Biomarker-Aware Super-Resolution for 4D Flow MRI in a Synthetic Pulmonary-Artery Benchmark

Purpose: To evaluate, within a synthetic pulmonary-artery benchmark, whether biomarker-aware super-resolution improves hemodynamic endpoint fidelity in 4D flow MRI. Methods: A 3D residual channel attention network (RCAN) was trained on 22 CFD simulations from 11 pulmonary-artery geometries with 2x spatial degradation. The original primary comparison evaluated full biomarker-aware training against a combined divergence-temporal-regularization control across 14 matched seeds on a fixed six-case test set. Additional matched analyses subsequently separated divergence and adjacent-frame temporal-difference regularization and evaluated biomarker supervision in a controlled 2x2 design with a common reconstruction schedule. Results: In the original primary comparison, biomarker-aware training reduced PI error relative to the matched combined-regularization control (12.76 +/- 2.34% vs. 17.12 +/- 1.23%; paired difference -4.35 percentage points [95% CI -5.58, -3.09]; p = 0.0015). In the matched factorial analysis, biomarker supervision reduced PI error without (-2.235 percentage points [95% CI -3.514, -0.849]) and with (-4.125 percentage points [95% CI -5.392, -2.732]) combined regularization. PI improvement was not mirrored by uniformly improved reconstruction metrics: PSNR changed by -0.058 (p = 0.50) and +0.144 dB (p = 0.28), while SSIM decreased by 0.009 (p = 0.004) and 0.007 (p = 0.009), respectively. Divergence alone changed PI by +0.034 percentage points [95% CI -0.705, 0.809] while reducing DivRMS by 1.869 percentage points; temporal-difference regularization increased PI error by 1.562 percentage points [95% CI 0.594, 2.439]. Conclusion: Within this synthetic, fixed-case RCAN benchmark, biomarker supervision improved PI under both regularization conditions. PI improvement was not mirrored by uniformly improved reconstruction metrics. Temporal-difference - not divergence - regularization was the only isolated component associated with reproducible PI deterioration. These findings are configuration-specific and require geometry-independent and in vivo validation.