Interleaved, undersampled radial multiple-acquisition steady-state free precession for improved left atrial cine imaging

Inversion recovery and saturation recovery pulmonary vein MR angiography using an image based navigator fluoro trigger and variable-density 3D cartesian sampling with spiral-like order

Contrast enhanced pulmonary vein magnetic resonance angiography (PV CE-MRA) has value in atrial ablation pre-procedural planning. We aimed to provide high fidelity, ECG gated PV CE-MRA accelerated by variable density Cartesian sampling (VD-CASPR) with image navigator (iNAV) respiratory motion correction acquired in under 4 min. We describe its use in part during the global iodinated contrast shortage. VD-CASPR/iNAV framework was applied to ECG-gated inversion and saturation recovery gradient recalled echo PV CE-MRA in 65 patients (66 exams) using .15 mmol/kg Gadobutrol. Image quality was assessed by three physicians, and anatomical segmentation quality by two technologists. Left atrial SNR and left atrial/myocardial CNR were measured. 12 patients had CTA within 6 months of MRA. Two readers assessed PV ostial measurements versus CTA for intermodality/interobserver agreement. Inter-rater/intermodality reliability, reproducibility of ostial measurements, SNR/CNR, image, and anatomical segmentation quality was compared. The mean acquisition time was 3.58 ± 0.60 min. Of 35 PV pre-ablation datasets (34 patients), mean anatomical segmentation quality score was 3.66 ± 0.54 and 3.63 ± 0.55 as rated by technologists 1 and 2, respectively (p = 0.7113). Good/excellent anatomical segmentation quality (grade 3/4) was seen in 97% of exams. Each rated one exam as moderate quality (grade 2). 95% received a majority image quality score of good/excellent by three physicians. Ostial PV measurements correlated moderate to excellently with CTA (ICCs range 0.52-0.86). No difference in SNR was observed between IR and SR. High quality PV CE-MRA is possible in under 4 min using iNAV bolus timing/motion correction and VD-CASPR.

A dual-stage partially interpretable neural network for joint suppression of bSSFP banding and flow artifacts in non-phase-cycled cine imaging

PURPOSE

To develop a partially interpretable neural network for joint suppression of banding and flow artifacts in non-phase-cycled bSSFP cine imaging.

METHODS

A dual-stage neural network consisting of a voxel-identification (VI) sub-network and artifact-suppression (AS) sub-network is proposed. The VI sub-network provides identification of artifacts, which guides artifact suppression and improves interpretability. The AS sub-network reduces banding and flow artifacts. Short-axis cine images of 12 frequency offsets from 28 healthy subjects were used to train and test the dual-stage network. An additional 77 patients were retrospectively enrolled to evaluate its clinical generalizability. For healthy subjects, artifact suppression performance was analyzed by comparison with traditional phase cycling. The partial interpretability provided by the VI sub-network was analyzed via correlation analysis. Generalizability was evaluated for cine obtained with different sequence parameters and scanners. For patients, artifact suppression performance and partial interpretability of the network were qualitatively evaluated by 3 clinicians. Cardiac function before and after artifact suppression was assessed via left ventricular ejection fraction (LVEF).

RESULTS

For the healthy subjects, visual inspection and quantitative analysis found a considerable reduction of banding and flow artifacts by the proposed network. Compared with traditional phase cycling, the proposed network improved flow artifact scores (4.57 ± 0.23 vs 3.40 ± 0.38, P = 0.002) and overall image quality (4.33 ± 0.22 vs 3.60 ± 0.38, P = 0.002). The VI sub-network well identified the location of banding and flow artifacts in the original movie and significantly correlated with the change of signal intensities in these regions. Changes of imaging parameters or the scanner did not cause a significant change of overall image quality relative to the baseline dataset, suggesting a good generalizability. For the patients, qualitative analysis showed a significant improvement of banding artifacts (4.01 ± 0.50 vs 2.77 ± 0.40, P < 0.001), flow artifacts (4.22 ± 0.38 vs 2.97 ± 0.57, P < 0.001), and image quality (3.91 ± 0.45 vs 2.60 ± 0.43, P < 0.001) relative to the original cine. The artifact suppression slightly reduced the LVEF (mean bias = -1.25%, P = 0.01).

CONCLUSIONS

The dual-stage network simultaneously reduces banding and flow artifacts in bSSFP cine imaging with a partial interpretability, sparing the need for sequence modification. The method can be easily deployed in a clinical setting to identify artifacts and improve cine image quality.

