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b) Fellows will be provided with reading materials, and should be prepared to discuss the content with the CMR attending,

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CARDIAC MRI Mission Statement: The mission of the Cardiac MR Center is to advance the diagnosis of cardiovascular disorders, and provide functional and anatomic cardiovascular information utilizing Magnetic
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CARDIAC MRI Mission Statement: The mission of the Cardiac MR Center is to advance the diagnosis of cardiovascular disorders, and provide functional and anatomic cardiovascular information utilizing Magnetic Resonance Imaging. Statement of Educational Ggals: The goal of this rotation is to provide the fellow with in depth exposure to cardiac MR (CMR) studies on both arnbulatory and hospitalized patients to promote an understanding of the applications and limitations of CMR imaging. Fellows completing the rotation should have a basic understanding of MRI physics, as well as the pulse sequences used, and should become familiar with the clinical indications for CMR in cardiovascular patients. In addition, fellows should gain an appreciation for the challenges and contrainidications to CMR testing, and learn about general MR safety. The CurriculFm is designed to promote six broad goals based on the ACGME Core Cor-npetencies: 1. Medical Knowledge: a) Fellows will gain exposure to the acquisition and interpretation of diagnostic CMR. b) Fellows will be provided with reading materials, and should be prepared to discuss the content with the CMR attending, c) The ACC CMR-SAP CD should be obtained from the Cardiovascular Fellowship office and reviewed during the rotation. d) Fellows will be expected to attend mini-didactic sessions on CMR by the attending. e) Fellows will be expected to complete and document 25 case interpretations (cornbination of live and teaching file cases) to satisfy COCATS Level I training in CMR. 2. Patient Care: A pre-study evaluation of the patient should be performed by the fellow (when possible) to tailor each study to the specific clinical problem. Accurate and precise interpretation of CMR studies will be performed in conjunction with the CMR attending. 3. Professionalism: Effective, mutual communication and respect are expected with the patient, referring physician, attending physician, other physicians in training, and the MR Technicians. 4. 5. Interpersonal & Communication Skills: The fellow is expected to participate in an active way with other members of the team. Clear and concise communication willbe expected with referring physicians and when providing interpretations of the exam findings. Practice based learning: Fellows will use information technology, literature sources, and other available resources to practice accurate and state-of-the-art CMR studies and interpretation. Fellows will be expected to apply their knowledge to think of potential research applications for CMR technology. Systems based learning: During interaction with other medical services and providers, fellows will gain an appreciation of their role as an imaging consultant. It will be important for the fellow to leam how the health care delivery systems work, and the role of diagnostic imaging in providing health care. Statement of Educational Obiectives: The goals of this service will be achieved by participation in MRI studies devoted to the evaluation of known or suspected cardiovascular problems on hospitaltzed and ambulatory patients. Fellows will be expected to play an active role in all aspects of patient care in the CMR Center, and interact directly with the faculty members and referring health care professionals. Fellows may be expected to communicate the findings and clinical significance of the findings of the CMR exam to the referring physician. Review of the provided reading material, ACC-SAP CMR CD, and additional review ofselected references listed below are necessary for the fellow to meet the goals of the rotation. Core Concepts: Fellows should attain a basic understanding of the Cartesian coordinate system, and how rt applies to MRI. Fellows should understand the concept of magnetization vectors, radioliequency pulses, and flip angles, and learn the difference between T1, T2, andt2* relaxation. Fellows should learn the fundamental difference between gradient and spin echo sequences, and should become familiar with balanced Steady State Free Precession (b-ssfp aka. FIESTA), double inversion recovery, and velocity encoding (VENC) sequences and their uses. Fellows should understand the concept of k space, and how it is filled. Fellows should gain an appreciation for cardiac anatomy, and learn the basic views obtained during the CMR examination. Fellows should become familiar with delayed enhancement imaging, and its clinical importance and significance in the identification of myocardial scar and the assessment of viability. Fellows should help oversee stress cardiac MRI testing when performed. Detailed Expectations for Fellows: It is expected