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This study sought to identify patients with repaired tetralogy of Fallot (rTOF) at high risk of death and malignant ventricular arrhythmia (VA).To date there is no robust risk stratification scheme to predict outcomes in adults with rTOF.Consecutive patients were prospectively recruited for late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) to define right and left ventricular (RV, LV) fibrosis in addition to proven risk markers.The primary endpoint was all-cause mortality. Of the 550 patients (median age 32 years, 56% male), 27 died (mean follow-up 6.4 ± 5.8; total 3,512 years). Mortality was independently predicted by RVLGE extent, presence of LVLGE, RV ejection fraction ≤47%, LV ejection fraction ≤55%, B-type natriuretic peptide ≥127 ng/L, peak exercise oxygen uptake (V0We present a score integrating multiple appropriately weighted risk factors to identify the subgroup of patients with rTOF who are at high annual risk of death who may benefit from targeted therapy.

Automated and accurate segmentations of left atrium (LA) and atrial scars from late gadolinium-enhanced cardiac magnetic resonance (LGE CMR) images are in high demand for quantifying atrial scars. The previous quantification of atrial scars relies on a two-phase segmentation for LA and atrial scars due to their large volume difference (unbalanced atrial targets). In this paper, we propose an inter-cascade generative adversarial network, namely JAS-GAN, to segment the unbalanced atrial targets from LGE CMR images automatically and accurately in an end-to-end way. Firstly, JAS-GAN investigates an adaptive attention cascade to automatically correlate the segmentation tasks of the unbalanced atrial targets. The adaptive attention cascade mainly models the inclusion relationship of the two unbalanced atrial targets, where the estimated LA acts as the attention map to adaptively focus on the small atrial scars roughly. Then, an adversarial regularization is applied to the segmentation tasks of the unbalanced atrial targets for making a consistent optimization. It mainly forces the estimated joint distribution of LA and atrial scars to match the real ones. We evaluated the performance of our JAS-GAN on a 3D LGE CMR dataset with 192 scans. Compared with the state-of-the-art methods, our proposed approach yielded better segmentation performance (Average Dice Similarity Coefficient (DSC) values of 0.946 and 0.821 for LA and atrial scars, respectively), which indicated the effectiveness of our proposed approach for segmenting unbalanced atrial targets., Comment: Accepted by IEEE Journal of Biomedical and Health Informatics

Highlights • Propose a fully automatic method for left atrial scar quantification, with promising performance. • Formulate a new framework of scar quantification based on surface projection and graph-cuts framework. • Propose the multi-scale learning CNN, combined with the random shift training strategy, to learn and predict the graph potentials, which significantly improves the performance of the proposed method, and enables the full automation of the framework. • Provide thorough validation and parameter studies for the proposed techniques using fifty-eight clinical images., Graphical abstract The proposed framework for left atrium (LA) scar quantication and analysis. In this framework, we rst use a well-developed multi-atlas whole heart segmentation (MA-WHS) to obtain an initial segmentation of the LA. Then, we project the LA myocardium to generate a surface mesh, where the quantication is performed. At the same time, both the texture and anatomical features of the LA endocardium can be adequately extracted by employing the multi-scale patch (MSP) strategy. Thus, the features of the nodes in the graph are represented by a set of MSPs. Finally, the labeling of scars is achieved by optimizing a cost function based on the graph-cuts framework, whose potentials for edge weights are explicitly learned and predicted by the proposed multi-scale convolutional neural network (MS-CNN)., Late gadolinium enhancement magnetic resonance imaging (LGE MRI) appears to be a promising alternative for scar assessment in patients with atrial fibrillation (AF). Automating the quantification and analysis of atrial scars can be challenging due to the low image quality. In this work, we propose a fully automated method based on the graph-cuts framework, where the potentials of the graph are learned on a surface mesh of the left atrium (LA) using a multi-scale convolutional neural network (MS-CNN). For validation, we have included fifty-eight images with manual delineations. MS-CNN, which can efficiently incorporate both the local and global texture information of the images, has been shown to evidently improve the segmentation accuracy of the proposed graph-cuts based method. The segmentation could be further improved when the contribution between the t-link and n-link weights of the graph is balanced. The proposed method achieves a mean accuracy of 0.856 ± 0.033 and mean Dice score of 0.702 ± 0.071 for LA scar quantification. Compared to the conventional methods, which are based on the manual delineation of LA for initialization, our method is fully automatic and has demonstrated significantly better Dice score and accuracy (p

Highlights • This work presents the methodologies and evaluation results for the WHS algorithms selected from the submissions to the Multi-Modality Whole Heart Segmentation (MM-WHS) challenge, in conjunction with MICCAI 2017. • This work introduces the related information to the challenge, discusses the results from the conventional methods and deep learning-based algorithms, and provides insights to the future research. • The challenge provides a fair and intuitive comparison framework for methods developed and being developed for WHS. • The challenge provides the training datasets with manually delineated ground truths and evaluation for an ongoing development of MM-WHS algorithms., Graphical abstract This manuscript presents the methodologies and evaluation results for the WHS algorithms selected from the submissions to the Multi-Modality Whole Heart Segmentation (MMWHS) challenge, in conjunction with MICCAI-STACOM 2017. The challenge provides 120 three-dimensional cardiac images covering the whole heart, including 60 CT and 60 MRI volumes, all acquired in clinical environments with manual delineation. Ten algorithms for CT data and eleven algorithms for MRI data, submitted from twelve groups, have been evaluated. The results show that many of the deep learning (DL) based methods achieved high accuracy, even though the number of training datasets were limited. Several of them also reported poor results in the blinded evaluation, probably due to over fitting in their training. The conventional algorithms, mainly based on multi-atlas segmentation, demonstrated robust and stable performance, even though the accuracy is not as good as the best DL method in CT segmentation. The challenge, including provision of the annotated training data and the blinded evaluation for submitted algorithms on the test data, continues as an ongoing benchmarking resource., Knowledge of whole heart anatomy is a prerequisite for many clinical applications. Whole heart segmentation (WHS), which delineates substructures of the heart, can be very valuable for modeling and analysis of the anatomy and functions of the heart. However, automating this segmentation can be challenging due to the large variation of the heart shape, and different image qualities of the clinical data. To achieve this goal, an initial set of training data is generally needed for constructing priors or for training. Furthermore, it is difficult to perform comparisons between different methods, largely due to differences in the datasets and evaluation metrics used. This manuscript presents the methodologies and evaluation results for the WHS algorithms selected from the submissions to the Multi-Modality Whole Heart Segmentation (MM-WHS) challenge, in conjunction with MICCAI 2017. The challenge provided 120 three-dimensional cardiac images covering the whole heart, including 60 CT and 60 MRI volumes, all acquired in clinical environments with manual delineation. Ten algorithms for CT data and eleven algorithms for MRI data, submitted from twelve groups, have been evaluated. The results showed that the performance of CT WHS was generally better than that of MRI WHS. The segmentation of the substructures for different categories of patients could present different levels of challenge due to the difference in imaging and variations of heart shapes. The deep learning (DL)-based methods demonstrated great potential, though several of them reported poor results in the blinded evaluation. Their performance could vary greatly across different network structures and training strategies. The conventional algorithms, mainly based on multi-atlas segmentation, demonstrated good performance, though the accuracy and computational efficiency could be limited. The challenge, including provision of the annotated training data and the blinded evaluation for submitted algorithms on the test data, continues as an ongoing benchmarking resource via its homepage (www.sdspeople.fudan.edu.cn/zhuangxiahai/0/mmwhs/).

