Associations between cardio-ankle vascular index score and aortic volume and hemodynamic parameters using four-dimensional magnetic resonance imaging

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Four-dimensional (4D) magnetic resonance imaging (MRI) has emerged as a promising tool for evaluating vascular blood flow. This study investigated the correlation between thoracic aortic volume (TAV) and hemodynamic parameters using 4D MRI in patients with and without AA as defined by the CAVI score. Methods This retrospective study involved 171 patients (77 with a low CAVI score and 94 with a high CAVI score) who underwent cardiac MRI with a 4D flow sequence. Hemodynamic parameters—including energy loss (EL), vorticity (Vort), and helicity (Hel)—were obtained. Results Patients in the high CAVI group had significantly larger TAV (113.6 ± 29.3 vs. 80.6 ± 30.5 cm 3 , P < 0.0001). The TAV was positively correlated with the CAVI score (R = 0.4147, P < 0.0001). EL maximum/TAV ( P = 0.0035), Vort average/TAV ( P = 0.0004), and Hel absolute maximum/TAV ( P = 0.0002) were significantly lower in the high CAVI group. Several hemodynamic parameters, including Vort maximum/TAV (R = −0.4082, P < 0.0001) and Hel right screw maximum/TAV (R = −0.4211, P < 0.0001), were moderately negatively correlated with the CAVI score, suggesting that aortic stiffness restricts luminal blood flow, particularly during systole. Conclusions Patients with high CAVI scores exhibited a larger TAV and lower voxel-based hemodynamic parameters than those with low CAVI scores. This method represents a novel approach for the noninvasive assessment of atherosclerosis. atherosclerosis four-dimensional magnetic resonance imaging cardio-ankle vascular index Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Aortic atherosclerosis (AA) is a chronic inflammatory condition characterized by the accumulation of plaques within the arterial wall. This results in arterial wall stiffness and is associated with an increased risk of cardiovascular events [1,2]. Therefore, early diagnosis, severity grading, and prediction of AA are crucial. The evaluation of patients with suspected or confirmed AA typically relies on imaging techniques. One of the most widely accepted imaging tests for atherosclerosis is computed tomography angiography, which provides anatomical imaging of plaques in coronary heart disease [3]. Magnetic resonance imaging (MRI) is another valuable noninvasive tool for assessing AA, enabling precise measurement and characterization of plaques [4]. Additionally, nuclear imaging techniques using fluorodeoxyglucose can visualize inflammation and macrophage activity within atherosclerotic plaques, offering insights into plaque activity [5]. Despite these advances, AA remains difficult to diagnose in routine clinical practice. A physiological measure known as the cardio-ankle vascular index (CAVI) was developed in Japan to address this. The CAVI measures arterial stiffness from the origin of the aorta to the ankle and is based on the stiffness parameter β, which adjusts the pulse wave velocity for changes in arterial diameter during the cardiac cycle [6]. The CAVI test is simple, noninvasive, and widely used in clinical medicine as an indicator for evaluating cardiovascular diseases and associated risk factors [7]. However, while the CAVI provides a measure of arterial stiffness, it does not assess the actual shape of the aorta or blood flow dynamics. Recently, three-dimensional (3D) phase-contrast MRI, commonly referred to as four-dimensional (4D) MRI, has emerged as a noninvasive method for evaluating and characterizing vascular blood flow [8-11]. This technique measures hemodynamic velocity by encoding motion in the x, y, and z directions, resolving these velocities in relation to the 3D anatomy and time over the cardiac cycle (3D + time = 4D). In this study, we hypothesized that aortic volume and hemodynamic parameters would correlate with the severity of AA because stiffened arterial walls can restrict blood flow through the vessel lumen. Historically, most methods for evaluating AA have focused on the arterial wall, with few approaches available to assess blood flow within the lumen. We believe that evaluating AA from this alternative perspective could provide new insights. Additionally, given that arteriosclerosis is a systemic disease, we sought to develop a method that could quantitatively assess it over a larger area. Therefore, we considered that quantitatively measuring aortic volume and hemodynamic parameters related to AA would be clinically useful. This study aimed to differentiate changes in aortic volume and blood flow in the thoracic aorta due to atherosclerotic arterial stiffness using 4D MRI-derived hemodynamic parameters in patients with and without AA, as defined by the CAVI. We also investigated the correlation between aortic volume, hemodynamic parameters, and the CAVI. Material and methods Patient population Our institutional review board approved this study and waived the need for written informed consent because of the retrospective study design. From April 2020 to July 2024, 398 consecutive patients (256 men [64.3%] and 142 women [35.7%]; mean age ± SD: 58.0 ± 17.3 years) underwent cardiac contrast-enhanced MRI to investigate cardiomyopathy or cardiac dysfunction for the first time; 317 of these patients also underwent 4D MRI. Data for four patients were unavailable for 4D flow analysis, and 139 patients without CAVI data, as well as three postoperative patients with tetralogy of Fallot or total arch replacement, were excluded from the study. Consequently, the final cohort consisted of 171 consecutive patients (Fig. 1). After the 4D MRI results were analyzed, the patients were divided into two groups (low CAVI group and high CAVI group) based on their CAVI results. The patient cohort comprised 77 patients with a low CAVI score (48 [62.3%] men and 29 [37.7%] women; mean ± SD age, 49.7 ± 16.1 years) and 94 patients with a high CAVI score (74 [78.7%] men and 20 [21.3%] women; mean ± SD age, 67.4 ± 9.9 years) (Table 1). All of these patients were identified through a retrospective review of the medical records at a single medical institution. CAVI score The CAVI score was automatically measured using the vascular screening system VaSera VS-1500 (Fukuda Denshi Co., Ltd., Tokyo, Japan). The patients rested in the supine position for at least 10 minutes while being monitored. Cuffs were attached to both upper arms and ankles, electrocardiogram electrodes were placed on the wrists, and a microphone was positioned on the sternum. The average CAVI values from both sides were used for analysis. A CAVI score of <8.0, as determined by the vascular screening system, is considered within the normal range [12,13]. In this study, CAVI scores of <8.0 were classified as low CAVI, while scores of ≥8.0 were classified as high CAVI. Echocardiographic estimation of left ventricular ejection fraction (LVEF) Within 1 week of cardiac MRI, echocardiographic examinations were performed by experienced cardiologists with >5 years of experience in cardiac echocardiography using the Vivid E95 system version 203 (GE Healthcare Japan, Tokyo, Japan). Images were acquired from standard views and recorded digitally. LVEF values were measured using transthoracic two-dimensional echocardiography, applying the modified Simpson’s rule. MRI protocol All patients were scanned using a 3.0-T scanner (MAGNETOM Vida; Siemens, Healthcare, Germany) with a 32-channel cardiac phased-array coil. The scanning parameters were similar to our previous study [14]. All 4D MR images were acquired under free-breathing conditions during the routine electrocardiographically gated cardiac MRI sequence, prior to late gadolinium enhancement imaging, 30 seconds after the administration of gadolinium at a dose of 0.10 mmol/kg. MRI analysis Aorta data were obtained from regions extending from the neck to the upper abdomen using datasets that included multislice sagittal planes from phase-contrast three-axis cine images, magnitude images, and steady-state free precession cine images. Hemodynamic parameters were measured using iTFlow (Cardio Flow Design Inc., Tokyo, Japan). The thoracic aorta segment evaluated in this study extended from the ascending aorta at the level of the right main pulmonary artery to the descending aorta at the level of the pulmonary valve (Fig. 2), as determined from the 3D cine images. One radiologist with 12 years of experience in reading cardiac MRI analyzed the MRI scans. The radiologist was blinded to the patients’ clinical conditions and investigated. Another radiologist with 15 years of experience interpreting cardiac MRI then reviewed the borders of the thoracic aorta to ensure accuracy. The mean thoracic aortic volume (TAV) (cm 3 ) and flow parameters were automatically calculated. The term “mean” referred to the average value across all phases of a single cardiac cycle because the TAV changes throughout the cycle. We then analyzed the TAV and hemodynamic parameters. Hemodynamic parameters Energy loss (EL) can be directly assessed by estimating viscous EL and turbulent kinetic energy (KE). Viscous dissipation of energy is a normal characteristic of aortic flow. In normal laminar flow, it is caused by friction between adjacent fluid layers with differing velocities. This friction increases with abnormal flow patterns, such as those due to aortic valve disease, resulting in elevated viscous EL [15]. In this study, the average EL (EL ave) was defined as the average value of EL across all phases of one cardiac cycle. The maximum EL (EL max) represented the EL in the phase with the highest value, and the minimum EL (EL min) indicated the EL in the phase with the lowest value across all phases of the cardiac cycle. These three parameters—ave, max, and min—were calculated automatically. Similarly, the ave, max, and min values of vorticity (Vort) and helicity (Hel), described below, were calculated as averages across all phases of one cardiac cycle. Vort is an index that quantifies the strength of the swirl in the velocity vector. High Vort values can increase stress on local blood vessel walls, promoting aneurysmal growth. They may also alter local vascular protective mechanisms, leading to reduced wall shear stress [16, 17]. Hel is an indicator of helical flow, representing corkscrew-like motion along the principal flow direction. Hel in the thoracic aorta can be exacerbated by common pathologies, such as aortic dilatation and alterations in the aortic valve (e.g., aortic valve stenosis or a bicuspid aortic valve) [18, 19]. Using the 4D voxel data, the absolute helicity (Hel abs) was calculated. Hel right screw and Hel left screw, along with their ave, max, and min values, were also calculated. These flow parameters were calculated similar to our previous study [14]. Additionally, we investigated voxel-based values for these flow parameters divided by the TAV because the flow parameters are the sum of the flow in the thoracic aorta and are influenced by TAV. Statistical analysis All statistical