Voxar 3D CardiaMetrix Reference Guide
The software described in this document is furnished under a license, and may be used or copied only according to the terms of such license. Toshiba means, Toshiba Medical Visualization Systems Europe, Limited, a private limited company (company number SC341779) registered in the United Kingdom, having an office at Bonnington Bond, 2 Anderson Place, Suites 7 and 8, EH6 5NP, United Kingdom. Toshiba assumes no responsibility for the use or reliability of software that is not supplied by Toshiba or of hardware used in connection with Toshiba-supplied software. The Software License and Limited Warranty are contracts between Toshiba and the purchaser which will use the software. Any descriptive information in this document about software is subject to change by Toshiba in its sole discretion without notice, and should not be considered as a commitment by Toshiba. Toshiba assumes no responsibility for any errors that may appear in this document. Copyright 2009 Toshiba Medical Visualization Systems Europe, Limited. All rights reserved All trademarks and registered trademarks are the property of their respective owners. Voxar 3D CardiaMetrix Reference Guide (TMVSE000054-00) January 2009.
Contents Chapter 1 Introduction 7 About this document... 7 About Voxar 3D CardiaMetrix... 7 About CardiaMetrix 4D Viewer... 7 About CardiaMetrix LV Analysis... 9 About CardiaMetrix Coronary Analysis...11 About CardiaMetrix Calcium Scoring...13 Notes...16 Chapter 2 Common tasks 17 Selecting the default mode...17 Panning a view...17 Zooming a view...18 Changing the window and level of a view...18 Cineing a plane in a view...19 Measuring a line on a 2D or MPR view...19 Measuring an angle on a 2D or MPR view...19 Measuring an elliptical region of interest on a 2D or MPR view...20 Making a text annotation on a view...20 Making an arrow annotation on a view...21 Using the mouse wheel and right mouse button...21 Notes...22 3
Contents Chapter 3 Tasks in CardiaMetrix 4D Viewer 23 Extracting the heart...23 Specifying an oblique plane in an MPR view...23 Cineing an oblique plane in an MPR view...24 Displaying the long axis of the heart in the MPR views...24 Rotating a volume in a 3D view...27 Sorting the series...28 Changing the R-R interval for a series...28 Playing a movie...29 Tagging the end diastole and end systole series...29 Capturing a view...29 Opening CardiaMetrix LV Analysis...30 Opening CardiaMetrix Coronary Analysis...30 Notes...31 Chapter 4 Tasks in CardiaMetrix LV Analysis 33 Defining the long axis of the heart...33 Creating short axis slices of the left ventricle...33 Tracing the contour of the epicardial and endocardial border...35 Excluding the papillary muscle from measurements...37 Analyzing the results...38 Saving your work...39 Creating a report...40 Notes...41 Chapter 5 Tasks in CardiaMetrix Coronary Analysis 43 Rotating a volume in a 3D view...43 Extracting the heart...43 Extracting the aortic root...44 Extracting the coronary tree...45 4
Contents Naming an artery...47 Modifying the center-line of an artery...47 Modifying the contour of an artery...49 Analyzing an artery...50 Saving your work...51 Creating a report...51 Notes...52 Chapter 6 Tasks in CardiaMetrix Calcium Scoring 53 Selecting an artery to score...53 Assigning a calcified plaque to an artery...53 Produce a calcium score...54 Capturing key images...55 Saving your work...55 Creating a report...55 Notes...56 Chapter 7 User scenarios 57 4D Review and LV Analysis...58 4D Review and Coronary Analysis...81 Calcium Scoring... 101 Notes... 103 Index 105 5
6 Contents
Chapter 1 Introduction About this document This document introduces the main features of Voxar 3D CardiaMetrix, and describes how to use these features in a typical scenario. Caution: Before using Voxar 3D CardiaMetrix, you must read the safety and regulatory information in the Voxar 3D online Help. Note: Some of the features described may not available on your system. About Voxar 3D CardiaMetrix Voxar 3D CardiaMetrix is a clinical application that allows you to analyze CT cardiac images. The application provides four modules: CardiaMetrix 4D Viewer CardiaMetrix LV Analysis CardiaMetrix Coronary Analysis CardiaMetrix Calcium Scoring About CardiaMetrix 4D Viewer CardiaMetrix 4D Viewer allows you to observe the motion of cardiac muscle. The module is designed to be used in a particular workflow: 1 Select two or more series from a cardiac study. 2 Display the heart in each series using MPR (Multi-planar Reformatting) and 3D views. 3 Extract the heart from the surrounding anatomy in each series. 7
Chapter 1: Introduction 4 Identify which series relates to which cardiac phase, and sort the series appropriately. 5 Play movies of the MPR and 3D views as they show each series in turn. Note: CardiaMetrix 4D Viewer can also be used to prepare for using other CardiaMetrix modules: Identifying the end diastolic and end systolic series is useful for CardiaMetrix LV Analysis Identifying which series relates to which cardiac phase is useful for CardiaMetrix Coronary Analysis CardiaMetrix 4D Viewer user interface Viewing area Window/Level Presets gallery Right bar Reading buttons 8
About CardiaMetrix LV Analysis Viewing area Displays your images in 2D, MPR and 3D views: The 2D views show the images in their original format The MPR views generate a volume from your images, and show planes within the volume you can cine these planes through the volume as required The 3D views generate a volume from your images, and show that volume in three-dimensions you can rotate the volume to any orientation Window/Level Presets gallery Allows you to change the window and level of the currently-selected view using presets. The presets are displayed as thumbnails to apply a preset, click the relevant thumbnail. Right bar Contains controls for manipulating the images and volumes in the views, identifying which series relates to which cardiac phase, ordering the series, and creating movies. Reading buttons Allow you to switch between CardiaMetrix modules, save your work, open the online Help, and exit CardiaMetrix. About CardiaMetrix LV Analysis CardiaMetrix LV Analysis allows you to analyze the function of the left ventricle. The module is designed to be used in a particular workflow: 1 Select two or more series from a cardiac study, including one for end diastole and one for end systole. You can select the series from the Study Browser, Reading Manager, or CardiaMetrix 4D Viewer. 2 Display the heart in each series using MPR views. 9
