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syngo MR E11Operator Manual – Cardio

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syngo MR E11Operator Manual – Cardio

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4 Cardio | Operator ManualPrint No. MR-05015.630.10.02.24

WARNINGIndicates a hazardous situation which, if not avoided, could result in death orserious injury.WARNING consists of the following elements:◾ Information about the nature of a hazardous situation

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syngo MR E11 5Print No. MR-05015.630.10.02.24

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1 Introduction 171.1 Layout of the operator manual 171.2 The current operator manual 171.3 Intended use 181.4 Authorized operating personnel 19

1.4.1 Definitions of different persons 19

2 Preparation 212.1 Physiological control of the measurement 22

2.1.1 Positioning the electrodes and PERU 222.1.2 Attaching ECG electrodes 23

Procurement addresses 242.1.3 Physiological display 24

Display of battery status 25Switching between signal values andcontrols 25Display of trigger events 25Setting the display rate 26Setting the number of signal tracks 26Selecting the physiological signal 26Selecting the trigger method 27Displaying time ranges 27

2.1.4 Checking the ECG signal 282.1.5 Prospective triggering: setting the

parameters 292.1.6 Retrospective gating: setting the

parameters 30Without arrhythmia detection 30With arrhythmia detection 30

3 Cardiac measurements 313.1 Heart localization 32

3.1.1 Measuring orthogonal multi-slicelocalizers 32

3.1.2 Measuring the 2-chamber localizer 333.1.3 Measuring the 4-chamber localizer 343.1.4 Measuring the short-axis localizer 34

Table of contents


3.2 Slice localization with interactive real-timeimaging 363.2.1 Localizing slices in real time 363.2.2 Transferring slice parameters 37

Pausing the measurement 37Stopping the measurement 38

3.2.3 Helpful hints 38Changing between different sliceorientations 40Automatic windowing 40Adjustment volume 40

3.3 Displaying standard views 413.3.1 Displaying the 4-chamber view 42

On the short-axis localizers 42On the 2-chamber localizer 42On the 4-chamber localizer 42

3.3.2 2-chamber view, displaying the leftventricle 44

On the short-axis localizers 44On the 4-chamber view 44On the 2-chamber localizer 44

3.3.3 Displaying the 3-chamber view (LV inflowand outflow tract) 46

On the basal short-axis localizers 46On the 4-chamber view 46

3.3.4 Displaying short-axis views 47On the 4-chamber view 47On the 2-chamber view 47On the short-axis localizer 47

3.3.5 2-chamber view, displaying the rightventricle 49

On the short-axis localizers 49On the 4-chamber view 49

3.3.6 Displaying the left ventricular outflowtract with aortic valve (LVOT) 51

On the 3-chamber view 513.4 Views of the heart valves 53

3.4.1 Displaying the aortic valve 543.4.2 Displaying the mitral valve 56

On the 3-chamber view 56On the 4-chamber view 56

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3.5 Display of the heart and valve functions 583.5.1 The CINE technique 583.5.2 Measuring multiple slices per breathhold 59

Concatenations 59Number of concatenations 60

3.5.3 FLASH sequences 60Area of application 60None-segmented 60Segmented 60Phase sharing 61PAT 61

3.5.4 TrueFISP sequences 61Advantages 61Segmentation and phase sharing 61PAT 61Radial sampling 62Real time 62

3.5.5 TrueFISP and image quality 623.5.6 TrueFISP parameter—example 623.5.7 Real-time measurements 633.5.8 Inline function examinations 65

Overview 65Performing Inline functionexaminations 66

3.6 Display of cardiac morphology 673.6.1 Increase in contrast using Dark Blood 67

Dark Blood preparation 68Timing 68Dark Blood parameter—example (TSE) 69

3.6.2 Bright Blood 70

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3.7 Display of coronary vessels 713.7.1 Measurement conditions 71