Background Renal impairment is common in patients with coronary artery disease and, if severe, late gadolinium enhancement (LGE) imaging for myocardial infarction (MI) evaluation cannot be performed. Purpose To develop a fully automatic framework for chronic MI delineation via deep learning on non-contrast material-enhanced cardiac cine MRI. Materials and Methods In this retrospective single-center study, a deep learning model was developed to extract motion features from the left ventricle and delineate MI regions on nonenhanced cardiac cine MRI collected between October 2015 and March 2017. Patients with chronic MI, as well as healthy control patients, had both nonenhanced cardiac cine (25 phases per cardiac cycle) and LGE MRI examinations. Eighty percent of MRI examinations were used for the training data set and 20% for the independent testing data set. Chronic MI regions on LGE MRI were defined as ground truth. Diagnostic performance was assessed by analysis of the area under the receiver operating characteristic curve (AUC). MI area and MI area percentage from nonenhanced cardiac cine and LGE MRI were compared by using the Pearson correlation, paired

Accurate delineation of heart substructures is a prerequisite for abnormality detection, for making quantitative and functional measurements, and for computer-aided diagnosis and treatment planning. Late Gadolinium-Enhanced Cardiac MRI (LGE-CMRI) is an emerging imaging technology for myocardial infarction or scar detection based on the differences in the volume of residual gadolinium distribution between scar and healthy tissues. While LGE-CMRI is a well-established non-invasive tool for detecting myocardial scar tissues in the ventricles, its application to left atrium (LA) imaging is more challenging due to its very thin wall of the LA and poor quality images, which may be produced because of motion artefacts and low signal-to-noise ratio. As the LGE-CMRI scan is designed to highlight scar tissues by altering the gadolinium kinetics, the anatomy among different heart substructures has less distinguishable boundaries. An accurate, robust and reproducible method for LA segmentation is highly in demand because it can not only provide valuable information of the heart function but also be helpful for the further delineation of scar tissue and measuring the scar percentage. In this study, we proposed a novel deep learning framework working on LGE-CMRI images directly by combining sequential learning and dilated residual learning to delineate LA and pulmonary veins fully automatically. The achieved results showed accurate segmentation results compared to the state-of-the-art methods. The proposed framework leads to an automatic generation of a patient-specific model that can potentially enable an objective atrial scarring assessment for the atrial fibrillation patients.

Compressed sensing magnetic resonance imaging (CS-MRI) enables fast acquisition, which is highly desirable for numerous clinical applications. This can not only reduce the scanning cost and ease patient burden, but also potentially reduce motion artefacts and the effect of contrast washout, thus yielding better image quality. Different from parallel imaging-based fast MRI, which utilizes multiple coils to simultaneously receive MR signals, CS-MRI breaks the Nyquist-Shannon sampling barrier to reconstruct MRI images with much less required raw data. This paper provides a deep learning-based strategy for reconstruction of CS-MRI, and bridges a substantial gap between conventional non-learning methods working only on data from a single image, and prior knowledge from large training data sets. In particular, a novel conditional Generative Adversarial Networks-based model (DAGAN)-based model is proposed to reconstruct CS-MRI. In our DAGAN architecture, we have designed a refinement learning method to stabilize our U-Net based generator, which provides an end-to-end network to reduce aliasing artefacts. To better preserve texture and edges in the reconstruction, we have coupled the adversarial loss with an innovative content loss. In addition, we incorporate frequency-domain information to enforce similarity in both the image and frequency domains. We have performed comprehensive comparison studies with both conventional CS-MRI reconstruction methods and newly investigated deep learning approaches. Compared with these methods, our DAGAN method provides superior reconstruction with preserved perceptual image details. Furthermore, each image is reconstructed in about 5 ms, which is suitable for real-time processing.

Purpose Atrial fibrillation (AF) is the most common heart rhythm disorder and causes considerable morbidity and mortality, resulting in a large public health burden that is increasing as the population ages. It is associated with atrial fibrosis, the amount and distribution of which can be used to stratify patients and to guide subsequent electrophysiology ablation treatment. Atrial fibrosis may be assessed noninvasively using late gadolinium‐enhanced (LGE) magnetic resonance imaging (MRI) where scar tissue is visualized as a region of signal enhancement. However, manual segmentation of the heart chambers and of the atrial scar tissue is time consuming and subject to interoperator variability, particularly as image quality in AF is often poor. In this study, we propose a novel fully automatic pipeline to achieve accurate and objective segmentation of the heart (from MRI Roadmap data) and of scar tissue within the heart (from LGE MRI data) acquired in patients with AF. Methods Our fully automatic pipeline uniquely combines: (a) a multiatlas‐based whole heart segmentation (MA‐WHS) to determine the cardiac anatomy from an MRI Roadmap acquisition which is then mapped to LGE MRI, and (b) a super‐pixel and supervised learning based approach to delineate the distribution and extent of atrial scarring in LGE MRI. We compared the accuracy of the automatic analysis to manual ground truth segmentations in 37 patients with persistent long‐standing AF. Results Both our MA‐WHS and atrial scarring segmentations showed accurate delineations of cardiac anatomy (mean Dice = 89%) and atrial scarring (mean Dice = 79%), respectively, compared to the established ground truth from manual segmentation. In addition, compared to the ground truth, we obtained 88% segmentation accuracy, with 90% sensitivity and 79% specificity. Receiver operating characteristic analysis achieved an average area under the curve of 0.91. Conclusion Compared with previously studied methods with manual interventions, our innovative pipeline demonstrated comparable results, but was computed fully automatically. The proposed segmentation methods allow LGE MRI to be used as an objective assessment tool for localization, visualization, and quantitation of atrial scarring and to guide ablation treatment.

Although the high prevalence of aortic root dilatation in adults with repaired tetralogy of Fallot (rTOF) is well established [(1,2)][1], evidence to guide clinical follow-up and decision making remains sparse. We sought to define the features, determinants, and rate of progression of aortic

Background We measured by cine cardiovascular magnetic resonance (CMR) main and branch pulmonary artery diameters and cross sectional areas in diastole and systole in order to establish normal ranges and the effects on them of age, gender and body surface area (BSA). Documentation of normal ranges provides a reference for research and clinical investigation in the fields of congenital heart disease, pulmonary hypertension and connective tissue disorders. Methods We recruited 120 healthy volunteers: ten males (M) and ten females (F) in each decile between 20 and 79 years, imaging them in a 1.5 Tesla CMR system. Scout acquisitions guided the placement of steady state free precession cine acquisitions transecting the main, right and left pulmonary arteries (MPA, RPA and LPA). Cross sections were rarely quite circular. Results From all subjects, the means of the greater and lesser orthogonal diastolic diameters in mm were: MPA, 22.9 ± 2.4 (M) and 21.2 ± 2.1 (F), RPA 16.6 ± 2.8 (M) and 14.7 ± 2.2 (F), and LPA 17.3 ± 2.5 (M) and 15.9 ± 2.0 (F), p

© 1982-2012 IEEE.Reconstruction of the anterior cruciate ligament (ACL) through arthroscopy is one of the most common procedures in orthopaedics. It requires accurate alignment and drilling of the tibial and femoral tunnels through which the ligament graft is attached. Although commercial computer-Assisted navigation systems exist to guide the placement of these tunnels, most of them are limited to a fixed pose without due consideration of dynamic factors involved in different knee flexion angles. This paper presents a new model for intraoperative guidance of arthroscopic ACL reconstruction with reduced error particularly in the ligament attachment area. The method uses 3D preoperative data at different flexion angles to build a subject-specific statistical model of knee pose. To circumvent the problem of limited training samples and ensure physically meaningful pose instantiation, homogeneous transformations between different poses and local-deformation finite element modelling are used to enlarge the training set. Subsequently, an anatomical geodesic flexion analysis is performed to extract the subject-specific flexion characteristics. The advantages of the method were also tested by detailed comparison to standard Principal Component Analysis (PCA), nonlinear PCA without training set enlargement, and other state-of-The-Art articulated joint modelling methods. The method yielded sub-millimetre accuracy, demonstrating its potential clinical value.