Chapter 1: Introduction 3 Define the long axis of the heart. 4 Create short axis slices of the left ventricle. 5 Trace the contour of the epicardial and endocardial borders. 6 Analyze the results, which include: Ejection fractions, for measuring the cardiac output Bull s eye plots, for evaluating the motion and thickness of the muscle wall 7 Create a report. CardiaMetrix LV Analysis user interface Viewing area Right bar Reading buttons 10
About CardiaMetrix Coronary Analysis Viewing area Generates a volume from your images, and displays that volume in MPR views. These views show planes within the volume, and allow you to cine those planes through the volume. Right bar Contains controls for changing the layout of the views, manipulating the planes in the views, specifying the contours, measuring the cardiac output, and evaluating the motion and thickness of the muscle wall. Reading buttons Allow you to switch between CardiaMetrix modules, create reports, save your work, open the online Help, and exit CardiaMetrix. About CardiaMetrix Coronary Analysis CardiaMetrix Coronary Analysis allows you to analyze the coronary arteries for stenoses. The module is designed to be used in a particular workflow: 1 Select a series from a cardiac study. You can select the series from the Study Browser, Reading Manager, or CardiaMetrix 4D Viewer. 2 Display the heart in the series using MPR and 3D views. 3 Extract the heart from the surrounding anatomy in the series. 4 Extract the aortic root. 5 Extract the coronary tree. 6 Analyze each artery in the tree for stenoses. 7 Create a report. 11
Chapter 1: Introduction CardiaMetrix Coronary Analysis user interface Workflow buttons Viewing area Right bar Reading buttons Workflow buttons Allow you to select different stages in the coronary analysis workflow. Each button changes the content of the viewing area and right bar so that the tasks for that stage can be performed. 12
About CardiaMetrix Calcium Scoring Viewing area Generates a volume from your images, and displays that volume in MPR and 3D views: The MPR views show planes within the volume, and allow you to cine those planes through the volume The 3D views show the volume in three-dimensions, and allow you to rotate that volume to any orientation Right bar Contains controls for manipulating the images and volumes in the views, extracting the heart, extracting the aortic root and coronary tree, calculating points of stenosis, and creating movies. Reading buttons Allow you to switch between CardiaMetrix modules, create reports, save your work, open the online Help, and exit CardiaMetrix. About CardiaMetrix Calcium Scoring CardiaMetrix Calcium Scoring allows you to perform coronary artery calcium scoring. The module is designed to be used in a particular workflow: 1 Select a series from a cardiac study. 2 Display the heart in the series using MPR views. 3 Assign calcified plaques to coronary arteries. 4 Produce a calcium score: An Agatston 130 score A volume score (in cubic millimeters) A user-specified score by setting the calcification threshold value, or A score per voxel 5 Create a report. 13
Chapter 1: Introduction CardiaMetrix Calcium Scoring user interface Vessel table Viewing area Right bar Reading buttons Vessel table Allows you to select coronary arteries for scoring, and displays the calcium scores for each artery. Viewing area Generates a volume from your images, and displays that volume in MPR views. These views show planes within the volume, and allow you to cine those planes through the volume. 14
About CardiaMetrix Calcium Scoring Right bar Contains controls for changing the layout of the views, manipulating the planes in the views, assigning calcified plaques to coronary arteries, producing a calcium score, and capturing key images. Reading buttons Allow you to create reports, save your work, open the online Help, and exit CardiaMetrix. 15
Chapter 1: Introduction Notes 16
Chapter 2 Common tasks Selecting the default mode When performing tasks, you may need to change mode. To return to the default mode for a module, click the relevant mode button: Animate 4D mode (CardiaMetrix 4D Viewer) Cardiac Analysis mode (CardiaMetrix LV Analysis) Coronary Analysis mode (CardiaMetrix Coronary Analysis) Calcium Scoring mode (CardiaMetrix Calcium Scoring) Panning a view Click the Pan and Zoom button, then click the Pan button. Now, drag on the required view. 17
Chapter 2: Common tasks Zooming a view Click the Pan and Zoom button, then click the Zoom button. Now, drag on the required view: Drag up to zoom in Drag down to zoom out Changing the window and level of a view Click the Change WW & WL button. Now, drag on the view: Drag down to increase the window level Drag up to decrease the window level Drag right to increase the window width Drag left to decrease the window width To change the window and level using a preset, right-click a view and select Show preset gallery > Show. The Window Level Presets gallery is displayed showing presets as thumbnails. To apply a preset, click the relevant thumbnail. 18
Cineing a plane in a view Cineing a plane in a view Move the mouse pointer over the view, then rotate the mouse wheel. Measuring a line on a 2D or MPR view Select the 2D or MPR view, and click the 2D measurement button. Then, in the 2D measurement method area, click the Line button. On the view, drag to draw the line. A measurement annotation is displayed, showing the line measured along with text describing the length of the line. To delete the annotation, click it and press the DELETE key. Measuring an angle on a 2D or MPR view Select the 2D or MPR view, and click the 2D measurement button. Then, in the 2D measurement method area, click the Angle button. On the view, specify the angle by drawing two connected lines: Click where you want the first line to start Click where you want the first line to end and the second line to start Click where you want the second line to end A measurement annotation is displayed, showing the lines along with text describing the angle between the lines. To delete the annotation, click it and press the DELETE key. 19
