1. A Typical Cardiac MRI Study
Victorian MRI Users’ Group
August 2006
A Typical Cardiac MRI Study
Step By Step
Glenn Cahoon
RCH Melbourne

2. A Typical Cardiac MRI Study - Overview
Preparation
Set Up
ECG Basics
Localisers
3 Plane
Cardiac Axis
Anatomical
Black Blood
Bright Blood
CeMRA
Functional
Cine Imaging
Flow Imaging
Viability Imaging
Quantitative
Enhancement
Applications
Case Study
Future Directions

3. Cardiac MR Preparation
The Five P’s
Prior
Preparation
Prevents
Poor
Performance
Pathology
Patient
Plan
Peripherals
Placement

4. Cardiac MRI Preparation - Pathology
Read Request
Discuss with Radiologist/Cardiologist
Review previous imaging/reports
Anatomy
Lead Placement
Localisers
Question/s
Sequences
Examination Order

5. Cardiac MRI Preparation - Patient
Safety Check
Previous Operations
Previous examinations
Explain Procedure
Breath Holding
Monitoring
Timing
Prepare Patient
Height and Weight
Change into gown
Site IV if necessary

6. Cardiac MRI Preparation - Plan
Coil Choice
Determined By patient
Decide on Sequence Types
Breath-hold/non breath-hold
Cine/Flow/Angiography
Arrange Sequences in Logical Order
List the sequences
Consider image plane alignment
Consider contrast timing

7. Cardiac MRI Preparation - Peripherals
ECG Electrodes and Leads
Check electrodes have not dried out
Check leads are operational/charged
Injector
Automatic - Loaded and operational
Manual – Informed and competent
Phones
Staff to manage peripheral environment
Take them off the hook!

8. Cardiac MRI – Vector ECG Basics
ECG Trace
Time varying dipole field created by the polarisation/ depolarisation of the heart muscle
AVF RA
R Wave
Dipole strongest in end diastole, when vector is pointing along the anatomical long axis – Base to Apex I LL RL
Vector Cardiogram
A vector sum derived from the aVF and lead I reducing artifact in the signal

9. Cardiac MRI Preparation - Placement
Skin Preparation
Scruffing lotion/Alcohol Swab
Check Trace
Well defined R wave
Adjust Electrodes
Increase Separation
Swap Leads
Inverted R Waves
Haemodynamic Effect
Software sweep
Spend Time!
Whatever it takes…

10. Cardiac MRI – ECG Trigger

11. Cardiac MRI - Localisers
Standard 3–Plane Localiser
Coronal
Sagittal
Axial

12. Cardiac MRI - Localisers
Vertical Long Axis (VLA)
2 Chamber View
Axial
VLA / 2 Chamber

13. Cardiac MRI - Localisers
Horizontal Long Axis (HLA)
4 Chamber View
VLA / 2 Chamber
HLA / 4 Chamber

14. Cardiac MRI - Localisers
Short Axis (SAX)
HLA / 4 Chamber
VLA / 2 Chamber

15. Cardiac MRI - Localisers
Short Axis (SAX)

16. Cardiac MRI – The Examination
Sequences and imaging planes are determined by:
Pathology
Myocardial Disease (CM)
Congenital HD (VSD/ASD)
Major vessel Dx (coarc/stenoses/TGA’s)
Valve dysfunction
Pericardial Disease
Ischaemic Heart Disease (IHD)
Cardiomyopathy

17. Cardiac MRI – The Examination
The examination is guided by:
Clinical questions
What does it look like?
How well does it work?
Is it likely to keep working?
Morphology
Function
Viability

18. Cardiac MRI – The Examination
Morphology :
Black Blood
T1 Segmented TSE
T1TSE /
T1 Haste
Haste
Tissue Characterisation

19. Cardiac MRI – The Examination
Morphology : Anatomical
Truefisp (steady-state)
Rapid acquisition
Thin Slice
High Contrast

20. Cardiac MRI – The Examination
Morphology : 3D Truefisp
LCA
RCA

21. Cardiac MRI – The Examination
Morphology : Vascular
Turboflash CeMRA

22. Cardiac MRI – The Examination
Morphology : Vascular
Time resolved (Tricks or Treats)

23. Cardiac MRI – Functional Imaging
Cine imaging
Truefisp
Turboflash
Flow Quantification
Phase contrast
Calcium / 3T
Cine
Off Resonance effects
Less Contrast (Pre Gd)

24. Cardiac MRI – Functional Cine
4 Chamber cine

25. Cardiac MRI – Functional Cine
LVOT / 3 Chamber Cine

26. Cardiac MRI – Functional Cine
RVOT Cine

27. Cardiac MRI – Functional Cine
Short Axis Stack (SAX)

28. Cardiac MRI – Functional Flow
Phase Contrast:
In-plane

29. Cardiac MRI – Functional Flow
Phase Contrast:
Through-plane
RPA

30. Cardiac MRI – Viability Imaging
Contractile Reserve
Preserved metabolism
Sufficient perfusion
Regional Wall Motion
Myocardial Tagging
Software Analysis
Quantification
23Na
31P
13C
Spectroscopy
Delayed enhancement

31. Cardiac MRI – Viability Imaging
Delayed Enhancement
Diseased Tissue Enhances later
Delayed Myocardial
Enhancement typically
Between minutes
Post injection
Normal Dynamic
Enhancement of
myocardium
Scarred and/or
Necrotic tissue
poorly perfused

32. Cardiac MRI – Viability Imaging
Delayed Enhancement
Inversion Recovery Sequence
TI set to null normal myocardium

33. Cardiac MRI – Viability Imaging
Delayed Enhancement
TI dependant
TI Independent
IR Prep
PSIR

34. Cardiac MRI – Clinical Applications
Case Study:
Left Ventricular Hypertrophy
14 yo Male Patient with severe cardiomyopathy
Aortic Stenosis?
Left ventricular function?
Fibrosis?
Cardiac transplant?
Morphology
Function
Viability

35. Cardiac MRI – Clinical Applications
Left Ventricular Hypertrophy
Morphology
Localisers
Truefisp Stack
T1 TSE
Short Axis

36. Cardiac MRI – Clinical Applications
Left Ventricular Hypertrophy
FUNCTIONAL
4 Chamber
LVOT 2 Chamber
LVOT 3 Chamber
Short Axis

37. Cardiac MRI – Clinical Applications
Left Ventricular Hypertrophy
Viability
late Enhancement
IR SAX
TI=290
PSIR SAX

38. Cardiac MRI – Future Directions
High Resolution Coronary Imaging
Spectroscopic Analysis of Function
Time Resolved & Perfusion Imaging

39. Thank you for your attention!
Cardiac MRI – The End
Thank you
for your
attention!
RCH Melbourne:
Michael Ditchfield
Michael Kean
Michael Cheung
Acknowledgements:
Siemens Medical Systems:
Wellesley Were
Lara Hanson