Background— Improvement in outcome of infants born with congenital heart defects has been accompanied by an increasing frequency of late arrhythmias. Ablation is difficult because of multiple tachycardias in the presence of complex anatomy with limited accessibility. We report on remote-controlled ablation using magnetic navigation in conjunction with 3D image integration in patients with previous intra-atrial baffle procedures. Methods and Results— Thirteen patients (8 male; age, 30.5±8 years) with supraventricular tachycardia (SVT) underwent catheter ablation. Group A had a medical history of a Mustard or Senning operation, whereas group B had undergone total cavopulmonary connection. A total of 26 tachycardias were treated in 17 procedures (median cycle length of 280 ms). Group A patients had more inducible SVTs than group B, and all index SVTs were located in the remainder of the morphological right atrium in all but 1 patient. Retrograde access through the aorta was performed and led to successful ablation, using magnetic navigation with a very low total radiation exposure (median of 3.8 minutes in group A versus 5.9 minutes in group B). Only 1 of 13 patients continued to have short-lasting SVTs despite 3 ablation procedures during a median follow-up time of >200 days. Conclusions— Remote-controlled catheter ablation by magnetic navigation in combination with accurate 3D image integration allowed safe and successful elimination of SVTs, using an exclusively retrograde approach, resulting in low radiation exposure for patients after intra-atrial baffle procedures (Mustard, Senning, or total cavopulmonary connection).

This study quantitatively assesses the effectiveness of retrospective beat-to-beat respiratory motion correction (B2B-RMC) at near 100% efficiency using high-resolution coronary artery imaging. Three-dimensional (3D) spiral images were obtained in a coronary respiratory motion phantom with B2B-RMC and navigator gating. In vivo, targeted 3D coronary imaging was performed in 10 healthy subjects using B2B-RMC spiral and navigator gated balanced steady-state free-precession (nav-bSSFP) techniques. Vessel diameter and sharpness in proximal and mid arteries were used as a measure of respiratory motion compensation effectiveness and compared between techniques. Phantom acquisitions with B2B-RMC were sharper than those acquired with navigator gating (B2B-RMC vs. navigator gating: 1.01±0.02 mm(-1) vs. 0.86±0.08 mm(-1), P.05). In vivo B2B-RMC respiratory efficiency was significantly and substantially higher (99.7%±0.5%) than nav-bSSFP (44.0%±8.9%, P.0001). Proximal and mid vessel sharpnesses were similar (B2B-RMC vs. nav-bSSFP, proximal: 1.00±0.14 mm(-1) vs. 1.08±0.11 mm(-1), mid: 1.01±0.11 mm(-1) vs. 1.05±0.12 mm(-1); both P=not significant [ns]). Mid vessel diameters were not significantly different (2.85±0.39 mm vs. 2.80±0.35 mm, P=ns), but proximal B2B-RMC diameters were slightly higher (2.85±0.38 mm vs. 2.70±0.34 mm, P.05), possibly due to contrast differences. The respiratory efficiency of B2B-RMC is less variable and significantly higher than navigator gating. Phantom and in vivo vessel sharpness and diameter values suggest that respiratory motion compensation is equally effective.

A novel technique to guide a subjects' breathing pattern using a respiratory biofeedback (rBF) "game" to improve respiratory efficiency is presented. The continuously adaptive windowing strategy, a fully automatic and highly efficient free-breathing navigator gated technique, is used to acquire the data as it ensures that all potential navigator acceptance windows are possible. This enables the rBF to be fully adaptable to a subject's respiratory pattern. Images of the thoracic aorta acquired using balanced steady-state free precession with continuously adaptive windowing strategy respiratory motion control, with and without rBF, were compared in 10 healthy subjects. Total scan time was reduced by using rBF. The mean scan time was reduced from 7 min 44 s (463 cardiac cycles, ± 127 cc) without rBF to 5 min 43 s (380 cardiac cycles, ± 118 cc) with the use of rBF (P < 0.05). Respiratory efficiency was increased from 45% without rBF to 56% with rBF (P < 0.01). Image quality was the same for both techniques (P = ns). In conclusion, rBF significantly improved respiratory efficiency and reduced acquisition duration without affecting image quality.

Purpose To quantitatively assess the performance and reproducibility of 3D spiral coronary artery wall imaging with beat-to-beat respiratory-motion-correction (B2B-RMC) compared to navigator gated 2D spiral and turbo-spin-echo (TSE) acquisitions. Materials and Methods High-resolution (0.7 × 0.7 mm) cross-sectional right coronary wall acquisitions were performed in 10 subjects using four techniques (B2B-RMC 3D spiral with alternate (2RR) and single (1RR) R-wave gating, navigator-gated 2D spiral (2RR) and navigator-gated 2D TSE (2RR)) on two occasions. Wall thickness measurements were compared with repeated measures analysis of variance (ANOVA). Reproducibility was assessed with the intraclass correlation coefficient (ICC). Results In all, 91% (73/80) of acquisitions were successful (failures: four TSE, two 3D spiral (1RR) and one 3D spiral (2RR)). Respiratory efficiency of the B2B-RMC was less variable and substantially higher than for navigator gating (99.6 ± 1.2% vs. 39.0 ± 7.5%, P < 0.0001). Coronary wall thicknesses (± standard deviation [SD]) were not significantly different: 1.10 ± 0.14 mm (3D spiral (2RR)), 1.20 ± 0.16 mm (3D spiral (1RR)), 1.14 ± 0.15 mm (2D spiral), and 1.21 ± 0.17 mm (TSE). Wall thickness reproducibility ranged from good (ICC = 0.65, 3D spiral (1RR)) to excellent (ICC = 0.87, 3D spiral (2RR)). Conclusion High-resolution 3D spiral imaging with B2B-RMC permits coronary vessel wall assessment over multiple thin contiguous slices in a clinically feasible duration. Excellent reproducibility of the technique potentially enables studies of disease progression/regression. J. Magn. Reson. Imaging 2011;33:77–86. © 2010 Wiley-Liss, Inc.

Human right coronary artery (RCA) haemodynamics is investigated using computational fluid dynamics (CFD) based on subject-specific information from magnetic resonance (MR) acquisitions. The dynamically varying vascular geometry is reconstructed from MR images, incorporated in CFD in conjunction with pulsatile flow conditions obtained from MR velocity mapping performed on the same subject. The effects of dynamic vessel motion on instantaneous and cycle-averaged haemodynamic parameters, such as wall shear stress (WSS), time-averaged WSS (TAWSS) and oscillatory shear index (OSI), are examined by comparing an RCA model with a time-varying geometry and those with a static geometry, corresponding to nine different time-points in the cardiac cycle. The results show that the TAWSS is similar for the dynamic and static wall models, both qualitatively and quantitatively (correlation coefficient 0.89-0.95). Conversely, the OSI shows much poorer correlations (correlation coefficient 0.38-0.60), with the best correspondence being observed with the static models constructed from images acquired in late diastole (at t = 0 and 800 ms, the cardiac cycle is 900 ms). These findings suggest that neglecting dynamic motion of the RCA is acceptable if TAWSS is the primary focus but may result in underestimation of haemodynamic parameters related to the oscillatory nature of the blood flow.

Purpose To compare the effectiveness and reproducibility of a new black-blood sequence vs. a conventional bright-blood gradient-echo T2* sequence for myocardial iron overload measurement in thalassemia. Materials and Methods Twenty thalassemia patients were studied. Black-blood sequence images were acquired in diastole after a double inversion recovery (DIR) preparation pulse. Bright-blood sequence images were acquired in both early systole and late diastole. The data were randomized and the T2* analysis was performed blindly by two independent observers. Results The T2* values from the black-blood sequence were comparable to those of the conventional bright-blood sequence (25.7 ± 12.9 msec vs. 26.4 ± 14.2 msec in early systole, P = 0.44; and 25.2 ± 13.1 msec in late diastole, P = 0.41). The coefficient of variation (CV) for black-blood image T2* analysis was 4.1% compared with 8.9% (early systole P = 0.03) and 7.8% (late diastole P = 0.05) for bright-blood image analysis. Conclusion The black-blood T2* technique yields high-contrast myocardial images, provides clearly depicted myocardial borders, and avoids blood signal contamination of the myocardium while yielding improvements in interobserver variability. J. Magn. Reson. Imaging 2007;25:1205–1209. © 2007 Wiley-Liss, Inc.