Chapter 2: Common tasks Measuring an elliptical region of interest on a 2D or MPR view Select the 2D or MPR view, and click the 2D measurement button. Then, in the 2D measurement method area, click the Ellipse button. On a view, drag to specify the size and shape of the region. A measurement annotation is displayed, showing the region along with text describing: The maximum, minimum, mean and standard deviation of pixel values in the region The area of the region To delete the annotation, click it and press the DELETE key. Making a text annotation on a view Click the Annotations button. Then, in the Comment area, click the Text annotation button. Click where you want the text annotation to be placed. A text area is displayed. Now, in the Application settings area, enter the required text. To delete the annotation, click it and press the DELETE key. 20
Making an arrow annotation on a view Making an arrow annotation on a view Click the Annotations button. Then, in the Comment area, click the Arrow annotation button. Click where you want the arrow to point. The arrow is displayed with an empty text box. Drag the text box to the required position. Now, in the Application settings area, enter the text for the annotation. To delete the annotation, click it and press the DELETE key. Using the mouse wheel and right mouse button In Voxar 3D CardiaMetrix, you can: Rotate the mouse wheel to cine Click the right mouse button to select tools and change display options Rotate the wheel to cine 21
Chapter 2: Common tasks Notes 22
Chapter 3 Tasks in CardiaMetrix 4D Viewer The following tasks are common in CardiaMetrix 4D Viewer. Extracting the heart Click the 4D button to select Animate 4D mode, then click the Extract heart button. Specifying an oblique plane in an MPR view Click the 4D button to select Animate 4D mode, then, in the Mouse Operation area, click the Rotate button. Now, drag the relevant green MPR crosshair clockwise or counter-clockwise. 23
Chapter 3: Tasks in CardiaMetrix 4D Viewer Cineing an oblique plane in an MPR view Move the mouse pointer over the view, then rotate the mouse wheel. Alternatively, click the 4D button to select Animate 4D mode, then, in the Mouse Operation area, click the Move button. Now, drag the relevant green MPR crosshair. Displaying the long axis of the heart in the MPR views Click the 4D button to select Animate 4D mode, then, in the Mouse Operation area, click the Rotate button. 24
Displaying the long axis of the heart in the MPR views In the upper-left MPR view, drag the green MPR crosshairs counter-clockwise. In the upper-right MPR view, drag the MPR crosshairs clockwise. Note that to move rather than rotate the crosshairs, you can drag the intersection of the crosshairs. In the Mouse Operation area, click the Move button. 25
Chapter 3: Tasks in CardiaMetrix 4D Viewer In the upper-right MPR view, drag the crosshairs down to the center of the left ventricle. In the lower-left MPR view, move the crosshairs to the center of the left ventricle. 26
Rotating a volume in a 3D view To rotate the short axis view, click the Rotate buttons at the top of the lower-left MPR view. Rotating a volume in a 3D view Click the 4D button to select Animate 4D mode, then drag on the 3D view. 27
Chapter 3: Tasks in CardiaMetrix 4D Viewer Sorting the series Click the 4D button to select Animate 4D mode. Then, in the R-R table, click the Sort button. From the menu, select: ImageNumber to order by image number SeriesNumber to order by series number ImageTime to order by the time of series capture Comment to order by the series description Changing the R-R interval for a series R-R intervals are not obtained from information in the DICOM header of images, and may need adjustment. Click the 4D button to select Animate 4D mode. Then, in the R-R table, select the series, and in the R-R% area, specify the new interval. 28
Playing a movie Playing a movie If required, sort the series (see page 28) and change the R-R interval for any required series (see page 28). Then, click the 4D button to select Animate 4D mode, and click the Play button. To stop the movie, click the Play button again. Tagging the end diastole and end systole series You can tag the end diastole and end systole series in preparation for CardiaMetrix LV analysis. Click the 4D button to select Animate 4D mode. Then, in the R-R table, click through the series until you identify the end diastole series. Click the Diastole button. Then, identify the end systole series, and click the Systole button. Capturing a view To capture a single view: Click the Capture button at the top of the view. The capture is taken and stored as a Secondary Capture image in the Reading Manager. 29
Chapter 3: Tasks in CardiaMetrix 4D Viewer Opening CardiaMetrix LV Analysis Click the 4D button to select Animate 4D mode, then click the Cardiac button at the bottom of the window. Note: If you tag the end diastole and end systole series, CardiaMetrix LV Analysis is opened with only those series. If you do not tag the series, CardiaMetrix LV Analysis is opened with all current series. Opening CardiaMetrix Coronary Analysis Click the 4D button to select Animate 4D mode. Then, in the R-R table, select the required series, and click the Coronary button at the bottom of the window. 30
Notes Notes 31
Chapter 3: Tasks in CardiaMetrix 4D Viewer 32
Chapter 4 Tasks in CardiaMetrix LV Analysis The following tasks are common in CardiaMetrix LV Analysis. Defining the long axis of the heart Click the Cardiac Analysis button to select Cardiac Analysis mode. Then, on the long axis views: Drag the green MPR crosshairs clockwise or counter-clockwise to rotate Drag the intersection of the MPR crosshairs to center Creating short axis slices of the left ventricle Define the long axis of the heart (see above). Then, click the arrow buttons at the top of the CardiaMetrix window to select the end diastole series. Now, click the Cardiac Analysis button to select Cardiac Analysis mode. Then, on the long axis views, drag the arrows to set the position of the base and apex of the heart. 33
Chapter 4: Tasks in CardiaMetrix LV Analysis Then, on the short axis view, drag the crosshairs to the center of the left ventricle. 34
Tracing the contour of the epicardial and endocardial border Check the range has covered the base to apex in the end systole series by clicking the arrow buttons again. Then return to the end diastole series. Now, click the Slice button. Tracing the contour of the epicardial and endocardial border Create short axis slices of the left ventricle (see page 33). Then, click the Cardiac Analysis button to select Cardiac Analysis mode and, on each long axis view, manually trace the epicardial border of the left ventricle: Click to drop the first control point Continue clicking to place the remaining control points Double-click, or right-click and select Fix, to complete the trace If required, use the Outline tools to edit the trace, then click the Analyze button. 35