Localization 71Acquisition window 72Breathhold technique 72

3.7.2 Localizing coronary blood vessels 723.7.3 Displaying coronary blood vessels 733.7.4 Respiratory control using navigator

technique 74Navigator and search window 74Acceptance window 74Slice correction with the navigator 75Navigator parameter free breathing—example 76Navigator parameter breathholdtechnique—example 77

3.8 Myocardial mapping 783.8.1 T1 mapping 79

Measurement technique 793.8.2 T2 mapping 81

Measurement technique 813.8.3 T2* mapping 82

Measurement technique 833.8.4 Generating T1 maps 843.8.5 Generating T2 maps 863.8.6 Generating T2* maps 88

Table of contents


3.9 Cardiac Dot Engine 903.9.1 Planning the heart examination and

measuring the localizer 92Adapting the examination to thepatient 93Starting the measurement of thelocalizer 94

3.9.2 Planning the localizer at the isocenter 953.9.3 Measuring thoracic overview images 973.9.4 Measuring the AAHeart_Scout 973.9.5 Defining and measuring the long-axis

localizer 99Checking the long-axis views 100Defining the long-axis view manually 100Measuring the CINE long-axis view 101

3.9.6 Editing CINE long-axis views (optional) 101Adding/removing cardiac views 102For 3T only: Improving image quality 102

3.9.7 Defining and measuring the short-axislocalizer 103

Defining function slices 103Defining a short-axis subset stack(optional) 104Starting the measurement 104

3.9.8 Performing dynamic test 1043.9.9 Performing dynamic stress 1053.9.10 Measuring CINE short-axis views 1063.9.11 Performing dynamic rest 1093.9.12 Performing tissue characterization 1093.9.13 Performing high resolution tissue

characterization (optional) 1103.9.14 Planning additional heart views (optional) 110

Duplicating a protocol 110Changing the heart view 111Opening guidance for positioning 112

3.9.15 Configuring protocol steps (optional) 113Adapting the Patient View (CardiacPatient View) 113Adapting protocol settings (all cardiacadd-ins) 116Adapting standard views (CardiacStandard) 117

Table of contents


Adapting short-axis protocols (CardiacSAX Planning) 119Adapting the DefineLongaxis protocol(Cardiac Marker Localization) 120

4 Flow measurements 1234.1 Measuring the flow in the heart 124

4.1.1 Measuring the localizers 1244.1.2 Determining the slice position of the

aorta 1254.1.3 Determining the slice position of the

pulmonary artery (pulmonalis) 1254.1.4 Determining the flow sensitivity 1264.1.5 Performing the measurement 127

5 Post-processing 1295.1 Argus Viewer 130

5.1.1 Starting Argus and loading images 130Image area in the Argus Viewer 131Sorting series in the matrix and theimage stack 131Layout in the image matrix 131Arrangement in the image stack 132

5.1.2 Selecting images in the matrix 132Selecting an individual image 132Selecting one or multiple series 132Selecting a complete row or column 132Selecting the entire matrix 133

5.1.3 Loading a series into a work segment 1335.1.4 Movie display 134

Multiple movie display using differentslice positions 136

Table of contents


5.2 Ventricular Analysis 1365.2.1 Loading images 1375.2.2 Checking assignment to ED, ES, base, and

apex 138Checking the assignment to the EDphase 138Checking the assignment to the EDbase 138Checking the assignment to the EDapex 139Checking the assignment to the ESphase 140Checking the assignment to the ESbase 141Checking the assignment to the ESapex 141

5.2.3 Drawing contours in the ED base image 141Selecting the ED base image forediting 142Activating “Left Ventricle” drawingmode 142Automatic contouring 142Manual contouring 143

5.2.4 Checking/correcting drawn contours 144Correcting with the Splice icon 144Correcting through Nudging 144Deleting and redrawing contours (ifapplicable) 145