Atrial fibrillation (AF) is the most common heart rhythm disorder. In order for late Gd enhancement cardiovascular magnetic resonance (LGE CMR) to ameliorate the AF management, the ready availability of the accurate enhancement segmentation is required. However, the computer-aided segmentation of enhancement in LGE CMR of AF is still an open question. Additionally, the number of centres that have reported successful application of LGE CMR to guide clinical AF strategies remains low, while the debate on LGE CMR’s diagnostic ability for AF still holds. The aim of this study is to propose a method that reliably distinguishes enhanced (abnormal) from non-enhanced (healthy) tissue within the left atrial wall of (pre-ablation and 3 months post-ablation) LGE CMR data-sets from long-standing persistent AF patients studied at our centre. Enhancement segmentation was achieved by employing thresholds benchmarked against the statistics of the whole left atrial blood-pool (LABP). The test-set cross-validation mechanism was applied to determine the input feature representation and algorithm that best predict enhancement threshold levels. Global normalized intensity threshold levels T PRE = 1 1/4 and T POST = 1 5/8 were found to segment enhancement in data-sets acquired pre-ablation and at 3 months post-ablation, respectively. The segmentation results were corroborated by using visual inspection of LGE CMR brightness levels and one endocardial bipolar voltage map. The measured extent of pre-ablation fibrosis fell within the normal range for the specific arrhythmia phenotype. 3D volume renderings of segmented post-ablation enhancement emulated the expected ablation lesion patterns. By comparing our technique with other related approaches that proposed different threshold levels (although they also relied on reference regions from within the LABP) for segmenting enhancement in LGE CMR data-sets of AF patients, we illustrated that the cut-off levels employed by other centres may not be usable for clinical studies performed in our centre. The proposed technique has great potential for successful employment in the AF management within our centre. It provides a highly desirable validation of the LGE CMR technique for AF studies. Inter-centre differences in the CMR acquisition protocol and image analysis strategy inevitably impede the selection of a universally optimal algorithm for segmentation of enhancement in AF studies.

Background Temporal patterns of coronary blood flow velocity can provide important information on disease state and are currently assessed invasively using a Doppler guidewire. A non-invasive alternative would be beneficial as it would allow study of a wider patient population and serial scanning. Methods A retrospectively-gated breath-hold spiral phase velocity mapping sequence (TR 19 ms) was developed at 3 Tesla. Velocity maps were acquired in 8 proximal right and 15 proximal left coronary arteries of 18 subjects who had previously had a Doppler guidewire study at the time of coronary angiography. Cardiovascular magnetic resonance (CMR) velocity-time curves were processed semi-automatically and compared with corresponding invasive Doppler data. Results When corrected for differences in heart rate between the two studies, CMR mean velocity through the cardiac cycle, peak systolic velocity (PSV) and peak diastolic velocity (PDV) were approximately 40 % of the peak Doppler values with a moderate - good linear relationship between the two techniques (R2: 0.57, 0.64 and 0.79 respectively). CMR values of PDV/PSV showed a strong linear relationship with Doppler values with a slope close to unity (0.89 and 0.90 for right and left arteries respectively). In individual vessels, plots of CMR velocities at all cardiac phases against corresponding Doppler velocities showed a consistent linear relationship between the two with high R2 values (mean +/−SD: 0.79 +/−.13). Conclusions High temporal resolution breath-hold spiral phase velocity mapping underestimates absolute values of coronary flow velocity but allows accurate assessment of the temporal patterns of blood flow.

Purpose To develop a reproducible fast spin-echo (FSE) technique for accurate myocardial T2 measurement with application to iron overload assessment in thalassemia. Materials and Methods An FSE sequence was developed to permit acquisition of multiple TE images in one breathhold (BH-FSE). A dynamic black-blood scheme was introduced to better cancel blood signal. A nonselective refocusing train was also adopted to suppress stimulated echoes. The optimized technique was tested on phantoms and then applied to 10 normal volunteers and 10 thalassemia patients. Interstudy reproducibility was measured on all the 20 subjects. Results The mean difference in T2 values was 1.7% from phantom experiments between BH-FSE and the conventional spin-echo (SE) technique. High contrast BH-FSE images were acquired from human subjects, with minimal stimulated echoes and effective blood suppression (P = 0.0005). The coefficient of variation for interstudy reproducibility was 4.3%. T2 values from thalassemia patients were substantially lower than those from the normal subjects (45.2 ± 26.1 msec vs. 56.9 ± 8.4ms, P = 0.02). Conclusion The dynamic black-blood T2 sequence is a fast reproducible acquisition that compares favorably with conventional techniques, is robust to motion artifacts, and yields high blood-myocardium contrast. This technique may provide a useful tool in thalassemia and other scenarios requiring myocardial T2 quantification. J. Magn. Reson. Imaging 2006. © 2006 Wiley-Liss, Inc.

Background Qualitative and quantitative assessment of renal blood flow is valuable in the evaluation of patients with renal and renovascular diseases as well as in patients with heart failure. The temporal pattern of renal flow velocity through the cardiac cycle provides important information about renal haemodynamics. High temporal resolution interleaved spiral phase velocity mapping could potentially be used to study temporal patterns of flow and measure resistive and pulsatility indices which are measures of downstream resistance. Methods A retrospectively gated breath-hold spiral phase velocity mapping sequence (TR 19 ms) was developed at 3 Tesla. Phase velocity maps were acquired in the proximal right and left arteries of 10 healthy subjects in each of two separate scanning sessions. Each acquisition was analysed by two independent observers who calculated the resistive index (RI), the pulsatility index (PI), the mean flow velocity and the renal artery blood flow (RABF). Inter-study and inter-observer reproducibility of each variable was determined as the mean +/− standard deviation of the differences between paired values. The effect of background phase errors on each parameter was investigated. Results RI, PI, mean velocity and RABF per kidney were 0.71+/− 0.06, 1.47 +/− 0.29, 253.5 +/− 65.2 mm/s and 413 +/− 122 ml/min respectively. The inter-study reproducibilities were: RI −0.00 +/− 0.04 , PI −0.03 +/− 0.17, mean velocity −6.7 +/− 31.1 mm/s and RABF per kidney 17.9 +/− 44.8 ml/min. The effect of background phase errors was negligible (

Purpose To improve 3D volume-selective turbo spin echo (TSE) carotid artery wall imaging by incorporating navigators to reduce artifacts caused by swallowing. Materials and Methods Images were acquired on a Siemens Magnetom Sonata 1.5T scanner. 3D volume-selective TSE scans of the carotid arteries were acquired in six healthy volunteers. A cross-pair navigator placed on the back of the tongue was used to detect swallowing and movement. Two swallowing patterns were tested: 1) a single swallow approximately halfway through the scan time, at the center of kz, and 2) repeated swallowing as often as possible throughout the scan period. Images were acquired with and without navigators for comparison. Signal intensity in the lumen was quantified for the quality of blood suppression, and the clarity of the vessel wall in the common carotid was ranked by four independent blinded observers. Results In general, lower signal intensity was recorded in the lumen, and decreased blurring and ghosting were observed on scans with navigator control. This reduction in lumen signal intensity signifies an improvement in the black-blood imaging technique. The differences likely reflect the improved double inversion/blood suppression efficiency due to cycles being rejected when the heart rate changed at the point of swallowing, or decreased motional blurring/ghosting of tissue when the navigator is used, or a combination of these two effects. A statistical analysis of image quality showed a significant difference between navigated and non-navigated scans as scored by four independent, blinded observers. For both swallowing patterns, the mean score for the navigator images was on average 0.6 greater than that of non-navigator images (on a scoring scale of 0–5, where 0 = no vessel visible, and 5 = good delineation and blood suppression) and P-values for all observers were less than 0.01. Overall, the central swallow scans were scored higher than the repeated swallow scans. One reason for this may be the fact that the heart rate increased on swallowing, and this often lasted for one or two cardiac cycles after the navigator returned to the normal acceptance position. The effect of the increased heart rate after swallowing is likely to have an effect on double inversion blood suppression efficiency. Therefore, the increased amount of heart rate changes with repeated swallowing may have a greater adverse effect, even if the navigator rejects data views during the swallowing motion. Conclusion The clarity of vessel wall delineation and the apparent efficiency of blood suppression are reduced by swallowing during acquisition. Both motion blurring and quality of blood suppression are factors that can be improved with the use of a navigator accept/reject method. J. Magn. Reson. Imaging 2005. © 2005 Wiley-Liss, Inc.

