syngo MR D13 Operator Manual - Cardio syngo MR D

Transcription

1 Siemens Healthcare Sector Cs2 Informatik, syngo Operator Cardio 06/2012 English n.a MR MR MRAG, Manual D13 Cape syngo MR D13 Operator Manual - Cardio syngo MR D

2 Manufacturer's notes: This product bears a CE marking in accordance with the provisions of regulation 93/42/EEC of June 14, 1993 for medical products. The CE marking applies only to medico-technical products/ medical products introduced in connection with the above-mentioned comprehensive EC regulation.

3 Overview of Contents Preparation Cardiac measurements Flow measurements Post-processing Index A B C D E syngo MR D13 i

4 syngo ii MR D13 - Cardio

5 Table of Contents A Preparation A.1 Physiological control of the measurement B Cardiac measurements B.1 Heart localization B.2 Slice localization with interactive real-time imaging B.3 Displaying standard views B.4 Views of the heart valves B.5 Display of the heart and valve functions B.6 Display of cardiac morphology B.7 Display of coronary vessels B.8 Cardiac Dot Engine C Flow measurements C.1 Measuring the flow in the heart syngo MR D13 iii

6 syngo D Post-processing D.1 Argus Viewer D.2 Ventricular Analysis D.3 4D Ventricular Analysis D.4 Flow analysis with Argus E Index iv MR D13 - Cardio

7 Introduction Introduction In order to operate the MR system accurately and safely, the operating personnel must have the necessary expertise as well as knowledge of the complete operator manual. The operator manual must be read carefully prior to using the MR system. Layout of the operator manual Your complete operator manual is split up into several volumes to improve readability. Each of these individual operator manuals covers a specific topic. Hardware components (system, coils, etc.) Software (measurement, evaluation, etc.) Another element of the complete operator manual is the information provided for the system owner of the MR system. The extent of the respective operator manual depends on the system configuration used and may vary. All components of the complete operator manual may include safety information that needs to be adhered to. The operator manuals for hardware and software address the authorized user. Basic knowledge in operating PCs and software is a prerequisite. syngo MR D13 v

8 syngo Introduction The current operator manual This manual may include descriptions covering standard as well as optional hardware and software. Contact your Siemens Sales Organization with respect to the hardware and software available for your system. The description of an option does not infer a legal requirement to provide it. The graphics, figures, and medical images used in this operator manual are examples only. The actual display and design of these may be slightly different on your system. Male and female patients are referred to as the patient for the sake of simplicity. References to Siemens Service include service personnel authorized by Siemens. Configuration This manual consists of multiple parts (Part A, Part B, etc.). A comprehensive Table of Contents can be found at the beginning of each part. vi MR D13 - Cardio

9 Introduction Important icons For readability, certain contents are highlighted. In the following sections, you will find the symbols and their contents used: Prerequisites for the operating steps to follow Request for action Item in list Notes for optimal use of the MR system. Remarks that facilitate work with the system. Problem Description of possible source of errors Requests for action to solve problems syngo MR D13 vii

10 syngo Introduction Intended use Your MAGNETOM MR system is indicated for use as a magnetic resonance diagnostic device (MRDD) that produces transverse, sagittal, coronal and oblique cross sectional images, spectroscopic images and/or spectra, and that displays the internal structure and/or function of the head, body, or extremities. Other physical parameters derived from the images and/or spectra may also be produced. Depending on the region of interest, contrast agents may be used. These images and/or spectra and the physical parameters derived from the images and/or spectra when interpreted by a trained physician yield information that may assist in diagnosis. Your MAGNETOM MR system may also be used for imaging during interventional procedures when performed with MR compatible devices such as in-room displays and MR-safe biopsy needles. The MAGNETOM MR system is not a device with measuring function as defined in the Medical Device Directive (MDD). Quantitative measured values obtained are for informational purposes and cannot be used as the only basis for diagnosis. For the USA only: Federal law restricts this device to sale, distribution and use by or on the order of a physician. viii MR D13 - Cardio

11 Introduction Authorized operating personnel The MAGNETOM MR system must be operated according to the intended use and only by qualified persons with the necessary knowledge in accordance with country-specific regulations, e.g. physicians, trained radiological technicians or technologists, subsequent to the necessary user training. This user training must include basics in MR technology as well as safe handling of MR systems. The user must be familiar with potential hazard and safety guidelines the same way the user is familiar with emergency and rescue scenarios. In addition, the user has to have read and understood the contents of the operator manual. syngo MR D13 ix

12 syngo Introduction x MR D13 - Cardio

13 A Preparation A A.1 Physiological control of the measurement A.1-1 Positioning the electrodes and PERU Attaching ECG electrodes Procurement addresses Physiological display Display of battery status Switching between signal values and controls Display of trigger events Setting the display rate Setting the number of signal tracks Selecting the physiological signal Selecting the trigger method Displaying time ranges Checking the ECG signal Prospective triggering: setting the parameters Retrospective gating: setting the parameters Without arrhythmia detection With arrhythmia detection A.1-2 A.1-4 A.1-5 A.1-6 A.1-7 A.1-7 A.1-8 A.1-8 A.1-9 A.1-9 A.1-10 A.1-11 A.1-12 A.1-13 A.1-15 A.1-16 A.1-16 syngo MR D13 A-1

14 syngo Preparation A-2 MR D13 - Cardio

15 The The The Physiological control of the measurement A.1 Physiological control of the measurement A.1 Detection of cardiac movement is a prerequisite for synchronizing the cardiac cycle and data acquisition. A.1 ECG signal A.1 ECG signal records the cumulative electrical depolarization and repolarization of cell membranes in the heart muscle during cardiac activity. A.1 A time-varying dipole field is generated that is displayed by an electrical dipole vector. The force of the dipole field is measured by the electrodes attached to the skin of the patient. A.1 R wave A.1 time point of the R wave corresponds to the end diastole. The R wave is depicted as a distinct peak and used as the reference point for triggered measurements. A.1 ECG leads A.1 ECG leads are selected according to the potential difference between the connected electrodes. The three leads I, II and III are used and acquired in parallel via the ECG channels. A.1 syngo MR D13 A.1-1

16 syngo Positioning The A.1 A.1 Preparation Positioning the electrodes and PERU A.1 Electrodes A.1 of the electrodes varies according to the position of the heart. An example is provided in the figure below. A.1 Use only disposable ECG electrodes as released by Siemens. ( Page A.1-5 Procurement addresses) PERU A.1 ECG sensor in the PERU ensures transfer of the ECG signal. Typically, the PERU is aligned in the direction of the foot end of the patient table even though the patient may be positioned feet first in the direction of the magnet bore. A.1 Position the PERU in the appropriate support or add absorbent material between the ECG cables, PERU and skin. The distance between PERU and patient should be at least 2 cm. Positioning the ECG electrodes (left) and the PERU (right). (1) A.1-2 MR D13 - Cardio

17 A.1 A.1 Physiological control of the measurement A.1 The transmitter unit of the PERU includes three LEDs for signaling the battery status and one LED as fault indicator (e.g. insufficient skin contact of the ECG electrodes). Battery status and electrode fault are also indicated on the Dot display above the magnet bore and the Physiological Display dialog window. If the red LED Electrode fault on the PERU flashes, the ECG electrodes are not attached correctly. Check to ensure that the electrodes are not falling off. syngo MR D13 A.1-3

18 syngo Preparation Attaching ECG electrodes A.1 The electrodes must be positioned and attached with care to ensure a sufficient and consistent ECG signal. A.1 Ensure satisfactory contact between the electrodes and the patient's skin. Thoroughly clean the patient's skin with a dry cloth or NUPREP ECG & EEG Abrasive Skin Prepping Gel. ( Page A.1-5 Procurement addresses) If the patient is hirsute, shave the location where you want to attach the electrodes. Dry the skin carefully. Check the signal. ( Page A.1-12 Checking the ECG signal) If the signal received is not satisfactory and consistent, vary the location of the electrodes. Use new electrodes every single time. If one of the leads does not provide a sufficient signal, change to a single ECG lead in the Physiological Display dialog window. A.1-4 MR D13 - Cardio

19 Disposable NUPREP Physiological control of the measurement A.1 Procurement addresses A.1 Disposable ECG electrodes A.1 ECG electrodes may be ordered from: A.1 Siemens Commercial goods (Catalog Med & More), CONMED 2700 Cleartrace A.1 Item no (30 pieces) or Item no (600 pieces) or from: A.1 CONMED CORPORATION, 310 Broad Street, Utica, New York 13501, USA A.1 Cleaning gel A.1 ECG & EEG Abrasive Skin Prepping Gel A.1 Weaver and Company, 565 Nucla Way, Unit B, Aurora, Colorado 80011, USA A.1 syngo MR D13 A.1-5

20 syngo A.1 A.1 A.1 A.1 Preparation Physiological display A.1 The Physiological Display dialog window is a window on the GSP. The window position is fixed and cannot be moved or resized. A.1 To open or close the Physiological Display dialog window, click the icon. If you have selected the GSP layout Cardiac UI, the Physiological Display dialog window is integrated into the user interface and cannot be closed, that is, the icon is dimmed. To close the Physiological Display dialog window, select another GSP layout from the main menu, for example, View > 2 Segments. Afterwards, the icon is active again. Recommendation: Use the Cardiac UI in general. A.1-6 MR D13 - Cardio

21 A.1 A.1 A.1 A.1 Physiological control of the measurement A.1 Display of battery status A.1 The Physiological Display dialog window displays the battery status of the PERU (Physiologic ECG and Respiratory Unit) and/ or the PPU (Peripheral Pulse Unit). The status of the battery is indicated via five different icons. A.1 Check the battery status and replace the battery if necessary. Switching between signal values and controls A.1 To display the controls, click the switch icon. To redisplay the signal values, click the switch icon again. syngo MR D13 A.1-7

22 syngo A.1 Preparation Display of trigger events A.1 The trigger information delivered by the PMU is shown as triangles above the signal curve. A.1 Large triangle: Channel is used for triggering. Small triangle: Channel is not used for triggering. Setting the display rate A.1 You can select between three different display rates; Slow, Medium, and Fast. A.1 Select the requested display rate by clicking the corresponding icon. or A.1 Select the requested display rate from the context menu (right-click with the mouse). A.1-8 MR D13 - Cardio

23 A.1 Physiological control of the measurement A.1 Setting the number of signal tracks A.1 You can display up to three time-synchronized signal tracks. A.1 Select the number of signals in the Display selection list. One Signal Two Signal All ECG: Displays all 3 ECG signals in one track Example: Two Signal selected. (2) Selecting the physiological signal A.1 Each signal track displays one of the physiological signals as a continuous curve, i.e., the ECG I signal, ECG II signal, ECG III signal, the pulse signal, the respiratory signal, and the external signal. A.1 Select the curve to be displayed (separately for both signal tracks) in the corresponding selection list. syngo MR D13 A.1-9

24 syngo A.1 Preparation Selecting the trigger method A.1 Select the respective trigger method in the Trigger selection list of the Physiological Display dialog window. Auto (default, automatic selection of best leads) VCG standard ECG I (II/III) only If Auto is used, the signal characteristics can be relearned by selecting Relearn in the context menu of the Physiological Display. A.1 You cannot change the trigger method during the measurement. A.1-10 MR D13 - Cardio

25 A.1 A.1 Physiological control of the measurement A.1 Displaying time ranges A.1 The following color-coded time ranges are displayed below the signal curve in a bar. A.1 Grey: Delay time Green: Measurement interval and/or acquisition window Dark green: Measurement pauses, e.g., for saturation pulses Red: Time out To switch the display of the time range bar on or off, click the icon. or A.1 Select Scanbars in the context menu (right-click with the mouse). The time ranges can be displayed on both signal tracks, but not with the All ECG mode. A.1 With display rate Fast, no time ranges are displayed. With display rate Slow, time ranges are displayed if the selected signal is a respiratory signal or an external signal. syngo MR D13 A.1-11

26 syngo The A.1 A.1 Preparation Checking the ECG signal A.1 Dot display A.1 R waves should be clearly visible, making them suitable for triggering the examination. A.1 The strength indicator represents the amplitude strength (optimal: five bars). The learning phase status is displayed in the status area of the display. A.1 Dot display. (3) (1) Signal strength (2) Battery status Check the signal via the Dot display above the magnet bore. To ensure reliable triggering, a minimum of two bars should be shown at least on one ECG channel. The other ECG channels should show a minimum of one bar. A.1-12 MR D13 - Cardio

27 A.1 Physiological control of the measurement A.1 Prospective triggering: setting the parameters A.1 The parameters for prospective triggering are set on the Physio Signal1 parameter card. A.1 Determine the physiological signal and the trigger mode in the 1st Signal/Mode field. Accept the value determined for the average cardiac cycle with Captured cycle. Check the time duration of the acquisition window. syngo MR D13 A.1-13

28 syngo Preparation By clicking Captured cycle, the average cycle 60 ms is automatically entered in the acquisition window during prospectively triggered measurements. A.1 Select the trigger pulse. When you start a measurement, select 1 for each trigger (R wave, pulse wave). Select 2 for starting a measurement at every second trigger (e.g., for T2-weighted measurements). A.1 Set the trigger delay to shift data acquisition into the diastole. If required, set additional measurement parameters to the desired values. A.1-14 MR D13 - Cardio

29 A.1 Physiological control of the measurement A.1 Retrospective gating: setting the parameters A.1 Use the Physio Signal1 parameter card to set the parameters for gating (with or without arrhythmia detection). A.1 Example with arrhythmia detection. (4) Determine the physiological signal and the gating mode in the 1st Signal/Mode field. syngo MR D13 A.1-15

30 syngo A.1 Preparation Without arrhythmia detection A.1 Determine the number of phases needed in the Calculated phases window. The phases are subsequently computed via interpolation. A.1 With arrhythmia detection A.1 Set the expected average RR interval in the Target RR window or click Captured cycle. Set the Trigger window. To avoid smearing, select a lower number of segments for a short cardiac cycle. A.1-16 MR D13 - Cardio

31 B Cardiac measurements B B.1 Heart localization B.1-1 Measuring orthogonal multi-slice localizers B.1-3 Measuring the 2-chamber localizer B.1-4 Measuring the 4-chamber localizer B.1-5 Measuring the short-axis localizer B.1-6 B.2 Slice localization with interactive real-time imaging Localizing slices in real time Transferring slice parameters Helpful hints B.2-1 B.2-1 B.2-3 B.2-4 B.3 Displaying standard views B.3-1 Displaying the 4-chamber view 2-chamber view, displaying the left ventricle Displaying the 3-chamber view (LV inflow and outflow tract) Displaying short-axis views 2-chamber view, displaying the right ventricle Displaying the left ventricular outflow tract with aortic valve (LVOT) B.3-4 B.3-6 B.3-8 B.3-10 B.3-12 B.3-14 B.4 Views of the heart valves B.4-1 Displaying the aortic valve Displaying the mitral valve B.4-3 B.4-5 syngo MR D13 B-1