analyses were performed using Prism for Windows, version 8.3.0 (GraphPad Software, San Diego, CA, USA). The D’Agostino–Pearson test was used to assess the normality of the data. Non-normally distributed variables are presented as median (range), while quantitative results are expressed as mean ± SD or median (range), as appropriate. We analyzed the patients’ CAVI score, age, body mass index (BMI), LVEF, TAV, and 4D hemodynamic parameters using either the paired t-test or the Wilcoxon signed-rank test between the two groups, depending on the data distribution. Sex, hypertension, diabetes mellitus, renal failure, smoking status, and final diagnosis were compared between the two groups using the chi-squared test. Spearman’s rank correlation coefficients were calculated to assess correlations between the CAVI score and the hemodynamic parameters. A two-sided p -value was used for all statistical tests, and differences with a P -value of <0.05 were considered statistically significant. Results Patient populations in low and high CAVI groups Of the 171 patients included in this study, 77 (45.0%) had a low CAVI score and 94 (55.0%) had a high CAVI score (Table 1). There were no significant differences between the groups in terms of hypertension ( P = 0.089), diabetes mellitus ( P = 0.250), renal failure ( P = 0.550), smoking ( P = 0.054), LVEF ( P = 0.120), unremarkable findings ( P = 0.887), dilated cardiomyopathy ( P = 0.060), hypertrophic cardiomyopathy ( P = 0.424), hypertensive heart disease ( P = 0.198), restrictive cardiomyopathy ( P = 0.116), myocardial infarction ( P = 0.447), vasospastic angina ( P = 0.447), myocarditis ( P = 0.140), drug-induced myocarditis ( P = 0.067), arrhythmia ( P = 0.808), cardiac sarcoidosis ( P = 0.840), left ventricular noncompaction ( P = 0.054), atrial septal defect ( P = 0.887), aortic regurgitation ( P = 0.111), or mitral regurgitation ( P = 0.067). The mean CAVI score was 6.5 ± 1.1 in the low CAVI group and 9.6 ± 1.1 in the high CAVI group. Significant differences were found between the groups in age ( P < 0.0001), sex ( P = 0.018), BMI ( P = 0.002), and cardiac amyloidosis ( P = 0.002). TAV The mean TAV was 80.6 ± 30.5 cm 3 in the low CAVI group and 113.6 ± 29.3 cm 3 in the high CAVI group, with significant differences between the groups ( P < 0.0001). The TAV was significantly positively correlated with the CAVI (R = 0.4147, P < 0.0001). Hemodynamic parameters in patients with low and high CAVI scores (Table 2) (Figure 3) EL between the two groups EL max/TAV differed significantly between the groups ( P = 0.0035). Although EL ave/TAV did not differ significantly, the P -value was very close to significance ( P = 0.0516). Vort between the two groups Vort ave, Vort ave/TAV, Vort max/TAV, and Vort min differed significantly between the groups ( P = 0.0248, P = 0.0004, P < 0.0001, and P = 0.0070, respectively). Hel between the two groups Hel abs ave/TAV and Hel abs max/TAV differed significantly between the groups ( P = 0.0426 and P = 0.0002, respectively). Although Hel abs min/TAV did not differ significantly between the groups, the P -values were very close to significance ( P = 0.0685). Both Hel right screw ave/TAV and Hel right screw max/TAV showed significant differences between the groups ( P < 0.0001 for both). Additionally, Hel left screw ave/TAV and Hel left screw min/TAV also differed significantly ( P = 0.0002 and P < 0.0001, respectively). Representative 4D hemodynamic images are shown in Figures 4 and 5. Figure 4 shows images of a patient with a low CAVI score, in whom the EL, Vort, and Hel values increased gradually as the systolic phase progressed. Figure 5 shows images of a patient with a high CAVI score, in whom the EL, Vort, and Hel values also increased during systole. However, the changes were smaller than those in the patient from Figure 4, especially during systole, with overall lower values. Notably, in the patient with the high CAVI score (Figure 5), the flow parameter values were higher near the arterial wall than near the lumen (indicated by white arrows), likely reflecting the impact of blood flow on the stiffened arterial wall. Correlations between CAVI score and hemodynamic parameters EL ave/TAV and EL max/TAV were weakly but significantly negatively correlated with the CAVI score (R = −0.1731, P = 0.0236 and R = −0.2785, P = 0.0002, respectively). By contrast, EL ave, EL max, EL min, and EL min/TAV were not significantly correlated with the CAVI score (R = −0.06954, P = 0.3195; R = −0.1498, P = 0.0505; R = 0.003303, P = 0.9658; and R = −0.06389, P = 0.4064, respectively). Vort ave/TAV was significantly but weakly negatively correlated with the CAVI score (R = −0.2856, P = 0.0002). Vort max/TAV was moderately negatively correlated with the CAVI score (R = −0.4082, P < 0.0001). Conversely, Vort min was weakly positively correlated with the CAVI score (R = 0.1574, P = 0.0398). However, Vort ave, Vort max, and Vort min/TAV were not significantly correlated with the CAVI score (R = 0.1087, P = 0.1571; R = 0.01243, P = 0.8718; and R = −0.1097, P = 0.1531, respectively). Hel abs ave/TAV, Hel abs max, and Hel abs max/TAV were weakly but significantly negatively correlated with the CAVI score (R = −0.2439, P = 0.0013; R = −0.2248, P = 0.0031; and R = −0.3777, P < 0.0001, respectively). Hel abs min/TAV was weakly positively correlated with the CAVI score (R = 0.2081, P = 0.0063). By contrast, Hel abs ave and Hel abs min were not significantly correlated with the CAVI score (R = −0.1101, P = 0.1518 and R = 0.1471, P = 0.0549, respectively). Hel right screw ave/TAV and Hel right screw max were weakly negatively correlated with the CAVI score (R = −0.3752, P < 0.0001 and R = −0.2080, P = 0.0063, respectively). Hel right screw max/TAV showed a moderate negative correlation with the CAVI score (R = −0.4211, P < 0.0001). By contrast, Hel right screw ave, Hel right screw min, and Hel right screw min/TAV were not significantly correlated with the CAVI score (R = −0.1221, P = 0.1116; R = 0.06518, P = 0.3970; and R = −0.02836, P = 0.7127, respectively). Hel left screw ave/TAV, Hel left screw min, and Hel left screw min/TAV were significantly positively correlated with the CAVI score (R = 0.3211, P < 0.0001; R = 0.1645, P = 0.0315; and R = 0.3776, P < 0.0001, respectively). By contrast, Hel left screw ave, Hel left screw max, and Hel left screw max/TAV were not significantly correlated with the CAVI score (R = 0.09810, P = 0.2018; R = −0.04128, P = 0.5919; and R = 0.04988, P = 0.5171, respectively) (Fig. S1). Discussion Aortic dilatation in older patients is associated with atherosclerosis [20, 21]. In this study, patients with a high CAVI score had a larger TAV and were older than patients with a low CAVI score. Furthermore, there was a relatively strong correlation between the CAVI score and TAV, suggesting a relationship between TAV and arteriosclerosis. Although other factors could account for the difference in TAV, there were no significant differences between the groups in terms of hypertension, diabetes mellitus, renal failure, or smoking. However, a higher proportion of male patients and those with a lower BMI were observed in the high CAVI group, and these factors may have contributed to the progression of atherosclerosis. We evaluated two types of hemodynamic parameters: those not divided by the TAV and voxel-based parameters that were divided by the TAV. We presumed that the hemodynamic parameters not divided by the TAV were strongly influenced by the TAV because they were calculated as the sum of the flow across the entire thoracic aorta. Notably, some hemodynamic parameters, such as Vort ave and Vort min, tended to have higher values in the high CAVI group than in the low CAVI group. However, most hemodynamic parameters not divided by the TAV did not show significant differences between the groups. Despite the larger TAV in the high CAVI group, there were no significant differences in hemodynamic parameter values compared with the low CAVI group, suggesting that hemodynamic parameters per unit volume were reduced in the high CAVI group. Therefore, we concluded that voxel-based flow parameters divided by the TAV better reflected the flow characteristics in the thoracic aorta related to AA. 4D MRI can provide various hemodynamic parameters, such as EL, Vort, and Hel [22]. In this study, there were significant differences in EL max/TAV between the groups. KE refers to the energy contained in the flow of blood due to its motion, while EL represents the KE lost as a result of frictional forces caused by fluid viscosity within the blood flow [23]. There were significant differences in Vort ave/TAV and Vort max/TAV between the groups. Vort is an indicator of spatial velocity gradients that may reveal complex hemodynamic phenomena [24]. Significant differences were also observed between the groups in Hel abs ave/TAV, Hel abs max/TAV, Hel right screw ave/TAV, Hel right screw max/TAV, Hel left screw ave/TAV, and Hel left screw min/TAV. Hel is an indicator of helical flow and was calculated by integrating the voxel-based absolute value of Vort × velocity. Hel describes corkscrew-like motion along the principal flow direction and is considered a normal feature in healthy individuals [25–27]. Helical flow increases as a result of altered aortic blood flow, often due to aortic valve disease [19, 28, 29]. In this study, the values for these voxel-based hemodynamic parameters tended to be lower in the high CAVI group than in the low CAVI group. The hemodynamic values were higher near the arteriosclerotic vessel walls. However, the overall lower values in the high CAVI group suggest that AA restricted blood flow within the lumen. Based on these findings, we propose that the primary pathogenesis of AA may involve the restriction of luminal blood flow rather than arterial wall sclerosis alone. Furthermore, many voxel-based parameters (e.g., max values) were lower in the high CAVI group, especially during the systolic phase, suggesting that AA may affect hemodynamic parameters, particularly during systole. Although previous research has shown that hemodynamic parameters can vary depending on the LVEF [30], and differences in the LVEF may influence these parameters, there was no difference in the LVEF between the groups in this study. Vort min was significantly weakly positively correlated with the CAVI score in this study. Flow parameters not divided by the TAV may be influenced by AA-induced increases in the TAV. Helical parameters such as Hel abs max, Hel right screw max, and Hel left screw min (not divided by TAV) were weakly correlated with the CAVI score, but those divided by the TAV showed stronger correlations with the CAVI score. EL ave/TAV, EL max/TAV, Vort ave/TAV, Hel abs ave/TAV, Hel abs max/TAV, Hel abs min/TAV, Hel right screw ave/TAV, Hel left screw ave/TAV, and Hel left screw min/TAV were significantly weakly correlated with the CAVI, whereas Vort max/TAV and Hel right screw max/TAV showed moderate negative correlations with the CAVI score. Notably, these max (or partial min) parameters