A review of cardiovascular clinical and research applications of MRI phase-contrast velocity imaging, also known as velocity mapping or flow imaging. Phase-contrast basic principles, advantages, limitations, common pitfalls and artefacts are described. It can measure many different aspects of the complicated blood flow in the heart and vessels: volume flow (cardiac output, shunt, valve regurgitation), peak blood velocity (for stenosis), patterns and timings of velocity waveforms and flow distributions within heart chambers (abnormal ventricular function) and vessels (pulse-wave velocity, vessel wall disease). The review includes phase-contrast applications in cardiac function, heart valves, congenital heart diseases, major blood vessels, coronary arteries and myocardial wall velocity.

The purpose of this study was to evaluate the feasibility and accuracy of combined coronary and perfusion cardiovascular magnetic resonance (CMR) in the assessment of coronary artery stenosis. Thirty-five consecutive patients (27 men, eight women, age range 34-81 years), undergoing cardiac catheterization, were assessed with 3D coronary CMR and rest-stress perfusion CMR. Significant coronary stenosis was determined by vessel narrowing or signal loss with coronary CMR, and by abnormal contrast enhancement with perfusion CMR. Coronary artery diameter stenosis greater than 50% was considered significant with conventional cardiac catheterization. Seventeen patients had significant coronary artery disease, and in these there were 35 significant stenoses on cardiac catheterization. All left main stem arteries were normal on both cardiac catheterization and coronary CMR. For the diagnosis of coronary artery stenosis, coronary CMR had a sensitivity of 92% for the left anterior descending artery (LAD), 79% for the right coronary artery (RCA), but only 13% for the circumflex coronary artery (LCX). Perfusion CMR had corresponding sensitivities of 69%, 86%, and 63%, respectively. For all arteries the accuracies for coronary and perfusion CMR were 67% and 72%, respectively. Combining coronary and perfusion CMR improved the accuracy to 77%. These data demonstrate that in patients with suspected coronary artery disease, combined coronary and perfusion CMR is feasible, increases the accuracy of detection of significant coronary stenosis, and offers the possibility of combined anatomical and hemodynamic assessment of coronary artery stenosis.

Purpose To determine the intra- and interstudy reproducibility of right coronary artery diameter assessment using serial magnetic resonance (MR) coronary angiography. Materials and Methods Two-dimensional (2D) navigator-gated segmented fast low angle shot (FLASH) images of the proximal right coronary artery were acquired three times in 11 healthy volunteers, the first two times in the same study session and the third time after repositioning the subject in the scanner. Coronary artery diameters were determined using automated segmentation software and intra- and interstudy reproducibility calculated as the standard deviation (SD) of the signed differences between measurements within and between study sessions, respectively. The reproducibility of the segmentation software was determined by repeated analysis of each individual scan. Results One subject was excluded from the study due to poor-quality images. In the remaining 10 subjects, the mean (± SD) intrastudy difference in coronary artery diameters was −0.05 ± 0.12 mm, a value that is very similar to between-frame (same-film) differences reported in quantitative coronary angiography (QCA). The mean (± SD) interstudy difference in coronary artery diameters was 0.16 ± 0.43 mm, although this was greatly skewed by one subject with poor image plane repositioning. Excluding that subject resulted in a mean (± SD) interstudy difference of 0.04 ± 0.20 mm. The reproducibility of the segmentation software was excellent, with the mean difference between repeat analyses of the images being 0.00 ± 0.03 mm. Conclusion The intrastudy variability of coronary artery diameter measurements is low, potentially allowing MR coronary angiography to be used as a tool for the noninvasive assessment of serial changes following pharmacological intervention. A major contributing factor to this is the high reproducibility of the segmentation software. Interstudy variability is approximately three times the intrastudy variability. J. Magn. Reson. Imaging 2004;20:160–166. © 2004 Wiley-Liss, Inc.

Purpose To develop high temporal resolution coronary artery spiral phase velocity mapping sequences and to compare the results obtained with those from FLASH sequences. Materials and Methods Velocity curves were obtained in eight left and eight right coronary arteries using breath-hold interleaved spiral (BH_SP), free-breathing interleaved spiral (FB_SP), breath-hold segmented FLASH (BH_FL), and free-breathing FLASH (FB_FL) sequences. Spatial resolution, temporal resolution, and acquisition durations (cardiac cycles) were as follows—BH_SP: 0.9 mm × 0.9 mm, 30 msec, 20 cycles; FB_SP: 0.9 mm × 0.9 mm, 42 msec, 100 cycles; BH_FL: 0.9 mm × 1.8 mm, 70 msec (effective), 20 cycles; FB_FL: 0.9 mm × 1.8 mm, 30 msec, 480 cycles. Peak systolic, peak diastolic, and mean velocities were compared between sequences. Results For left and right arteries, the FB_SP velocity profiles closely followed those from the FB_FL sequence. By comparison, the BH_FL sequence failed to resolve the sharp peaks in the temporal velocity profiles of the right coronary artery, significantly underestimating the peak systolic (88 mm/second vs. 252 mm/second, P < 0.001), peak diastolic (114 mm/second vs. 153 mm/second, P < 0.01), and mean (56 mm/second vs. 93 mm/second, P < 0.001) velocities. For the less mobile left artery, the peak systolic, peak diastolic, and mean velocities were also underestimated by the BH_FL sequence, although this only reached statistical significance for the systolic peak (80 mm/second vs. 135 mm/second, P < 0.01), 142 mm/second vs. 168 mm/second, (P = ns), and 87 mm/second vs. 101 mm/second, (P = ns) respectively. Conclusion We have shown that the FB_SP sequence developed agrees well with the FB_FL sequence, while the study duration is reduced by a factor of 10 for the same spatial resolution. By comparison, the BH_FL sequence underestimates flow velocities, particularly in the more mobile right coronary artery. J. Magn. Reson. Imaging 2004;19:40–49. © 2003 Wiley-Liss, Inc.

Like X-Ray contrast angiography, MR coronary angiograms show the vessel lumens rather than the vessels themselves. Consequently, outward remodeling of the vessel wall, which occurs in subclinical coronary disease before luminal narrowing, cannot be seen. The current gold standard for assessing the coronary vessel wall is intravascular ultrasound, and more recently, optical coherence tomography, both of which are invasive and use ionizing radiation. A noninvasive, low-risk technique for assessing the vessel wall would be beneficial to cardiologists interested in the early detection of preclinical disease and for the safe monitoring of the progression or regression of disease in longitudinal studies. In this review article, the current state of the art in MR coronary vessel wall imaging is discussed, together with validation studies and recent developments.

Combined coronary and perfusion cardiovascular magnetic resonance was performed in three sisters with angina and suspected anomalous coronary arteries. Two sisters had anomalous coronary arteries passing between the aorta and right ventricular outflow tract and had abnormal myocardial perfusion. One sister had normal anatomy and perfusion. The combined approach identified the anatomy and functional significance of suspected anomalous coronary arteries.

Based on varying tissue contrasts at different RF flip angles, a new TrueFISP imaging strategy for cardiac function measurement is presented. A single breath-hold dual RF flip angle cine multi-slice TrueFISP imaging sequence was implemented which provides a significant increase in signal contrast between blood and myocardium. The increase in image contrast combined with different characteristics in RF response facilitates the delineation of cardiovascular borders. Based on this imaging strategy it is demonstrated how a simple 2D histogram clustering algorithm can be used for the fully automatic segmentation of the left ventricular (LV) blood pool. The method is validated with data acquired from 10 asymptomatic subjects, and the results are shown to be comparable to that of manual delineation by experienced observers.

