFP, determined...

Abstract Introduction Although widely adopted in clinical practice, the left ventricular ejection fraction (LVEF) has significant limitations in heart failure assessment1. Gold standard physiological measures of heart function utilise pressure-volume (PV) loops, particularly the stroke work (SW), represented as the area bounded by the loop. Invasiv...

Introduction Accurate assessment of degenerative mitral regurgitation (MRegurg) by transthoracic echocardiography (TTE) can be challenging. Phase-contrast cardiovascular magnetic resonance (PCMR) imaging enables reliable quantitation of MRegurg volume, even in the presence of eccentric and multiple jets, highlighting its advantage in the evaluation...

Automatic segmentation of the cardiac left ventricle with scars remains a challenging and clinically significant task, as it is essential for patient diagnosis and treatment pathways. This study aimed to develop a novel framework and cost function to achieve optimal automatic segmentation of the left ventricle with scars using LGE-MRI images. To en...

Background: TAVI is a widely accepted treatment for patients with severe aortic stenosis (AS). Despite the adoption of diverse therapies, opportunities remain to develop technologies tailored to provide optimal acute and potential long-term benefits, particularly around haemodynamics, flow and durability. Aims: We aimed to evaluate the safety an...

Acting upon clinical patient data, acquired in the pathway of percutaneous intervention, we deploy hierarchical, multi-stage, data-handling protocols and interacting low- and high-order mathematical models (chamber elastance, state-space system and CFD models), to establish and then validate a framework to quantify the burden of ischaemia. Our core...

Objective To investigate whether left atrial (LA) volume and left ventricular filling pressure (LVFP) assessed by cardiovascular magnetic resonance (CMR) change during adenosine delivered myocardial hyperaemia as part of a first-pass stress perfusion study. Methods and results We enrolled 33 patients who had stress CMR. These patients had a baseli...

Background: The reproducibility of mitral regurgitation (MR) quantification by cardiovascular magnetic resonance (CMR) imaging using different software solutions remains unclear. This research aimed to investigate the reproducibility of MR quantification between two software solutions: MASS (version 2019 EXP, LUMC, Netherlands) and CAAS (version 5....

Introduction Severe pulmonary hypertension (mean pulmonary artery pressure ≥35 mmHg) in chronic lung disease (PH-CLD) is associated with high mortality and morbidity. Data suggesting potential response to vasodilator therapy in patients with PH-CLD is emerging. The current diagnostic strategy utilises transthoracic Echocardiography (TTE), which can...

Our perspectives on aortic stenosis (AS) are changing. Evolving from the traditional thought of a passive degenerative disease, developing a greater understanding of the condition’s mechanistic underpinning has shifted the paradigm to an active disease process. This advancement from the ‘wear and tear’ model is a result of the growing economic and...