exhibited stronger correlations with the CAVI score than did their ave counterparts. These results suggest that the CAVI score is associated with greater restriction of blood flow within the lumen, especially during systole. Blood flow in the thoracic aorta can be quantitatively evaluated using 4D MRI. To date, only one study has reported a correlation between the CAVI score and aortic distensibility using cardiovascular MRI [31]. However, to the best of our knowledge, no previous studies have examined the relationship between the CAVI score and hemodynamic parameters using MRI. The global burden of ischemic atherosclerotic cardiovascular disease has risen, making it one of the leading causes of morbidity, loss of life years, and mortality [32]. Importantly, atherosclerosis is a condition that can be prevented through lifestyle changes and early intervention. Thus, the early diagnosis, severity grading, and prediction of atherosclerosis are crucial. The results of this study may be clinically useful because noninvasive quantitative evaluation of aortic volume and hemodynamic parameters could aid in diagnosing and evaluating patients with AA. Moreover, incorporating a 4D MR sequence into routine cardiac MRI, as done in this study, could help detect AA early because there is a relationship between heart failure and AA [33, 34]. This study had several limitations. First, it included patients from a single institution and lacked an external validation cohort. Second, most patients underwent cardiac MRI with a 4D flow sequence because of suspected heart disease; thus, the results may not be generalizable to the entire population. Finally, although we used the CAVI score to assess AA, we were unable to directly evaluate AA within the thoracic aorta. Conclusion The TAV was larger, and the voxel-based hemodynamic parameters (EL, Vort, and Hel/TAV), were lower in the high CAVI group than in the low CAVI group. Moreover, these hemodynamic parameters were correlated with the CAVI score, which may reflect restricted luminal blood flow in the thoracic aorta due to AA. Thus, simultaneously measuring aortic volume and hemodynamic parameters using 4D MRI could represent a novel method for evaluating atherosclerosis. Abbreviations AA: aortic atherosclerosis CAVI: cardio-ankle vascular index 3D: three-dimensional 4D: four-dimensional MRI: magnetic resonance imaging LVEF: left ventricular ejection fraction EL: energy loss KE: kinetic energy Vort: vorticity Hel: helicity TAV: thoracic aortic volume BMI: body mass index SD: standard deviation ave: average min: minimum max: maximum abs: absolute Declarations Acknowledgment We thank Angela Morben, DVM, ELS, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript. Authors’ contributions HK: Conception and design of the research, Writing of the manuscript. ES: Critical Review of the Manuscript. RT: Manuscript drafting. TN, MM, SM: Acquisition of data. All authors read and approved the final draft. Funding JSPS KAKENHI (Granted No. 21K07733). Data availability Data will be provided upon reasonable request by the corresponding author. Ethics approval and consent to participate This study was approved by the Institutional Review Board of the Nagasaki University Hospital (The date of approval (16/9/2020) and the project identification code (20091416)) and adhered to the ethical standards of the Declaration of Helsinki. Informed consent was waived because of the retrospective study design, and patient records and information were anonymized and de-identified prior to analysis. Clinical trial number Not applicable. Consent to publication Not applicable. Competing interests The authors declare no competing interests. Author details 1 Department of Radiology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan 2 Cardio Flow Design Inc, 22-3 Ichiban-cho Chiyoda-ku, Tokyo 102-0082, Japan References Willum-Hansen T, Staessen JA, Torp-Pedersen C, et al. Prognostic value of aortic pulse wave velocity as index of arterial stiffness in the general population. Circulation 2006;113:664-70. https://doi.org/10.1161/CIRCULATIONAHA.105.579342 Mattace-Raso FU, van der Cammen TJ, et al. Arterial stiffness and risk of coronary heart disease and stroke: The Rotterdam Study. Circulation 2006;113:657-63. https://doi.org/10.1161/circulationaha.105.555235 Knuuti Juhani, Wijns W, Saraste A, et al. 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2019;41:407-77. https://doi.org/10.1093/eurheartj/ehz425 Wüst Rob CI, Calcagno C, Daal MRR, et al. 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Patients’ demographic and clinical characteristics (n = 171) Parameter Low CAVI (n = 77) High CAVI (n = 94) P -value CAVI score 6.5 ± 1.1 9.6 ± 1.1 <0.0001* Age, years 49.7 ± 16.1 67.4 ± 9.9 <0.0001* Sex, male:female 48:29 74:20 0.018* BMI, kg/m 2 24.8 ± 5.2 22.2 ± 3.4 0.002* Hypertension 35 (45.5) 55 (58.5) 0.089 Diabetes mellitus 14 (18.2) 24 (25.5) 0.250 Renal failure 4 (5.2) 7 (7.4) 0.550 Smoking 37 (48.1) 59 (62.8) 0.054 LVEF, % 44.7 ± 16.7 48.5 ± 15.2 0.120 Final diagnosis Unremarkable findings 1 (1.3) 1 (1.1) 0.887 DCM 30 (39.0) 24 (25.5) 0.060 HCM 9 (11.7) 15 (16.0) 0.424 HHD 0 (0.0) 2 (2.1) 0.198 RCM 2 (2.6) 0 (0.0) 0.116 MI 7 (9.1) 12 (12.8) 0.447 VSA 2 (2.6) 1 (1.1) 0.447 Myocarditis 10 (13.0) 6 (6.4) 0.140 Drug-induced myocarditis 0 (0.0) 4 (4.3) 0.067 Arrhythmia 5 (6.5) 7 (7.4) 0.808 Cardiac sarcoidosis 2 (2.6) 2 (2.1) 0.840 Cardiac amyloidosis 1 (1.3) 14 (14.9) 0.002* LVNC 3 (3.9) 0 (0.0) 0.054 ASD 1 (1.3) 1 (1.1) 0.887 AR 4 (5.2) 1 (1.1) 0.111 MR 0 (0.0) 4 (4.3) 0.067 Data are expressed as n (%) or mean ± standard deviation (range). * P < 0.05. CAVI, cardio-ankle vascular index; BMI, body mass index; LVEF, left ventricular ejection fraction; DCM, dilated cardiomyopathy; HCM, hypertrophic cardiomyopathy; HHD, hypertensive heart disease; RCM, restrictive cardiomyopathy; MI, myocardial infarction; VSA, vasospastic angina; LVNC, left ventricular noncompaction; ASD, atrial septal defect; AR, aortic regurgitation; MR, mitral regurgitation Table 2. Thoracic aortic volume and hemodynamic parameters in patients with low and high CAVI scores (n = 171) Parameter Low CAVI (n = 77) High CAVI (n = 94) P- value TAV (cm 3 ) 80.6 ± 30.5 113.6 ± 29.3 <0.0001* Energy loss ave (× 10 2 mW) 157 ± 258 146 ± 188 0.7304 Energy loss ave/TAV (× 10 2 mW) 1.9 ± 2.0 1.3 ± 1.8 0.0516 Energy loss max (× 10 2 mW) 368 ± 725 267 ± 273 0.2165 Energy loss max/TAV (× 10 2 mW) 4.4 ± 5.5 2.5 ± 2.6 0.0035* Energy loss min (× 10 2 mW) 86 ± 156 95 ± 140 0.6854 Energy loss min/TAV (× 10 2 mW) 0.97 ± 1.2 0.83 ± 1.3 0.4583 Vorticity ave (× 10 4 m 3 s -1 ) 34 ± 20 40 ± 16 0.0248* Vorticity ave/TAV (× 10 4 m 3 s -1 ) 0.42 ± 0.13 0.36 ± 0.12 0.0004* Vorticity max (× 10 4 m 3 s -1 ) 55 ± 34 61 ± 21 0.1630 Vorticity max/TAV (× 10 4 m 3 s -1 ) 0.71 ± 0.25 0.55 ± 0.18 <0.0001* Vorticity min (× 10 4 m 3 s -1 ) 24 ± 16 31 ± 15 0.0070* Vorticity min/TAV (× 10 4 m 3 s -1 ) 0.29 ± 0.11 0.27 ± 0.11 0.1531 Helicity abs ave (× 10 6 m 4 s -2 ) 12 ± 37 12 ± 26 0.9377 Helicity abs ave/TAV (× 10 6 m 4 s -2 ) 0.25 ± 0.55 0.12 ± 0.25 0.0426* Helicity abs max (× 10 6 m 4 s -2 ) 162 ± 152 132 ± 134 0.1671 Helicity abs max/TAV (× 10 6 m 4 s -2 ) 2.4 ± 2.7 1.2 ± 1.4 0.0002* Helicity abs min (× 10 6 m 4 s -2 ) −160 ± 529 −78 ± 95 0.1443 Helicity abs min/TAV (× 10 6 m 4 s -2 ) −1.8 ± 5.6 −0.74 ± 1.1 0.0685 Helicity right screw ave (× 10 6 m 4 s -2 ) 169 ± 169 155 ± 115 0.5328 Helicity right screw ave/TAV (× 10 6 m 4 s -2 ) 2.2 ± 1.5 1.4 ± 1.0 <0.0001* Helicity right screw max (× 10 6 m 4 s -2 ) 504 ± 555 407 ± 255 0.1341 Helicity right screw max/TAV (× 10 6 m 4 s -2 ) 6.8 ± 5.5 3.8 ± 2.6 <0.0001* Helicity right screw min (× 10 6 m 4 s -2 ) 56 ± 80 69 ± 88 0.3061 Helicity right screw min/TAV (× 10 6 m 4 s -2 ) 0.64 ± 0.54 0.60 ± 0.74 0.6680 Helicity left screw ave (× 10 6 m 4 s -2 ) −156 ± 164 −143 ± 111 0.5480 Helicity left screw ave/TAV (× 10 6 m 4 s -2 ) −1.9 ± 1.3 −1.3 ± 1.0 0.0002* Helicity left screw max (× 10 6 m 4 s -2 ) −53 ± 78 −63 ± 73 0.3830 Helicity left screw max/TAV (× 10 6 m 4 s -2 ) −0.61 ± 0.53 −0.55 ± 0.66 0.5427 Helicity left screw min (× 10 6 m 4 s -2 ) −426 ± 533 −351 ± 229 0.2259 Helicity left screw min/TAV (× 10 6 m 4 s -2 ) −5.4 ± 4.4 −3.2 ± 2.2 <0.0001* Data are expressed as mean ± standard deviation. * P < 0.05. CAVI, cardio-ankle vascular index; TAV, thoracic aortic volume; ave, average; max, maximum; min, minimum; abs, absolute. Additional Declarations No competing interests reported. Supplementary Files FigureS1.docx Cite Share Download PDF Status: Published Journal Publication published 29 Apr, 2026 Read the published version in BMC Cardiovascular Disorders → Version 1 posted Editorial decision: Revision requested 22 Jan, 2026 Reviews received at journal 22 Jan, 2026 Reviews received at journal 14 Jan, 2026 Reviewers agreed at journal 27 Dec, 2025 Reviewers agreed at journal 24 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviews received at journal 19 Nov, 2025 Reviewers agreed at journal 18 Nov, 2025 Reviewers invited by journal 23 Oct, 2025 Editor invited by journal 22 Oct, 2025 Editor assigned by journal 22 Oct, 2025 Submission checks completed at journal 20 Oct, 2025 First submitted to journal 20 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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13:13:03","extension":"tif","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":165962,"visible":true,"origin":"","legend":"","description":"","filename":"FigureS1zE.tif","url":"https://assets-eu.researchsquare.com/files/rs-7837857/v1/e416c3736024e7890c2b175c.tif"},{"id":95205720,"identity":"ffc8f74e-0eb0-4887-bac5-d4632ca89185","added_by":"auto","created_at":"2025-11-05 13:13:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":123282,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart showing patient selection.\u003c/p\u003e\n\u003cp\u003eMRI, magnetic resonance imaging; 4D, four-dimensional; CAVI, cardio-ankle vascular index\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7837857/v1/785686664984a6394ee8c7e1.png"},{"id":95227451,"identity":"ed3bd289-3a49-437c-93df-0f2e44a7c0ff","added_by":"auto","created_at":"2025-11-05 16:32:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":550475,"visible":true,"origin":"","legend":"\u003cp\u003eEvaluation of segmented thoracic aorta.\u003c/p\u003e\n\u003cp\u003eThe green area represents the segmented thoracic aorta in the same cross-section. (a) Sagittal cine image of the ascending aorta at the level of the upper border of the right main pulmonary artery (white arrow). (b) Sagittal cine image of the descending aorta at the level of the upper border of the pulmonary valve (white arrow).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7837857/v1/1c1587c5766bdef6e2145521.png"},{"id":95205723,"identity":"0c027154-b42d-4361-a2de-6d1f17cc9a8b","added_by":"auto","created_at":"2025-11-05 13:13:02","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":220630,"visible":true,"origin":"","legend":"\u003cp\u003eIndividual data for TAV, Energy loss max/TAV, Vorticity max/TAV, Helicity abs max/TAV, Helicity right screw max/TAV, and Helicity left screw min/TAV in patients in the low CAVI and high CAVI groups.