5.2.5 Propagating contours within the EDphase 146

5.2.6 Checking/correcting propagated contours 1475.2.7 Propagating contours to all columns 1475.2.8 Confirming propagated contours 1475.2.9 Starting volume analysis 1485.2.10 Starting thickening analysis 152

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5.3 4D Ventricular Analysis 1545.3.1 Loading images 1565.3.2 Setting landmarks 157

Setting the apical point of the centralaxis 157Setting the basal point of the centralaxis 158Setting the base plane 159Determining the transition from left toright ventricle 160Setting control points 161

5.3.3 Handling of offset slices 1625.3.4 Correcting the offset 162

Cancelling registration 163Excluding slices with offsets 163Cancelling the exclusion of slices 164

5.3.5 Evaluating the results 164Movie segment slider 165Work segment slider 165ED and ES slider 165Image navigator 166

5.3.6 4D view 166Showing/hiding slices 168

Table of contents


5.4 Flow analysis with Argus 1685.4.1 Preparing the data 168

Loading the image data 168Optimizing the image display 170

5.4.2 Defining the evaluation regions 171Drawing the ROI for the ascendingaorta 171Drawing the ROI for the descendingaorta 171Analyzing low velocities (optional) 172Propagating the vessel contours toother cardiac phases 172Confirming the propagated vesselcontours 173

5.4.3 Evaluating the vessels 174Calculating results with standardsettings 174Limiting the time range 175Performing baseline correction 175Correcting phase aliasing 176

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Table of contents


Introduction

In order to operate the MR system accurately and safely, theoperating personnel must have the necessary expertise as well asknowledge of the complete operator manual. The operator manualmust be read carefully prior to using the MR system.

Layout of the operator manualYour complete operator manual is split up into several volumes toimprove readability. Each of these individual operator manuals coversa specific topic:

◾ Hardware components (system, coils, etc.)◾ Software (measurement, evaluation, etc.)Another element of the complete operator manual is the informationprovided for the system owner of the MR system.The extent of the respective operator manual depends on the systemconfiguration used and may vary.

All components of the complete operator manual may includesafety information that needs to be adhered to.

The operator manuals for hardware and software address theauthorized user. Basic knowledge in operating PCs and software is aprerequisite.

The current operator manualThis manual may include descriptions covering standard as well asoptional hardware and software. Contact your Siemens SalesOrganization with respect to the hardware and software available foryour system. The description of an option does not infer a legalrequirement to provide it.

1

1.1

1.2

Introduction 1


The graphics, figures, and medical images used in this operatormanual are examples only. The actual display and design of thesemay be slightly different on your system.Male and female patients are referred to as “the patient” for the sakeof simplicity.

Intended useYour MAGNETOM MR system is indicated for use as a magneticresonance diagnostic device (MRDD) that produces transverse,sagittal, coronal and oblique cross sectional images, spectroscopicimages and/or spectra, and that displays the internal structure and/orfunction of the head, body, or extremities. Other physical parametersderived 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 derivedfrom the images and/or spectra when interpreted by a trainedphysician yield information that may assist in diagnosis.Your MAGNETOM MR system may also be used for imaging duringinterventional procedures when performed with MR compatibledevices such as in-room displays and MR Safe biopsy needles.

The MAGNETOM MR system is not a device with measuringfunction as defined in the Medical Device Directive (MDD).Quantitative measured values obtained are for informationalpurposes 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.

Your MR system is a medical device for human use only!

1.3

1 Introduction


Authorized operating personnelThe MAGNETOM MR system must be operated according to theintended use and only by qualified persons with the necessaryknowledge 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 assafe handling of MR systems. The user must be familiar with potentialhazard and safety guidelines the same way the user is familiar withemergency and rescue scenarios. In addition, the user has to haveread and understood the contents of the operator manual.Please contact Siemens Service for more information on availabletraining options and suggested duration and frequency of suchtraining.