Chapter 4: Tasks in CardiaMetrix LV Analysis Removing border contours On the Phase table, drag the mouse to cover the cells that represent the contours you want to remove. Then, right-click the selected cells and select Clear. Editing an epicardial border contour In the Mouse Operation area, ensure that the Trace button is selected. Then, In the Target area, ensure that the Wall button is selected. The original slice views show the epicardial border contour. On the original slice views, drag to trace the new contour. 36
Excluding the papillary muscle from measurements Editing an endocardial border contour In the Mouse Operation area, ensure that the Trace button is selected. Then, In the Target area, ensure that the Ventricle button is selected. The original slice views show the endocardial border contour. On the original slice views, drag to trace the new contour. Excluding the papillary muscle from measurements You can set a density threshold value to exclude the papillary muscle from the LV analysis measurements. Tissue with a density equal to, or less than, this value is automatically excluded. Trace the contour of the epicardial and endocardial border (see page 35). Then, click the Cardiac Analysis button to select Cardiac Analysis mode, and in the Papillary muscle threshold area, select the Remove papillary muscle check box. 37
Chapter 4: Tasks in CardiaMetrix LV Analysis Purple masks are displayed in the short axis views. In the Papillary muscle threshold area, specify the threshold as required. Analyzing the results Trace the contour of the epicardial and endocardial border (see page 35). Then, click the tabs at the top of the CardiaMetrix window to display the required results. 38
Saving your work Phase table Displays an overview of the current series, along with the current slices, color-coded end diastole and end systole phases, and the results of contour editing Graph Displays the end diastole volume, end systole volume, and ejection fraction results, along with volume and volume slope graphs Result Displays the extended set of results, that is, the full set of global parameters Plot Displays various functional parameters on bull s eye plots 4D View Displays a 4D movie of the ventricle, based on the contour information in the end systole and end diastole phases To fully populate the analysis results, click the Cardiac Analysis button to select Cardiac Analysis mode, then click the Application settings button to display the Application Settings dialog box. In the Patient area, enter the height, weight, and heart rate of the patient. Saving your work At the bottom of the CardiaMetrix window, click the Save button a Live Image capture is taken. If you want to postpone a reading, switch to the Reading Manager and click the Finish and Archive button. Then, to return to the reading, you simply restore the Live Image. 39
Chapter 4: Tasks in CardiaMetrix LV Analysis Creating a report Analyze the results (see page 38), click the Cardiac Analysis button to select Cardiac Analysis mode, then click the Application Settings button to display the Application Settings dialog box. In the Report area, select the check boxes for the results required in the report. Now, click the Report button at the bottom of the CardiaMetrix window. 40
Notes Notes 41
Chapter 4: Tasks in CardiaMetrix LV Analysis 42
Chapter 5 Tasks in CardiaMetrix Coronary Analysis The following tasks are common in CardiaMetrix Coronary Analysis. Rotating a volume in a 3D view Click the Coronary Analysis button to select Coronary Analysis mode. Then, drag on the 3D view. Extracting the heart Click the Coronary Analysis button to select Coronary Analysis mode. Then, click the Extract button. Note: If you extract the heart in CardiaMetrix 4D Viewer, then open CardiaMetrix Coronary Analysis from there, the heart remains extracted. 43
Chapter 5: Tasks in CardiaMetrix Coronary Analysis Extracting the aortic root Extract the heart (see page 43). Then, in the workflow bar at the top of the CardiaMetrix window, click the Extract Aortic Root button. Click the Coronary Analysis button to select Coronary Analysis mode. Then, in the coronal MPR view, set the range for extraction of the aortic root by dragging the green range guides to cover the aortic root. Now, in the axial MPR view, click the center of the aorta to position the crosshairs. 44
Extracting the coronary tree Click the Extract button the aortic root is displayed in the 3D view. The Extract Coronary Tree button is automatically selected in the workflow bar at the top of the CardiaMetrix window. Extracting the coronary tree Extract the aortic root (see page 44). Then, click the Coronary Analysis button to select Coronary Analysis mode, and on the Vessel tab, click the Left vessel button to track the left coronary artery. 45
Chapter 5: Tasks in CardiaMetrix Coronary Analysis Cine through the volume until the start of the left coronary artery is displayed, then, click once at the origin of the artery to deposit a control point. On the Vessel tab, click the Right vessel button to track the right coronary artery and repeat the steps for that artery. If there are other arteries, click the Other vessel button and repeat for those arteries. 46
Naming an artery Now, click the Start Tracking button. The arteries are tracked blue lines indicate the tracking. When the tracking is complete, click OK to analyze. Naming an artery Extract the coronary tree (see page 45). Then, click the Coronary Analysis button to select Coronary Analysis mode, and on the 3D view, click the green control point at the end of the artery. The artery is highlighted along with the corresponding label on the Vessel tab. On the Vessel tab, right-click the label and select Edit label. The Name dialog box is displayed. Enter the name, and click OK. Modifying the center-line of an artery Extract the coronary tree (see page 45). Then, in the workflow bar at the top of the CardiaMetrix window, click the Modify button. 47