\u003c/p\u003e\n\u003cp\u003e(a) TAV: low CAVI vs high CAVI, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001\u003c/p\u003e\n\u003cp\u003e(b) Energy loss max/TAV: low CAVI vs high CAVI, \u003cem\u003eP\u003c/em\u003e= 0.0035\u003c/p\u003e\n\u003cp\u003e(c) Vorticity max/TAV: low CAVI vs high CAVI, \u003cem\u003eP\u003c/em\u003e\u0026lt; 0.0001\u003c/p\u003e\n\u003cp\u003e(d) Helicity abs max/TAV: low CAVI vs high CAVI, \u003cem\u003eP\u003c/em\u003e= 0.0002\u003c/p\u003e\n\u003cp\u003e(e) Helicity right screw max/TAV: low CAVI vs high CAVI, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001\u003c/p\u003e\n\u003cp\u003e(f) Helicity left screw min/TAV: low CAVI vs high CAVI, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001\u003c/p\u003e\n\u003cp\u003eAbbreviations: TAV, thoracic aortic volume; abs, absolute; max, maximum; min, minimum; CAVI, cardio-ankle vascular index\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7837857/v1/f43ca6d04032ea04a22cf8db.png"},{"id":95228912,"identity":"312d7fee-d10b-4d4d-aa04-3b537004b4dc","added_by":"auto","created_at":"2025-11-05 16:34:15","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":844065,"visible":true,"origin":"","legend":"\u003cp\u003eFour-dimensional flow map imaging of a 38-year-old man with hypertrophic cardiomyopathy in the low CAVI group. The left ventricular ejection fraction was 48%, and the CAVI score was 6.3.\u003c/p\u003e\n\u003cp\u003e(a) EL in the end-diastolic phase. (b) EL in the early systolic phase. (c) EL in the end-systolic phase. (d) EL in the early diastolic phase. (e) Vort in the end-diastolic phase. (f) Vort in the early systolic phase. (g) Vort in the end-systolic phase. (h) Vort in the early diastolic phase. (i) Hel in the end-diastolic phase. (j) Hel in the early systolic phase. (k) Hel in the end-systolic phase. (l) Hel in the early diastolic phase. Abbreviations: CAVI, cardio-ankle vascular index; EL, energy loss; Vort, vorticity; Hel, helicity\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-7837857/v1/1fe3a2b92be0701b68383c7b.png"},{"id":95205728,"identity":"2278c7be-b549-41d8-b46f-ebb33cec7d53","added_by":"auto","created_at":"2025-11-05 13:13:02","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":778178,"visible":true,"origin":"","legend":"\u003cp\u003eFour-dimensional flow map imaging of a 58-year-old man with myocarditis in the high CAVI group. The left ventricular ejection fraction was 47%, and the CAVI score was 9.8.\u003c/p\u003e\n\u003cp\u003e(a) EL in the end-diastolic phase. (b) EL in the early systolic phase. (c) EL in the end-systolic phase. (d) EL in the early diastolic phase. (e) Vort in the end-diastolic phase. (f) Vort in the early systolic phase. (g) Vort in the end-systolic phase. (h) Vort in the early diastolic phase. (i) Hel in the end-diastolic phase. (j) Hel in the early systolic phase. (k) Hel in the end-systolic phase. (l) Hel in the early diastolic phase. Abbreviations: CAVI, cardio-ankle vascular index; EL, energy loss; Vort, vorticity; Hel, helicity\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-7837857/v1/192fc6eca3003d73aedd5a52.png"},{"id":108438055,"identity":"5ba39b83-e231-4be4-9b1e-a184da13c15f","added_by":"auto","created_at":"2026-05-04 16:06:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2804230,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7837857/v1/d94002d6-e7dd-473f-9d3c-35517d840ec3.pdf"},{"id":95205721,"identity":"0c871aa8-dcff-42ea-9f37-e8a17efb6cb4","added_by":"auto","created_at":"2025-11-05 13:13:02","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":690125,"visible":true,"origin":"","legend":"","description":"","filename":"FigureS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7837857/v1/f2c6437caf4f201961cb997e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Associations between cardio-ankle vascular index score and aortic volume and hemodynamic parameters using four-dimensional magnetic resonance imaging","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAortic atherosclerosis (AA) is a chronic inflammatory condition characterized by the accumulation of plaques within the arterial wall. This results in arterial wall stiffness and is associated with an increased risk of cardiovascular events [1,2]. Therefore, early diagnosis, severity grading, and prediction of AA are crucial. The evaluation of patients with suspected or confirmed AA typically relies on imaging techniques. One of the most widely accepted imaging tests for atherosclerosis is computed tomography angiography, which provides anatomical imaging of plaques in coronary heart disease [3]. Magnetic resonance imaging (MRI) is another valuable noninvasive tool for assessing AA, enabling precise measurement and characterization of plaques [4]. Additionally, nuclear imaging techniques using fluorodeoxyglucose can visualize inflammation and macrophage activity within atherosclerotic plaques, offering insights into plaque activity [5].\u003c/p\u003e\n\u003cp\u003eDespite these advances, AA remains difficult to diagnose in routine clinical practice. A physiological measure known as the cardio-ankle vascular index (CAVI) was developed in Japan to address this. The CAVI measures arterial stiffness from the origin of the aorta to the ankle and is based on the stiffness parameter \u0026beta;, which adjusts the pulse wave velocity for changes in arterial diameter during the cardiac cycle [6]. The\u0026nbsp;CAVI test is simple, noninvasive, and widely used in clinical medicine as an indicator for evaluating cardiovascular diseases and associated risk factors [7]. However, while the CAVI provides a measure of arterial stiffness, it does not assess the actual shape of the aorta or blood flow dynamics.\u003c/p\u003e\n\u003cp\u003eRecently, three-dimensional (3D) phase-contrast MRI, commonly referred to as four-dimensional (4D) MRI, has emerged as a noninvasive method for evaluating and characterizing vascular blood flow [8-11]. This technique measures hemodynamic velocity by encoding motion in the x, y, and z directions, resolving these velocities in relation to the 3D anatomy and time over the cardiac cycle (3D + time = 4D).\u003c/p\u003e\n\u003cp\u003eIn this study, we hypothesized that\u0026nbsp;aortic volume and hemodynamic parameters would correlate with the severity of AA because stiffened arterial walls can restrict blood flow through the vessel lumen. Historically, most methods for evaluating AA have focused on the arterial wall, with few approaches available to assess blood flow within the lumen. We believe that evaluating AA from this alternative perspective could provide new insights. Additionally, given that arteriosclerosis is a systemic disease, we sought to develop a method that could quantitatively assess it over a larger area. Therefore, we considered that quantitatively measuring aortic volume and hemodynamic parameters related to AA would be clinically useful.\u003c/p\u003e\n\u003cp\u003eThis study aimed to differentiate changes in aortic volume and blood flow in the thoracic aorta due to atherosclerotic arterial stiffness using 4D MRI-derived hemodynamic parameters in patients with and without AA, as defined by the CAVI. We also investigated the correlation between aortic volume, hemodynamic parameters, and the CAVI.\u0026nbsp;\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003e\u003cem\u003ePatient population\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOur institutional review board approved this study and waived the need for written informed consent because of the retrospective study design. From April 2020 to July 2024, 398 consecutive patients (256 men [64.3%] and 142 women [35.7%]; mean age \u0026plusmn; SD: 58.0 \u0026plusmn; 17.3 years) underwent cardiac contrast-enhanced MRI to investigate cardiomyopathy or cardiac dysfunction for the first time; 317 of these patients also underwent 4D MRI. Data for four patients were unavailable for 4D flow analysis, and 139 patients without CAVI data, as well as three postoperative patients with tetralogy of Fallot or total arch replacement, were excluded from the study. Consequently, the final cohort consisted of 171 consecutive patients (Fig. 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter the 4D MRI results were analyzed, the patients were divided into two groups (low CAVI group and high CAVI group) based on their CAVI results. The patient cohort comprised 77 patients with a low CAVI score (48 [62.3%] men and 29 [37.7%] women; mean \u0026plusmn; SD age, 49.7 \u0026plusmn; 16.1 years) and 94 patients with a high CAVI score (74 [78.7%] men and 20 [21.3%] women; mean \u0026plusmn; SD age, 67.4 \u0026plusmn; 9.9 years) (Table 1). All of these patients were identified through a retrospective review of the medical records at a single medical institution.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCAVI score\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe CAVI score was automatically measured using the vascular screening system VaSera VS-1500 (Fukuda Denshi Co., Ltd., Tokyo, Japan). The patients rested in the supine position for at least 10 minutes while being monitored. Cuffs were attached to both upper arms and ankles, electrocardiogram electrodes were placed on the wrists, and a microphone was positioned on the sternum. The average CAVI values from both sides were used for analysis. A CAVI score of \u0026lt;8.0, as determined by the vascular screening system, is considered within the normal range [12,13]. In this study, CAVI scores of \u0026lt;8.0 were classified as low CAVI, while scores of \u0026ge;8.0 were classified as high CAVI.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEchocardiographic estimation of left ventricular ejection fraction (LVEF)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWithin 1 week of cardiac MRI, echocardiographic examinations were performed by experienced cardiologists with \u0026gt;5 years of experience in cardiac echocardiography using the Vivid E95 system version 203 (GE Healthcare Japan, Tokyo, Japan). Images were acquired from standard views and recorded digitally. LVEF values were measured using transthoracic two-dimensional echocardiography, applying the modified Simpson\u0026rsquo;s rule.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMRI protocol\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll patients were scanned using a 3.0-T scanner (MAGNETOM Vida; Siemens, Healthcare, Germany) with a 32-channel cardiac phased-array coil. The scanning parameters were similar to our previous study [14].\u003c/p\u003e\n\u003cp\u003eAll 4D MR images were acquired under free-breathing conditions during the routine electrocardiographically gated cardiac MRI sequence, prior to late gadolinium enhancement imaging, 30 seconds after the administration of gadolinium at a dose of 0.10 mmol/kg.