32 syngo Cardiac measurements B.5 Display of the heart and valve functions B.5-1 The CINE technique Measuring multiple slices per breathhold Concatenations Number of concatenations FLASH sequences Area of application None-segmented Segmented Phase sharing PAT TrueFISP sequences Advantages Segmentation and phase sharing PAT Radial sampling Real time TrueFISP and image quality TrueFISP parameter example Real-time measurements Inline function examinations Overview Performing Inline function examinations B.5-2 B.5-3 B.5-3 B.5-4 B.5-5 B.5-5 B.5-5 B.5-6 B.5-6 B.5-6 B.5-7 B.5-7 B.5-7 B.5-8 B.5-8 B.5-8 B.5-9 B.5-10 B.5-12 B.5-14 B.5-14 B.5-15 B-2 MR D13 - Cardio

33 Cardiac measurements B B.6 Display of cardiac morphology B.6-1 Increase in contrast using Dark Blood Dark Blood preparation Timing Dark Blood parameter example (TSE) Bright Blood B.6-1 B.6-2 B.6-2 B.6-4 B.6-6 B.7 Display of coronary vessels B.7-1 Measurement conditions Localization Acquisition window Breathhold technique Localizing coronary blood vessels Displaying coronary blood vessels Respiratory control using navigator technique Navigator and search window Acceptance window Slice correction with the navigator Navigator parameter free breathing example Navigator parameter breathhold technique example B.7-2 B.7-2 B.7-2 B.7-3 B.7-4 B.7-5 B.7-7 B.7-7 B.7-9 B.7-10 B.7-11 B.7-13 syngo MR D13 B-3

34 syngo Cardiac measurements B.8 Cardiac Dot Engine B.8-1 Planning the heart examination and measuring the localizer Adapting the examination to the patient Starting the measurement of the localizer Planning the localizer at the isocenter Measuring thoracic overview images Measuring the AAHeart_Scout Defining and measuring the long-axis localizer Editing CINE long-axis views (optional) Defining and measuring the short-axis localizer Performing dynamic test Performing dynamic stress Measuring CINE short-axis views Performing dynamic rest Performing tissue characterization Performing high resolution tissue characterization (optional) Planning additional heart views (optional) B.8-3 B.8-5 B.8-8 B.8-9 B.8-11 B.8-12 B.8-14 B.8-17 B.8-21 B.8-24 B.8-26 B.8-27 B.8-30 B.8-31 B.8-32 B.8-33 Configuring protocol steps (optional) B.8-37 Adapting the Patient View (Cardiac Patient View) B.8-38 Adapting protocol settings (all cardiac add-ins) B.8-43 Adapting standard views (Cardiac Standard) B.8-44 Adapting short-axis protocols (Cardiac SAX Planning) B.8-47 Adapting the DefineLongaxis protocol (Cardiac Marker Localization) B.8-48 B-4 MR D13 - Cardio

35 The B.1 Heart localization B.1 Heart localization B.1 The location of the heart may vary greatly from patient to patient. For this reason, localization is the basis of cardiovascular MR examinations. Standard views and the display of heart valves are based on this. B.1 Different location of the heart in three patients. (5) Localization in four steps B.1 more accurate the localization is, the more accurate the pathologies or functional interferences will be displayed in the images. B.1 syngo MR D13 B.1-1

36 syngo Cardiac measurements Localizer sequence: B.1 Orthogonal multi-slice localizer 2-chamber localizer 4-chamber localizer Short-axis localizer Fast single-shot protocols (TrueFISP, TurboFLASH, HASTE) are used for localizing. As an alternative, real-time protocols may be used. B.1 To avoid motion artifacts, the measurement is shifted into the diastole by using the trigger delay. For accurate reproducibility, the slices are acquired in breathhold technique. They should be measured in the same respiratory phase (end expiration or end inspiration) used for subsequently acquiring high-resolution images. B.1 B.1-2 MR D13 - Cardio

37 B.1 B.1 Heart localization B.1 Measuring orthogonal multi-slice localizers B.1 Consistent ECG signal An orthogonal multi-slice localizer provides several transverse, sagittal, and coronal slices of the heart. B.1 Position the heart in the center of the magnetic field. Measure the orthogonal multi-slice localizers. Check the images to see if the heart is in the center of the magnetic field and the correct coils have been selected. Body and Spine Array elements should be choosen to cover the complete heart. If corrections are required (e.g., repositioning the patient into the center of the magnetic field), repeat the measurement. Orthogonal localizers. (6) syngo MR D13 B.1-3

38 syngo B.1 Cardiac measurements Measuring the 2-chamber localizer B.1 Orthogonal multi-slice localizers have been measured As a first step you set the vertical long axis using the 2-chamber localizer. B.1 Select a transverse slice at the height of the ventricle from the orthogonal multi-slice localizers. Position this slice vertically on this image, parallel to the septum and through the apex of the left ventricle. You obtain a cut through the vertical long axis with a view of the left ventricle and left atrium. B.1 Positioning and 2-chamber localizer. (7) B.1-4 MR D13 - Cardio

39 B.1 Heart localization B.1 Measuring the 4-chamber localizer B.1 2-chamber localizer has been measured Starting with the vertical long axis, you are looking for the horizontal long axis of the heart. B.1 Position the slice vertically in the 2-chamber localizer through the apex of the heart and through the center of the mitral valve. The result is an image with 4 heart chambers. The right ventricle may be too short and part of the left ventricular outflow tract may be visible. B.1 Positioning and 4-chamber localizer. (8) syngo MR D13 B.1-5

40 syngo B.1 Cardiac measurements Measuring the short-axis localizer B.1 4-chamber and/or 2-chamber localizer has/have been measured Conclude localization by measuring the short-axis localizer. B.1 Position the slice vertically on the 4-chamber and/or 2-chamber localizer, parallel to the plane of the heart valves and approximately at a right angle to the septum. Acquire part of the atria and left outflow tract as well as both ventricles. B.1-6 MR D13 - Cardio

41 B.1 B.1 Heart localization B.1 Check the slice position in the 2-chamber localizer. The slices should be located at a right angle to the long axis. Slice positioning and short-axis views. (9) syngo MR D13 B.1-7

42 syngo Cardiac measurements B.1-8 MR D13 - Cardio

43 B.2 Slice localization with interactive real-time imaging B.2 Slice localization with interactive real-time imaging B.2 Localizing slices in real time B.2 Localizer has been measured The localization measurement runs in an infinite loop and provides the exact position and orientation of the slice to be measured. During the measurement, you can change the position and orientation of the slice to be measured. B.2 Open the real-time protocol (BEAT_IRT) in the Online Editor. Optimize the measurement parameters, if necessary. Plan the measurement using a maximum number of repetitions. For this purpose, select the Infinite measurement checkbox on the Contrast Dynamic parameter card. B.2 To control the measurement in progress, the protocol needs to remain open in the Online Editor during the measurement. This is ensured by starting the measurement with Apply in the program control. syngo MR D13 B.2-1

44 syngo B.2 B.2 Cardiac measurements Start the localization measurement. In the Online Editor, the real-time protocol changes from planning to the interactive mode. With the exception of the slice position and orientation parameters that are controlled interactively, all parameters are dimmed. B.2 During the localization measurement, change the slice position and orientation. For this purpose, use the same tools you normally use for slice planning. B.2 The reconstructed images are shown in the Inline Display. B.2 B.2-2 MR D13 - Cardio

45 B.2 Prior B.2 B.2 Slice localization with interactive real-time imaging B.2 Transferring slice parameters B.2 Slice has been localized As soon as the requested slice plane has been reached, you can save it for later use (e.g., other imaging strategy). For this purpose, you can continue, pause, stop, or end the measurement. B.2 In the Inline Display: Save the requested image. You are able to locate and save several orientations during the measurement. Pausing the measurement B.2 to saving the image orientation, you can pause the measurement. This pause may be used for example, to give breathing commands in order to optimize the orientation. B.2 In the Inline Display: Pause the localization measurement. To continue the measurement, click Pause again. syngo MR D13 B.2-3

46 syngo B.2 B.2 Cardiac measurements Stopping the measurement B.2 In the program control: Stop the localization measurement. The real-time protocol changes again from interactive to planning mode in the Online Editor. If necessary, you are now able to optimize the protocol again. B.2 In the program control: End the localization measurement. The real-time protocol is closed and, if available, the next protocol opens. B.2 Helpful hints B.2 In the following example, a typical setting for an interactive heart localization measurement is explained. B.2 Protocol has been selected Select Properties... from the context menu (right-click with the mouse). The Protocol properties dialog window opens. B.2 B.2-4 MR D13 - Cardio

47 B.2 B.2 Slice localization with interactive real-time imaging B.2 Select the Auto load subtask card. Load images to graphic segments B.2 Auto open Inline Display B.2 Auto close Inline Display B.2 The images measured interactively are automatically loaded into a segment of graphic slice positioning. You can continue localizing interactively in real time on these images. B.2 When starting the protocol, Inline Display opens automatically with the display options last used. B.2 Automatically closes Inline Display at the end of the measurement. B.2 syngo MR D13 B.2-5

48 syngo B.2 B.2 Cardiac measurements Select the Auto store images option only, if you want to view several measurements simultaneously (e.g., motion studies). In this case, ensure that Multiple series is deselected (see also next hint). To minimize the number of series: Deselect the Multiple series option on the Contrast Dynamic parameter card. In this case, the images will be automatically loaded into graphic slice positioning only after completion of the protocol. However, you are able to manually load unfinished series into image segments during the measurement. B.2-6 MR D13 - Cardio

49 You B.2 Slice localization with interactive real-time imaging B.2 Changing between different slice orientations B.2 Load the images into stamp segments. Automatically during the measurement B.2 The Load images to stamp segments and Multiple series options are selected. B.2 Automatically after the measurement B.2 The Load images to stamp segments option is selected and the Multiple series option is deselected. In this case loading images may take a long time in case of large data volumes. B.2 Manually B.2 can drag the image icon from the measurement queue to an image stamp segment at any time. B.2 Subsequently, you are able to select from the images during the measurement (Copy image position in the graphic slice positioning context menu). B.2 syngo MR D13 B.2-7

50 syngo If If Cardiac measurements Automatic windowing B.2 the windowing of the first images of the localization measurement is not optimal, do not transfer the window values to the following images. In that case: B.2 Deselect Window On Succeeding On (from the Inline Display context menu). Adjustment volume B.2 the adjustment volume (green rectangle) covers the slice during graphic slice positioning: B.2 Switch off the display of the adjustment volume (View > Adjustment Volume on/off menu). or B.2 Select the adjustment volume large enough so it covers the entire display area. B.2-8 MR D13 - Cardio

51 Displaying standard views B.3 Displaying standard views B.3 Accurately determined standard views constitute an important basis for many examinations. B.3 2-chamber view, left ventricle B.3 The 2-chamber view of the left ventricle (LV) shows: B.3 Left ventricle Front and back wall LV Left atrium Mitral valve 2-chamber view, right ventricle B.3 The 2-chamber view of the right ventricle (RV) shows: B.3 Right ventricle Front and back wall RV Right atrium Tricuspid valve syngo MR D13 B.3-1

52 syngo The The Cardiac measurements 4-chamber view B.3 4-chamber view shows: B.3 Atrial septum Intra-ventricular septum Ventricular lateral walls of LV and RV Mitral and tricuspid valves 3-chamber view B.3 3-chamber view (left ventricular inflow and outflow tract) shows: B.3 Left ventricle Left atrium Anterior septum Back side wall of left ventricle Aortic and mitral valves B.3-2 MR D13 - Cardio

53 The Displaying standard views B.3 Short-axis views B.3 short-axis views simultaneously show both ventricles at a right angle to the septum, including all cardiac walls. B.3 The post-processing software Argus requires this view for analyzing the LV or RV functional values. ( Page D.2-1 Ventricular Analysis) B.3 Left ventricular outflow tract with aortic valve B.3 The image of the left ventricular outflow tract with aortic valve (LVOT) shows: B.3 Left ventricle Outflow tract LV Aortic valve Aortic bulb Ascending aortic arch syngo MR D13 B.3-3

54 syngo Cardiac measurements Displaying the 4-chamber view B.3 High-resolution standard views are generated on the basis of the localizers. B.3 Localizers have been measured On the short-axis localizers B.3 Position the slice vertically on the septum through the largest expansion of the right and left ventricle. Ensure that the planned slice is not crossing the aortic root by scrolling to the base of the heart. On the 2-chamber localizer B.3 Position the slice through the mitral valve and the apex of the heart. On the 4-chamber localizer B.3 Adjust the size of the FoV, position, and inline rotation. The 4-chamber view shows the left and right ventricles in their entire length as well as both atria. B.3 B.3-4 MR D13 - Cardio

55 B.3 Displaying standard views B.3 Positioning and 4-chamber view. (10) (1) Left ventricle (2) Left atrium (3) Right ventricle (4) Right atrium (5) Mitral valve (6) Tricuspidal valve (7) Apex of the heart (8) Atrial septum (9) Ventricular septum (10)Aorta (11)Lungs syngo MR D13 B.3-5

56 syngo Cardiac measurements 2-chamber view, displaying the left ventricle B.3 On the short-axis localizers B.3 Position the slice parallel to the connection line between the back and front connection points of the right ventricle and shift the slice into the center of the left ventricle. On the 4-chamber view B.3 If required, turn the slice into the apex of the heart. On the 2-chamber localizer B.3 Adjust the size of the FoV, position, and inline rotation. B.3-6 MR D13 - Cardio

57 B.3 Displaying standard views B.3 Positioning and 2-chamber view LV. (11) (1) Left ventricle (2) Left atrium (3) Mitral valve (4) Papillary muscle (5) Anterior wall (6) Posterior wall (7) Apex of the heart (8) Vein of the lungs (9) Lungs syngo MR D13 B.3-7

58 syngo Cardiac measurements Displaying the 3-chamber view (LV inflow and outflow tract) B.3 On the basal short-axis localizers B.3 Position the slice through the aorta and through the center of the left ventricle as well as the left atrium. On the 4-chamber view B.3 Adjust the slice in the 4-chamber view so that it passes through the apex of the left ventricle. B.3-8 MR D13 - Cardio

59 B.3 Displaying standard views B.3 Positioning and 3-chamber view. (12) (1) Left ventricle (2) Left atrium (3) Right ventricular outflow tract (4) Mitral valve (5) Papillary muscle (6) Aortic valve (7) Apex of the heart (8) Anterior septum (9) Aorta (10)Pulmonary artery syngo MR D13 B.3-9

60 syngo B.3 B.3 Cardiac measurements Displaying short-axis views B.3 On the 4-chamber view B.3 Position the slice(s) vertically on the 4-chamber view, approximately at a right angle to the septum and parallel to the cardiac valves. On the 2-chamber view B.3 Adjust the slices, if necessary, so that they run parallel to the mitral valve. On the short-axis localizer B.3 To avoid aliasing artifacts in the read-out direction, adjust the FoV. When planning slices, please factor in cardiac motion and location as a function of the cardiac cycle. Use CINE images for accurate slice positioning. ( Page B.5-2 The CINE technique) If you cover the entire heart with short axes for a volumetric measurement, please ensure that all slices are measured with the same slice orientation. B.3-10 MR D13 - Cardio