Definitions of different persons

Term used Explanation

User/Operator/Operating per-sonnel

Person who operates the system or software,takes care of the patient or reads imagesTypically physicians, trained radiological techni-cians, or technologists

System owner Person who is responsible for the MR environ-ment. This includes legal requirements, emer-gency plans, employee information and qualifica-tions, as well as maintenance/repair.

MR worker Person who works within the controlled accessarea or MR environmentUser/Operator as well as further personnel (forexample, cleaning staff, facility manager, servicepersonnel)

1.4

1.4.1

Introduction 1


Term used Explanation

Siemens Serv-ice/service per-sonnel

Group of specially trained persons who areauthorized by Siemens to perform certain mainte-nance activitiesReferences to “Siemens Service” include servicepersonnel authorized by Siemens.

1 Introduction


Preparation

2.1 Physiological control of the measurement 22

2

Preparation 2


Physiological control of the measurementDetection of cardiac movement is a prerequisite for synchronizing thecardiac cycle and data acquisition.ECG signal: The ECG signal records the cumulative electricaldepolarization and repolarization of cell membranes in the heartmuscle during cardiac activity.A time-varying dipole field is generated that is displayed by anelectrical dipole vector. The force of the dipole field is measured bythe electrodes attached to the skin of the patient.R wave: The time point of the R wave corresponds to the enddiastole. The R wave is depicted as a distinct peak and used as thereference point for triggered measurements.ECG leads: The ECG leads are selected according to the potentialdifference between the connected electrodes. The three leads I, II andIII are used and acquired in parallel via the ECG channels.

MAGNETOM Avanto/Verio: Two leads (I and AVF) are available.

Positioning the electrodes and PERUElectrodes: Positioning of the electrodes varies according to theposition of the heart. An example is provided in the figure below.

Use only disposable ECG electrodes as released by Siemens.( Page 24 Procurement addresses)

PERU: The ECG sensor in the PERU ensures transfer of the ECG signal.Typically, the PERU is aligned in the direction of the foot end of thepatient table even though the patient may be positioned feet first inthe direction of the magnet bore.◆ Position the PERU in the appropriate support or add absorbent

material between the ECG cables, PERU and skin. The distancebetween PERU and patient should be at least 2 cm.

2.1

2.1.1

2 Preparation


Example MAGNETOM Aera/Skyra: Positioning the ECG electrodes (left) and thePERU (right).

The transmitter unit of the PERU includes three LEDs for signalingthe battery status and one LED as fault indicator (e.g. insufficientskin contact of the ECG electrodes).Battery status and electrode fault are also indicated on the Dotdisplay above the magnet bore and the Physiological Displaydialog window.

If the red LED Electrode fault on the PERU flashes, the ECGelectrodes are not attached correctly. Check to ensure that theelectrodes are not falling off.

Attaching ECG electrodesThe electrodes must be positioned and attached with care to ensure asufficient and consistent ECG signal.1 Ensure satisfactory contact between the electrodes and the

patient's skin.

2 Thoroughly clean the patient's skin with a dry cloth or NUPREP ECG& EEG Abrasive Skin Prepping Gel . ( Page 24 Procurementaddresses)

3 If the patient is hirsute, shave the location where you want toattach the electrodes.

4 Dry the skin carefully.

5 Check the signal. ( Page 28 Checking the ECG signal)

2.1.2

Preparation 2


6 If the signal received is not satisfactory and consistent, vary thelocation of the electrodes. Use new electrodes every single time.

7 If one of the leads does not provide a sufficient signal, change to asingle ECG lead in the Physiological Display dialog window.

Procurement addressesDisposable ECG electrodes: Disposable ECG electrodes may beordered from:Siemens Commercial goods (Catalog Med & More), CONMED 2700Cleartrace

◾ Item no. 07437598 (600 pieces)or from:CONMED CORPORATION, 310 Broad Street, Utica, New York 13501,USACleaning gel: NUPREP ECG & EEG Abrasive Skin Prepping GelWeaver and Company, 565 Nucla Way, Unit B, Aurora, Colorado80011, USA

Physiological displayThe Physiological Display dialog window is a window on the GSP.The window position is fixed and cannot be moved or resized.