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMRI analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAorta data were obtained from regions extending from the neck to the upper abdomen using datasets that included multislice sagittal planes from phase-contrast three-axis cine images, magnitude images, and steady-state free precession cine images. Hemodynamic parameters were measured using iTFlow (Cardio Flow Design Inc., Tokyo, Japan). The thoracic aorta segment evaluated in this study extended from the ascending aorta at the level of the right main pulmonary artery to the descending aorta at the level of the pulmonary valve (Fig. 2), as determined from the 3D cine images.\u003c/p\u003e\n\u003cp\u003eOne radiologist with 12 years of experience in reading cardiac MRI analyzed the MRI scans. The radiologist was blinded to the patients\u0026rsquo; clinical conditions and investigated. Another radiologist with 15 years of experience interpreting cardiac MRI then reviewed the borders of the thoracic aorta to ensure accuracy. The mean thoracic aortic volume (TAV) (cm\u003csup\u003e3\u003c/sup\u003e) and flow parameters were automatically calculated. The term \u0026ldquo;mean\u0026rdquo; referred to the average value across all phases of a single cardiac cycle because the TAV changes throughout the cycle. We then analyzed the TAV and hemodynamic parameters.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHemodynamic parameters\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEnergy loss (EL) can be directly assessed by estimating viscous EL and turbulent kinetic energy (KE). Viscous dissipation of energy is a normal characteristic of aortic flow. In normal laminar flow, it is caused by friction between adjacent fluid layers with differing velocities. This friction increases with abnormal flow patterns, such as those due to aortic valve disease, resulting in elevated viscous EL [15].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this study, the average EL (EL ave) was defined as the average value of EL across all phases of one cardiac cycle. The maximum EL (EL max) represented the EL in the phase with the highest value, and the minimum EL (EL min) indicated the EL in the phase with the lowest value across all phases of the cardiac cycle. These three parameters\u0026mdash;ave, max, and min\u0026mdash;were calculated automatically.\u003c/p\u003e\n\u003cp\u003eSimilarly, the ave, max, and min values of vorticity (Vort) and helicity (Hel), described below, were calculated as averages across all phases of one cardiac cycle.\u003c/p\u003e\n\u003cp\u003eVort is an index that quantifies the strength of the swirl in the velocity vector. High Vort values can increase stress on local blood vessel walls, promoting aneurysmal growth. They may also alter local vascular protective mechanisms, leading to reduced wall shear stress [16, 17].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHel is an indicator of helical flow, representing corkscrew-like motion along the principal flow direction. Hel in the thoracic aorta can be exacerbated by common pathologies, such as aortic dilatation and alterations in the aortic valve (e.g., aortic valve stenosis or a bicuspid aortic valve) [18, 19].\u0026nbsp;Using the 4D voxel data, the absolute helicity (Hel abs) was calculated. Hel right screw and Hel left screw, along with their ave, max, and min values, were also calculated. These flow parameters were calculated similar to our previous study [14].\u003c/p\u003e\n\u003cp\u003eAdditionally, we investigated voxel-based values for these flow parameters divided by the TAV because the flow parameters are the sum of the flow in the thoracic aorta and are influenced by TAV.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll statistical analyses were performed using Prism for Windows, version 8.3.0 (GraphPad Software, San Diego, CA, USA). The D\u0026rsquo;Agostino\u0026ndash;Pearson test was used to assess the normality of the data. Non-normally distributed variables are presented as median (range), while quantitative results are expressed as mean \u0026plusmn; SD or median (range), as appropriate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe analyzed the patients\u0026rsquo; CAVI score, age, body mass index (BMI), LVEF, TAV, and 4D hemodynamic parameters using either the paired t-test or the Wilcoxon signed-rank test between the two groups, depending on the data distribution. Sex, hypertension, diabetes mellitus, renal failure, smoking status, and\u0026nbsp;final diagnosis were compared between the two groups using the chi-squared test. Spearman\u0026rsquo;s rank correlation coefficients were calculated to assess correlations between the CAVI score and the hemodynamic parameters.\u003c/p\u003e\n\u003cp\u003eA two-sided \u003cem\u003ep\u003c/em\u003e-value was used for all statistical tests, and differences with a \u003cem\u003eP\u003c/em\u003e-value of \u0026lt;0.05 were considered statistically significant.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003ePatient populations in\u0026nbsp;low and high CAVI groups\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOf the 171 patients included in this study, 77 (45.0%) had a low CAVI score and 94 (55.0%) had a high CAVI score (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere were no significant differences between the groups in terms of hypertension (\u003cem\u003eP\u003c/em\u003e = 0.089), diabetes mellitus (\u003cem\u003eP\u003c/em\u003e = 0.250), renal failure (\u003cem\u003eP\u003c/em\u003e = 0.550), smoking (\u003cem\u003eP\u003c/em\u003e = 0.054), LVEF (\u003cem\u003eP\u003c/em\u003e = 0.120), unremarkable findings (\u003cem\u003eP\u003c/em\u003e = 0.887), dilated cardiomyopathy (\u003cem\u003eP\u003c/em\u003e = 0.060), hypertrophic cardiomyopathy (\u003cem\u003eP\u003c/em\u003e = 0.424), hypertensive heart disease (\u003cem\u003eP\u003c/em\u003e = 0.198), restrictive cardiomyopathy (\u003cem\u003eP\u003c/em\u003e = 0.116), myocardial infarction (\u003cem\u003eP\u003c/em\u003e = 0.447), vasospastic angina (\u003cem\u003eP\u003c/em\u003e = 0.447), myocarditis (\u003cem\u003eP\u003c/em\u003e = 0.140), drug-induced myocarditis (\u003cem\u003eP\u003c/em\u003e = 0.067), arrhythmia (\u003cem\u003eP\u003c/em\u003e = 0.808), cardiac sarcoidosis (\u003cem\u003eP\u003c/em\u003e = 0.840), left ventricular noncompaction (\u003cem\u003eP\u003c/em\u003e = 0.054), atrial septal defect (\u003cem\u003eP\u003c/em\u003e = 0.887), aortic regurgitation (\u003cem\u003eP\u003c/em\u003e = 0.111), or mitral regurgitation (\u003cem\u003eP\u003c/em\u003e = 0.067).\u003c/p\u003e\n\u003cp\u003eThe mean CAVI score was 6.5 \u0026plusmn; 1.1 in the low CAVI group and 9.6 \u0026plusmn; 1.1 in the high CAVI group. Significant differences were found between the groups in age (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.0001), sex (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.018), BMI (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.002), and cardiac amyloidosis (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.002).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTAV\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe mean TAV was 80.6 \u0026plusmn; 30.5 cm\u003csup\u003e3\u003c/sup\u003e in the low CAVI group and 113.6 \u0026plusmn; 29.3 cm\u003csup\u003e3\u003c/sup\u003e in the high CAVI group, with significant differences between the groups (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001). The TAV was significantly positively correlated with the CAVI (R = 0.4147, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.0001).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHemodynamic\u003c/em\u003e\u003cem\u003e\u0026nbsp;parameters in patients\u0026nbsp;\u003c/em\u003e\u003cem\u003ewith low and high CAVI scores (Table 2) (Figure 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEL between the two groups\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEL max/TAV differed significantly between the groups\u0026nbsp;(\u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.0035). Although EL ave/TAV did not differ significantly, the \u003cem\u003eP\u003c/em\u003e-value was very close to significance (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.0516).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eVort between the two groups\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eVort ave, Vort ave/TAV, Vort max/TAV, and Vort min differed significantly between the groups (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.0248, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.0004, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.0001, and \u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.0070, respectively).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHel between the two groups\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHel abs ave/TAV and Hel abs max/TAV differed significantly between the groups (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.0426 and \u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.0002, respectively). Although Hel abs min/TAV did not differ significantly between the groups, the \u003cem\u003eP\u003c/em\u003e-values were very close to significance (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.0685).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBoth Hel right screw ave/TAV and Hel right screw max/TAV showed significant differences between the groups (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001 for both). Additionally, Hel left screw ave/TAV and Hel left screw min/TAV also differed significantly (\u003cem\u003eP\u003c/em\u003e = 0.0002 and \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001, respectively).\u003c/p\u003e\n\u003cp\u003eRepresentative 4D hemodynamic images are shown in Figures 4 and 5. Figure 4 shows images of a patient with a low CAVI score, in whom the EL, Vort, and Hel values increased gradually as the systolic phase progressed. Figure 5 shows images of a patient with a high CAVI score, in whom the EL, Vort, and Hel values also increased during systole. However, the changes were smaller than those in the patient from Figure 4, especially during systole, with overall lower values. Notably, in the patient with the high CAVI score (Figure 5), the flow parameter values were higher near the arterial wall than near the lumen (indicated by white arrows), likely reflecting the impact of blood flow on the stiffened arterial wall.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCorrelations between CAVI score and hemodynamic parameters\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEL ave/TAV and EL max/TAV were weakly but significantly negatively correlated with the CAVI score (R = \u0026minus;0.1731, \u003cem\u003eP\u003c/em\u003e = 0.0236 and R = \u0026minus;0.2785, \u003cem\u003eP\u003c/em\u003e = 0.0002, respectively). By contrast, EL ave, EL max, EL min, and EL min/TAV were not significantly correlated with the CAVI score (R = \u0026minus;0.06954, \u003cem\u003eP\u003c/em\u003e = 0.3195; R = \u0026minus;0.1498, \u003cem\u003eP\u003c/em\u003e = 0.0505; R = 0.003303, \u003cem\u003eP\u003c/em\u003e = 0.9658; and R = \u0026minus;0.06389, \u003cem\u003eP\u003c/em\u003e = 0.4064, respectively).