61 B.3 Displaying standard views B.3 Positioning and short-axis view. (13) (1) Left ventricle (2) Right ventricle (3) Papillary muscle (4) Anterior wall (5) Side wall (6) Posterior wall (7) Right ventricular Free wall (8) Anterior septum (9) Posterior septum (10)Lungs syngo MR D13 B.3-11

62 syngo Cardiac measurements 2-chamber view, displaying the right ventricle B.3 On the short-axis localizers B.3 Position the slice approximately parallel to the 2-chamber view LV. On the 4-chamber view B.3 Adjust the slice so that the angle through the right ventricle is not too oblique and you are not cutting into parts of the left ventricle. Most of the time you are able to simultaneously show both the tricuspid valve and the pulmonary valve. B.3 B.3-12 MR D13 - Cardio

63 B.3 Displaying standard views B.3 Positioning and 2-chamber view RV. (14) (1) RV Anterior wall (2) RV Posterior wall (3) Right atrium (4) Tricuspid valve (5) Aorta ascendens (6) Truncus brachiocephalicus (7) Vena cava superior (8) Lungs syngo MR D13 B.3-13

64 syngo B.3 B.3 Cardiac measurements Displaying the left ventricular outflow tract with aortic valve (LVOT) B.3 On the 3-chamber view B.3 Position the slice along the ascending aorta and vertically to the aortic valve. Consider the movement of the aortic root during slice planning. Use CINE images for accurate slice positioning. ( Page B.5-2 The CINE technique) Arms frequently lead to overfolding artifacts. However, these are usually located outside the structures of interest. B.3-14 MR D13 - Cardio

65 B.3 Displaying standard views B.3 Positioning and outflow tract LV. (15) (1) Left ventricle (2) Right ventricle (3) Right atrium (4) Aortic valve (5) Papillary muscle (6) Aorta ascendens (7) Pulmonary artery (8) Truncus brachiocephalicus (9) Lungs syngo MR D13 B.3-15

66 syngo Cardiac measurements B.3-16 MR D13 - Cardio

67 The Views of the heart valves B.4 Views of the heart valves B.4 The position of the heart valves changes as a function of the phase of the cardiac cycle. As a result, their display during the systole requires a different slice position than during the diastole. B.4 In case of stenosing valves, the leaflets or atrioventricular valves no longer open uniformly. For slice positioning it is helpful to know the main orientation of the blood flow through the valve ring. B.4 FLASH versus TrueFISP B.4 FLASH sequence is especially suitable for displaying valve openings due to its characteristics of displaying inflowing blood as bright in color. Equally, FLASH provides for excellent displays of jets (blood flow in the wrong direction and/or turbulent flow in case of stenoses).inflowing blood is not as bright in a TrueFISP sequence, however, the valve rings are clearly shown. B.4 syngo MR D13 B.4-1

68 syngo The B.4 Cardiac measurements Evaluation B.4 size of the valve opening is evaluated by drawing in the valve margins and/or evaluating the bright blood flow as a function of the cardiac phase. B.4 Inflow through a normal (top) and stenosing mitral valve (bottom) during early and late diastole. (16) B.4-2 MR D13 - Cardio

69 B.4 Views of the heart valves B.4 Displaying the aortic valve B.4 The slices for imaging the aortic valve ring are easily positioned on the displays of the 3-chamber view or LVOT. B.4 Depending on the cardiac phase to be examined, determine the position of the valve on the CINE images as a function of the time after the trigger pulse. To show the valve in full, generate several slices running in parallel to the valve plane. Position the slice vertically to a 3-chamber and LVOT view on the aortic valves. Shifts in the valve plane are less noticeable with sclerosing valves or older patients. The aortic valve is open during the systole. The opening is usually shown as a bright triangle. In 3-chamber and LVOT views, stenoses are indicated by jet effects in the blood flow direction. As compared to stenoses, insufficiencies are indicated by a jet effect in the opposite direction of the blood flow. B.4 syngo MR D13 B.4-3

70 syngo B.4 Cardiac measurements Positioning and aortic valve. (17) (1) Right semilunar valve (2) Left semilunar valve (3) Acoronary (posterior) semilunar valve (4) Left atrium (5) Right ventricle (6) Right atrium (7) Tricuspid valve (8) Right ventricular outflow tract (9) Aorta descendens (10)Lungs B.4-4 MR D13 - Cardio

71 B.4 Views of the heart valves B.4 Displaying the mitral valve B.4 The mitral valve can be seen on the long axis cuts. The most optimal display is provided with a 3-chamber view. B.4 Determine the position of the valve as a function of time after the trigger pulse. On the 3-chamber view B.4 Position the slice on the mitral valve. To display the entire valve, measure several parallel slices. On the 4-chamber view B.4 Correct the slice as required and turn it parallel to the valve plane. syngo MR D13 B.4-5

72 syngo B.4 Cardiac measurements Positioning and mitral valve. (18) (1) Anterior leaflet (2) Posterior leaflet (3) Right atrium (4) Pulmonary valve (5) Vena cava inferior (6) Lungs B.4-6 MR D13 - Cardio

73 B.5 Display of the heart and valve functions B.5 Display of the heart and valve functions B.5 The examination of functions plays an important role within cardiovascular MR. Various programs provide different methods for CINE imaging. In general, the different options enable you to compromise between temporal and spatial resolution, measurement time as well as image contrast. B.5 As a prerequisite for functional examinations, the complete cardiac cycle must be imaged. This means that the acquisition window includes the entire cardiac cycle. Additionally, there is no trigger delay between triggering and the start of data acquisition. B.5 2-chamber view of the left ventricle during different cardiac phases. (19) syngo MR D13 B.5-1

74 syngo To Cardiac measurements The CINE technique B.5 CINE B.5 display the cardiac function, MR images are acquired during different phases of the cardiac cycle and automatically shown in an endless loop. The viewer has the feeling of watching a video on cardiac activity. B.5 The more phases are shown, the better the resolution of cardiac motion. B.5 The CINE technique uses gradient echo sequences: B.5 FLASH TrueFISP The sequences are combined with the following techniques: B.5 Segmentation Phase sharing ipat (integrated and separated reference lines) tpat Radial (TrueFISP only) Real time (TrueFISP only) B.5-2 MR D13 - Cardio

75 B.5 Display of the heart and valve functions B.5 (1) Mitral valve (FLASH) (2) 4-chamber view (TrueFISP) Measuring multiple slices per breathhold B.5 Protocols for functional examinations enable you to measure several slices in the same orientation within a breathhold. B.5 Concatenations B.5 The concatenation parameter determines the number of slices to be measured per breathhold. The following applies: B.5 Total number of slices/concatenations = Number of slices per breathhold B.5 syngo MR D13 B.5-3

76 syngo If Cardiac measurements Example B.5 twelve slices are required to cover the entire heart for an ejection fraction examination and six concatenations are selected, two slices per breathhold can be measured. B.5 Settings for this example: B.5 On the Physio PACE parameter card select Breath-hold for respiratory control. On the Routine parameter card or the Physio Signal 1 or Physio PACE parameter cards, set the Concatenations to 6. Number of concatenations B.5 The concatenations have to be adjusted to the length of the breathhold that is not difficult for the patient to handle. B.5 A small number of concatenations divides the measurement into only few but long breathholds. A large number of concatenations divides the measurement into many short breathholds. The length of the breathhold can be displayed by holding the mouse pointer over the total measurement time displayed. B.5 B.5-4 MR D13 - Cardio

77 Display of the heart and valve functions B.5 FLASH sequences B.5 Area of application B.5 High-resolution display of the valves of the heart and/or flow phenomena For patients with valve replacement that could lead to strong artifacts with TrueFISP None-segmented B.5 Only one raw data line is measured per cardiac cycle. The measurement time is too long for breathhold technique. B.5 To reduce motion artifacts, the data are acquired repeatedly and subsequently averaged. Today this method is rarely used. B.5 syngo MR D13 B.5-5

78 syngo Cardiac measurements Segmented B.5 Several raw data lines are measured per cardiac cycle. The measurement can be performed within a breathhold. B.5 The number of segments limits temporal resolution. If you increase the number of segments, temporal resolution as well as the entire measurement time are reduced (and vice versa). B.5 Phase sharing B.5 Each phase acquires several previously measured raw data lines from adjacent phases. As a result, fewer raw data lines have to be measured per phase. B.5 The number of segments can be increased and the measurement time reduced, or the repetition time TR can be reduced and the number of phases increased for the same amount of segments and measurement time. B.5 PAT B.5 Parallel data acquisition techniques allow for faster measurement times or increases in the temporal or spatial resolution. B.5 B.5-6 MR D13 - Cardio

79 Display of the heart and valve functions B.5 TrueFISP sequences B.5 TrueFISP sequences are highly suitable for displaying the beating heart with high temporal and spatial resolution. B.5 Advantages B.5 As compared to FLASH, the advantages of TrueFISP are: B.5 Blood displayed at higher signal intensity Improved blood-tissue contrast Higher temporal resolution is possible Combinations with real time and radial are possible Segmentation and phase sharing B.5 TrueFISP sequences acquire data either segmented or in a single shot (all raw data lines are measured within one heart beat). As is the case with FLASH, phase sharing enables even shorter measurement times or increases temporal resolution (a higher number of phases). B.5 syngo MR D13 B.5-7

80 syngo Cardiac measurements PAT B.5 Just like FLASH, TrueFISP may be used with the different PAT technologies. B.5 Radial sampling B.5 TrueFISP can be combined with radial sampling. In this case, the k space is not filled line-by-line, but rather through radial projections. The results are very high temporal and spatial resolutions within a short measurement time. B.5 Real time B.5 TrueFISP can also be used to measure in real time. B.5 B.5-8 MR D13 - Cardio

81 Display of the heart and valve functions B.5 TrueFISP and image quality B.5 Using TrueFISP, the best possible image quality is obtained by using the shortest possible echo time TE. For this reason, the system automatically sets the smallest possible values for TE and TR. B.5 Magnetic field homogeneity is the most important prerequisite for good image quality. Inhomogeneities lead to ribbon artifacts noticeable as dark stripes in the image. B.5 In the majority of cases, image interference is remedied by adjusting the adjustment volume. B.5 B.5 TrueFISP images: Artifacts caused by field inhomogeneity (left, center) and good image quality by correcting the adjustment volume (right). (20) syngo MR D13 B.5-9

82 syngo The B.5 Cardiac measurements TrueFISP parameter example B.5 In the following example, a typical setting for TrueFISP with retrospective gating is explained for the Physio Signal1 parameter card. These settings also apply to the respective FLASH and flow sequences. B.5 TR B.5 repetition time TR is computed by the system as a function of the number of segments and echo spacing time. B.5 To shorten TR you can reduce the number of segments. B.5 B.5-10 MR D13 - Cardio

83 B.5 B.5 Display of the heart and valve functions B.5 Select the number of phases so that one phase does not correspond to more than double the temporal resolution of TR. This means that not more than 40 phases should be computed at a TR of 40 ms and an average cardiac cycle of 800 ms. It is recommended to adjust temporal resolution to the cardiac cycle.this may be especially important for stress examinations with short cardiac cycles. syngo MR D13 B.5-11

84 syngo When B.5 Cardiac measurements Real-time measurements B.5 Using TrueFISP sequences, cardiac motion may be displayed in real time. B.5 Real-time measurements may be performed without triggering and breathhold techniques. This makes real-time measurements an excellent alternative for examining uncooperative patients or patients who are unable to hold their breath. The measurement is fast enough to avoid respiratory artifacts. B.5 PAT B.5 real-time measurements are combined with various PAT techniques, an improved temporal resolution is obtained. B.5 (1) Real-time measurement (2) High-resolution measurement B.5-12 MR D13 - Cardio

85 Overfolding By B.5 B.5 Display of the heart and valve functions B.5 Radial sequences B.5 effects are eliminated with radial sequences. The FoV can be closely limited to the cardiac area which results in high spatial resolution. B.5 It is not possible to combine real-time radial sequences with ipat. Preparation pulse B.5 switching off the preparation pulses (Dummy heartbeats = 0), the total measurement time can be considerably reduced for real-time measurements, because only half of the heartbeats have to be measured. B.5 syngo MR D13 B.5-13

86 syngo Automatic Cardiac measurements Inline function examinations B.5 Overview B.5 In addition to segmenting and analyzing short-axis images with the Argus ventricular analysis ( Page D.2-1 Ventricular Analysis), an automatic inline-segmentation of the left ventricle (LV) is possible as well. B.5 Progression B.5 segmentation is performed across all CINE phases and slices. The results of segmentation are superposed as color graphics in the short-axis images. B.5 As soon as a complete image stack has been acquired, calculation of the most important functional parameters starts (ejection fraction, cardiac output, end- diastolic and end-systolic volumes). B.5 The calculated parameters are shown in the Inline Display and saved as their own series in the database (Inline_VF_results). B.5 Automatically generated contours can be edited retroactively with Argus. B.5 B.5-14 MR D13 - Cardio

87 B.5 B.5 Display of the heart and valve functions B.5 Automatic segmentation of the left ventricle. (21) (1) End diastole (2) End systole Performing Inline function examinations B.5 The Inline ventricular analysis is performed with a stack of parallel short-axis images which cover the left ventricle. You activate the function on the Physio Cardiac parameter card. B.5 syngo MR D13 B.5-15

88 syngo B.5 Cardiac measurements Prerequisites for the measurement: B.5 triggered CINE images Slice positioning: at the end systole, the second slice should be positioned approximately at the level of the mitral valve (refer to figure). (1) Slice positioning in the end diastole (2) Slice positioning in the end systole B.5-16 MR D13 - Cardio

89 During B.5 Display of the heart and valve functions B.5 Automatic segmentation B.5 the acquisition, non-contoured images are displayed immediately in the Inline Display and saved in the database. As soon as all short-axis images are acquired, automatic segmentation of the left ventricle is performed. When segmentation is completed, the contoured images and the table of results are displayed in the Inline Display and saved as a separate series in the database. B.5 Please be aware that the results calculated in the Inline Ventricular Function may differ from those calculated in 2D Ventricular Analysis. This is mainly due to improvements to the base-plane segmentation. syngo MR D13 B.5-17

90 syngo Cardiac measurements B.5-18 MR D13 - Cardio

91 Display of cardiac morphology B.6 Display of cardiac morphology B.6 A large number of different imaging methods are available for evaluating the morphology of the heart. Where cardiac morphology relied on spin echo and Turbo spin echo sequences in the past, additional high-speed techniques, such as TrueFISP and HASTE, are available today as well. B.6 Increase in contrast using Dark Blood B.6 The contrast between the myocardium and the blood can be considerably increased with the Dark Blood technique. The blood is shown low in signal and appears dark in images. B.6 syngo MR D13 B.6-1

92 syngo Cardiac measurements Dark Blood preparation B.6 Dark Blood preparation is obtained via a double preparation pulse. The first pulse inverts the blood and myocardial signal inside as well as outside the slice to be measured. The subsequent pulse reinverts the signal inside the measurement slice only. B.6 During the cardiac cycle, blood with an inverted signal flows into the measurement slice. Blood is shown dark when data acquisition is performed during the zero crossing of its magnetization. B.6 Timing B.6 Dark Blood measurements must meet two requirements: B.6 During the reinversion pulse, the heart must be in a similar position as during data acquisition. Otherwise, the tissue of the slice to be measured will not be reinverted. Data acquisition must occur in the diastole and during the zero crossing of the blood signal. B.6-2 MR D13 - Cardio