◆ To open or close the Physiological Display dialog window, clickthe icon.

2.1.3

2 Preparation


If you have selected the GSP layout Cardio UI, the PhysiologicalDisplay dialog window is integrated into the user interface andcannot be closed, that is, the icon is dimmed.To close the Physiological Display dialog window, select anotherGSP layout from the main menu, for example, View > 2Segments. Afterwards, the icon is active again.

Recommendation: Use the Cardio UI in general.

Display of battery statusThe Physiological Display dialog window displays the battery statusof the PERU (Physiologic ECG and Respiratory Unit) and/or the PPU(Peripheral Pulse Unit). The status of the battery is indicated via fivedifferent icons.

◆ Check the battery status and replace the battery if necessary.

Switching between signal values and controls1 To display the controls, click the switch icon.

2 To redisplay the signal values, click the switch icon again.

Display of trigger eventsThe trigger information delivered by the PMU is shown as trianglesabove the signal curve.

Preparation 2


◾ Large triangle: Channel is used for triggering.◾ Small triangle: Channel is not used for triggering.Setting the display rateYou can select between three different display rates; Slow, Medium,and Fast.◆ Select the requested display rate by clicking the corresponding

icon.

– or –

Select the requested display rate from the context menu (right-click with the mouse).

Setting the number of signal tracksYou can display up to three time-synchronized signal tracks.◆ 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.

MAGNETOM Avanto/Verio: Two ECG signals can be displayed inone track.

Selecting the physiological signalEach signal track displays one of the physiological signals as acontinuous curve, i.e., the ECG I signal, ECG II signal, ECG III signal,the pulse signal, the respiratory signal, and the external signal.◆ Select the curve to be displayed (separately for both signal tracks)

in the corresponding selection list.

2 Preparation


Selecting the trigger method◆ 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

MAGNETOM Avanto/Verio: Two different single derivatives canbe selected.

If Auto is used, the signal characteristics can be relearned byselecting Relearn in the context menu of the PhysiologicalDisplay.

You cannot change the trigger method during the measurement.

Displaying time rangesThe following color-coded time ranges are displayed below the signalcurve in a bar.◾ 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 –

Select Scanbars in the context menu (right-click with the mouse).

The time ranges can be displayed on both signal tracks, but notwith the All ECG mode.

Preparation 2


With display rate Fast, no time ranges are displayed.With display rate Slow, time ranges are displayed if the selectedsignal is a respiratory signal or an external signal.

Checking the ECG signalDot display: The R waves should be clearly visible, making themsuitable for triggering the examination.The strength indicator represents the amplitude strength (optimal:five bars). The learning phase status is displayed in the status area ofthe display.

Dot display.

(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 beshown at least on one ECG channel. The other ECG channelsshould show a minimum of one bar.

2.1.4

2 Preparation


MAGNETOM Avanto/Verio: Use the PMU display to check the ECGsignal. (For a detailed description of the PMU display, please referto the Operator Manual "MR System".)

Prospective triggering: setting the parametersThe parameters for prospective triggering are set on the PhysioSignal1 parameter card.

1 Determine the physiological signal and the trigger mode in the 1stSignal/Mode field.

2 Accept the value determined for the average cardiac cycle withCaptured cycle.

3 Check the time duration of the acquisition window.

By clicking Captured cycle, the average cycle−60 ms isautomatically entered in the acquisition window duringprospectively triggered measurements.

4 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 secondtrigger (e.g., for T2-weighted measurements).

5 Set the trigger delay to shift data acquisition into the diastole.

2.1.5

Preparation 2


6 If required, set additional measurement parameters to the desiredvalues.

Retrospective gating: setting the parametersUse the Physio Signal1 parameter card to set the parameters forgating (with or without arrhythmia detection).

Example with arrhythmia detection.