Chapter 5: Tasks in CardiaMetrix Coronary Analysis Now, click the Coronary Analysis button to select Coronary Analysis mode, and on the Vessel tab, select the artery. In the vessel localizer view, drag one of the green arrows along the artery to cine through the volume and identify the center-line that you want to modify. In the Modify mode area, click the Centerline button. Now, modify the center-line: In the standard MPR views, drag the crosshairs over the green lines In the stretched CPR view, draw a new center-line In the oblique MPR view, drag the intersection of the green crosshairs 48
Modifying the contour of an artery Modifying the contour of an artery Extract the coronary tree (see page 45). Then, in the workflow bar at the top of the CardiaMetrix window, click the Modify button. Now, click the Coronary Analysis button to select Coronary Analysis mode, and on the Vessel tab, select the artery. In the vessel localizer view, drag one of the green arrows along the artery to cine through the volume and identify the contour that you want to modify. In the Modify mode area, click the Contour button. 49
Chapter 5: Tasks in CardiaMetrix Coronary Analysis In the Configuration area, click the Freehand button. In the oblique MPR view, drag to draw a new contour, and double-click to finish. Analyzing an artery Extract the coronary tree (see page 45). Then, in the workflow bar at the top of the CardiaMetrix window, click the Coronary analysis button. Now, click the Coronary Analysis button to select Coronary Analysis mode, and on the Vessel tab, select the artery. 50
Saving your work Click the Status tab. Then, in the vessel localizer view, drag the yellow lines to set a range for measuring the maximum stenosis. The maximum stenosis result is displayed in pink on the vessel localizer view and on the Status tab. Saving your work At the bottom of the CardiaMetrix window, click the Save button a Live Image capture is taken. If you want to postpone a reading, switch to the Reading Manager and click the Finish and Archive button. Then, to return to the reading, you simply restore the Live Image. Note: You can only save your work once you have started to analyze coronary arteries for stenoses. Creating a report Analyze the arteries (see page 50). Then, click the Report tab at the top of the CardiaMetrix window. Now, click the Add button images are automatically captured for the report. Then, click the Report button at the bottom of the CardiaMetrix window. 51
Chapter 5: Tasks in CardiaMetrix Coronary Analysis Notes 52
Chapter 6 Tasks in CardiaMetrix Calcium Scoring The following tasks are common in CardiaMetrix Calcium Scoring. Selecting an artery to score In the vessel table at the top of the CardiaMetrix window, select the required artery. Assigning a calcified plaque to an artery Select an artery to score (see above). Then, click the Calcium Scoring button to select Calcium Scoring mode. In the views, calcified plaque and other high-density tissue is automatically highlighted in blue, green, yellow, or red the higher the density, the warmer the color. On the axial MPR view, cine through the volume until calcified plaques are displayed on the artery. 53
Chapter 6: Tasks in CardiaMetrix Calcium Scoring Select the calcified plaques: To select a single plaque on the displayed image, click the 2D button in the Selection tool area, then click the plaque To select multiple plaques on the displayed image, click the ROI button in the Selection tool area, then drag to draw around the plaques To select a single plaque on the displayed image and any plaque connected to it on other images, click the 3D button in the Selection tool area, then click the plaque. In the vessel table, the Volume cell for the artery shows the volume of calcium in cubic millimeters. Produce a calcium score Assign calcified plaques to arteries (see page 53). Then, click the Calcium Scoring button to select Calcium Scoring mode, and click the Scoring button to score. All scores for the arteries are displayed in the vessel table. 54
Capturing key images Capturing key images Produce a calcium score (see page 54). Then, click the Calcium Scoring button to select Calcium Scoring mode, and click the Image Capture button. In the Key area, click the Capture Key Images button. The Key box displays thumbnails of the key images. Saving your work At the bottom of the CardiaMetrix window, click the Save button a Live Image capture is taken. If you want to postpone a reading, switch to the Reading Manager and click the Finish and Archive button. Then, to return to the reading, you simply restore the Live Image. Creating a report Produce a calcium score (see page 54). Then, click the Report button at the bottom of the CardiaMetrix window. 55
Chapter 6: Tasks in CardiaMetrix Calcium Scoring Notes 56
Chapter 7 User scenarios This chapter illustrates workflows using the features available within Voxar 3D CardiaMetrix. The workflows are: 4D Review and LV Analysis 4D Review and Coronary Analysis Calcium Scoring 57
Chapter 7: User scenarios 4D Review and LV Analysis Select the study In Voxar 3D, select the study and read all the series of the study with CardiaMetrix 4D Viewer. Perform 4D analysis Extract the heart 1 To extract the heart from the surrounding anatomy, click the Extract heart button. The extraction result depends on contrast enhancement, so unnecessary anatomy may remain. To perform further extraction, click the Volume Editing button and use the cutting tools: 2 Click the 4D button to return to Animate 4D mode. 58
4D Review and LV Analysis Set up the chamber views 1 Position the mouse pointer over the upper-left MPR view, and rotate the mouse wheel to cine to the aortic valve. 2 Set the long axis: a In the Mouse Operation area, click the Rotate button. b In the upper-left MPR view, drag the green MPR crosshairs counter-clockwise. 59
Chapter 7: User scenarios c In the upper-right MPR view, drag the MPR crosshairs clockwise. d Note that to move rather than rotate the crosshairs, you can drag the intersection of the crosshairs. In the Mouse Operation area, click the Move button. e In the upper-right MPR view, drag the crosshairs down to the center of the left ventricle. 60
4D Review and LV Analysis f In the lower-left MPR view, move the crosshairs to the center of the left ventricle. 3 To rotate the short axis view, click the Rotate buttons at the top of the lower-left MPR view. 61
Chapter 7: User scenarios 4 Rotate the crosshairs further on the short axis view to display a 4 chamber view in the upper-right MPR view. 62