93 B.6 Display of cardiac morphology B.6 Both conditions are met when preparation is completed in the late diastole, immediately after the R wave, and the measurement follows ms later. The time for optimal acquisition is determined by selecting a suitable TR value. B.6 (1) TR is too short: No signal from the myocardium (2) TR is correct: Blood signal equals zero, and the heart muscle is well-delineated (3) TR is too long: The blood signal recovers syngo MR D13 B.6-3

94 syngo B.6 B.6 Cardiac measurements Dark Blood parameter example (TSE) B.6 The settings are either made on the Physio Signal1 parameter card or on the Physio Cardiac parameter card. B.6 B.6-4 MR D13 - Cardio

95 The The The Display of cardiac morphology B.6 The acquisition window is defined using the Captured Cycle button. A TR of e.g., 700 ms ends the measurement within this time interval after the trigger. B.6 During a short cardiac cycle, a protocol with a small turbo factor should be selected for suppressing motion artifacts. This keeps the acquisition time (TR min) as short as possible. B.6 Where there is poor contrast, it usually suffices to vary TR by approx ms. This will shift the measurement within the cardiac cycle. B.6 T1-weighted B.6 trigger pulse is at 1. This means one measurement per cardiac cycle. B.6 T2-weighted B.6 trigger pulse is at 2. This means one measurement every other cardiac cycle. TE is long ( ms) compared to the T1 measurement. B.6 Dark Blood preparation B.6 trigger delay is 0, the preparation pulses immediately follow the R wave. The thickness of the selective preparation pulse and the flip angle can be changed for the measurement. With short cardiac intervals, the image quality can be improved by thickening the selective preparation pulse. B.6 syngo MR D13 B.6-5

96 syngo As Cardiac measurements Bright Blood B.6 Hyperintense blood flowing into the slice is used for obtaining contrast optimization with Bright Blood techniques. B.6 The Bright Blood technique is suitable for combining with True- FISP and FLASH. B.6 TrueFISP B.6 single shot technique: B.6 Without breathhold technique (for uncooperative patients) One slice per heartbeat Segmented: B heartbeats are required per slice For patients with a short cardiac cycle (with breathhold technique) B.6-6 MR D13 - Cardio

97 B.6 Display of cardiac morphology B.6 FLASH B.6 Segmented only One slice per breathhold is measured Usually combined with fat saturation Suitable for localizing coronaries (1) Bright Blood (FLASH) (2) Bright Blood (TrueFISP) syngo MR D13 B.6-7

98 syngo Cardiac measurements B.6-8 MR D13 - Cardio

99 2D Usually, Display of coronary vessels B.7 Display of coronary vessels B.7 Again, there are several methods available for displaying coronary arteries. The fine structures of coronary vessels require consistently good spatial resolution. B.7 2D imaging B.7 imaging may be used to display the proximal segments of the coronary arteries. Due to the non-isotropic voxel size, it is not possible to reformat the data sets. Contrast agents are not used. B.7 3D imaging B.7 the coronaries are shown in the 3D mode. The measurement can be taken using the breathhold technique or free breathing plus the navigator. B.7 syngo MR D13 B.7-1

100 syngo Cardiac measurements Measurement conditions B.7 The success of the measurement depends on satisfactory localization as well as planning the specifics of sequence timing. It is also equally important to reduce motion artifacts using the breathhold or navigator technique. B.7 Localization B.7 Images with different slice orientations are used for localization. HASTE has proved to be highly suitable for many patients. However, if the display with HASTE does not meet requirements, TrueFISP or FLASH may be used as an alternative. B.7 Acquisition window B.7 To ensure that the fine structures of the coronary arteries are displayed, data acquisition must be performed during the low-motion phase of the diastole. B.7 A 4-chamber view with a section of the right coronary provides a suitable display. Based on this measurement, the time can be defined when the coronary is motionless. Usually, this corresponds to the diastole. B.7 B.7-2 MR D13 - Cardio

101 B.7 Display of coronary vessels B.7 Breathhold technique B.7 The patient produces the end expiration phase more accurately than the end inspiration phase. For this reason, the end expiration phase is better suited for displaying the coronary arteries. As the basis for slice positioning, localization must be performed in the end expiration phase as well. Also, since the navigator-supported protocols measure in the expiration phase, this phase doubles as a constant exposure parameter that ensures comparison and reproducibility of the technique. B.7 Right coronary in the 4-chamber view. (22) syngo MR D13 B.7-3

102 syngo Cardiac measurements Localizing coronary blood vessels B.7 Measure transverse localizers that cover the entire left ventricle. B.7 Select thin slices with a maximum slice thickness of 6 mm and start at the aortic root. B.7 If the coronaries cannot be displayed clearly, measure an additional localizer in another slice orientation, e.g., orientation of the 4-chamber view or coronal slices. B.7 In conclusion, take a CINE series in the 4-chamber view and visually determine the low-motion phase of the coronaries in the images. B.7 B.7-4 MR D13 - Cardio

103 B.7 B.7 Display of coronary vessels B.7 Displaying coronary blood vessels B.7 Search for the course of the blood vessels on the localizers. B.7 You can also include existing, high-resolution images. As soon as you recognize the course, position the slice orientation using the 3-point mode. B.7 3-point method used with the right coronary artery (example). (23) Adjust the acquisition window and position the exposure with a suitable trigger delay on the low-motion phase. B.7 syngo MR D13 B.7-5

104 syngo B.7 Cardiac measurements When setting the trigger delay, factor in sequence and magnetization-related delays which have to be subtracted. A tool tip for the Trigger delay input field helps to determine the correct time. The tool tip shows when data acquisition starts with the currently set trigger delay. In addition, the measurement time during the akinetic phase is shown. B.7 Reduce the number of segments for patients with a short cardiac cycle. In this way, you are able to minimize blurring. B.7 Start the measurement. B.7 B.7-6 MR D13 - Cardio

105 The Display of coronary vessels B.7 Respiratory control using navigator technique B.7 Navigator and search window B.7 The navigator technique detects respiratory motion. Navigator echoes are integrated in the imaging sequence. These echoes allow you to determine the current respiratory position. B.7 Navigator B.7 navigator signal consists of two slice-selective pulses (90 and 180 ). With their help, the motion of the diaphragm can be acquired and displayed continuously in real time. B.7 For this purpose, the intersection of the two navigator slices must be positioned on the dome of the liver. B.7 A spin echo profile is generated in the cranial/caudal direction which describes the current respiratory status. B.7 syngo MR D13 B.7-7

106 syngo B.7 Cardiac measurements Search position and search window B.7 The search position is determined using the display of the respiratory position. B.7 Select the search window (red) so that the entire movement of the diaphragm is included as well. B.7 Display of the navigator pulses (turquoise) and diaphragm position in the search window (red). (24) (1) Lungs (2) Liver B.7-8 MR D13 - Cardio

107 B.7 Display of coronary vessels B.7 Acceptance window B.7 During free breathing, the acceptance window is positioned on the end expiration phase of the patient. B.7 The data are used for image reconstruction only when the diaphragm is located within the acceptance window. B.7 If the diaphragm lies outside this position, the data are discarded. B.7 During measurements in breathhold technique the acceptance window is selected large enough to cover the entire respiratory cycle. B.7 Size of the acceptance window B.7 A large acceptance window enables data acquisition during a longer phase (shorter overall measurement duration), a smaller window limits data acquisition (stronger respiratory motion suppression). B.7 Acceptance window (green) and search window (red). (25) syngo MR D13 B.7-9

108 syngo During The B.7 Cardiac measurements Slice correction with the navigator B.7 Gate and Follow B.7 the slice following mode, the exact position of the diaphragm in the acceptance window is evaluated and corrected. B.7 Tracking factor B.7 correlation between the current changes in the diaphragm position and the slice shift to be performed is determined by the tracking factor. B.7 The connection between respiratory motion and cardiac position is not linear, instead it is based on three-dimensional movement. For this reason, slice alignment is useful within limits. B.7 Avoid selecting an acceptance window that is too large. During imaging in the breathhold technique, a large acceptance window must be selected. All data are accepted. B.7 Slice alignment may have a corrective effect when respiration is started prematurely. B.7 B.7-10 MR D13 - Cardio

109 B.7 Display of coronary vessels B.7 Respiratory motion adaptation B.7 During free breathing examinations the patient may breath differently. The acceptance window, which had been defined at the beginning of the exam, might therefore not fit any longer to these changing conditions. B.7 By enabling Resp. Motion Adaptation, the system will adapt the acceptance window automatically to the different expiration states. B.7 Thus, the measurement can be continued and must not be started all over again, even under these circumstances. B.7 Navigator parameter free breathing example B.7 The navigator parameters are set on the Physio PACE parameter card. The example shows the parameters of a measurement with slice alignment. B.7 syngo MR D13 B.7-11

110 syngo Cardiac measurements Respiratory control is set to Gate & Follow. Data are used for image reconstruction when the diaphragm position is located within the acceptance window and slice alignment is performed within the acceptance range. B.7 The Navigator mode can be changed via the Respiratory control option in the Physio PACE parameter card. Using Gate, data acquisition is performed in the acceptance window without slice alignment. B.7 By activating the scout mode, the individual diaphragm position of the patient can be determined prior to the measurement. B.7 By selecting suitable parameters, the Search position and Accept position are set to the end expiration phase. B.7 The size of the acceptance window can be enlarged to obtain a shorter overall measurement time. However, it can be also reduced in size for improved motion suppression. The value corresponds to the tolerance range used to expand the search position during data acquisition. B.7 B.7-12 MR D13 - Cardio

111 B.7 Display of coronary vessels B.7 Navigator parameter breathhold technique example B.7 The example shows the parameters of a measurement with slice alignment. B.7 Respiratory control is set to Gate & Follow. Search position and Search window as well as the Acceptance position and Acceptance window cover the entire respiratory cycle. B.7 The Navigator mode can be changed via the Respiratory control option in the Physio PACE parameter card. Using Gate, data acquisition is performed in the acceptance window without slice alignment. B.7 syngo MR D13 B.7-13

112 syngo B.7 B.7 Cardiac measurements By activating the scout mode, the individual diaphragm position of the patient can be determined prior to the measurement. B.7 You must select a very large Search window and Acceptance window. All data have to be accepted. Otherwise, the breathhold cycle is too long. If the patient begins to breathe at the end of the measurement, it may be possible to use slice alignment for correction. However, should the picture continue to be blurry, shorten the measurement time or switch to free breathing. B.7-14 MR D13 - Cardio

113 B.8 Cardiac Dot Engine B.8 Cardiac Dot Engine B.8 The Dot Engine user interfaces shown in this operator manual are examples only. The actual guidance texts and the design may be slightly different on your system. Advantages/Features B.8 Guided personalized exam Measurement program is adaptable to patient s breathhold capacity and/or to the presence of arrhythmias System automatically captures the heart rate of the patient and automatically adapts the measurement parameters Automatic localization of short-axis views Automatic localization of long-axis views (AutoAlign Heart) Easy way for matching slice positions (short-axis) between dynamic examinations, tissue characterization and CINE Cardiac views can be selected as protocol parameters Automatic calculation of FoV Inline post-processing Adaptive triggering Automatic series re-naming Standardized cardiovascular views syngo MR D13 B.8-1

114 syngo Ventricular Dynamic Dynamic Dynamic Tissue B.8 Cardiac measurements The Cardiac Dot Engine offers two workflows. B.8 Workflows B.8 Function B.8 B.8 B.8 Ischemic Heart Disease B.8 Measurement steps Localizer B.8 Thoracic overview B.8 AutoAlign Heart Scout B.8 Long-axis localizer B.8 CINE long-axis B.8 n.a. B.8 n.a. B.8 n.a. B.8 n.a. B.8 Short-axis localizer B.8 test B.8 stress B.8 CINE short-axis B.8 rest B.8 characterization B.8 B.8-2 MR D13 - Cardio

115 Cardiac Dot Engine B.8 Planning the heart examination and measuring the localizer B.8 Electrodes have been positioned Patient has been registered Cardiac Dot Engine has been selected After registration of a cardiac exam, the Patient View opens automatically. The default examination parameters are loaded. The GSP changes automatically to the cardio-specific screen layout with an integrated Physiological Display dialog window. B.8 syngo MR D13 B.8-3

116 syngo B.8 Cardiac measurements B.8-4 MR D13 - Cardio

117 B.8 B.8 Cardiac Dot Engine B.8 The features of the Physiological Display dialog window are: B.8 Fixed position and permanent display Indication of battery status Use of fade-in/fade-out controls Automatic selection of best leads Automatic display of messages and warnings with fade-in status bar For a detailed description, please refer to: ( Page A.1-6 Physiological display) Please check the Physiological Display dialog window for messages. Adapting the examination to the patient B.8 In the Patient View, you select a suitable examination strategy and adapt the physiological and breathhold parameters to the patient s needs. The pending protocols of the measurement queue are updated with your selection. B.8 Accessing the Patient View B.8 You can access the Patient View at any time during the examination. B.8 To open the view, click the icon. To confirm the settings and close the view, click the icon. syngo MR D13 B.8-5

118 syngo For Measurements B.8 B.8 B.8 Cardiac measurements Selecting the examination strategy B.8 From the list: Select a suitable Examination Strategy for the patient. Breath-Hold B.8 Realtime B.8 standard measurements. B.8 are performed with real-time protocols. Suitable for patients with reduced breathhold capabilities or arrhythmia. B.8 In the following example, the strategy Breath-Hold is selected. Setting the breathhold parameters B.8 Enter the Breath-hold Capability of the patient. The number of slices per breathhold for each pending protocol are updated accordingly. B.8 If you want to use Automatic Breath-hold Commands throughout the whole examination, activate the checkbox and set the timing and language for the commands. You are also able to set the breathhold commands individually for each protocol (in the Protocol properties dialog window). B.8-6 MR D13 - Cardio

119 B.8 Cardiac Dot Engine B.8 Adapting the physiological parameters B.8 Change the Trigger Source, if necessary. The patient s heart rate may change with the breathhold. To overwrite the automatically captured heart rate, open the Patient View again and enter the RR-interval during the breathhold (parameter: Overwrite RR-Interval). Modifying parameters of measured protocols B.8 Changes in the Patient View only apply to pending protocols in the measurement queue. B.8 To change the status of a protocol from measured to pending, select the measured protocol. Select Rerun from here from the context menu (right-click with the mouse). Open the Patient View. or B.8 Select Rerun from here with from the context menu (right-click with the mouse). The Patient View opens automatically. B.8 Enter the requested modifications. syngo MR D13 B.8-7

120 syngo B.8 B.8 B.8 Cardiac measurements Starting the measurement of the localizer B.8 Confirm the patient-specific settings. The coronal localizer is automatically measured and displayed. The protocol opens. B.8 Automatic series re-naming: The series name automatically includes the names of the views acquired. For example, if the protocol name is CineRetro and the acquired cardiovascular view is 2-chamber, the series name is CineRetro_2CH. Standardized cardiovascular views: All common cardiovascular MR imaging planes are presented in a consistent manner as shown in the figure below. B.8-8 MR D13 - Cardio