that each fellow will complete these requirements during one of the imaging block rotations that has been allocated, if desired, in order to attain COCATS level 1 training in cardiac MRI, Tammy Michielsen should be notified prior to beginning the imaging block that the MRI elective will be completed. The MR Center is located at G Elective exams are typically scheduled at 8:00AM, 10:00AM, 12:00Noon, and 2:00PM on Wednedays for elective outpatients. Urgent/emergent exams are scheduled as indicated. CMR studies are performed on the L5 Telsa GE Twinspeed MR Scanner (Front Scanner, G-4505), and the 1.0 Tesla Phillips Panorama open scanner (G-4465A, next to angio). Interpretation is performed at the ReporlCard/Phillips workstation in the MR center. Fellows are expected to be present at the time the cardiac MR exams are performed. Active participation in providing pre-study consultation, as well as interpretation and appropriate post exam consultation with communication of findings and recommendations to the referring physician will be expected. The fellow is expected to keep a 1og of the exams read. Fellows will also be asked to prepare a case presentation for Cardiology Morning Reporl or the Lnaging Case Conference. optional: Fellows may complete the scmr online course once during their fellowship. This may be accomplished during any of the MRl/Imaging months. You may complete this as a member of the SCMR (which requires a 60 dollar fee), If you become a member you will be awarded a certificate at the end of your training module. You may also elect to complete the training module not as an SCMR member and will need to sign in as a guest. Completion of this module is sufficient to attain COCATS level 1 training in CMR. At the end of the module, you must print off the completion form or a copy of the cerlificate and turn it in to Tammy Michielsen. The link is listed below. http : //trainin s. scmr. or g/course/vi ew, php?i d'=2 Selected list of References: 1. Higgins, CB. Cardiovascular MRI & MRA, Lippincott Williams. 2003' 2. Higgins, CB, Cardiac MR Imaging. Lippincott Williams. CD ROM' 3. Maning, Warren J. Cardiovascular Magnetic Resonance. Elsevier Woods, P. Pocket Atlas of Cardiac MRI. Lippincott Williams. 5. Weissman. Cardiac MRI Secrets. Elsevier. 2003' 6. ACC-SAP CMR CD. 7. Duke Cardiovascular Magnetic Resonance Center MRI Physics Course DVD (upon request from Dr. Fong) 8. Cardiovascular MRI Teaching File: 8 cases (upon request from Dr. Fong) Credentials of the Cardiac MR Staff: David A. Dombroski, M.D. Co-Director, Cardiac MRI Associate Professor of Imaging Sciences University of Notre Dame, B.S. SLINY Upstate Medical University, M.D. Internal Medicine Residency, University of Rochester Medical Center Radiology Residency. University of Rochester Medical Center Body Imaging Fellowship, University of Rochester David Lee, M.D. Chief, Diagnostic Imaging, F.F. Thompson Hospital Associate Professor of Imaging Sciences Muhlenberg College, B. S. Internal Medicine Internship, Thomas Jefferson University Hospital Radiology Residency, University of Rochester Medical Center Interventional Radiology Fellowship, University of Rochester Medical Center Susan Hobbs, M.D., Ph.D, Director, Cardiothoracic Radiology Assistant Professor of Imaging Sciences Harvard School of Medicine, M.D. Transitional Internship, St. Vincent's Hospital and Medical Center Radiology Residency, University of Minnesota and University of California San Diego NCI Tumor Imaging Fellow, Stanford Thoracic Radiology Fellow, University of California San Francisco Technical Staff: Bill Badger (lead MRI tech) Mary Jo McMannis (lead cardiovascular MRI tech) Tina Hopeful Shyla Streb Nursine Staff Colleen Eckert, Nurse Manager Administrative Staff : Fax ; Room G-3400C Colleen Gillette Michele Smith Useful Phone Numbers Front Scanner (MR3) Open Scanner (MR4) 64433 BBquired Reading 1-. ACR Guidance Document for Safe Practices: 2007 (ARJ L88:1 447-74) 2. What is MRI? (The Cardiac Atlas: Auckland MRI Research Group 3. Technologr lnsight: MRI of the Myocardium (Nature Clinical Practice: Cardiovascular Medicine (1-1): ) 4. The Role of Cardiovascular MRI in Heart Failure and the Cardiomyopathies. (Cardiol Clin \- e5.) 5. Fundamental Concepts in Myocardial Viability Assessment Revisited: When Knowing How Much is Alive is not Enough (Heart. 2OO4.90: ) 6. Clinical Cardiac MRI Textbook Chapters 1, 3, 4, 5 Supplemental Reading 1. Clinical lndications for Cardiovascular Magnetic Resonance (CMR): Consensus Panel Report (Eur Heart ) : ) 2. lmproved Detection of Coronary Artery Disease by Stress Perfusion Cardiovascular Magnetic Resonance with use of Delayed Enhancement lnfarction lmaging (JACC (8) ) 3^ Frontiers in Cardiovascular Magnetic Resonance (Circulation LL2: ) 4, The Use of Contrast Enhanced Magnetic Resonance lmaging to ldentify Reversible lvlyocardial Dysfu nction (NEJ M :L445-53) 5. Clinical Utility and Safety of a Protocol of Noncardiac and Cardiac Magnetic Resoance lmaging of patiens with Permanent and lmplantable-cardioverter Defibrillators at 1.5 Tesla (Circulation L44:7277-L284) 6. Acute