4D Review and LV Analysis Create a movie 1 Adjust the R-R intervals to correspond with the real R-R values: a In the R-R table, select the first series you wish to adjust. b c In the R-R% area, enter 10 in the box on the right, or adjust the current figure by dragging the slider. Repeat for the remaining R-R intervals. 2 In the Heart rate area, adjust the heart rate by entering a figure in the box or by dragging the slider. 63
Chapter 7: User scenarios 3 Click the Play button to start the movie in the views. 4 To stop the movie, click the Play button again. Rotate the heart In the Volume viewer area: Click the LAO/RAO button or other buttons on that row to rotate horizontally Click the CRA/CAU button or other buttons on that row to rotate vertically To rotate a specific number of degrees, enter a number in one of the boxes on the right Note: You can also rotate the heart by dragging on the 3D view. Assess the aortic valve 1 Click the Clip volume data button to go into the clip mode. 2 Click the Plane button 64
4D Review and LV Analysis 3 In the upper MPR views, drag the three green clip plane controllers so that they are positioned over the mitral valve. 4 If the preset gallery is not displayed, right-click the 3D view. From the menu, select Show preset gallery > show. 5 On the Endoscopy tab of the preset gallery, click the Great Vessel preset. 6 Rotate the 3D view so you are looking down on the valve. 7 To invert the window and level: a Click an MPR view. b Click the Change WW & WL button. 65
Chapter 7: User scenarios c Select the Invert check box. 8 Click the 4D button to return to 4D mode. 9 Click the Play button again to create another movie, then click the Play button again to stop. Tag the end diastole and end systole series You can tag the end diastole and end systole series in preparation for CardiaMetrix LV analysis. 1 In the R-R table, scroll up and down the series until you identify the end diastole series. 2 Click the Diastole button to tag the series accordingly. 3 Scroll up and down the series until you identify the end systole series. 4 Click the Systole button to tag the series accordingly. 66
4D Review and LV Analysis Capture views 1 To capture views as DICOM images, click on the Capture button at the top of each view. The view is captured exactly as it appears and sent to the Reading Manager. 2 To capture a view as a non-dicom image: a Right-click and select Save image to desktop. b Select a directory for the capture, name the capture, and specify the type of image file images can be saved as JPEG, PNG, BMP or XPM. c Click OK. Note: By default, images captured in this way are not automatically anonymized they may contain patient information. To remove the patient information before capturing, right-click the view. From the menu, click Other > Patient information. Open CardiaMetrix LV Analysis To read the images using CardiaMetrix LV Analysis, click the Cardiac button at the bottom of the window. Note: If you open more than one CardiaMetrix module during a reading, you can toggle between the modules by selecting the relevant button at the bottom of the CardiaMetrix window. 67
Chapter 7: User scenarios Perform LV analysis Create short axis slices of the left ventricle To analyze the ventricular volume, you need to create short axis slices of the left ventricle between the base and the apex of the heart. 1 To set the range for slicing: a Click the arrow buttons at the top of the CardiaMetrix window to select the end diastole series. b c On the long axis views, drag the arrows up and down to set the position of the base and apex. On the short axis view, center the crosshairs on the left ventricle. 68
4D Review and LV Analysis d Check the range has covered the base to apex in the end systole series by clicking the arrow buttons again. e Using the arrows, return to the end diastole series. 2 To specify that you require 15 slices, click the By number button and enter 15 in the Number box. 3 Click the Slice button to slice the data. Note: If you need to redo slicing, click the Back button. Trace the epicardial and endocardial border 1 On each long axis view, manually trace the epicardial border of the left ventricle: a Click to drop the first control point. b Continue clicking to place the remaining control points. c Double-click, or right-click and select Fix, to complete the trace. 69
Chapter 7: User scenarios 2 If required, use the Outline tools to edit the trace. 3 To discriminate between the ventricular cavity and the cardiac wall, change the density threshold by moving the Threshold setting slider. The ventricular cavity is shown as a green mask on the short axis views. 70
4D Review and LV Analysis Note: Clicking the Auto threshold button returns the threshold to its default setting. 4 Click the Analyze button. The endocardial border is traced automatically, and the short axis views show contours of the epicardial and endocardial borders in green. Note: For maximum accuracy, you can trace both borders manually. In addition, if the series are of sufficent quality, you are able to trace both borders automatically by simply clicking the Analyze button. Remove contours where the ventricular outflow tract is visble To maximize accuracy, you need to remove the contours where the ventricular outflow tract is visble. To do this, use the Phase table: In the Phase table: The vertical axis is the slice axis, and the horizontal axis is the series axis Yellow and green cells are images currently being displayed to display other images, click the relevant cell The blue cell at the bottom in the series axis is diastole, and the pink cell is systole Purple cells indicate where contours have been edited 71
Chapter 7: User scenarios 1 Drag the mouse to cover the cells that represent the contours you want to remove. 2 Right-click the selected cells and select Clear the contours are removed. 72
4D Review and LV Analysis Edit the remaining contours 1 To display more views, click on the Layout button and select 3x3. 2 Cine through the end diastole and end systole series until you see a contour that you want to edit. 3 Edit the endocardial contour: a In the Mouse Operation area, ensure that the Trace button is selected. 73
Chapter 7: User scenarios b In the Target area, ensure that the Ventricle button is selected. The original slice views show the endocardial contour. c On the original slice views, drag to trace the new endocardial contour. 4 Edit the epicardial contour: a In the Target area, click the Wall button. 74