121 B.8 B.8 Cardiac Dot Engine B.8 Planning the localizer at the isocenter B.8 To ensure the best possible image quality, you first position the heart at the magnet isocenter for all subsequent measurements. B.8 Coronal localizer has been measured Position the heart at the magnet isocenter by shifting the slices and table position (blue line) to the left ventricle. You can modify the text and image examples of a guidance view at any time. ( Page B.8-37 Configuring protocol steps (optional)) syngo MR D13 B.8-9

122 syngo B.8 B.8 B.8 Cardiac measurements For 3T only: Position the shim volume by centering the shim box (green) over the heart. The shim volume is used for all subsequent measurements. B.8 Inform the patient about potential table movements. Start the measurement. The table automatically moves into the magnet isocenter. The is measured. B.8 B.8-10 MR D13 - Cardio

123 B.8 B.8 Cardiac Dot Engine B.8 Measuring thoracic overview images B.8 Localizer at isocenter has been measured Open the protocol for thoracic overview images. Position the coronal and transverse slices. Start the measurement. The thoracic overview images are displayed in the GSP. B.8 syngo MR D13 B.8-11

124 syngo B.8 B.8 Cardiac measurements Measuring the AAHeart_Scout B.8 Within the measurement step AAHeart_Scout, pseudo short-axis images are measured. Based on these images, 3D segmentation is performed and MPRs are generated (not displayed to the user) by the sytem. Based on the MPRs, marker points and slices are calculated subsequently. B.8 Thoracic overview images have been measured Open the AAHeart_Scout protocol. Check the slice position on the sagittal localizer. Do not modify any measurement parameters except the slice shift in the A >> P or F >> H direction, if necessary. B.8-12 MR D13 - Cardio

125 B.8 B.8 B.8 B.8 Cardiac Dot Engine B.8 Start the measurement. Check, if the AutoAlign step was executed successfully. The icon is displayed in the measurement queue. B.8 The DefineLongaxis protocol opens and displays the automatically calculated 3 long-axis views in the GSP. B.8 In case of failure, set the marker points manually. ( Page B.8-15 Defining the long-axis view manually) If you open the long-axis protocol before the preceding measurement has been finished, an overlay window is displayed on top of the protocol parameters. The information from the previous step is needed for the automatic calculation of the long-axis views. Wait until the previous step is finished and the window disappears or close the protocol with Cancel. syngo MR D13 B.8-13

126 syngo B.8 Cardiac measurements Defining and measuring the long-axis localizer B.8 In order to define the long-axis cardiac views, five markers on anatomical landmarks of the pseudo short-axis views are necessary: B.8 Left atrium Aortic root Right ventricle Left ventricle Apex These marker points are automatically calculated by the AutoAlign Heart Scout. B.8 AAHeart_Scout has been measured Checking the long-axis views B.8 Check the position of the slices. B.8-14 MR D13 - Cardio

127 B.8 Cardiac Dot Engine B.8 If you want to display or modify the marker points: Select the marker card, e.g., Left Atrium. Reselect the marker (in the GSP or on the guidance view) and move it with the mouse to the new position. In the GSP: You may also position the marker on another slice. Defining the long-axis view manually B.8 Scroll through the AAHeart_Scout images and select the slice that best represents the landmark described for each guidance step. Set the marker by clicking the image. The system automatically jumps to the next guidance view. B.8 Display the standard long-axis heart views (2, 3, 4-chamber view) with Display Slices. The slices of the long-axis heart views are displayed in the GSP. B.8 syngo MR D13 B.8-15

128 syngo B.8 Cardiac measurements Measuring the CINE long-axis view B.8 Start the measurement of the long-axis localizer. The optimal FoV for all subsequent long-axis measurements is calculated and computed, based on the localizer measurement with a large FoV. B.8 Subsequently, the measurement of the CINE view is started automatically. The orientation is preconfigured and copied from the preceding step. The physiological parameters are adapted to the actual heart rate. Breathhold commands are voice outputs that are applied before and after the measurement. The images are loaded into the GSP and displayed in Movie Mode. B.8 B.8-16 MR D13 - Cardio

129 B.8 B.8 Cardiac Dot Engine B.8 Editing CINE long-axis views (optional) B.8 If desired, you can edit the settings of the long-axis views as well as add or remove additional standard views. B.8 Long-axis localizer has been measured Open the CINE long axis protocol. On the left-hand side, the selected Heart Views measured in this program step are displayed. On the right-hand side the function-specific parameters are displayed. B.8 In the case of the ischemic heart disease workflow, only the 4-chamber view is available. The 2- and 3-chamber views are measured after the CINE short-axis views are acquired. syngo MR D13 B.8-17

130 syngo B.8 B.8 Cardiac measurements Changing slice parameters B.8 Open the Edit Slice Group Parameters dialog window with Edit. Change the requested slice parameters. Changing the number of slices and the gap is valid only for the opened step. B.8 If you want to save the changes in orientation and position for the selected slice, activate the Store Slice Position checkbox. Otherwise, these changes are valid only for the opened step. If you have modified the number of slices, changes made on the slice orientation and position cannot be saved, and therefore the checkbox is dimmed. Confirm the changes with Close. B.8-18 MR D13 - Cardio

131 B.8 Cardiac Dot Engine B.8 Adding/removing cardiac views B.8 Open the Adding/Removing Views dialog window with Add/Remove. Add or remove the requested cardiac views (via drag&drop of the views from Available Views to Selectable Views and vice versa). Confirm the changes with OK. The views displayed in the dialog window are changed accordingly. B.8 syngo MR D13 B.8-19

132 syngo B.8 Cardiac measurements For 3T only: Improving image quality B.8 Especially with the CINE TrueFISP protocols, it may be necessary to adjust the offset frequency to move the TrueFISP banding artifacts typically seen outside the region of interest. B.8 Select the frequency scout clinical decision point. Start the frequency scout measurement. Several images of identical geometry, but of different offset frequencies are acquired. B.8 Locate the image with the best image quality. In the image text: Note the frequency offset value. For the subsequent CINE TrueFISP measurement: Enter the frequency offset value for the Trufi delta freq parameter. The same frequency offset is automatically used in all subsequent CINE TrueFISP measurements. B.8 B.8-20 MR D13 - Cardio

133 The B.8 Cardiac Dot Engine B.8 Defining and measuring the short-axis localizer B.8 4-chamber view has been measured Defining function slices B.8 Shortaxis all slices will cover the left ventricle. B.8 Review and adjust the position and orientation of the slices, as well as the number of slices, if necessary. syngo MR D13 B.8-21

134 syngo B.8 Cardiac measurements Defining a short-axis subset stack (optional) B.8 The Shortaxis subset slices are a subset of the function slices and partially cover the heart. By default, the position of the slices is related to the position of the function slices. That is, if you move the short-axis subset slices, they will snap to an invisible grid of the function slices. B.8 Review and adjust the position and orientation of the slices, as well as the number of slices, if necessary. B.8-22 MR D13 - Cardio

135 B.8 Cardiac Dot Engine B.8 If you want to move the slices independently of the function slices, deactivate the Snap "Shortaxis subset" Slices to "Shortaxis all" Slices checkbox. If you want to display the function slices together with the short-axis subset slices, activate the Show "Shortaxis all" Slices checkbox. Starting the measurement B.8 Start the measurement. The short-axis localizer stack is measured for all slices. The optimal FoV for all subsequent short-axis measurements is calculated and computed, based on the localizer measurement with a large FoV. B.8 syngo MR D13 B.8-23

136 syngo B.8 Cardiac measurements Performing dynamic test B.8 You can run the test without any interaction. If you want to change the settings, please follow the description below. B.8 Short-axis localizer has been measured Open the Dynamic test protocol. Change the scan order, if requested (via drag&drop of the heart views). B.8-24 MR D13 - Cardio

137 B.8 B.8 B.8 Cardiac Dot Engine B.8 Adaptive triggering: optional heart views are measured only if the heart cycle is long enough, otherwise they are skipped (optimal use of time without the risk of missing heart beats.) Start the measurement. The result images are displayed in the GSP. B.8 Verify the image quality. If there are artifacts, repeat the dynamic test with modified image parameters. To make changes to the measurement: Select the protocol, then select Repeat & Open from the context menu (right-click with the mouse). syngo MR D13 B.8-25

138 syngo B.8 B.8 Cardiac measurements Performing dynamic stress B.8 You can run the dynamic stress measurement without any interaction. If you want to change the settings, please follow the description below. B.8 Dynamic test has been performed Open the Dynamic stress protocol. Change the scan order, if requested (via drag&drop of the heart views). Start the measurement. In addition to the original images, motion-corrected images and parameter maps are calculated. B.8 B.8-26 MR D13 - Cardio

139 B.8 Cardiac Dot Engine B.8 Measuring CINE short-axis views B.8 The following measurement can be performed without any interactions. B.8 If you want to change the settings, please follow the descriptions on the referenced page. ( Page B.8-17 Editing CINE long-axis views (optional)) Repeating short-axis measurements: Select the short-axis protocol, then select Repeat & Open from the context menu (right-click with the mouse). Open the Adding/Removing Views dialog window and move the requested short-axis view to the Selectable Views list. ( Page B.8-19 Adding/ removing cardiac views) During the measurement, the images are displayed in the Inline Display. B.8 After all short-axis images have been acquired, an Inline Ventricular Function (Inline VF) evaluation is performed. The base plane of the mitral valve is detected on the long-axis views and displayed in the resulting mosaic images. The epicardial and endocardial borders are segmented automatically. B.8 syngo MR D13 B.8-27

140 syngo B.8 Cardiac measurements Slices that are repeated in subsequent protocol steps replace the already measured images. Slices that are added in subsequent protocol steps extend the Inline VF evaluation. In both cases, a new evaluation is performed. The Inline VF evaluation produces the following images in the database: B.8 Result table with the quantitative functional parameters Mosaic images with end-diastolic and end-systolic images of all evaluated slices Segmented images used in the evaluation B.8-28 MR D13 - Cardio

141 B.8 Cardiac Dot Engine B.8 (1) Series with segmented images (2) Result table (3) Long-axis mosaic image (4) Short-axis mosaic image syngo MR D13 B.8-29

142 syngo B.8 B.8 Cardiac measurements Performing dynamic rest B.8 The following measurement can be performed without any interactions. B.8 Perform the same steps as with the dynamic stress measurement. ( Page B.8-26 Performing dynamic stress) Recommendation: For best comparison of the rest and stress data, leave the protocol settings unchanged. Do not administer any stress medication. B.8-30 MR D13 - Cardio

143 B.8 B.8 Cardiac Dot Engine B.8 Performing tissue characterization B.8 You can run the tissue characterization measurement without any interaction. If you want to change the settings, please follow the description below. B.8 Open the Tissue Characterization overview protocol. Modify the inversion time TI, if necessary. Start the measurement. The result images are displayed in the GSP. B.8 syngo MR D13 B.8-31

144 syngo Cardiac measurements Performing high resolution tissue characterization (optional) B.8 If required, you can add high-resolution tissue characterization measurements of the short and long axes without any interactions. B.8 If you want to change the settings, please follow the descriptions on the referenced page. ( Page B.8-31 Performing tissue characterization) B.8-32 MR D13 - Cardio

145 Cardiac Dot Engine B.8 Planning additional heart views (optional) B.8 You can acquire additional heart views which were not scheduled via landmarks during localization (e.g., 2-chamber view RV). A guidance text will support you while planning the requested views. B.8 The system does not know the position and orientation of a preconfigured cardiac view Duplicating a protocol B.8 Select an already measured protocol. Select Repeat & Open from the context menu (right-click with the mouse). syngo MR D13 B.8-33

146 syngo B.8 B.8 Cardiac measurements On the left-hand side, the selected Heart Views measured in this program step are displayed. On the right-hand side, the function-specific parameters are shown. B.8 If you have already set up an additional heart view, you can adapt the slice positioning by clicking Plan. ( Page B.8-36 Opening guidance for positioning) B.8-34 MR D13 - Cardio

147 B.8 Cardiac Dot Engine B.8 Changing the heart view B.8 Open the Adding/Removing Views dialog window with Add/Remove. Add the requested cardiac view (e.g., RV 2 Chamber) from Available Views to Selectable Views via drag&drop. Remove the cardiac view not wanted in the same way. Confirm the changes with OK. The views displayed in the dialog window are changed accordingly. B.8 syngo MR D13 B.8-35

148 syngo B.8 B.8 B.8 Cardiac measurements Opening guidance for positioning B.8 Open the guidance view with Plan. Position the slices as shown on the guidance view. Close the guidance view with Close Guidance. Start the measurement. The selected heart view is measured and available for all subsequent measurements. B.8 B.8-36 MR D13 - Cardio

149 The Dot Cardiac Dot Engine B.8 Configuring protocol steps (optional) B.8 Dot Engine Step B.8 Dot Engine Step defines which strategies, decisions and global parameters are valid for the complete Dot Engine workflow examination. For a detailed description, please refer to: ( Operator Manual - System and data management). B.8 Dot add-ins B.8 add-ins are predefined add-ins for Dot Engine Steps and program steps. Depending on the selected Dot add-in, you can configure different parameters of the Dot Engine Step. B.8 Cardiac Dot add-ins B.8 Cardiac Patient View Cardiac Basic (= Generic add-in + Cardiac Config) Cardiac Marker Localization Cardiac Standard Cardiac SAX Planning syngo MR D13 B.8-37

150 syngo B.8 Cardiac measurements Adapting the Patient View (Cardiac Patient View) B.8 In the Exam Explorer: Select a protocol. Open the protocol by double-clicking. Open the Dot Add-In Configurator by clicking Setup. Adapting the workflow B.8 Select the Strategies card. Here, you can set the examination strategy, patient context decisions, and clinical decision points. B.8 B.8-38 MR D13 - Cardio

151 B.8 Cardiac Dot Engine B.8 Adapting guidance text and example images B.8 Select the Slice Group Guidance Config card. Here, you can define guidance text and example images for multiple cardiac views in the Cardiac Standard add-in supported steps. B.8 syngo MR D13 B.8-39

152 syngo B.8 Cardiac measurements Labeling your own heart views B.8 From the heart view list: Select a User View. Click Rename View. The Enter new name for User view dialog window is opened. B.8 Enter the new name. Confirm with OK. B.8-40 MR D13 - Cardio

153 B.8 B.8 Cardiac Dot Engine B.8 Adapting the GSP layout B.8 Select the GSP card. Here, you can switch the GSP layout to the cardio-specific screen layout (Cardio UI). In this case, the Physiological Display dialog window is displayed and cannot be switched off during the examination. B.8 To ensure that the short-axis dynamic slices match the short-axis CINE slices, select the Extent Mode Distance. syngo MR D13 B.8-41

154 syngo B.8 B.8 Cardiac measurements Adapting the measurement queue B.8 Select the Queue card. The Disable Scan Button option is set to On to prevent unexperienced users from operation errors (scan button is dimmed during the cardiac workflow). B.8-42 MR D13 - Cardio