Myocardial lnfarction: Safety of Cardiac MR lmaging after Percutaneous Revascularization with Stents (Radiology (3): 647 80) Trai[in g Requirement Documenls L. Task Force 12: Training in Advanced Cardiovascular lmaging (CMR) (JACC. 2006, a7(4t:91a-la) 2. ACCF/AHA Clinical Competence Statement on Cardiac lmaging With Comptuted Tomography and Magnetic Resonance (JACC. 2005, 46(2): ) Fellows Checklist n Reviewed course curriculum n Completed required reading n Completed 16 sample case studies and reviewed with attending n Completed Duke CMR Teaching File (8 Cases) n lnterpreted 50 CRM cases (combination of live and taching file) n Understand the Core Conecpts as outlined in the course curriculum n Presented case at Thursday lmaging Case Conference or Morning Report Patient Imaging Set-up Cardiac MRI Examination Position the patient on the table head first with ECG gating leads applied and a phased-array receiver coil placed correctly on the chest for highest signal intensity cardiac imaging. It is crucial to have a high quality ECG signal to ensure accurate cardiac triggering and optimum image quality. Localizer and Cardiac Scout Images Obtain initial thoracic localizing images in sagittal, coronal, and transverse planes cnsuring correct cardiac positioning with the heart at the magnet bore center point. Localizer images are non-brcath held. Using the localizer images, obtain scout images during which the patient is instructed to hold their breath at a relaxed point in end-expiration. Patients should not be instructed to blow all the way out or to hold their breath after forced end-expiration since then the breath-hold time will be limited. A. 2 Chamber Scout - Using the best axial (pseudo 4 chamber) localizcr image, prcscribe an imaging plane that bisects the LV and travcrses through the LV apex. Transverse (4 chamber) Localizer + 2 Chamber Scout 4 Chamber Scout - Using the 2 chamber scout, prescribe with an imaging plane placed perpendicular through the center of the LV apex, that bisects the LV at the level of the mitral valve resulting in a double oblique horizontal long axis view (4-chamber) of the heart. 2 Chamber Scout 4 Chamber Scout Documentation of Image Acquisitions As each image is acquired, the series number and, if applicable, the slice offset of the image should be documented on the MR Imaging Form (see Appendix A) in the column(s) adjacent to the protocol designated image type and location. If sequences are repeated, document the series number of the 'best'image. Cine Images The required technique for acquiring cine images is a SSFP (steady state free procession) with retrospective ECG gating and breath hold imaging sequence. The following imaging parameters are provided as guidelines: ' Field of View -. Temporal Resolution - 45 msec. Slice thickness. - 6 mm Inter-slice gap * 4 mm. Flip Angle * Maximized (often 60 degrees) Tailored to the patient's size (minimum possible without fold-in arlifact) A. 4 Chamber Cine Prescribe by copying the 4 chamber scout image and then running cine sequence as per parameters listed above. 4-Chamber Cine B. Short axis (SA) cines Prescribe with an imaging plane perpendicular to the intraventricular septum at the insertion points of the mitral valve in diastole. You may also use the 2 chamber scout to ensure you are obtaining a double oblique short axis image. Proceed with separate, breath held short axis cine images every 8mm from the mitral valve plane at the base to the true apex, ensuring complete ventricular coverage. 4 Chamber End-diastole SA Cine - Base SA Cine - Mid-Ventricle Contrast Administration Inject a commercially available gadolinium-based contrast agent (i.e., gadopentetate dimeglumine, gadoteridol) through the patient's peripheral IV by hand or slow infusion using an injector pump at a dose of 0.15 mmol/kg of body weight (see weight based dosing chart in Appendix). Following the administration of contrast, flush the IV with l0 cc of saline. Document the time and total dose of contrast administered on Data Submission Form; usc the time as indicated on the scanner so that it can be matched to the time stamps of the image acquisitions automatically savcd in the image file. The remainder of the cine images can now be obtained while waiting for 5 minutes before starting the acquisition of the delayed contrast enhanced images. Long Axis Cines C. 2 Chamber Cine Prescribe with an imaging plane perpendicular through the short axis cine images at an angle intersecting the left ventricular anterior and inferior walls, and passing through the apex, while ensuring no RV/RA inclusion. You may use the 4 chamber cine to assist proper placement. SA Cine - Base SA Cinc - Apex 2 Chamber Cine D. LV Outflow Tract Cine (3 Chamber View) Prcscribe with an imaging plane perpendicular through the short axis cine images at an angle intersecting the left ventricular outflow tract and through the apex. SA Cine - Base SA Cine - Apex 3 Chamber Cine Delayed Contrast-Enhancement (DE-MRI) Images Two techniques will be used for acquiring delayed contrast enhancement images as described below. Selecting the appropriate