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Objective: To assess the diagnostic performance of cardiac magnetic resonance (CMR)-based four-dimensional (4D)-flow analysis in identifying CpcPH. Methods: Prospective observational study of heart failure (HF) patients with suspected pulmonary hypertension (PH) who underwent simultaneous CMR and right heart catheterization. The 4D-flow biomarkers were calculated using an automatic pipeline. A predictive model including 4D-flow biomarkers associated with CpcPH with a p-value &lt; 0.20 was built to determine the diagnostic performance of 4D-flow analysis to identify CpcPH. Results: A total of 46 HF patients (55.4 \u00b1 14 years, 63% male) with confirmed PH (19 [41%] isolated postcapillary PH [IpcPH], 27 [59%] CpcPH) were included. No differences were found in baseline characteristics, echocardiography, or CMR anatomical and functional parameters, except for a higher Doppler-estimated systolic pulmonary pressure and larger pulmonary artery in CpcPH patients. The 4D-flow CMR analysis was performed in 31 patients (67%). The maximal peak velocity (67.1 [62.2\u201377.5] cm\/s\u2014IpcPH vs. 58.2 [45.8\u201366.0] cm\/s\u2014CpcPH; p = 0.021) and maximal helicity (339.9 [290.0\u2013391.8]) cm\/s2\u2014IpcPH vs. 226.0 (173.5\u2013343.7) cm\/s2\u2014CpcPH; p = 0.026) were significantly lower in patients with CpcPH. A maximal multivariable model including sex, maximal average, and peak velocities, Reynolds number, flow rate, and helicity showed fair diagnostic performance (area under the curve: 0.768 [95%-CI: 0.572\u20130.963]; sensitivity: 100%; specificity: 55%). Conclusions: In HF patients with PH, 4D-flow-derived maximal peak velocity and maximal helicity were significantly lower in CpcPH patients. A multiparametric model including maximal 4D-flow-derived biomarkers showed good diagnostic performance for identifying CpcPH.<\/jats:p>","DOI":"10.3390\/jcm14030929","type":"journal-article","created":{"date-parts":[[2025,1,31]],"date-time":"2025-01-31T05:08:26Z","timestamp":1738300106000},"page":"929","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Four-Dimensional Magnetic Resonance Pulmonary Flow Imaging for Assessing Pulmonary Vasculopathy in Patients with Postcapillary Pulmonary Hypertension"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8269-2244","authenticated-orcid":false,"given":"Jorge","family":"Nuche","sequence":"first","affiliation":[{"name":"Cardiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigaci\u00f3n Sanitaria Hospital 12 de Octubre (imas12), Servicio de Cardiolog\u00eda, Avenida de C\u00f3rdoba s\/n, 28041 Madrid, 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CardioVasculares (CIBERCV), 28029 Madrid, Spain"},{"name":"Centro Nacional de Investigaciones Cardiovasculares, Calle de Melchor Fern\u00e1ndez Almagro 3, 28029 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-6969-3946","authenticated-orcid":false,"given":"Javier","family":"B\u00f3beda","sequence":"additional","affiliation":[{"name":"Vicomtech, Basque Research and Technology Alliance (BRTA), Paseo Mikeletegi 57, 20009 San Sebasti\u00e1n, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2165-1975","authenticated-orcid":false,"given":"\u00c1ngel","family":"Gait\u00e1n","sequence":"additional","affiliation":[{"name":"Medical Physics Department, Hospital Universitario 12 de Octubre, Instituto de Investigaci\u00f3n Sanitaria Hospital 12 de Octubre, Avenida de C\u00f3rdoba s\/n, 28041 Madrid, Spain"},{"name":"eHealth Group, Biogipuzkoa Health Research Institute, Paseo Dr. 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