Balanced Steady-State Free Precession Cine MR Imaging in the Presence of Cardiac Devices: Value of Interleaved Radial Linear Combination Acquisition With Partial Dephasing

BACKGROUND

Balanced steady-state free precession (bSSFP) is important in cardiac MRI but suffers from off-resonance artifacts. The interpretation-limiting artifacts in patients with cardiac implants remain an unsolved issue.

PURPOSE

To develop an interleaved radial linear combination bSSFP (lcSSFP) method with partial dephasing (PD) for improved cardiac cine imaging when implanted cardiovascular devices are present.

STUDY TYPE

Prospective.

PHANTOM AND SUBJECTS

Flow phantom adjacent to a pacemaker and 10 healthy volunteers (mean age ± standard deviation: 31.9 ± 2.9 years, 4 females) with a cardioverter-defibrillator (ICD) positioned extracorporeally at the left chest in the prepectoral region.

FIELD STRENGTH/SEQUENCE

A 3-T, 1) Cartesian bSSFP, 2) Cartesian gradient echo (GRE), 3) Cartesian lcSSFP, and 4) radial lcSSFP cine sequences.

ASSESSMENT

Flow artifacts mitigation using PD was validated with phantom experiments. Undersampled radial lcSSFP with interleaving across phase-cyclings and cardiac phases (RLC-SSFP), combined with PD, was then employed for achieving improved quality of cine images from left ventricular short-axis view. The image quality in the presence of cardiac devices was qualitatively assessed by three independent raters (1 = worst, 5 = best), regarding five criteria (banding artifacts, streak artifacts, flow artifacts, cavity visibility, and overall image quality).

STATISTICAL TESTS

Wilcoxon rank-sum test for the five criteria between Cartesian bSSFP cine and RLC-SSFP with PD. Fleiss kappa test for inter-reader agreement. A P value < 0.05 was considered statistically significant.

RESULTS

Based on simulations and phantom experiments, 60 projections per phase cycling and 1/6 PD were chosen. The in vivo experiments demonstrated significantly reduced banding artifacts (4.8 ± 0.4 vs. 2.7 ± 0.7), fewer streak artifacts (3.7 ± 0.6 vs. 2.6 ± 0.7) and flow artifacts (4.4 ± 0.4 vs. 3.7 ± 0.6), therefore improved cavity visibility (4.1 ± 0.4 vs. 2.9 ± 0.9) and overall quality (4.0 ± 0.4 vs. 2.7 ± 0.7).

DATA CONCLUSION

RLC-SSFP method with PD may improve cine image quality in subjects with cardiac devices.

EVIDENCE LEVEL

2.

TECHNICAL EFFICACY

Stage 1.

Left atrial evaluation by cardiovascular magnetic resonance: sensitive and unique biomarkers

Left atrial (LA) imaging is still not routinely used for diagnosis and risk stratification, although recent studies have emphasized its importance as an imaging biomarker. Cardiovascular magnetic resonance is able to evaluate LA structure and function, metrics that serve as early indicators of disease, and provide prognostic information, e.g. regarding diastolic dysfunction, and atrial fibrillation (AF). MR angiography defines atrial anatomy, useful for planning ablation procedures, and also for characterizing atrial shapes and sizes that might predict cardiovascular events, e.g. stroke. Long-axis cine images can be evaluated to define minimum, maximum, and pre-atrial contraction LA volumes, and ejection fractions (EFs). More modern feature tracking of these cine images provides longitudinal LA strain through the cardiac cycle, and strain rates. Strain may be a more sensitive marker than EF and can predict post-operative AF, AF recurrence after ablation, outcomes in hypertrophic cardiomyopathy, stratification of diastolic dysfunction, and strain correlates with atrial fibrosis. Using high-resolution late gadolinium enhancement (LGE), the extent of fibrosis in the LA can be estimated and post-ablation scar can be evaluated. The LA LGE method is widely available, its reproducibility is good, and validations with voltage-mapping exist, although further scan-rescan studies are needed, and consensus regarding atrial segmentation is lacking. Using LGE, scar patterns after ablation in AF subjects can be reproducibly defined. Evaluation of 'pre-existent' atrial fibrosis may have roles in predicting AF recurrence after ablation, predicting new-onset AF and diastolic dysfunction in patients without AF. LA imaging biomarkers are ready to enter into diagnostic clinical practice.