\u003c/p\u003e\n\u003cp\u003eVort ave/TAV was significantly but weakly negatively correlated with the CAVI score (R = \u0026minus;0.2856, \u003cem\u003eP\u003c/em\u003e = 0.0002). Vort max/TAV was moderately negatively correlated with the CAVI score (R = \u0026minus;0.4082, P \u0026lt; 0.0001). Conversely, Vort min was weakly positively correlated with the CAVI score (R = 0.1574, \u003cem\u003eP\u003c/em\u003e = 0.0398). However, Vort ave, Vort max, and Vort min/TAV were not significantly correlated with the CAVI score (R = 0.1087, \u003cem\u003eP\u003c/em\u003e = 0.1571; R = 0.01243, \u003cem\u003eP\u003c/em\u003e = 0.8718; and R = \u0026minus;0.1097, \u003cem\u003eP\u003c/em\u003e = 0.1531, respectively).\u003c/p\u003e\n\u003cp\u003eHel abs ave/TAV, Hel abs max, and Hel abs max/TAV were weakly but significantly negatively correlated with the CAVI score (R = \u0026minus;0.2439, \u003cem\u003eP\u003c/em\u003e = 0.0013; R = \u0026minus;0.2248, \u003cem\u003eP\u003c/em\u003e = 0.0031; and R = \u0026minus;0.3777, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001, respectively). Hel abs min/TAV was weakly positively correlated with the CAVI score (R = 0.2081, \u003cem\u003eP\u003c/em\u003e = 0.0063). By contrast, Hel abs ave and Hel abs min were not significantly correlated with the CAVI score (R = \u0026minus;0.1101, \u003cem\u003eP\u003c/em\u003e = 0.1518 and R = 0.1471, \u003cem\u003eP\u003c/em\u003e = 0.0549, respectively).\u003c/p\u003e\n\u003cp\u003eHel right screw ave/TAV and Hel right screw max were weakly negatively correlated with the CAVI score (R = \u0026minus;0.3752, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001 and R = \u0026minus;0.2080, \u003cem\u003eP\u003c/em\u003e = 0.0063, respectively). Hel right screw max/TAV showed a moderate negative correlation with the CAVI score (R = \u0026minus;0.4211, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001). By contrast, Hel right screw ave, Hel right screw min, and Hel right screw min/TAV were not significantly correlated with the CAVI score (R = \u0026minus;0.1221, \u003cem\u003eP\u003c/em\u003e = 0.1116; R = 0.06518, \u003cem\u003eP\u003c/em\u003e = 0.3970; and R = \u0026minus;0.02836, \u003cem\u003eP\u003c/em\u003e = 0.7127, respectively).\u003c/p\u003e\n\u003cp\u003eHel left screw ave/TAV, Hel left screw min, and Hel left screw min/TAV were significantly positively correlated with the CAVI score (R = 0.3211, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001; R = 0.1645, \u003cem\u003eP\u003c/em\u003e = 0.0315; and R = 0.3776, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001, respectively). By contrast, Hel left screw ave, Hel left screw max, and Hel left screw max/TAV were not significantly correlated with the CAVI score (R = 0.09810, \u003cem\u003eP\u003c/em\u003e = 0.2018; R = \u0026minus;0.04128, \u003cem\u003eP\u003c/em\u003e = 0.5919; and R = 0.04988, \u003cem\u003eP\u003c/em\u003e = 0.5171, respectively) (Fig. S1).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAortic dilatation in older patients is associated with atherosclerosis [20, 21]. In this study, patients with a high CAVI score had a larger TAV and were older than patients with\u0026nbsp;a low CAVI score. Furthermore, there was a relatively strong correlation between the CAVI score and TAV, suggesting a relationship between TAV and arteriosclerosis. Although other factors could account for the difference in TAV, there were no significant differences between the groups in terms of hypertension, diabetes mellitus, renal failure, or smoking. However, a higher proportion of male patients and those with a lower BMI were observed in the high CAVI group, and these factors may have contributed to the progression of atherosclerosis.\u003c/p\u003e\n\u003cp\u003eWe evaluated two types of hemodynamic parameters: those not divided by the TAV and voxel-based parameters that were divided by the TAV. We presumed that the hemodynamic parameters not divided by the TAV were strongly influenced by the TAV because they were calculated as the sum of the flow across the entire thoracic aorta. Notably, some hemodynamic parameters, such as Vort ave and Vort min, tended to have higher values in the high CAVI group than in the low CAVI group. However, most hemodynamic parameters not divided by the TAV did not show significant differences between the groups. Despite the larger TAV in the high CAVI group, there were no significant differences in hemodynamic parameter values compared with the low CAVI group, suggesting that hemodynamic parameters per unit volume were reduced in the high CAVI group. Therefore, we concluded that voxel-based flow parameters divided by the TAV better reflected the flow characteristics in the thoracic aorta related to AA.\u003c/p\u003e\n\u003cp\u003e4D MRI can provide various hemodynamic parameters, such as EL, Vort, and Hel [22]. In this study, there were significant differences in EL max/TAV between the groups. KE refers to the energy contained in the flow of blood due to its motion, while EL represents the KE lost as a result of frictional forces caused by fluid viscosity within the blood flow [23].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere were significant differences in Vort ave/TAV and Vort max/TAV between the groups. Vort is an indicator of spatial velocity gradients that may reveal complex hemodynamic phenomena [24].\u003c/p\u003e\n\u003cp\u003eSignificant differences were also observed between the groups in Hel abs ave/TAV, Hel abs max/TAV, Hel right screw ave/TAV, Hel right screw max/TAV, Hel left screw ave/TAV, and Hel left screw min/TAV. Hel is an indicator of helical flow and was calculated by integrating the voxel-based absolute value of Vort \u0026times; velocity. Hel describes corkscrew-like motion along the principal flow direction and is considered a normal feature in healthy individuals [25\u0026ndash;27]. Helical flow increases as a result of altered aortic blood flow, often due to aortic valve disease [19, 28, 29].\u003c/p\u003e\n\u003cp\u003eIn this study, the values for these voxel-based hemodynamic parameters tended to be lower in the high CAVI group than in the low CAVI group. The hemodynamic values were higher near the arteriosclerotic vessel walls. However, the overall lower values in the high CAVI group suggest that AA restricted blood flow within the lumen. Based on these findings, we propose that the primary pathogenesis of AA may involve the restriction of luminal blood flow rather than arterial wall sclerosis alone. Furthermore, many voxel-based parameters (e.g., max values) were lower in the high CAVI group, especially during the systolic phase, suggesting that AA may affect hemodynamic parameters, particularly during systole. Although previous research has shown that hemodynamic parameters can vary depending on the LVEF [30],\u0026nbsp;and differences in the LVEF may influence these parameters, there was no difference in the LVEF between the groups in this study.\u003c/p\u003e\n\u003cp\u003eVort min was significantly weakly positively correlated with the CAVI score in this study. Flow parameters not divided by the TAV may be influenced by AA-induced increases in the TAV. Helical parameters such as Hel abs max, Hel right screw max, and Hel left screw min (not divided by TAV) were weakly correlated with the CAVI score, but those divided by the TAV showed stronger correlations with the CAVI score. EL ave/TAV, EL max/TAV, Vort ave/TAV, Hel abs ave/TAV, Hel abs max/TAV, Hel abs min/TAV, Hel right screw ave/TAV, Hel left screw ave/TAV, and Hel left screw min/TAV were significantly weakly correlated with the CAVI, whereas Vort max/TAV and Hel right screw max/TAV showed moderate negative correlations with the CAVI score. Notably, these max (or partial min) parameters exhibited stronger correlations with the CAVI score than did their ave counterparts. These results suggest that the CAVI score is associated with greater restriction of blood flow within the lumen, especially during systole.\u003c/p\u003e\n\u003cp\u003eBlood flow in the thoracic aorta can be quantitatively evaluated using 4D MRI. To date, only one study has reported a correlation between the CAVI score and aortic distensibility using cardiovascular MRI [31].\u0026nbsp;However, to the best of our knowledge, no previous studies have examined the relationship between the CAVI score and hemodynamic parameters using MRI.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe global burden of ischemic atherosclerotic cardiovascular disease has risen, making it one of the leading causes of morbidity, loss of life years, and mortality [32]. Importantly, atherosclerosis is a condition that can be prevented through lifestyle changes and early intervention. Thus, the early diagnosis, severity grading, and prediction of atherosclerosis are crucial. The results of this study may be clinically useful because noninvasive quantitative evaluation of aortic volume and hemodynamic parameters could aid in diagnosing and evaluating patients with AA. Moreover, incorporating a 4D MR sequence into routine cardiac MRI, as done in this study, could help detect AA early because there is a relationship between heart failure and AA [33, 34].\u003c/p\u003e\n\u003cp\u003eThis study had several limitations. First, it included patients from a single institution and lacked an external validation cohort. Second, most patients underwent cardiac MRI with a 4D flow sequence because of suspected heart disease; thus, the results may not be generalizable to the entire population. Finally, although we used the CAVI score to assess AA, we were unable to directly evaluate AA within the thoracic aorta.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe TAV was larger, and the voxel-based hemodynamic parameters (EL, Vort, and Hel/TAV), were lower in the high CAVI group than in the low CAVI group. Moreover, these hemodynamic parameters were correlated with the CAVI score, which may reflect restricted luminal blood flow in the thoracic aorta due to AA. Thus, simultaneously measuring aortic volume and hemodynamic parameters using 4D MRI could represent a novel method for evaluating atherosclerosis.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAA: aortic atherosclerosis\u003c/p\u003e\n\u003cp\u003eCAVI: cardio-ankle vascular index\u003c/p\u003e\n\u003cp\u003e3D: three-dimensional\u003c/p\u003e\n\u003cp\u003e4D: four-dimensional\u003c/p\u003e\n\u003cp\u003eMRI: magnetic resonance imaging\u003c/p\u003e\n\u003cp\u003eLVEF: left ventricular ejection fraction\u003c/p\u003e\n\u003cp\u003eEL: energy loss\u003c/p\u003e\n\u003cp\u003eKE: kinetic energy\u003c/p\u003e\n\u003cp\u003eVort: vorticity\u003c/p\u003e\n\u003cp\u003eHel: helicity\u003c/p\u003e\n\u003cp\u003eTAV: thoracic aortic volume\u003c/p\u003e\n\u003cp\u003eBMI: body mass index\u003c/p\u003e\n\u003cp\u003eSD: standard deviation\u003c/p\u003e\n\u003cp\u003eave: average\u003c/p\u003e\n\u003cp\u003emin: minimum\u003c/p\u003e\n\u003cp\u003emax: maximum\u003c/p\u003e\n\u003cp\u003eabs: absolute\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Angela Morben, DVM, ELS, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHK: Conception and design of the research, Writing of the manuscript. ES: Critical Review of the Manuscript. RT: Manuscript drafting. TN, MM, SM: Acquisition of data. All authors read and approved the final draft.