Respiration causes continuous change in cardiac position, which leads to image degradation. Phase-encode reordering methods are often used to reduce these artifacts. An improved method for suppressing motion artifacts by reordering the acquisition of k space has been developed that is less sensitive to change of breathing patterns and bulk movement. We describe the theory behind the new approach and compare its results with those of existing methods by use of a phantom with simulated and actual acquired breathing patterns. The comparison was also made in vivo; cardiac scans were performed in 15 subjects with image planes that are known to be particularly susceptible to respiratory artifact. A significant improvement in image quality was achieved compared with conventional nonreordered and existing reordering methods.

High resolution three-dimensional (3D) late gadolinium enhancement (LGE) imaging is performed with single R-wave gating to minimize lengthy acquisition durations. In patients with atrial fibrillation (AF), heart rate variability results in variable magnetization recovery between sequence repeats, and image quality is often poor. In this study, we implemented and tested a dynamic inversion time (dynamic-TI) scheme designed to reduce sequence sensitivity to heart rate variations.An inversion-prepared 3D segmented gradient echo sequence was modified so that the TI varied automatically from beat-to-beat (dynamic-TI) based on the time since the last sequence repeat. 3D LGE acquisitions were performed in 17 patients prior to radio frequency ablation of persistent AF both with and without dynamic-TI. Qualitative image quality scores, blood signal-to-ghosting ratios (SGRs). and blood-myocardium contrast-to-ghosting ratios (CGRs) were compared.Image quality scores were higher with dynamic-TI than without dynamic-TI (2.2 ± 0.9 vs. 1.8 ± 1.1, P = 0.008), as were blood-myocardium CGRs (13.8 ± 7.6 vs. 8.3 ± 6.1, P = 0.003) and blood SGRs (19.6 ± 8.5 vs. 13.1 ± 8.0, P = 0.003).The dynamic-TI algorithm improves image quality of 3D LGE imaging in this difficult patient population by reducing the sequence sensitivity to RR interval variations

Purpose Navigator-gated three-dimensional (3D) late gadolinium enhancement (LGE) imaging demonstrates scarring following ablation of atrial fibrillation. An artifact originating from the slice-selective navigator-restore pulse is frequently present in the right pulmonary veins (PVs), obscuring the walls and making quantification of enhancement difficult. We describe a simple sequence modification to greatly reduce or remove this artifact. Methods A navigator-gated inversion-prepared gradient echo sequence was modified so that the slice-selective navigator-restore pulse was delayed in time from the nonselective preparation (NAV-restore-delayed). Both NAV-restore-delayed and conventional 3D LGE acquisitions were performed in 11 patients and the results compared. Results One patient was excluded due to severe respiratory motion artifact in both NAV-restore-delayed and conventional acquisitions. Moderate to severe artifact was present in 9 of the remaining 10 patients using the conventional sequence and was considerably reduced when using the NAV-restore-delayed sequence (ostial PV to blood pool ratio, 1.7 ± 0.5 versus 1.1 ± 0.2, respectively [P

Purpose Acquisition durations of navigator-gated high-resolution three-dimensional late gadolinium enhancement studies may typically be up to 10 min, depending on the respiratory efficiency and heart rate. Implementation of the continuously adaptive windowing strategy (CLAWS) could increase respiratory efficiency, but the resulting non-smooth k-space acquisition order during gadolinium wash-out could result in increased artifact. Methods Navigator-gated three-dimensional late gadolinium enhancement acquisitions were performed in 18 patients using tracking end-expiratory accept/reject (EE-ARA) and CLAWS algorithms in random order. Results Retrospective analysis of the stored navigator data shows that CLAWS scan times are very close to (within 1%) or equal to the fastest achievable scan times while EE-ARA significantly extends the acquisition duration (P

Background Three-directional phase velocity mapping (PVM) is capable of measuring longitudinal, radial and circumferential regional myocardial velocities. Current techniques use Cartesian k-space coverage and navigator-gated high spatial and high temporal resolution acquisitions are long. In addition, prospective ECG-gating means that analysis of the full cardiac cycle is not possible. The aim of this study is to develop a high temporal and high spatial resolution PVM technique using efficient spiral k-space coverage and retrospective ECG-gating. Detailed analysis of regional motion over the entire cardiac cycle, including atrial systole for the first time using MR, is presented in 10 healthy volunteers together with a comprehensive assessment of reproducibility. Methods A navigator-gated high temporal (21 ms) and spatial (1.4 × 1.4 mm) resolution spiral PVM sequence was developed, acquiring three-directional velocities in 53 heartbeats (100% respiratory-gating efficiency). Basal, mid and apical short-axis slices were acquired in 10 healthy volunteers on two occasions. Regional and transmural early systolic, early diastolic and atrial systolic peak longitudinal, radial and circumferential velocities were measured, together with the times to those peaks (TTPs). Reproducibilities were determined as mean ± SD of the signed differences between measurements made from acquisitions performed on the two days. Results All slices were acquired in all volunteers on both occasions with good image quality. The high temporal resolution allowed consistent detection of fine features of motion, while the high spatial resolution allowed the detection of statistically significant regional and transmural differences in motion. Colour plots showing the regional variations in velocity over the entire cardiac cycle enable rapid interpretation of the regional motion within any given slice. The reproducibility of peak velocities was high with the reproducibility of early systolic, early diastolic and atrial systolic peak radial velocities in the mid slice (for example) being −0.01 ± 0.36, 0.20 ± 0.56 and 0.14 ± 0.42 cm/s respectively. Reproducibility of the corresponding TTP values, when normalised to a fixed systolic and diastolic length, was also high (−13.8 ± 27.4, 1.3 ± 21.3 and 3.0 ± 10.9 ms for early systolic, early diastolic and atrial systolic respectively). Conclusions Retrospectively gated spiral PVM is an efficient and reproducible method of acquiring 3-directional, high resolution velocity data throughout the entire cardiac cycle, including atrial systole.

The aim of this study was to implement a quantitative in vivo cardiac diffusion tensor imaging (DTI) technique that was robust, reproducible, and feasible to perform in patients with cardiovascular disease. A stimulated-echo single-shot echo-planar imaging (EPI) sequence with zonal excitation and parallel imaging was implemented, together with a novel modification of the prospective navigator (NAV) technique combined with a biofeedback mechanism. Ten volunteers were scanned on two different days, each time with both multiple breath-hold (MBH) and NAV multislice protocols. Fractional anisotropy (FA), mean diffusivity (MD), and helix angle (HA) fiber maps were created. Comparison of initial and repeat scans showed good reproducibility for both MBH and NAV techniques for FA (P0.22), MD (P0.15), and HA (P0.28). Comparison of MBH and NAV FA (FAMBHday1 = 0.60 ± 0.04, FANAVday1 = 0.60 ± 0.03, P = 0.57) and MD (MDMBHday1 = 0.8 ± 0.2 × 10(-3) mm(2) /s, MDNAVday1 = 0.9 ± 0.2 × 10(-3) mm(2) /s, P = 0.07) values showed no significant differences, while HA values (HAMBHday1Endo = 22 ± 10°, HAMBHday1Mid-Endo = 20 ± 6°, HAMBHday1Mid-Epi = -1 ± 6°, HAMBHday1Epi = -17 ± 6°, HANAVday1Endo = 7 ± 7°, HANAVday1Mid-Endo = 13 ± 8°, HANAVday1Mid-Epi = -2 ± 7°, HANAVday1Epi = -14 ± 6°) were significantly different. The scan duration was 20% longer with the NAV approach. Currently, the MBH approach is the more robust in normal volunteers. While the NAV technique still requires resolution of some bulk motion sensitivity issues, these preliminary experiments show its potential for in vivo clinical cardiac diffusion tensor imaging and for delivering high-resolution in vivo 3D DTI tractography of the heart.

