ORIGINAL RESEARCH Patient-Specific Requirements and Clinical Validation of MRI-Based Pressure Mapping: A Two-Center Study in Patients With Aortic Coarctation Leonid Goubergrits, PhD, 1 Florian Hellmeier, MS, 1 Dominik Neumann, PhD, 2 Viorel Mihalef, PhD, 3 Mehmet A. Gulsun, PhD, 3 Marcello Chinali, MD, 4 Aurelio Secinaro, MD, 5 Kilian Runte, 1,6 Stephan Schubert, PhD, 6 Felix Berger, PhD, 6,7,8 Titus Kuehne, PhD, 1,8 Anja Hennemuth, PhD, 1 and Marcus Kelm, MD 1,6,8 * Background: Invasive peak-to-peak pressure gradients are the current clinical reference standard for assessing aortic coarctation. To obtain them, patients need to undergo arterial heart catheterization. Unless an intervention is performed, the procedure remains purely diagnostic, while the concomitant risks remain. Purpose: To validate MRI-based pressure mapping against pressure drop derived from heart catheterization and to define minimal clinical requirements. Study Type: Prospective clinical validation study. Population: Twenty-seven coarctation patients with an indicated heart catheterization were enrolled at two clinical centers. MRI Sequences: 1.5T including 4D velocity-encoded MRI and 3D anatomical imaging of the aorta. Assessment: Pressure drop across the stenosis was calculated by pressure mapping based on the pressure Poisson equa- tion. Calculated pressure drops were compared with catheter measured data. Spatial and temporal resolution were ana- lyzed using in silico phantom-based data as well as in vivo measurements. Statistics: Pressure drop was compared to peak-to-peak measurements. A two-sample paired mean equivalence test was used. Results: In patients without imaging artifacts and a required spatial resolution ≥5 voxel/diameter, significant equivalence of pressure mapping compared to heart catheterization was found (17.5 ± 6.49 vs. 16.6 ± 6.53 mmHg, P < 0.001). Data Conclusion: Pressure mapping provides equivalent accuracy to pressure drop obtained from heart catheterization in patients 1) without previous stenting and 2) with sufficient spatial image resolution (at least 5 voxels/diameter). In these patients the method can reliably be performed prior to the actual procedure, and thus allows safe noninvasive treatment planning based on MRI. Level of Evidence: 2 Technical Efficacy: Stage 3 J. MAGN. RESON. IMAGING 2018;00:00–00. A ccording to current American College of Cardiology (ACC) and American Heart Association (AHA) guide- lines, catheter-derived peak-to-peak pressure drop (gradients) are considered the reference standard in aortic coarctation (CoA). 1 To evaluate treatment indications, the patient needs to receive invasive heart catheterization with its associated View this article online at wileyonlinelibrary.com. DOI: 10.1002/jmri.26230 Received Mar 3, 2018, Accepted for publication May 25, 2018. * Address reprint requests to: M.K., German Heart Center Berlin, Department of Congenital Heart Diseases, Unit of Cardiovascular Imaging, Augustenburger Platz 1, 13353 Berlin, Germany. E-mail: mkelm@dhzb.de From the 1 Institute for Computational and Imaging Science in Cardiovascular Medicine, Charité, Universitätsmedizin Berlin, Berlin, Germany; 2 Medical Imaging Technologies, Siemens Healthcare, Erlangen, Germany; 3 Medical Imaging Technologies, Siemens Medical Solutions, Princeton, New Jersey, USA; 4 Department of Cardiology and Cardiac Surgery, Bambino Gesú Children's Research Hospital, Rome, Italy; 5 Department of Imaging, Bambino Gesú Children's Research Hospital, Rome, Italy; 6 German Heart Center Berlin, Department of Congenital Heart Disease, Unit of Cardiovascular Imaging, Berlin, Germany; 7 Charité, Universitätsmedizin Berlin, Pediatric Cardiology, Berlin, Germany; and 8 DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany © 2018 International Society for Magnetic Resonance in Medicine 1