155 B.8 Cardiac Dot Engine B.8 Adapting protocol settings (all cardiac add-ins) B.8 In the Exam Explorer: Select a protocol. Open the protocol by double-clicking. Open the Dot Add-In Configurator by clicking Setup. Select the Cardiac Config card. The settings ensure the heart rate and the breathhold adaptions. B.8 syngo MR D13 B.8-43

156 syngo B.8 Cardiac measurements Adapting standard views (Cardiac Standard) B.8 The CINE, dynamic and delayed enhancement steps are supported by the Cardiac Standard add-in. B.8 In the Exam Explorer: Select a protocol. Open the protocol by double-clicking. Open the Dot Add-In Configurator by clicking Setup. Select the Cardiac Standard card. Different parameter groups can be defined, e.g., Cine retrospective. B.8 B.8-44 MR D13 - Cardio

157 B.8 B.8 Cardiac Dot Engine B.8 The guidance text and example images for all available slices are defined in the Cardiac Patient View and can only be changed there. ( Page B.8-38 Adapting the Patient View (Cardiac Patient View)) Adapting a dynamic parameter group B.8 To set up the slices for a dynamic measurement, you can differentiate between Guaranteed and Optional slices. B.8 Select the Dynamic parameter group. syngo MR D13 B.8-45

158 syngo B.8 Cardiac measurements Open the Adding/Removing Views dialog window with Add/Remove. Select the requested views from the Selectable Views list. Confirm with OK. The slices are automatically inserted into the Optional slice group. B.8 You can move any slices via drag&drop to the Guaranteed slice group. B.8 B.8-46 MR D13 - Cardio

159 B.8 Cardiac Dot Engine B.8 Adapting short-axis protocols (Cardiac SAX Planning) B.8 In the Exam Explorer: Select a short-axis protocol. Open the protocol by double-clicking. Open the Dot Add-In Configurator by clicking Setup. Select the Short Axis Config card. Set the Number of "Shortaxis subset" Slices which should be positioned as a subset of all CINE slices. Enter the Slice Distance of "Shortaxis all" Slices. syngo MR D13 B.8-47

160 syngo B.8 Cardiac measurements A slice thickness of 8 mm and a distance factor of 25% corresponds to a slice distance of 10 mm to match the slices exactly. Activate the Adapt Slice Distance for exact coverage checkbox, if you want to adapt the slice distance for exact coverage of the left ventricle. If you want to keep the slice distance as configured, deactivate the checkbox. Activate the Snap "Shortaxis subset" Slices to "Shortaxis all" Slices checkbox. This option ensures that the short-axis CINE slices and the subset of short-axis dynamic slices are measured at the same slice position. B.8 Adapting the DefineLongaxis protocol (Cardiac Marker Localization) B.8 In the Exam Explorer: Select a long-axis protocol. Open the protocol by double-clicking. Open the Dot Add-In Configurator by clicking Setup. B.8-48 MR D13 - Cardio

161 B.8 Cardiac Dot Engine B.8 Select the Marker Localization card. Activate the Measure stacked views in this step checkbox if you want to measure multi-slice stacks per heart view instead of single slices. Set the Number of Slices for each standard long-axis heart view stack (2-, 3-,and 4-chamber view) The defined long-axis view stacks are available for subsequent measurements. B.8 syngo MR D13 B.8-49

162 syngo Cardiac measurements B.8-50 MR D13 - Cardio

163 C Flow measurements C C.1 Measuring the flow in the heart C.1-1 Measuring the localizers Determining the slice position of the aorta Determining the slice position of the pulmonary artery (pulmonalis) Determining the flow sensitivity Performing the measurement C.1-2 C.1-3 C.1-4 C.1-5 C.1-6 syngo MR D13 C-1

164 syngo Flow measurements C-2 MR D13 - Cardio

165 C.1 Measuring the flow in the heart C.1 Measuring the flow in the heart C.1 MR flow measurements are very suitable for determining the cardiac output volume of the ventricle and for determining the different shunt volumes. To display flow and the encoding of the flow velocity, phase contrast images are used. (For a detailed description of the phase contrast technique, please refer to the MR Basic Manual Magnets, Flows, and Artifacts.) In what follows, the measurement of the blood flow through the aorta ascendens and the truncus pulmonalis are introduced. C.1 For the following examination, experience in MR Cardio is a prerequisite. syngo MR D13 C.1-1

166 syngo Flow measurements Measuring the localizers C.1 ECG electrodes have been attached to the patient ( Page A.1-4 Attaching ECG electrodes) Flow measurement program has been selected Measure orthogonal multislice localizers. You will be obtaining transverse, sagittal and coronal survey images of the heart's location. C.1 Position the transverse images on the orthogonal multislice localizers such that they cover the area between the aortic arc and the heart. C.1 Multislice localizers in the transverse, sagittal and coronal orientation. (26) C.1-2 MR D13 - Cardio

167 C.1 C.1 Measuring the flow in the heart C.1 Determining the slice position of the aorta C.1 Localizers have been measured Position the slice in a way that minimizes measurement errors due to turbulent flow. Use a suitable transverse localizer, position a slice para-sagittal at the height of the aortic arc and acquire a CINE image. Use the images to determine the area with turbulent flow. Position the measurement slice vertical to the aorta outside the turbulent flow area. The optimal slice position is frequently at the height of the pulmonalis since turbulent flow may also be present in the aortic arc. (1) Slice positioning for determining turbulence (2) Positioning of the measurement slice syngo MR D13 C.1-3

168 syngo C.1 C.1 Flow measurements Determining the slice position of the pulmonary artery (pulmonalis) C.1 Localizers have been measured Position the slice on a suitable transverse localizer at the height of bifurcation of the truncus pulmonalis and as much as possible parallel to the vessel walls. Create a CINE image and determine the area of turbulent flow in the images. Position the measurement slice vertical to the pulmonalis outside the turbulent area. Ensure that you are as far away from the pulmonary valve as possible, but prior to the branching of the pulmonary artery (pulmonalis). (1) Slice positioning for determining turbulence (2) Positioning of the measurement slice C.1-4 MR D13 - Cardio

169 C.1 C.1 Measuring the flow in the heart C.1 Determining the flow sensitivity C.1 To obtain the optimal measurement result, proceed by first determining the area of maximum flow velocity. C.1 Measurement slice has been determined On the Physio Signal1 parameter card: Adjust the target RR to the average cycle. On the Angio Common parameter card: Set the velocity encoding. Velocity encoding: Aorta 500 cm/s, Pulmonalis 350 cm/s Start the measurement of the velocity localizer. Load the image series into Argus and read the maximum velocity. Calculate the optimal area of flow sensitivity. venc v max 1.2 syngo MR D13 C.1-5

170 syngo C.1 Flow measurements Performing the measurement C.1 Flow sensitivity has been determined On the Physio Signal1 parameter card: Accept the average heart cycle for the acquisition window. On the Angio Common parameter card: Enter the computed venc into the velocity encoding window. Ensure that Through Plane is entered in the direction window. Activate the checkbox of the image series you would like to save. Enter the breathhold command and start the measurement. After completing the measurement, enter the command for breathing. Please note: The cardiac output volume is smaller with breathhold technique during inspiration than with free breathing or breathhold during expiration. C.1-6 MR D13 - Cardio

171 C.1 C.1 C.1 C.1 Measuring the flow in the heart C.1 Flow-compensated, flow-encoded, and phase-contrast image of the aorta (1). (27) Flow-compensated, flow-encoded, and phase-contrast image of the pulmonalis (2). (28) As an alternative, the measurement can be performed with retrospective gating. The average heart cycle is then accepted in the target RR window. Use retrospective gating for determining the shunt volume. syngo MR D13 C.1-7

172 syngo Flow measurements C.1-8 MR D13 - Cardio

173 D Post-processing D D.1 Argus Viewer D.1-1 Starting Argus and loading images Image area in the Argus Viewer Sorting series in the matrix and the image stack Layout in the image matrix Arrangement in the image stack Selecting images in the matrix Loading a series into a work segment Movie display D.1-1 D.1-2 D.1-3 D.1-4 D.1-4 D.1-5 D.1-7 D.1-8 D.2 Ventricular Analysis D.2-1 Loading images Checking assignment to ED, ES, base, and apex Drawing contours in the ED base image Checking/correcting drawn contours Propagating contours within the ED phase Checking/correcting propagated contours Propagating contours to all columns Confirming propagated contours Starting volume analysis Starting thickening analysis D.2-2 D.2-3 D.2-9 D.2-13 D.2-16 D.2-17 D.2-18 D.2-18 D.2-19 D.2-24 syngo MR D13 D-1

174 syngo Post-processing D.3 4D Ventricular Analysis D.3-1 Loading images Setting landmarks Handling of offset slices Correcting the offset Evaluating the results 4D view D.3-2 D.3-3 D.3-10 D.3-11 D.3-13 D.3-17 D.4 Flow analysis with Argus D.4-1 Preparing the data Loading the image data Optimizing the image display Defining the evaluation regions Drawing the ROI for the ascending aorta Drawing the ROI for the descending aorta Analyzing low velocities (optional) Propagating the vessel contours to other cardiac phases Confirming the propagated vessel contours Evaluating the vessels Calculating results with standard settings Limiting the time range Performing baseline correction Correcting phase aliasing D.4-2 D.4-2 D.4-4 D.4-5 D.4-6 D.4-7 D.4-7 D.4-8 D.4-8 D.4-10 D.4-11 D.4-12 D.4-12 D.4-13 D-2 MR D13 - Cardio

175 D.1 Argus Viewer D.1 Argus Viewer D.1 Starting Argus will launch the Argus Viewer. The Argus Viewer is used to view and compare cardiac images and series. Argus protocols for evaluation can be started from the Argus Viewer. D.1 Starting Argus and loading images D.1 Select Patient > Browser. Select the patient in the Patient Browser. Transfer the data to the Argus task card by clicking the Argus icon. The Argus task card opens in the Argus Viewer mode. All series of the patient are loaded. D.1 syngo MR D13 D.1-1

176 syngo D.1 D.1 D.1 Post-processing (1) Work segments (2) Matrix You can load additional images later on. Image area in the Argus Viewer D.1 The image area contains work segments and matrix cells. The work segments and matrix cells in thr Argus Viewer contain image stacks. D.1 Each image stack contains a series of images with different acquisition times. D.1 Browse the image stacks using the dog ears. D.1-2 MR D13 - Cardio

177 D.1 D.1 Argus Viewer D.1 Sorting series in the matrix and the image stack D.1 The sorting of images within series (layout in the image stack) is different from the sorting of series (layout in the image matrix). D.1 When you load new images into the Argus task card after removing current images, the last sorting scheme is applied. How to change the sort scheme: D.1 Select a scheme from the Image Sorting selection lists. syngo MR D13 D.1-3

178 syngo Description Layout Arrangement Description Images Images The D.1 D.1 Post-processing Layout in the image matrix D.1 Sorting scheme D.1 Series No. D.1 Orientation D.1 D.1 according to series number D.1 according to the slice position in the head-feet orientation D.1 Series then Orientation D.1 Orientation then Series D.1 Identical to series number, then same as orientation D.1 Identical to orientation, then same as series number D.1 Arrangement in the image stack D.1 Sorting scheme D.1 Triggered D.1 Chronological D.1 Anatomical D.1 D.1 of a series are sorted according to their trigger time, followed by their acquisition time and then according to their image number D.1 of a series are sorted according to their acquisition time and then according to their image number D.1 images are sorted according to their orientation and then according to their anatomical position D.1 D.1-4 MR D13 - Cardio

179 Argus Viewer D.1 Selecting images in the matrix D.1 You select images for the following reasons D.1 To load an image into the active segment. To select the image range for editing (e.g., windowing). To select the image range for saving or filming. To change the arrangement of images in the matrix. To load a selection of images from the Argus Viewer into an Argus protocol. Selecting an individual image D.1 Click an image in the matrix. The selected image is highlighted with a dashed blue border. D.1 Selecting one or multiple series D.1 Press and hold the Ctrl key while clicking the selected series (image stacks). All selected images are highlighted with a blue border. D.1 syngo MR D13 D.1-5

180 syngo D.1 D.1 D.1 Post-processing Selecting a complete row or column D.1 You can select complete rows or columns using the numbered buttons at the top and left side of the matrix D.1 Click the button for the respective row or column. Selecting the entire matrix D.1 Click the icon in the upper left corner of the matrix. D.1-6 MR D13 - Cardio

181 D.1 Argus Viewer D.1 Loading a series into a work segment D.1 The work segments are used to edit the image display and start movie display. D.1 Use the mouse to load the series into a work segment. The series in the 1st segment is highlighted in the matrix by using a pink frame. The series in the 2nd segment is highlighted with a yellow frame. D.1 (1) Image in 1st segment (2) Image in 2nd segment syngo MR D13 D.1-7

182 syngo D.1 D.1 Slider D.1 D.1 D.1 D.1 Post-processing Movie display D.1 With movie display, you can show the images of a series as a movie. The image sequence in the movie is determined by the time of measurement or the slice position, depending on the parameter that is different. D.1 Multiple movie display allows you to view up to eight series simultaneously. D.1 Keys for operating movie display D.1 Start the movie display D.1 to set the speed D.1 Pause movie display D.1 Single frame return D.1 Single frame advance D.1 D.1-8 MR D13 - Cardio

183 D.1 D.1 D.1 D.1 D.1 D.1 D.1 D.1 D.1 Argus Viewer D.1 Displaying contours drawn (only in 1*1 and 1*2 layouts) D.1 Movie display of single series D.1 Movie display of 2 series in parallel D.1 Movie display of 4 series in parallel D.1 Movie display of 8 series in parallel D.1 Stop movie display D.1 Multiple movie display using different slice positions D.1 For stress examinations, for example, movie display is useful to compare images measured with the same sequence, but with different slice positions. D.1 Select the 2*4 layout from the View card. Select a series and load it into the first work segment. Start the movie display. Each of the two work segments is divided into 4 sub-segments. D.1 The remaining seven series are loaded into the other sub-segments and included in the movie display. D.1 During movie display, you can load other series into any sub-segment using the mouse. syngo MR D13 D.1-9

184 syngo Post-processing D.1-10 MR D13 - Cardio

185 D.2 D.2 Ventricular Analysis D.2 Ventricular Analysis D.2 Ventricular Analysis is used to determine important physiological cardiac parameters. D.2 Ventricular analysis lets you perform Volume Analysis as well as Thickening Analysis: D.2 Volume analysis Volume analysis provides information about ventricular volumes, the myocardial mass, and the functional parameters of stroke volume, ejection fraction, and cardiac output. D.2 Thickening analysis Thickening analysis lets you assess the change in myocardial wall thickness of the left ventricle. D.2 Typically, you will evaluate the left ventricle. However, you are also able to evaluate the right ventricle. In this case, only a volume analysis can be performed. You need short-axis images for a ventricular analysis. syngo MR D13 D.2-1

186 syngo D.2 D.2 Post-processing Loading images D.2 Select the short axis series of the patient in the matrix. Click the icon in the control area. The Argus task card is updated. The images in the matrix are rearranged: D.2 Images in a row are from the same slice position. Images in a column are from the same cardiac phase. D.2-2 MR D13 - Cardio