Objective To compare a contrast-enhanced 3D angiography (CE-3D-MRA) with the ECG- and respiratory gated 3D balanced steady state free precession (bSSFP) sequence using the CLAWS algorithm (3D-bSSFP-CLAWS) with respect to acquisition time, image quality, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR). Methods 14 patients (4 women, mean age ± SD: 52 ± 18) with known or suspected thoracic aortic disease were imaged on a 1.5 T scanner with both sequences. Two readers scored image quality of predefined levels of the thoracic aorta. Acquisition time, SNR and CNR were calculated for each examination. Results Image quality achieved with the 3D-bSSFP-CLAWS was scored significantly better than with the CE-3D-MRA for the aortic annulus ( P = 0.003), the sinuses of Valsalva ( P = 0.001), the proximal coronary arteries ( P = 0.001) and the sinotubular junction ( P = 0.001). Effective acquisition time for the 3D-bSSFP-CLAWS and corrected acquisition time (corrected for imaging parameters) was significantly longer compared to the CE-3D-MRA ( P = 0.004 and P = 0.028). SNR and CNR were significantly higher for the CE-3D-MRA ( P = 0.007 and P = 0.001). Conclusions Providing the highest scan efficiency for a given breathing pattern, image quality for the proximal ascending aorta achieved with the 3D-bSSFP-CLAWS is significantly superior in contrast to the CE-3D-MRA.

A segmented kappa-space breath hold phase velocity mapping technique has been developed for the study of coronary artery blood flow velocity. In vitro validation has been performed using a number of pulsatile flow phantoms and the accuracy of the technique for determining the velocity increase at the site of a stenosis demonstrated in several phantom models. Examples of both in-plane and through-plane velocity maps of the left anterior descending and right coronary arteries of normal subjects in early diastole are presented. In one subject, through-plane velocity maps were obtained in the right and left anterior descending arteries throughout the cardiac cycle in order to generate flow velocity time curves. The problems associated with coronary artery velocity mapping are discussed.

Regional myocardial function can be measured by several MR techniques including tissue tagging, phase velocity mapping, and more recently, displacement encoding with stimulated echoes (DENSE) and strain encoding (SENC). Each of these techniques was developed separately and has undergone significant change since its original implementation. As a result, in the current literature, the common features and the differences between the techniques and what they measure are often unclear and confusing. This review article delivers an extensively referenced introductory text which clarifies the current methodology from the starting point of the Bloch equations. By doing this in a consistent way for each method, the similarities and differences between them are highlighted. In addition, their capabilities and limitations are discussed, together with their relative advantages and disadvantages. While the focus is on sequence design and development, the principal parameters measured by each technique are also summarized, together with brief results, with the reader being directed to the extensive literature on data processing and clinical applications for more detail.

Background— In patients presenting with new-onset heart failure of uncertain etiology, the role of coronary angiography (CA) is unclear. Although conventionally performed to differentiate underlying coronary artery disease from dilated cardiomyopathy, CA is associated with a risk of complications and may not detect an ischemic cause resulting from arterial recanalization or an embolic episode. In this study, we assessed the diagnostic accuracy of a cardiovascular magnetic resonance (CMR) protocol incorporating late gadolinium enhancement (LGE) and magnetic resonance CA as a noninvasive gatekeeper to CA in determining the etiology of heart failure in this subset of patients. Methods and Results— One hundred twenty consecutive patients underwent CMR and CA. The etiology was ascribed by a consensus panel that used the results of the CMR scans. Similarly, a separate consensus group ascribed an underlying cause by using the results of CA. The diagnostic accuracy of both strategies was compared against a gold-standard panel that made a definitive judgment by reviewing all clinical data. The study was powered to show noninferiority between the 2 techniques. The sensitivity of 100%, specificity of 96%, and diagnostic accuracy of 97% for LGE-CMR were equivalent to CA (sensitivity, 93%; specificity, 96%; and diagnostic accuracy, 95%). As a gatekeeper to CA, LGE-CMR was also found to be a cheaper diagnostic strategy in a decision tree model when United Kingdom–based costs were assumed. The economic merits of this model would change, depending on the relative costs of LGE-CMR and CA in any specific healthcare system. Conclusion— This study showed that LGE-CMR is a safe, clinically effective, and potentially economical gatekeeper to CA in patients presenting with heart failure of uncertain etiology.

The development of ultra low power wireless sensors for customized wearable and implantable medical devices requires patient specific models for radio frequency simulation to understand wave propagation in the body. In practice, the creation of a patient specific whole-body model is difficult and time consuming to create. It is therefore necessary to establish a method for studying a population in a statistical manner. In this paper, we present a statistical shape model for the whole body for RF simulation. It is built from 10 male and 10 female subjects of varying size and height. This model has the ability to instantiate a new surface mesh with the parameters allowed by the training set. This model would provide shapes of varying sizes for studies, without the requirement of obtaining subject specific whole body models. Results from finite-differences time-domain simulation are presented on the extreme shapes from the model and demonstrate the need for a full understanding of the range in body shapes.

Purpose: To demonstrate coronary artery wall thickening with age in a small healthy cohort using a highly efficient, reliable, and reproducible high-resolution MR technique. Materials and Methods: A 3D cross-sectional MR vessel wall images (0.7 × 0.7 × 3 mm resolution) with retrospective beat-to-beat respiratory motion correction (B2B-RMC) were obtained in the proximal right coronary artery of 21 healthy subjects (age, 22–62 years) with no known cardiovascular disease. Lumen and outer wall (lumen + vessel wall) areas were measured in one central slice from each subject and average wall thickness and wall area/outer wall area ratio (W/OW) calculated. Results: Imaging was successful in 18 (86%) subjects with average respiratory efficiency 99.3 ± 1.7%. Coronary vessel wall thickness and W/OW significantly correlate with subject age, increasing by 0.088 mm and 0.031 per decade respectively (R = 0.53, P = 0.024 and R = 0.48, P = 0.046). No relationship was found between lumen area and vessel wall thickness (P = NS), but outer wall area increased significantly with vessel wall thickness at 19 mm2 per mm (P = 0.046). This is consistent with outward vessel wall remodeling. Conclusion: Despite the small size of our healthy cohort, using high-resolution MR imaging and B2B-RMC, we have demonstrated increasing coronary vessel wall thickness and W/OW with age. The results obtained are consistent with outward vessel wall remodeling. J. Magn. Reson. Imaging 2011;. © 2011 Wiley-Liss, Inc.

Pulmonary edema is a serious complication of heart failure, but often patients with chronic heart failure resist pulmonary edema despite elevated pulmonary venous pressures. This protection might be a result of decreased pulmonary microvascular permeability. Double-isotope scintigraphy with 113mindium-labeled transferrin and 99mtechnetium-labeled erythrocytes allows noninvasive estimation of pulmonary microvascular permeability; an index of transferrin accumulation is calculated that reflects microvascular permeability. Fourteen patients with severe chronic left ventricular dysfunction were compared with a control group of 15 patients with mild coronary artery disease. In the control group the transferrin accumulation index was 0.35 (range -0.3 to 1.0) x 10(-3)/min, and in patients with heart failure the index was 0.0 (range -1.0 to 0.7) x 10(-3)/min, which was significantly lower (p less than 0.01). The reduction in the transferrin accumulation index correlated weakly with the duration of heart failure (R = -0.5, p less than 0.02). These data indicate reduced protein efflux consistent with a decrease in pulmonary microvascular permeability in patients with severe chronic heart failure. Similar changes have been observed in severe mitral stenosis and may reflect a generalized adaptation to chronic pulmonary venous hypertension.

