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Our aim was to identify distinct Marfan patient subgroups based on aortic 4D flow MRI and Z-score for stratification of distinct hemodynamic profiles and clinical features by means of hierarchical cluster analysis.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Materials and methods<\/jats:title>\n            <jats:p>One hundred Marfan patients underwent baseline aortic 4D flow MRI at 3\u2009T. Z-scores, degree of helical and vortical flow, wall shear stress, flow displacement, and peak velocity were determined in the ascending aorta. Sex, age, BMI, antihypertensive medication, and dural ectasia were recorded. Hierarchical cluster analysis was performed using 4D flow MRI variables and Z-scores as input.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Results<\/jats:title>\n            <jats:p>Cluster analysis resulted in three distinct clusters characterized by different Z-scores (mean\u2009\u00b1\u2009SD); cluster 1: 0.4\u2009\u00b1\u20091.1 vs. cluster 2: 3.1\u2009\u00b1\u20091.1 vs. cluster 3: 3.6\u2009\u00b1\u20091.9. The three clusters delivered differences in helical and vortical flow patterns (global <jats:italic>p<\/jats:italic>\u2009=\u20090.003 and <jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001, respectively), wall shear stress (0.49\u2009\u00b1\u20090.11 vs. 0.44\u2009\u00b1\u20090.12 vs. 0.37\u2009\u00b1\u20090.09\u2009N\/m<jats:sup>2<\/jats:sup>, global <jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001), flow displacement (0.11\u2009\u00b1\u20090.05 vs. 0.16\u2009\u00b1\u20090.08 vs. 0.15\u2009\u00b1\u20090.07, global <jats:italic>p<\/jats:italic>\u2009=\u20090.006), and peak velocity (76.3\u2009\u00b1\u20099.0 vs. 60.1\u2009\u00b1\u20097.3 vs. 56.0\u2009\u00b1\u20097.8\u2009cm\/s, global <jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001). Patients in cluster 1 and 2 were relevantly younger than in cluster 3 (32.3\u2009\u00b1\u200913.8 vs. 32.8\u2009\u00b1\u200912.6 vs. 40.2\u2009\u00b1\u200915.0 years, all pairwise \u2206<jats:italic>p<\/jats:italic>\u2009&lt;\u20090.0297).<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusion<\/jats:title>\n            <jats:p>Hierarchical cluster analysis based on aortic 4D flow MRI and Z-score revealed three distinct subgroups of Marfan patients, each characterized by specific hemodynamic profiles and clinical features. Follow-up of our patients is warranted to assess if 4D flow MRI- and Z-score-based stratification can predict future aortic diameter growth and ultimately improve outcomes.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Clinical relevance statement<\/jats:title>\n            <jats:p>A combination of Z-score and 4D flow MRI-derived parameters may help identify subgroups of Marfan patients representing different stages or phenotypes of aortic disease, which require specific management strategies.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Key Points<\/jats:title>\n            <jats:p>\n              <jats:list list-type=\"bullet\">\n                <jats:list-item>\n                  <jats:p>\n                    <jats:italic>Four-dimensional (4D) flow MRI-derived variables of Marfan patients are highly heterogeneous across varying Z-scores<\/jats:italic>.<\/jats:p>\n                <\/jats:list-item>\n                <jats:list-item>\n                  <jats:p>\n                    <jats:italic>Cluster analysis based on 4D flow MRI and Z-score revealed three distinct subgroups of Marfan patients<\/jats:italic>.<\/jats:p>\n                <\/jats:list-item>\n                <jats:list-item>\n                  <jats:p>\n                    <jats:italic>A combination of Z-score and 4D flow MRI-derived parameters may identify different stages of aortic disease in Marfan patients<\/jats:italic>.<\/jats:p>\n                <\/jats:list-item>\n              <\/jats:list>\n            <\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Graphical Abstract<\/jats:title>\n          <\/jats:sec>","DOI":"10.1007\/s00330-024-11034-6","type":"journal-article","created":{"date-parts":[[2024,9,16]],"date-time":"2024-09-16T13:02:30Z","timestamp":1726491750000},"page":"2200-2212","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Cluster analysis of 100 Marfan patients based on aortic 4D flow MRI and Z-score: insights into disease heterogeneity and stratification of subgroups"],"prefix":"10.1007","volume":"35","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1916-1317","authenticated-orcid":false,"given":"Alexander","family":"Lenz","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Flora","family":"Bahr","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christoph","family":"Riedel","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Felicia","family":"Wright","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Martin","family":"Sinn","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shuo","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marion","family":"Schuett","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lennart","family":"Well","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gerhard","family":"Adam","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yskert","family":"von Kodolitsch","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bjoern P.","family":"Schoennagel","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Peter","family":"Bannas","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2024,9,16]]},"reference":[{"key":"11034_CR1","doi-asserted-by":"crossref","unstructured":"von Kodolitsch Y, De Backer J, Sch\u00fcler H et al (2015) Perspectives on the revised Ghent criteria for the diagnosis of Marfan syndrome. 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One coauthor (S.Z.) is an employee (senior clinical scientist) at Koninklijke Philips NV but had no control of the data. B.P.S. is co-founder and stakeholder of northh medical GmbH. The remaining authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}},{"value":"One of the authors has significant statistical expertise.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Statistics and biometry"}},{"value":"Written informed consent was obtained from all subjects (patients) in this study.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Informed consent"}},{"value":"This study was approved by the local ethics committee.","order":6,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical approval"}},{"value":"No study subjects or cohorts have been previously reported.","order":7,"name":"Ethics","group":{"name":"EthicsHeading","label":"Study subjects or cohorts overlap"}},{"order":8,"name":"Ethics","group":{"name":"EthicsHeading","label":"Methodology"}}]}}