4D Review and LV Analysis The original slice views shows the epicardial contour. b On the original slice views, drag to trace the new epicardial contour. 5 Edit the epicardial contour using control points: a Cine to another contour that you want to edit. b Click the Application Settings button. c d The Application Settings dialog box is displayed. In the Trace mode box, select Control points. Click the Close button. 75
Chapter 7: User scenarios In the Mouse Operation area, the buttons for moving and deleting control points are enabled: e To move a control point, click the relevant button in the Mouse Operation area and drag the point To delete a control point, click the relevant button in the Mouse Operation area and click the point On the views, move and delete the control points as required. 6 Repeat for all required contours. 76
4D Review and LV Analysis Exclude the papillary muscle from measurements You can set a density threshold value to exclude the papillary muscle from the LV analysis measurements. Tissue with a density equal to, or less than, this value is automatically excluded. 1 In the Papillary muscle threshold area, select the Remove papillary muscle check box. Purple masks are displayed in the short axis views. Before After 2 In the Papillary muscle threshold area, drag the threshold slider to change the threshold as required. Analyze the results 1 To fully populate the analysis results, enter the required patient information: a Click the Application Settings button. The Application Settings dialog box is displayed. 77
Chapter 7: User scenarios b In the Patient area, enter the height, weight, and heart rate of the patient. 2 Close the Application Settings dialog box. 3 Click the Analysis result button. The Analysis result window is displayed. 4 Click the tabs at the top of the window to display the required results. Save the analysis At any point during the reading, you can save your current work status by taking a Live Image capture. 1 At the bottom of the CardiaMetrix window, click the Save button. 2 Switch to the Reading Manager. A thumbnail of the Live Image capture is displayed. 78
4D Review and LV Analysis 3 To return to CardiaMetrix LV Analysis, click the Continue reading button. Note: If you wanted to postpone the reading, you could click the Finish and Archive button. Then, to return to the reading, you simply restore the Live Image. Create a report 1 Click the Application Settings button. The Application Settings dialog box is displayed. 2 In the Report area, select the check boxes for the results required in the report. 3 Close the Application Settings dialog box. 4 Click the Report button at the bottom of the CardiaMetrix window. The report is created. 5 Switch to the Reading Manager, and click the report thumbnail to display the report. 79
Chapter 7: User scenarios 6 Click the Finish and Archive button to finish the reading and archive the results. 80
4D Review and Coronary Analysis 4D Review and Coronary Analysis Select the study Extract the heart In Voxar 3D, select the study and read all the series of the study with CardiaMetrix 4D Viewer. To extract the heart from the surrounding anatomy, click the Extract heart button. The extraction result depends on contrast enhancement, so unnecessary anatomy may remain. To perform further extraction, click the Volume Editing button and use the cutting tools: Select the series for coronary analysis In the R-R table, click through the series until you identify the correct series for analysis. 81
Chapter 7: User scenarios Open CardiaMetrix Coronary Analysis To read the images in CardiaMetrix Coronary Analysis, click the Coronary button at the bottom of the window. Note: If you open more than one CardiaMetrix module during a reading, you can toggle between the modules by selecting the relevant button at the bottom of the CardiaMetrix window. Extract the aortic root 1 From the workflow buttons at the top of the CardiaMetrix window, click the Extract Aortic Root button. 2 In the coronal MPR view, set the range for extraction of the aortic root by moving the green range guides to cover the aortic root. 82
4D Review and Coronary Analysis 3 In the axial MPR view, click the center of the aorta to position the crosshairs. 4 Click the Extract button. The aortic root is displayed in the 3D view. The Extract Coronary Tree button is automatically selected in the workflow bar at the top of the CardiaMetrix window. 83
Chapter 7: User scenarios On the Vessel tab, the Left vessel button is highlighted ready to start tracking the left artery. Extract the coronary tree 1 Click the Show vessel localizer button. The vessel localiser view is displayed in the upper part of the CardiaMetrix window. 84
4D Review and Coronary Analysis 2 Drag the slider at the right of the axial MPR view to cine through the images until the origin of the left coronary artery is displayed. 3 Click once at the origin of the left coronary artery to deposit a control point. Note: You can use any view to deposit a control point for tracking If you deposit the control point in the wrong position: Drag the point to the desired position Right-click a view and select Delete last point or Clear points In the Control points area, click the Delete last point or Clear points button 4 On the Vessel tab, click the Right vessel button to track the right coronary artery and repeat the steps for that artery. 85
Chapter 7: User scenarios 5 To track the arteries and their branches, click the Start Tracking button. The arteries are tracked blue lines indicate the tracking. When the tracking is complete, you are prompted about whether you want to analyze the result, click OK to analyze. Note: If the tracking is unsuccessful, the following message is displayed: 86