Background— Cardiovascular magnetic resonance is widely used for aortic root visualization and measurement, but methods still need to be standardized. Our aim was to identify appropriate planes of acquisition and lines of measurement and record corresponding normal values. Methods and Results— We studied 120 healthy volunteers, 10 of each gender in each decile between 20 and 80 years, by using a 1.5-T cardiovascular magnetic resonance system. Steady-state free precession cine acquisitions aligned with the left ventricular outflow tract in oblique sagittal and coronal orientations were used to locate 2 sinus planes that transected the root at its widest point in its maximally expanded systolic and at its end diastolic positions. We measured the cusp-cusp and the cusp-commissure dimensions in these cine planes, each as the average of 3. Diastolic cusp-commissure dimensions were smaller than diastolic cusp-cusp dimensions (32.0�3.5 mm versus 34.6�4.0 mm in men, 28.4�2.8 mm versus 30.7�3.3 mm in women, P P R 2 values with respect to age and body surface area (0.40 for men, 0.27 for women) than diastolic cusp-cusp, systolic cusp-commissure, or sinus measurements made in the left ventricular outflow tract planes. Conclusions— The results indicate the importance of consistent methods for measurement of the aortic root by cardiovascular magnetic resonance. We recommend diastolic cusp-commissure measurements, which yielded favorable R 2 values with respect to age and body surface area and were found to correspond closely with reference echocardiographic root measurements recorded in the Framingham cohort. We recorded reference values for these and other possible aortic root measurements by cardiovascular magnetic resonance.

The aim of this study was to develop a fully subject-specific model of the right coronary artery (RCA), including dynamic vessel motion, for computational analysis to assess the effects of cardiac-induced motion on hemodynamics and resulting wall shear stress (WSS). Vascular geometries were acquired in the right coronary artery (RCA) of a healthy volunteer using a navigator-gated interleaved spiral sequence at 14 time points during the cardiac cycle. A high temporal resolution velocity waveform was also acquired in the proximal region. Cardiac-induced dynamic vessel motion was calculated by interpolating the geometries with an active contour model and a computational fluid dynamic (CFD) simulation with fully subject-specific information was carried out using this model. The results showed the expected variation of vessel radius and curvature throughout the cardiac cycle, and also revealed that dynamic motion of the right coronary artery consequent to cardiac motion had significant effects on instantaneous WSS and oscillatory shear index. Subject-specific MRI-based CFD is feasible and, if scan duration could be shortened, this method may have potential as a non-invasive tool to investigate the physiological and pathological role of hemodynamics in human coronary arteries.

Modern rapid magnetic resonance (MR) imaging techniques have led to widespread use of the modality in cardiac imaging. Despite this progress, many MR studies suffer from image degradation due to involuntary motion during the acquisition. This review describes the type and extent of the motion of the heart due to the cardiac and respiratory cycles, which create image artifacts. Methods of eliminating or reducing the problems caused by the cardiac cycle are discussed, including electrocardiogram gating, subject-specific acquisition windows, and section tracking. Similarly, for respiratory motion of the heart, techniques such as breath holding, respiratory gating, section tracking, phase-encoding ordering, subject-specific translational models, and a range of new techniques are considered.

In conventional CMR, bulk cardiac motion causes target structures to move in and out of the static acquisition plane. Due to the partial volume effect, accurate localisation of subtle features through the cardiac cycle, such as the trabeculae and papillary muscles, is difficult. This problem is exacerbated by the short acquisition window necessary to avoid motion blur and ghosting, especially during early systole. This paper presents an adaptive imaging approach with COMB multi-tag tracking that follows true 3D motion of the myocardium so that the same tissue slice is imaged throughout the cine acquisition. The technique is demonstrated with motion-compensated multi-slice imaging of ventricles, which allows for tracked visualisation and analysis of the trabeculae and papillary muscles for the first time. This enables novel in-vivo measurement of circumferential and radial strain for trabeculation and papillary muscle contractility. These statistics will facilitate the evaluation of diseases such as mitral valve insufficiency and ischemic heart disease. The adaptive imaging technique will also have significant implications for CMR in general, including motion-compensated quantification of myocardial perfusion and blood flow, and motion-correction of sequences with long acquisition windows.

Purpose To demonstrate the feasibility of retrospective beat-to-beat correction of respiratory motion, without the need for a respiratory motion model. Materials and Methods A high-resolution three-dimensional (3D) spiral black-blood scan of the right coronary artery (RCA) of six healthy volunteers was acquired over 160 cardiac cycles without respiratory gating. One spiral interleaf was acquired per cardiac cycle, prior to each of which a complete low-resolution fat-selective 3D spiral dataset was acquired. The respiratory motion (3D translation) on each cardiac cycle was determined by cross-correlating a region of interest (ROI) in the fat around the artery in the low-resolution datasets with that on a reference end-expiratory dataset. The measured translations were used to correct the raw data of the high-resolution spiral interleaves. Results Beat-to-beat correction provided consistently good results, with the image quality being better than that obtained with a fixed superior–inferior tracking factor of 0.6 and better than (N = 5) or equal to (N = 1) that achieved using a subject-specific retrospective 3D translation motion model. Conclusion Non-model-based correction of respiratory motion using 3D spiral fat-selective imaging is feasible, and in this small group of volunteers produced better-quality images than a subject-specific retrospective 3D translation motion model. J. Magn. Reson. Imaging 2007;26:624–629. © 2007 Wiley-Liss, Inc.

Purpose To improve dark-blood and short tau inversion recovery (STIR) prepared turbo spin-echo (TSE) imaging of the heart, particularly in the basal short-axis plane where cardiac misregistration between the preparation and imaging phases is high. Materials and Methods In the first approach (tracked), the basal short-axis plane was labeled and tracked over the cardiac cycle. The slice-selective 180° dark-blood and STIR preparation pulses were then independently positioned on the appropriately timed labeled images. In the second approach (offset), the preparation pulses were output in the same orientation as the imaging plane, but with a user-defined slice offset that was derived from the labeled data. Both approaches were compared with the standard untracked dark-blood STIR TSE sequence (7-mm slice thickness) in 10 healthy volunteers. Results For typical preparation slice thicknesses, tracked and offset TSE images were superior to the untracked images (both P < 0.01). For the more mobile right ventricle (RV), the image quality of the tracked images was superior to that of the offset images (P < 0.05). Conclusion Tracking the through-plane motion of the heart between preparation and imaging phases improves the quality of thin-slice basal short-axis TSE images, particularly for the more mobile RV. J. Magn. Reson. Imaging 2006. © 2006 Wiley-Liss, Inc.

Cardiovascular magnetic resonance of anomalous coronary arteries is a class I indication. The term anomalous coronary artery encompasses those with an abnormal origin (from the incorrect sinus, too-high or too-low from the correct sinus, or from the pulmonary artery) and/or number of ostia. Their clinical significance results from the increased risk of myocardial infarction and sudden cardiac death associated with those traversing an interarterial course between the aorta and main pulmonary artery/right ventricular outflow tract. In this article, we review the role and practice of cardiovascular magnetic resonance in this field.

Purpose To compare a volume-selective three-dimensional turbo spin echo (TSE) technique with ultrasound (US) for assessing carotid artery wall structure and function. Materials and Methods A three-dimensional volume-selective TSE technique was used to image the carotid artery in 10 healthy subjects and five hypertensive subjects (each of whom were scanned three times while they received different hypertension treatments). Lumen and wall area were measured on MR images. Two-dimensional US measurements of the intima-media thickness (IMT) and lumen diameter were taken in three orientations through a single cross section. The lumen area change over the cardiac cycle was used to determine distension. For validation, a Bland-Altman analysis was used to compare the vessel wall and lumen areas measured by three-dimensional MRI volumes with those obtained by US scans. Results Agreement between the two methods was found. The mean difference in distension between US and MRI was 1.2% (±5.1%). For the wall area measurements, good agreement was shown, but there was a systematic difference due to the visualization of the adventitia by MRI. Both techniques offer an easy way to objectively measure lumen indices. MRI can provide the complete circumference over the length of a vessel, while US is flexible and relatively inexpensive. The application of US is limited, however, when subjects are poorly echogenic. A difference between hypertensive and healthy subjects was found. Conclusion There was a good agreement between MRI and the clinically established two-dimensional US method. The MRI method has the advantage of providing increased vessel coverage, which permits one to assess localized abnormalities without assuming vessel uniformity. J. Magn. Reson. Imaging 2005;21:282–289. © 2005 Wiley-Liss, Inc.