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJSPS KAKENHI (Granted No. 21K07733).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData will be provided upon reasonable request by the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of the Nagasaki University Hospital (The date of approval (16/9/2020) and the project identification code (20091416)) and adhered to the ethical standards of the Declaration of Helsinki. Informed consent was waived because of the retrospective study design, and patient records and information were anonymized and de-identified prior to analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Department of Radiology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003eCardio Flow Design Inc, 22-3 Ichiban-cho Chiyoda-ku, Tokyo 102-0082, Japan\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWillum-Hansen T, Staessen JA, Torp-Pedersen C, et al. 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Circulation 2022;145:e895-1032. https://doi.org/10.1161/cir.0000000000001063\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Patients\u0026rsquo; demographic and clinical characteristics (n = 171)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow CAVI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 77)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh CAVI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 94)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCAVI score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e6.5 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e9.6 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e\u0026lt;0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge, years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e49.7 \u0026plusmn; 16.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e67.4 \u0026plusmn; 9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e\u0026lt;0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex, male:female\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e48:29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e74:20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.018*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ekg/m\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e24.8 \u0026plusmn; 5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e22.2 \u0026plusmn; 3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypertension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e35 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e55 (58.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.089\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes mellitus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e14 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e24 (25.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.250\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRenal failure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e4 (5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e7 (7.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.550\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e37 (48.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e59 (62.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLVEF, %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e44.7 \u0026plusmn; 16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e48.5 \u0026plusmn; 15.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.120\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinal diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 59.596%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnremarkable findings\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.887\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDCM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e30 (39.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e24 (25.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.060\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHCM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e9 (11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e15 (16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.424\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHHD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e2 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.198\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRCM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e2 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.116\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e7 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e12 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.447\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVSA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e2 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.447\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMyocarditis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e10 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e6 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.140\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDrug-induced myocarditis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e4 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eArrhythmia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e5 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e7 (7.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.808\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiac sarcoidosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e2 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e2 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.840\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiac amyloidosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e14 (14.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLVNC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e3 (3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eASD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.887\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e4 (5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.111\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.404%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2121%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.202%;\"\u003e\n \u003cp\u003e4 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.1818%;\"\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are expressed as n (%) or mean \u0026plusmn; standard deviation (range). *\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003eCAVI, cardio-ankle vascular index; BMI, body mass index; LVEF, left ventricular ejection fraction; DCM, dilated cardiomyopathy; HCM, hypertrophic cardiomyopathy; HHD, hypertensive heart disease; RCM, restrictive cardiomyopathy; MI, myocardial infarction; VSA, vasospastic angina; LVNC, left ventricular noncompaction; ASD, atrial septal defect; AR, aortic regurgitation; MR, mitral regurgitation \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. Thoracic aortic volume and hemodynamic parameters in patients with low and high CAVI scores (n = 171)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow CAVI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 77)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh CAVI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 94)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP-\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eTAV (cm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e80.6 \u0026plusmn; 30.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e113.6 \u0026plusmn; 29.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026lt;0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eEnergy loss ave (\u0026times; 10\u003csup\u003e2\u003c/sup\u003e mW)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e157 \u0026plusmn; 258\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e146 \u0026plusmn; 188\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.7304\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eEnergy loss ave/TAV (\u0026times; 10\u003csup\u003e2\u003c/sup\u003e mW)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e1.9 \u0026plusmn; 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e1.3 \u0026plusmn; 1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.0516\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eEnergy loss max (\u0026times; 10\u003csup\u003e2\u003c/sup\u003e mW)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e368 \u0026plusmn; 725\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e267 \u0026plusmn; 273\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.2165\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eEnergy loss max/TAV (\u0026times; 10\u003csup\u003e2\u003c/sup\u003e mW)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e4.4 \u0026plusmn; 5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e2.5 \u0026plusmn; 2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.0035*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eEnergy loss min (\u0026times; 10\u003csup\u003e2\u003c/sup\u003e mW)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e86 \u0026plusmn; 156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e95 \u0026plusmn; 140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.6854\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eEnergy loss min/TAV (\u0026times; 10\u003csup\u003e2\u003c/sup\u003e mW)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.97 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.83 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.4583\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eVorticity ave (\u0026times; 10\u003csup\u003e4\u003c/sup\u003em\u003csup\u003e3\u003c/sup\u003es\u003csup\u003e-1\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e34 \u0026plusmn; 20\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e40 \u0026plusmn; 16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.0248*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eVorticity ave/TAV (\u0026times; 10\u003csup\u003e4\u003c/sup\u003em\u003csup\u003e3\u003c/sup\u003es\u003csup\u003e-1\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.42 \u0026plusmn; 0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.36 \u0026plusmn; 0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.0004*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eVorticity max (\u0026times; 10\u003csup\u003e4\u003c/sup\u003em\u003csup\u003e3\u003c/sup\u003es\u003csup\u003e-1\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e55 \u0026plusmn; 34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e61 \u0026plusmn; 21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.1630\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eVorticity