4D Review and Coronary Analysis If the message is displayed: Deposit the control points again if the points are the same, the result is the same Deposit two or more control points at each origin Change the window and level so that the vessels are clear Zoom the views to ensure that you deposit a control point within the vessel Track each artery manually on the Vessel tab, click the button for the artery, click the Manual tab, then deposit control points along the artery. Now, click the Path extract button, the Center extract button, and the Edge fitting button. The Name dialog box is displayed. Enter the name of the artery, then click OK. Name the arteries Note that if you tracked each artery manually, the arteries may already be named. 1 In the Name dialog box, enter RCA and click OK. On the Vessel tab, the label name is updated. 2 To label the left coronary arteries: a On the 3D view, click the green control point at the end of the left anterior decending artery. The vessel is highlighted along with the corresponding label on the Vessel tab. b On the Vessel tab, right-click the label and select Edit label. The Name dialog box is displayed. c Enter LAD, and click OK. 3 Repeat for the circumflex. 87
Chapter 7: User scenarios Note: To aid the identification of the arteries you can view the coronary tree superimposed onto the 3D view of the heart. To do this, in the Views area, click the Heart button. Modify the artery center-lines and contours 1 From the workflow buttons at the top of the CardiaMetrix window, click the Modify button. 2 On the Vessel tab, select the artery you want to modify. 88
4D Review and Coronary Analysis 3 In the vessel localizer view, drag one of the green arrows along the artery to cine through the images to identify any center-lines or contours that you want to edit. 4 If you identify an artery center-line that requires modification, in the Modify mode area, ensure that the Centerline button is selected. 5 Modify the center-line: In the standard MPR views, drag the crosshairs over the green lines In the stretched CPR view, draw a new center-line In the oblique MPR view, drag the intersection of the green crosshairs Note: You can hide elements in the oblique MPR view to enable you to see the intersection of the crosshairs more clearly clear the Show gradient at position and Show vessel edge check boxes. 6 In the Modify mode area, click the Contour button. 89
Chapter 7: User scenarios 7 Ensure that the Show vessel edge check box is selected, and clear the Show center line check box. 8 In the Configuration area, click the button for the contour modification method that you want to use: Freehand allows you to draw a new contour in the oblique MPR view, using a double-click to finish Control point allows you to drag the control points of an existing contour in the oblique MPR view 9 In the vessel localizer view, drag one of the green arrows over a section that does not have a contour. 90
4D Review and Coronary Analysis 10 In the oblique MPR view, modify the contour. Analyze the arteries 1 From the workflow buttons at the top of the CardiaMetrix window, click the Coronary analysis button. 2 On the Vessel tab, click the Left vessel button and select LAD. 91
Chapter 7: User scenarios 3 Click the Status tab. 4 In the vessel localizer view, drag the yellow lines to set a range for measuring the maximum stenosis. Note that the default vessel profile is area to change the profile, select the required entry in the Vessel profile box. The maximum stenosis result is displayed in pink on the vessel localizer view and on the Status tab. 92
4D Review and Coronary Analysis Note: On the Status tab: Yellow text shows the reference length, which is the distance between the two yellow lines on the vessel localizer. Green text refers to the position of the green pointer in the vessel localizer. When viewing the two cross-vessel MPR views at the bottom of the CardiaMetrix window, the top view represents this position. Blue text refers to the position of the blue pointer in the vessel localizer. When viewing the cross vessel views in the bottom area of the CardiaMetrix window, the bottom view represents this position. Pink text shows the maximum percentage stenosis within the reference length. 5 Select the Show Reference button. 93
Chapter 7: User scenarios The vessel localizer view automatically zooms into the reference length. Edit the 3D view 1 On the 3D views tab at the top of the CardiaMetrix window, click the Heart button and select trans from the menu 94
4D Review and Coronary Analysis In the 3D view, the aortic root and coronary tree are shown, with the rest of the heart in a semi-transparent form. 2 Ensure that the 3D view is displayed. 3 Click the 3D views tab half-way down the CardiaMetrix window. 95
Chapter 7: User scenarios 4 Click the Virtual angiography button. The 3D view becomes shows the aortic root and coronary tree rendered to simulate a standard angiography image. 5 Click the Virtual angiography button again to return to the previous rendering. Display a stretched MPR slab 1 Above the lower-left view, click the Stretched button above the the bottom left frame. 96
4D Review and Coronary Analysis A stretched MPR view is displayed. 2 Click the Slab views tab. 97
Chapter 7: User scenarios 3 To create a 5 mm slab, in the Slab thickness of CPR area, click the Stretched button, then the 5 button. Save the analysis At any point during the reading, you can save your current work status by taking a Live Image capture. 1 At the bottom of the CardiaMetrix window, click the Save button. 2 Switch to the Reading Manager. A thumbnail of the Live Image capture is displayed. 98
4D Review and Coronary Analysis 3 To return to CardiaMetrix Coronary Analysis, click the Continue reading button. Note: If you wanted to postpone the reading, you could click the Finish and Archive button. Then, to return to the reading, you simply restore the Live Image. Create a report 1 Click the Report tab at the top of the CardiaMetrix window. 2 Click the Add button. Images are automatically captured for the report. 3 Click the Report button at the bottom of the CardiaMetrix window. 4 Switch to the Reading Manager, and click the report thumbnail to display the report. 99
Chapter 7: User scenarios 5 Click the Finish and Archive button to finish the reading and archive the results. 100
Calcium Scoring Calcium Scoring Read images using CardiaMetrix Calcium Scoring Assign calcified plaques to the coronary arteries The left main coronary artery is selected by default Cine through the images, and click the calcified plaques to select them Click the next artery, and click the calcified plaques to select them Go to the top of the next page Continue with the remaining arteries 101
Chapter 7: User scenarios Produce a calcium score Click the Scoring button Capture the key images Click the Image Capture button, then click the Capture Key Images button Create a report Click the Report button 102