inversion time (TI) to null the myocardium is extremcly important for acquiring accurate images with maximizcd intensity diffcrences between infarction (bright), the noreflow zone that is due to microvascular damage (black within an area of bright) and normal myocardial tissue (black). You may need to test multiple TI times to ensure optimal myocardial nulling. The TI may need to be increased as you image, as the contrast within normal myocardium gradually washes out. Below are delayed enhancement short axis images with an inferolateral infarction and a no-reflow zone within the area of infarction using two different TI times acquired at approximately minutes post contrast injection. Incorrect Short TI (28Omsec) Correct TI (440msec) A. IR TTUeFISP/FIESTA/SSPF Single Shot, ECG-triggered, non-breath held inversion recovery sequence - starting 5 minutes post contrast. The purpose of these single-shot images is to get additional information regarding microvascular damage. These images only require I -2 minutes ol additional scanner timc. The following imaging paramcters are provided as guidelines: ' Field of View - ' ){umber of slices - should be at the exact same spatial iocations as the cine images). Slice thickness. - 6 mm Inter-slice gap -. 4 mm Flip.{ngle - 45 degrees Tailored to the patient's size (minimum possible without fold-in arlifact) Tailored to individual patient ventricular coverage (slice positions . Matrix - ' Data Acquisition time - patient heart rate). Trigger Pulse - ' TI (inversion time) - I92 (frequency encoded direction) centered mid diastole (actual time after R-wave is dependant on 3 4 (to allow full recovery of relaxation between slices) Begin with 300 msec, assess image quality for myocardial nulling and adjust up or down by l0-20 msec increments to ensure optimal myocardial nulling. Important: for imaging choosc a TI that is l0 msec longer than the TI with maximum nulling. it is preferable, by far. to havc a TI that is slightly too long than one that is too short. Using the IR single shot sequence, copy a mid-ventricular cine image to test the TI until optimum myocardial nulling is achieved. Once the correct TI has been determined, run a nonbreath held sequence (instruct the patient to breath quietly) with multiple slices at the exact same slice positions acquired during short axis cine imaging. This will result in a stack of shortaxis images starling from just above the AV valves and through the ventricles into the apex in a single sequence acquisition. B. IR turboflash/gradient-recall echo ECG-gated, breath held, segmented, inversion rccovery sequence. This sequence should begin at least 10 minutes, but not more than 30 minutes postcontrast. C. The following imaging parameters are provided as guidelines: ' Field of View - Number of slices. - I Slice thickness - 6 mm. Inter-slice gap * 4 mm Tailored to the patient's size (minimum possible without fold-in artifact) Temporal resolution - 200 ms. Voxel size - (typical) 1.9 x 1.4 x 6 cm ' Flip Angle - 25 degrees ' Data Acquisition time - centered at mid-diastole (actual time after R-wave is dependant on patient heart rate) Trigger Pulse - 2 (to allow more recovery of relaxation between slices) ' TI (inversion time) - Begin with TI at least 50 msec greater than the one uscd for singleshot imaging, then, assess image quality for myocardial nulling and adjust up or down by msec increments to find the TI with maximum myocardial nulling. Important: for imaging. choose a TI that is 10 msec longer than the TI with maximum nullingl it is preferable. by far. to have a TI that is siightly too long than one that is too short. Using this sequence, copy a mid-ventricular cine image to test the TI until optimum myocardial nulling is achieved. Once the correct TI has been determined, acquirc each short axis slice individually, with repeated -8-second breath holds. Slice locations should be identical to cine MRI locations. Copy each long axis cine image (4,2,and 3 chamber views) and acquire an IR Flash image in these views. Be sure to asscss for myocardial nulling with each image acquisition and adjust your TI longer as needed. A. Shofi axis views: 4 Chamber End-diastole SA Cine - Base SA Cine - Mid-Ventricle SA Cine - Apex B. Long axis Views: 4 Chamber 3 Chamber 2 Chamber li. Repeat IR TTueFISP/FIESTA/SSPF Single Shot, ECG-triggered, non-breath hcld inversion recovery sequence. This sequence should be repeated 15 minutes after contrast to assess for microvascular damage. However. use a fixed TI of 600 msec for all patients. This last set of images will be used to help differentiate between notmal myocardium and no-reflow zones (see figures below). No-reflow as seen in 5 min image No- reflow with TI of 600 msec post 15 mins RECAP OUTLINE OF IMAGING PROCEDURES 1. Standard Scout images of the heart leading to double oblique horizontal long axis view (4 Chamber) of the heart. 2. Cine image of the horizontal long axis view of the heart. 3. Prescribed double oblique short axis view of the heart with first slice at the mitral valve
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