max/TAV (\u0026times; 10\u003csup\u003e4\u003c/sup\u003em\u003csup\u003e3\u003c/sup\u003es\u003csup\u003e-1\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.71 \u0026plusmn; 0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.55 \u0026plusmn; 0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026lt;0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eVorticity min (\u0026times; 10\u003csup\u003e4\u003c/sup\u003em\u003csup\u003e3\u003c/sup\u003es\u003csup\u003e-1\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e24 \u0026plusmn; 16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e31 \u0026plusmn; 15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.0070*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eVorticity min/TAV (\u0026times; 10\u003csup\u003e4\u003c/sup\u003em\u003csup\u003e3\u003c/sup\u003es\u003csup\u003e-1\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.29 \u0026plusmn; 0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.27 \u0026plusmn; 0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.1531\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity abs ave (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e12 \u0026plusmn; 37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e12 \u0026plusmn; 26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.9377\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity abs ave/TAV (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.25 \u0026plusmn; 0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.12 \u0026plusmn; 0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.0426*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity abs max (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e162 \u0026plusmn; 152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e132 \u0026plusmn; 134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.1671\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity abs max/TAV (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e2.4 \u0026plusmn; 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e1.2 \u0026plusmn; 1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.0002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity abs min (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026minus;160 \u0026plusmn; 529\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026minus;78 \u0026plusmn; 95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.1443\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity abs min/TAV (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026minus;1.8 \u0026plusmn; 5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026minus;0.74 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.0685\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity right screw ave (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e169 \u0026plusmn; 169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e155 \u0026plusmn; 115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.5328\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity right screw ave/TAV (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e2.2 \u0026plusmn; 1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e1.4 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026lt;0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity right screw max (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e504 \u0026plusmn; 555\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e407 \u0026plusmn; 255\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.1341\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity right screw max/TAV (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e6.8 \u0026plusmn; 5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e3.8 \u0026plusmn; 2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026lt;0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity right screw min (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e56 \u0026plusmn; 80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e69 \u0026plusmn; 88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.3061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity right screw min/TAV (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.64 \u0026plusmn; 0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.60 \u0026plusmn; 0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.6680\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity left screw ave (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026minus;156 \u0026plusmn; 164\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026minus;143 \u0026plusmn; 111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.5480\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity left screw ave/TAV (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026minus;1.9 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026minus;1.3 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.0002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity left screw max (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026minus;53 \u0026plusmn; 78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026minus;63 \u0026plusmn; 73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.3830\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity left screw max/TAV (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026minus;0.61 \u0026plusmn; 0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026minus;0.55 \u0026plusmn; 0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.5427\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity left screw min (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026minus;426 \u0026plusmn; 533\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026minus;351 \u0026plusmn; 229\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e0.2259\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51.0204%;\"\u003e\n \u003cp\u003eHelicity left screw min/TAV (\u0026times; 10\u003csup\u003e6\u003c/sup\u003em\u003csup\u003e4\u003c/sup\u003es\u003csup\u003e-2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026minus;5.4 \u0026plusmn; 4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026minus;3.2 \u0026plusmn; 2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.3265%;\"\u003e\n \u003cp\u003e\u0026lt;0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are expressed as mean \u0026plusmn; standard deviation. *\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003eCAVI, cardio-ankle vascular index; TAV, thoracic aortic volume; ave, average; max, maximum; min, minimum; abs, absolute. \u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"atherosclerosis, four-dimensional magnetic resonance imaging, cardio-ankle vascular index","lastPublishedDoi":"10.21203/rs.3.rs-7837857/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7837857/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackgroud\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe cardio-ankle vascular index (CAVI) is a noninvasive measure of aortic atherosclerosis (AA), but it does not assess blood flow or aortic shape. Four-dimensional (4D) magnetic resonance imaging (MRI) has emerged as a promising tool for evaluating vascular blood flow. This study investigated the correlation between thoracic aortic volume (TAV) and hemodynamic parameters using 4D MRI in patients with and without AA as defined by the CAVI score.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study involved 171 patients (77 with a low CAVI score and 94 with a high CAVI score) who underwent cardiac MRI with a 4D flow sequence. Hemodynamic parameters—including energy loss (EL), vorticity (Vort), and helicity (Hel)—were obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients in the high CAVI group had significantly larger TAV (113.6 ± 29.3 vs. 80.6 ± 30.5 cm\u003csup\u003e3\u003c/sup\u003e, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001). The TAV was positively correlated with the CAVI score (R = 0.4147, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001). EL maximum/TAV (\u003cem\u003eP\u003c/em\u003e = 0.0035), Vort average/TAV (\u003cem\u003eP\u003c/em\u003e = 0.0004), and Hel absolute maximum/TAV (\u003cem\u003eP\u003c/em\u003e = 0.0002) were significantly lower in the high CAVI group. Several hemodynamic parameters, including Vort maximum/TAV (R = −0.4082, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001) and Hel right screw maximum/TAV (R = −0.4211, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001), were moderately negatively correlated with the CAVI score, suggesting that aortic stiffness restricts luminal blood flow, particularly during systole.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients with high CAVI scores exhibited a larger TAV and lower voxel-based hemodynamic parameters than those with low CAVI scores. This method represents a novel approach for the noninvasive assessment of atherosclerosis.\u003c/p\u003e","manuscriptTitle":"Associations between cardio-ankle vascular index score and aortic volume and hemodynamic parameters using four-dimensional magnetic resonance imaging","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-05 13:12:57","doi":"10.21203/rs.3.rs-7837857/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-22T09:02:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-22T05:55:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-14T22:40:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"219384614148335852336839899360559888751","date":"2025-12-27T05:33:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"248672438148092804658149822066329300415","date":"2025-12-24T11:22:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284991297620905586940743361609098263927","date":"2025-12-03T13:35:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-19T22:59:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"249994498984551644908480256748641950291","date":"2025-11-19T02:36:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-23T20:48:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-22T05:54:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-22T04:51:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-21T02:06:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2025-10-21T02:05:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0d92b540-d019-4299-b3ea-3450beceefa5","owner":[],"postedDate":"November 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T16:06:09+00:00","versionOfRecord":{"articleIdentity":"rs-7837857","link":"https://doi.org/10.1186/s12872-026-05925-3","journal":{"identity":"bmc-cardiovascular-disorders","isVorOnly":false,"title":"BMC Cardiovascular Disorders"},"publishedOn":"2026-04-29 15:57:24","publishedOnDateReadable":"April 29th, 2026"},"versionCreatedAt":"2025-11-05 13:12:57","video":"","vorDoi":"10.1186/s12872-026-05925-3","vorDoiUrl":"https://doi.org/10.1186/s12872-026-05925-3","workflowStages":[]},"version":"v1","identity":"rs-7837857","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7837857","identity":"rs-7837857","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}