187 D.2 D.2 D.2 D.2 Ventricular Analysis D.2 Checking assignment to ED, ES, base, and apex D.2 After loading the images, the system automatically assigns them to base, apex, ED, and ES phases. D.2 Check whether the assignment is correct for this evaluation or has to be changed. If the automatic assignment is correct and no changes are necessary, confirm the allocation with the icon on the Drawing subtask card. The manual ED/ES or base/apex assignment does not have to be explicitly confirmed. D.2 The ED/ES and base/apex assignments remain effective when saving the data set in a new Argus series. Checking the assignment to the ED phase D.2 In most cases you can accept the suggested ED phase (first column). Ensure that the image with max. expansion is allocated to the ED phase. syngo MR D13 D.2-3

188 syngo D.2 D.2 Post-processing Checking the assignment to the ED base D.2 The assignment to the base is correct if the image shows the beginning of the ventricle just below the ventricular plane. D.2 Load the suggested ED base image into the 1st work segment. Start movie display and check whether the slice is suitable for use as ED base. When the image shows most of the myocardium, the outflow tract should be detectable as well. However, if the image shows little of the myocardium, the slice position is not suitable as a basis. It will lead to incorrect results. If the suggested slice cannot be used, define a new ED base image from a suitable slice: D.2 Move the base image marker (bar with down arrow) to the selected ED base image using the mouse. You can use the arrow keys to browse the images when checking the ED base. If you want to apply the reassignment to all columns, select the entire row before moving the marker. D.2-4 MR D13 - Cardio

189 D.2 D.2 Ventricular Analysis D.2 Checking the assignment to the ED apex D.2 The assignment to the apex is correct if you can still detect a bright blood signal inside the ventricle. D.2 Load the suggested ED apex image into the 1st work segment. Start movie display and check whether the slice is suitable for use as an ED apex image. You can use the arrow keys to browse the images when checking the ED apex image. syngo MR D13 D.2-5

190 syngo D.2 D.2 Post-processing If the suggested slice cannot be used, define a new ED apex image from a suitable slice: D.2 Move the apex image marker (bar with up arrow) to the selected ED apex image using the mouse. If you want to apply the reassignment to all columns, select the entire row before moving the marker. D.2-6 MR D13 - Cardio

191 D.2 D.2 Ventricular Analysis D.2 Checking the assignment to the ES phase D.2 From the suggested ES phase, select an image of the mid-ventricular slice position and load it into the 2nd work segment. Use the arrow keys to browse all phases of the selected slice position and select the image with maximum myocardial contraction. Move the ES button with the mouse to the column containing the selected image. The column is now defined as the ES phase. D.2 syngo MR D13 D.2-7

192 syngo D.2 D.2 Post-processing Checking the assignment to the ES base D.2 Load the suggested ES base image into the 2nd work segment. Check the ES base image by following the procedure described for the ED base image. The ES base image should be defined in the same column as the ES phase. Checking the assignment to the ES apex D.2 Load the suggested ES apex image into the 2nd work segment. Check the ES apex image by following the procedure described for the ED apex image. D.2-8 MR D13 - Cardio

193 D.2 Ventricular Analysis D.2 Drawing contours in the ED base image D.2 The next step is to draw the epicardial and endocardial contours in the ED base image. D.2 The tools on the Drawing card are used for this purpose. D.2 (1) Draw contours (2) Edit contours (3) Propagate contours (4) Select drawing mode (epicardial/endocardial contour;left/ right ventricle) (5) Confirm definitions and contours syngo MR D13 D.2-9

194 syngo D.2 Use D.2 D.2 Post-processing Contours should be drawn and corrected with great care and precision. The more precisely you draw the contours, the more reliable the results of your cardiac analysis. Selecting the ED base image for editing D.2 Load the ED base image into the 1st work segment. Activating "Left Ventricle" drawing mode D.2 Click the icon. The mode for drawing the contours of the left ventricle is activated. D.2 Automatic contouring D.2 the Auto Adjust tool to draw easily detectable contours. D.2 Click the icon. An endocardial contour (red) and an epicardial contour (green) are automatically drawn in the ED base image. D.2 D.2-10 MR D13 - Cardio

195 Difficult D.2 D.2 Ventricular Analysis D.2 Manual contouring D.2 contours that cannot be created using the Auto Adjust tool can be drawn using the Drawing tool. D.2 Click the icon. Select VF Options > Use Contour Cycling. The mode for drawing the endocardial contour is activated automatically. D.2 Drag the tool along the endocardial contour in the active image. Double-click to close the freehand contour. The endocardial contour is shown in the ED base image. D.2 syngo MR D13 D.2-11

196 syngo D.2 D.2 Post-processing The mode for drawing the epicardial contour is activated automatically. D.2 Trace the anatomical contour with the mouse button pressed. Double-click to close the freehand contour. The epicardial contour is shown in the ED base image in addition to the endocardial contour. D.2 D.2-12 MR D13 - Cardio

197 D.2 Ambiguous D.2 D.2 Ventricular Analysis D.2 Checking/correcting drawn contours D.2 After drawing the contours in the ED base image, you correct them using the contour editing tools (if applicable). D.2 CAUTION D.2 marking of the heart wall contour! Incorrect ventricular analysis Correct the markings for the heart wall contour. Correcting with the Splice icon D.2 The Splice icon is used to correct the shape of a completed contour by redrawing a segment. D.2 Click to select the endocardial or epicardial drawing mode. Click the icon. Click the point of the contour in the active image where you want to correct the shape. Draw the new contour segment while pressing and holding the mouse button. Double-click when the new contour line meets the old contour line. syngo MR D13 D.2-13

198 syngo D.2 D.2 D.2 Post-processing The contour is corrected accordingly. D.2 Double-click to deactivate the tool. Correcting through Nudging D.2 Click to select the endocardial or epicardial drawing mode. Select the endocardial or epicardial contour. Click the icon. Click inside or outside the contour near the contour line and keep the mouse button pressed. The mouse pointer takes the shape of a circle. D.2 D.2-14 MR D13 - Cardio

199 D.2 D.2 D.2 Ventricular Analysis D.2 The size of the circle, i.e., the precision of the tool, depends on how close you click to the contour: If you click close to the contour, the circle is small and you can perform very fine corrections. If you click farther away from the contour, the circle is large and you can perform rough corrections. Move the circular mouse pointer toward the contour. When the circle touches the line, the contour is pushed in the direction of the mouse movement. D.2 Double-click to deactivate the tool. Deleting and redrawing contours (if applicable) D.2 If you want to redraw the active contour, it has to be deleted first. D.2 Click the icon. The active contour is deleted. D.2 You can use the menu commands under Argus Tools > Delete All Contours to delete contours in multiple images simultaneously. Redraw the contour in the ED base image. syngo MR D13 D.2-15

200 syngo D.2 D.2 Post-processing Propagating contours within the ED phase D.2 Propagating contours is not the same as copying them. Instead, they are fitted to the anatomical contours from image to image.d.2 Tools for propagating contours D.2 (1) Propagate within the ED column (2) Propagate from ED to ES images (3) Propagate left (4) Propagate right (5) Propagate within the row (6) Propagate to all columns First, you propagate the contours drawn in the ED base image to the other images of the ED phase. D.2 Click the icon. Epicardial and endocardial contours are drawn in the remaining ED phase images. D.2 D.2-16 MR D13 - Cardio

201 D.2 D.2 Ventricular Analysis D.2 Checking/correcting propagated contours D.2 Check whether the propagated contours match the anatomical structures. Monitor the propagation in the active segment and stop it with the icon, if necessary. Load all images of the ED phase into a work segment, one by one. Check the propagated contours and correct them with the drawing and editing tools, if necessary. The propagation applies only to the selected ventricle. If you have drawn contours for both ventricles, they have to be propagated separately. syngo MR D13 D.2-17

202 syngo D.2 D.2 D.2 D.2 D.2 Post-processing Propagating contours to all columns D.2 After all contours in the ED images have been drawn precisely, they are propagated to the other columns. D.2 Click the icon. Epicardial and endocardial contours are drawn in the images of the remaining columns. D.2 If you want to evaluate the ED and ES phase only, you can propagate the contours from the ED images to the ES images: D.2 Click the icon. Check the propagated contours and correct them, if necessary. Check the propagated contours by starting movie display with the contours showing. Confirming propagated contours D.2 You must confirm propagated contours before you can start calculating the results. D.2 Click the icon. If propagated contours are not explicitly confirmed, a warning will be displayed in the results of the ventricular analysis. D.2-18 MR D13 - Cardio

203 D.2 D.2 D.2 Ventricular Analysis D.2 Starting volume analysis D.2 Click Volume in the Result subtask card. If the patient data are incomplete, the Patient Info Dialog dialog window will be displayed. D.2 Enter the heart rate, and the patient height and weight. Click OK. The calculation results are displayed in graphic and table format. D.2 If the patient information is incomplete, certain results cannot be calculated. The corresponding fields in the result table remain empty. You can use the dog ears to toggle between the result graph and the result table. D.2 syngo MR D13 D.2-19

204 syngo D.2 Post-processing Result diagrams D.2 Two graphs are displayed for each ventricle evaluated: D.2 1 Ventricular volume as a function of time 2 Speed of volume changes as a function of time Example for diagram (1). (29) D.2-20 MR D13 - Cardio

205 The D.2 Ventricular Analysis D.2 You can choose how the measurement points are connected in the graph. D.2 Select one of the following options under VF Options > Curve Fit Types: Raw data D.2 measurement points are connected by straight lines. D.2 Default Cubic Spline D.2 Manual Cubic Spline D.2 The curve between measurement points is smoothed with a spline function. D.2 The curve type allows you to define the acceptable deviation of the characteristic of the spline function from the measurement points in ml. D.2 The newly calculated spline curve is displayed as a dotted green line in the graph. D.2 The graph does not show a spline curve if only the ED and ES phases have been evaluated. D.2 Result tables D.2 Two tables with volume parameter values are displayed for each ventricle evaluated: D.2 1 Absolute values and normal range 2 Normalized values and normal range Normal range D.2 The normal range is determined from the parameter values of healthy patients while considering standard deviations. D.2 syngo MR D13 D.2-21

206 syngo D.2 D.2 Post-processing The normal range for the various volume parameters depends on the patient's gender. D.2 Normalized values. D.2 D.2-22 MR D13 - Cardio

207 Normalized Myocardial Stroke Cardiac Max. Max. D.2 Ventricular Analysis D.2 The normalized values are calculated by dividing the cardiac parameters by different values: D.2 Parameters D.2 parameter D.2 Ventricular volumes D.2 Ventricular volume/body surface D.2 Myocardial mass D.2 Stroke volume D.2 Cardiac index D.2 Peak ejection rate D.2 Peak filling rate D.2 mass/body surface D.2 volume/body surface D.2 output/body surface D.2 cardiac output/ed volume D.2 fill rate/ed volume D.2 Time to max. ejection fraction D.2 Time to max. fill rate D.2 Time to max. cardiac output/% systole D.2 Time to max. fill rate/% diastole D.2 syngo MR D13 D.2-23

208 syngo D.2 D.2 Post-processing Starting thickening analysis D.2 Thickening analysis lets you assess the change in myocardial wall thickness of the left ventricle. D.2 The thickening analysis is used for the left ventricle only. Only the images of the ED and ES phases are required to perform thickening analysis. D.2 Click Thickening in the Result subtask card. D.2-24 MR D13 - Cardio

209 D.2 D.2 Ventricular Analysis D.2 On the Result subtask card, you can change the following settings for thickening analysis to recalculate the thickening parameters: Smooth Contours Number of Sectors Orientation of reference line (Angle) The thickening parameters are calculated using the default settings. D.2 The contours are divided into six sectors by one yellow reference line and five blue lines. D.2 Argus calculates the following parameters for all sectors and slices: D.2 ED wall thickness (in mm) ES wall thickness (in mm) ED/ES thickening (in mm) ED/ES thickening (in %) The calculation results are displayed in graphic and table format. D.2 You can browse the individual thickening graphs using the dog ears. D.2 syngo MR D13 D.2-25

210 syngo D.2 Post-processing Thickening graphic - bull s-eye D.2 The bull's-eye is a stylized view onto a short axis image. The center of the circle corresponds to the cardiac apex and the outer circumference to the cardiac base. D.2 One thickening graph is generated for each parameter. D.2 One parameter is displayed for all sectors at the same time. The parameter value is symbolized by a color shade: D.2 Values within the normal range are displayed from blue (small values) to red (high values). Values outside the normal range are displayed in white (values > normal range) or black (values < normal range). If you evaluate multiple slice positions, the various slice positions are indicated by concentric rings. D.2 D.2-26 MR D13 - Cardio

211 D.2 Ventricular Analysis D.2 Result table D.2 One table with thickening parameters is displayed for each slice position evaluated. D.2 syngo MR D13 D.2-27

212 syngo Post-processing D.2-28 MR D13 - Cardio

213 D.3 4D Ventricular Analysis D.3 4D Ventricular Analysis D.3 The 4D ventricular analysis provides you with the possibility of analyzing the functions of the left ventricle with an adjustable 4D heart model. D.3 Evaluation is limited to the left ventricle. The application enables you: D.3 to determine clinically relevant function parameters quickly and easily to obtain meaningful results with little effort and less than optimal image quality to visualize the heart's motion in 4D Sequence of 4D ventricular analysis D.3 1 Loading images 2 Initializing the heart model by identifying just a few anatomical landmarks 3 Refining the model as needed by setting control points 4 Correcting, as needed, the spatial offset of individual slices caused by different breathhold positions 5 Evaluating results syngo MR D13 D.3-1

214 syngo D.3 D.3 Post-processing Loading images D.3 (1) Short-axis images (2) Long-axis images (3) Movie segments (pink frame) (4) Work segments (yellow frame) You need short-axis as well as long-axis cuts for the 4D ventricular analysis. Select the series in the Patient Browser. Click the icon on the toolbar of the Patient Browser. The Argus task card is displayed in the Argus Viewer mode. D.3 D.3-2 MR D13 - Cardio

215 D.3 D.3 D.3 4D Ventricular Analysis D.3 Click the icon in the control area. The Argus task card is updated. D.3 You need at least 2 short-axis cuts and 1 long-axis cut for the 4D ventricular analysis. Results will be more accurate by using an additional long-axis cut as well as additional short-axis cuts. Setting landmarks D.3 Initialize the 4D heart model by identifying a few anatomical landmarks. D.3 You start by determining the central axis of the left ventricle. Subsequently, you identify the base plane and then the transition from the left to the right ventricle. D.3 Setting the apical point of the central axis D.3 Click the Apical Central Axis in the control area. syngo MR D13 D.3-3

216 syngo D.3 D.3 D.3 Post-processing As soon as you have selected the Apical Central Axis, the short-axis work segment shows the ED phase of the apical slice.d.3 Place a point into the center of the left ventricle in the short-axis work segment. If you want to change its position, click the point with the left mouse button and shift it. Setting the basal point of the central axis D.3 Click the Basal Central Axis in the control area. D.3-4 MR D13 - Cardio

217 D.3 D.3 D.3 4D Ventricular Analysis D.3 As soon as you have selected the Basal Central Axis, the short-axis work segment shows the ED phase of the basal slice. D.3 Place a point into the center of the left ventricle in the short-axis work segment. If you want to change its position, click the point with the left mouse button and shift it. Setting the base plane D.3 Click Base Plane Points in the control area syngo MR D13 D.3-5

218 syngo D.3 D.3 Post-processing As soon as you have selected the Base Plane Points mode, the long-axis work segment shows the ED phase of the selected slice. D.3 Use the time-volume diagram to check the correct allocation of the images to the ED or ES phase. Place 2 points at the height of the base plane in the ED and ES phase in the long-axis work segment. Check the position of the points in the remaining phases. If you want to change their position, click the points with the left mouse button and shift them. D.3-6 MR D13 - Cardio

219 D.3 D.3 4D Ventricular Analysis D.3 Determining the transition from left to right ventricle D.3 Click the RV Insertion Points in the control area. As soon as you have selected the RV Insertion Points mode, two purple points are displayed as an automatic suggestion for the transition from the left to the right ventricle. D.3 At the same time the model is initialized specific to the patient. D.3 syngo MR D13 D.3-7

220 syngo D.3 D.3 Post-processing Check to ensure that the automatically determined transition from the left to the right ventricle in the short-axis cuts is correct. If you want to change the position of a point, click it with the left mouse button and shift it. Setting control points D.3 Click Guide Points in the control area. The model can be further adapted to the patient's anatomy by setting additional control points. D.3 D.3-8 MR D13 - Cardio

221 D.3 D.3 D.3 4D Ventricular Analysis D.3 In the short-axis work segment, you set points to adjust the contours to the patient's anatomy. If you want to change its position, click the point with the left mouse button and shift it. Right-click to delete control points. The model can be refined and adjusted further to the patient's anatomy by setting/editing/deleting control points. The model is calculated again in real time and the contours are updated accordingly. syngo MR D13 D.3-9

222 syngo D.3 Post-processing For a detailed display of the results of the analysis, use the brief summary in the time-volume diagram. D.3 Click the result mode with the left mouse button. Identical to the classic ventricular function analysis, the results are shown in the form of diagrams and tables. Additional details to help interpret these diagrams and tables are included in: ( Page D.2-1 Ventricular Analysis) D.3 It is not possible to change the model in the "result" mode interactively. As soon as the result windows are closed, the program changes into the "setting control points" mode and full interactivity is available again. Handling of offset slices D.3 By measuring the heart during different breathhold positions, an offset between slices of different acquisitions can occur. The offset has a negative effect on the accuracy of the evaluation. D.3 For this reason, the 4D ventricle analysis provides you with the possibility to correct the spatial offset between images. In addition, an option is available that eliminates affected slices from the evaluation. D.3 D.3-10 MR D13 - Cardio

223 D.3 D.3 4D Ventricular Analysis D.3 Correcting the offset D.3 The Registration mode compensates for the offset between slices. D.3 Click the icon on the View subtask card. Press the left mouse button and drag the contours within the active work segment to the desired position. As soon as you release the left mouse button, the model is calculated anew and the contours are updated. D.3 syngo MR D13 D.3-11

224 syngo D.3 D.3 You D.3 D.3 Post-processing The icon is activated through registration. D.3 Cancelling registration D.3 Click the icon in the matrix cell shown below the image. The previously determined spatial offset is cancelled in the respective slice. D.3 Excluding slices with offsets D.3 can exclude slices from the evaluation D.3 Click the icon in the area of the matrix cells. It is not possible to exclude slices when an Apical Central Axis, a Basal Central Axis, Base Plane Points or RV Insertion Points were set in these slices. Also, slices cannot be excluded when minimum data requirements are no longer met. The respective image data are no longer part of the evaluation calculation. To inform the user, the associated icon is activated. D.3 Cancelling the exclusion of slices D.3 Click the icon in the respective matrix cell. The previously excluded slice is part of the calculation again. D.3 D.3-12 MR D13 - Cardio

225 D.3 D.3 4D Ventricular Analysis D.3 Evaluating the results D.3 (1) Slider (pink)for the movie segments,left side (2) Slider (yellow)for the work segments,right side (3) Position end-diastole (ED)/end-systole (ES) (4) Result display The times during which the image data measured are available for a 4D ventricular analysis are shown via filled circles in the time-volume graph. Phases where control points were set are shown in color. syngo MR D13 D.3-13

226 syngo The Analogous Post-processing Click the respective data point in the graph to read out the concrete numerical value for one of these magnitudes (e.g. the endocardial ventricular volume). The numerical value is shown above the data point. D.3 Movie segment slider D.3 Movie segment slider shows the time when the current images are displayed in the Movie segments. D.3 Use the mouse to move the slider to a new position. The images of the selected phase are shown in the Movie segments. D.3 While the movie is running, the slider moves synchronously with the film along the time axis. D.3 Work segment slider D.3 to the movie slider, the work segment slider shows the phase of the images displayed in the work segment. D.3 Use the mouse to move the slider to a new position. The work segments with the images of the new phase are updated accordingly. D.3 D.3-14 MR D13 - Cardio

227 The D.3 D.3 4D Ventricular Analysis D.3 ED and ES slider D.3 ED or ES sliders show the end-diastolic or end-systolic phases. D.3 To change an end-diastolic or end-systolic phase, use the mouse to move the slider to a new phase position. When you move the respective slider to a position that does not correspond to the end-diastole or end-systole of the current time-volume graph, the color of the slider will turn red. Result display: D.3 The respective value of the cardiac parameters Ejection Fraction, Myocardial Mass, ED volume and ES volume appears in the result display. D.3 Each time the model is changed, the values are recalculated. syngo MR D13 D.3-15

228 syngo To D.3 D.3 D.3 Post-processing Image navigator D.3 obtain an overview of the spatial relationship of the slice data during two-dimensional displays, you can have the position of the short-axis cuts displayed in the long-axis cuts (or vice versa). D.3 Click the icon in the control area of the View subtask card (dimmed in the 4D view). The position of the other slices is visualized by yellow lines. D.3 The current slice is shown in red. D.3 You can change the current slice by clicking the enlarged circle-shaped end of the corresponding line with the mouse. D.3-16 MR D13 - Cardio

229 D.3 D.3 D.3 4D Ventricular Analysis D.3 4D view D.3 The 4D view shows the 3D display of the left ventricle model over time. D.3 Click the icon in the control area of the View subtask card. The model is shown in a 1 x 1 layout. D.3 An orientation cube shows the orientation of the heart. D.3 Symbols on the orientation cube: D.3 S: Septal L: Lateral I: Inferior A: Anterior B: Base X: Apex Click the icon in the control area of the View subtask card. The endocardial surface is displayed. D.3 Click the icon again to hide the endocardial surface. Click the icon in the control area of the View subtask card. The epicardial surface is displayed. D.3 syngo MR D13 D.3-17

230 syngo D.3 D.3 D.3 D.3 Post-processing By default, the endo- and epicardial surfaces are hidden in the 4D view. The endo- and epicardial wire mesh models and the base plane are set by default. Click the icon again to hide the epicardial surface. Click the icon in the control area of the View subtask card. The endocardial wire mesh model is displayed. D.3 Click the icon again to hide the endocardial wire mesh model. Click the icon in the control area of the View subtask card. The epicardial wire mesh model is displayed. D.3 Click the icon again to hide the epicardial wire mesh model. Click the icon in the control area of the View subtask card. The base plane is displayed. D.3 Click the icon again to hide the base plane. Showing/hiding slices D.3 Click the icon in the area of the matrix cells. The respective slice is shown/hidden. D.3 D.3-18 MR D13 - Cardio

231 D.4 Flow analysis with Argus D.4 Flow analysis with Argus D.4 Flow analysis is used to determine the mean and maximum velocity of blood flow and the vessel cross-sections depending on the trigger time. D.4 The following example describes how to perform flow analysis of through-plane data for the ascending and descending aorta. As the analysis for in-plane data is largely the same, it is not described in what follows. D.4 Please note that it is not possible to simultaneously process through-plane and in-plane data within the Argus flow analysis. syngo MR D13 D.4-1

232 syngo D.4 D.4 D.4 Post-processing Preparing the data D.4 Loading the image data D.4 Phase-contrast images and corresponding rephased images are available Select the data series to be analyzed in the Patient Browser (use the Ctrl key for multi-selection). You may also select magnitude images for loading as additional data. Transfer the data to the Argus task card by clicking the Argus icon. The Argus task card opens in the Argus Viewer mode. D.4 Start flow analysis by clicking the icon. The image matrix is rearranged: D.4 Images in a row are from the same image reconstruction type. Images in a column are from the same cardiac phase. D.4-2 MR D13 - Cardio

233 D.4 Flow analysis with Argus D.4 (1) Work segments (2) Rephased images (labeled M) (3) Magnitude images (labeled MAG) (4) Phase-contrast images (labeled P) syngo MR D13 D.4-3

234 syngo D.4 D.4 D.4 Post-processing Optimizing the image display D.4 Enlarge the image area showing the ascending and descending aorta. Window the images to optimize their contrast and brightness. The grayscale values of the phase-contrast images represent flow velocities. D.4 If necessary, you can assign a linear color scale instead of the grayscale in the Color selection list of the View subtask card. D.4 Example: Assignment of the Red to Blue color scale. D.4 You cannot window phase-contrast images in color. However, you can continue to use zooming and panning. D.4-4 MR D13 - Cardio

235 D.4 D.4 Flow analysis with Argus D.4 Defining the evaluation regions D.4 You draw the contours of the vessel cross-sections to define the ROIs for flow analysis. D.4 All tools for ROI definition are available on the Drawing subtask card. D.4 You can draw ROIs into any image. Later during propagation, they are copied automatically to the images belonging to the same phase. D.4 The rephased images show the edges of the vessels more clearly than the phase-contrast images. This makes them especially suitable for drawing. syngo MR D13 D.4-5

236 syngo D.4 D.4 D.4 Post-processing Drawing the ROI for the ascending aorta D.4 R1 icon for drawing the 1st ROI is active Load an image containing easily recognizable vessel cross-sections into a work segment. Draw a circular ROI around the cross section of the ascending aorta. Fit the ROI to the vessel contours of the ascending aorta by clicking the icon. Once the ROI is drawn, the result of the statistical evaluation is shown next to it. D.4 The value of the highest flow velocity in the ROI is marked by a point in the image. D.4 D.4-6 MR D13 - Cardio

237 D.4 D.4 D.4 D.4 D.4 Flow analysis with Argus D.4 Drawing the ROI for the descending aorta D.4 To start drawing the second ROI, click the R2 icon. Draw a circular ROI around the cross section of the descending aorta. Fit the ROI to the vessel contours of the descending aorta by clicking the icon. Analyzing low velocities (optional) D.4 When analyzing low velocities you have to define a reference ROI. D.4 Start drawing the reference ROI by clicking the Ref. icon. Draw a small reference ROI in an area with stationary tissue near the vessel of interest (e.g., in the chest wall or the spine). The flow parameters of the reference ROI are used for subsequent baseline correction. D.4 Please note that if the background signal in the reference region differs significantly from the vessel region, the correction by the reference ROI might not be valid! syngo MR D13 D.4-7

238 syngo D.4 D.4 D.4 Post-processing Propagating the vessel contours to other cardiac phases D.4 During propagation, the contours of the ROIs are fitted to the anatomy. The contour of the reference ROI is copied without fitting. D.4 Select all vessel cross-section ROIs that were drawn by clicking the icon. Start the propagation by clicking the icon. Select the reference ROI with the Ref. icon. Copy the reference ROI by clicking the icon. The ROIs are drawn into the remaining images of the matrix row. D.4 Confirming the propagated vessel contours D.4 Checking the ROIs D.4 View the images in a work segment one by one by scrolling through them with the arrow keys of the keyboard. or D.4 Display the images using the movie display function of the View subtask card with Graphics On. D.4-8 MR D13 - Cardio

239 If D.4 D.4 D.4 D.4 If D.4 Flow analysis with Argus D.4 Correcting the ROIs D.4 ROIs are misaligned, you correct them with the drawing and editing tools. D.4 Change the size and the position of the ROI with the Move tool. Correct the shape of the ROI with the Nudge tool. Redraw a segment of the ROI with the Splice tool. To apply the correction to the other series of this phase, browse through the images with the arrow keys or click the icon on the Drawing subtask card. Confirming the ROIs D.4 propagated ROIs are not explicitly confirmed, a warning will be displayed in the results of the flow analysis. D.4 Accept the contours by clicking the icon. syngo MR D13 D.4-9

240 syngo D.4 D.4 D.4 Post-processing Evaluating the vessels D.4 All tools for evaluation are available on the Result subtask card. D.4 You can graph the following parameters as a function of time: D.4 Velocity D.4 Peak Velocity D.4 Flow D.4 Net Flow D.4 Area D.4 Mean velocity within the ROI D.4 Peak velocity within the ROI D.4 Product of mean velocity and surface aread.4 Difference between forward and return flow D.4 Cross-section of the vessel D.4 During the analysis of in-plane data, it is physically not useful to compute the (net) flow because the vessels are merely truncated. As a result, it is not possible to reliably determine the blood flow through the vessel. For this reason, only the velocity as well as the cross-sectional area of the ROI are determined with in-plane data. D.4-10 MR D13 - Cardio

241 D.4 D.4 D.4 Flow analysis with Argus D.4 Calculating results with standard settings D.4 If the patient data are incomplete, the Patient Information dialog window is displayed when starting the calculation. Select the vessels with the R1, R2, and Ref. icons. Start the calculation by clicking the respective parameter icon. The results for each ROI are displayed in graphic format. D.4 To smooth the curve characteristic using a spline function, select Flow Options > Fit Curve as Cubic Spline. The spline curve is displayed in the graph as a dotted line. D.4 Display the result tables by clicking Summary. syngo MR D13 D.4-11

242 syngo D.4 Post-processing Limiting the time range D.4 By default, the time between the first and last trigger time is used for evaluation. D.4 Change the time range by overwriting the start and end values in the Result subtask card. Start the recalculation with the Enter key. Performing baseline correction D.4 Reference ROI has been defined Apply baseline correction with Flow Options > Use Baseline Correction. A baseline is calculated from the flow parameters of the reference ROI and subtracted from the result curve. D.4 Baseline correction is indicated in both the image text and the result tables. D.4-12 MR D13 - Cardio

243 D.4 D.4 Flow analysis with Argus D.4 Correcting phase aliasing D.4 Flow velocities that exceed the defined flow sensitivity are shown with an incorrect grey value, resulting in phase aliasing. An exceedingly high positive velocity is shown as a high negative flow velocity (black) and vice versa ( phase reversals ). D.4 Phase aliasing can be corrected, as long as the maximum flow velocity does not exceed double the value set as flow sensitivity during the measurement. Examples D.4 (1) Blood flowing too fast causes dark spots in the region of the ascending aorta and bright spots in the region of the descending aorta. (2) Phase reversals can be identified by the local minimum in the systolic phase. The highest velocities are much smaller than expected. syngo MR D13 D.4-13