◆ Determine the physiological signal and the gating mode in the 1stSignal/Mode field.

Without arrhythmia detection◆ Determine the number of phases needed in the Calculated phases

window.

The phases are subsequently computed via interpolation.

With arrhythmia detection1 Set the expected average RR interval in the Target RR window or

click Captured cycle.

2 Set the Trigger window.

To avoid smearing, select a lower number of segments for a shortcardiac cycle.

2.1.6

2 Preparation


Cardiac measurements

3.1 Heart localization 323.2 Slice localization with interactive real-time imaging 363.3 Displaying standard views 413.4 Views of the heart valves 533.5 Display of the heart and valve functions 583.6 Display of cardiac morphology 673.7 Display of coronary vessels 713.8 Myocardial mapping 783.9 Cardiac Dot Engine 90

3

Cardiac measurements 3


Heart localizationThe location of the heart may vary greatly from patient to patient. Forthis reason, localization is the basis of cardiovascular MRexaminations. Standard views and the display of heart valves arebased on this.

Different location of the heart in three patients.

Localization in four steps: The more accurate the localization is, themore accurate the pathologies or functional interferences will bedisplayed in the images.Localizer sequence:

◾ Orthogonal multi-slice localizer◾ 2-chamber localizer◾ 4-chamber localizer◾ Short-axis localizerFast single-shot protocols (TrueFISP, TurboFLASH, HASTE) are usedfor localizing. As an alternative, real-time protocols may be used.To avoid motion artifacts, the measurement is shifted into thediastole by using the trigger delay. For accurate reproducibility, theslices are acquired in breathhold technique. They should be measuredin the same respiratory phase (end expiration or end inspiration) usedfor subsequently acquiring high-resolution images.

Measuring orthogonal multi-slice localizers✓ Consistent ECG signal

An orthogonal multi-slice localizer provides several transverse,sagittal, and coronal slices of the heart.

1 Position the heart in the center of the magnetic field.

2 Measure the orthogonal multi-slice localizers.

3.1

3.1.1

3 Cardiac measurements


3 Check the images to see if the heart is in the center of themagnetic field and the correct coils have been selected.

Body and Spine Array elements should be choosen to cover thecomplete heart.

4 If corrections are required (e.g., repositioning the patient into thecenter of the magnetic field), repeat the measurement.

Orthogonal localizers.

Measuring the 2-chamber localizer✓ Orthogonal multi-slice localizers have been measured

As a first step you set the vertical long axis using the 2-chamberlocalizer.

1 Select a transverse slice at the height of the ventricle from theorthogonal multi-slice localizers.

2 Position this slice vertically on this image, parallel to the septumand through the apex of the left ventricle.

You obtain a cut through the vertical long axis with a view of theleft ventricle and left atrium.

3.1.2



Positioning and 2-chamber localizer.

Measuring the 4-chamber localizer✓ 2-chamber localizer has been measured

Starting with the vertical long axis, you are looking for the horizontallong axis of the heart.

◆ Position the slice vertically in the 2-chamber localizer through theapex of the heart and through the center of the mitral valve.

The result is an image with 4 heart chambers. The right ventriclemay be too short and part of the left ventricular outflow tract maybe visible.

Positioning and 4-chamber localizer.

Measuring the short-axis localizer✓ 4-chamber and/or 2-chamber localizer has/have been measured

Conclude localization by measuring the short-axis localizer.

1 Position the slice vertically on the 4-chamber and/or 2-chamberlocalizer, parallel to the plane of the heart valves andapproximately at a right angle to the septum.

3.1.3

3.1.4



Acquire part of the atria and left outflow tract as well as bothventricles.

2 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.



Slice localization with interactive real-timeimaging

Localizing slices in real time✓ Localizer has been measured

The localization measurement runs in an infinite loop and providesthe exact position and orientation of the slice to be measured. Duringthe measurement, you can change the position and orientation of theslice to be measured.

1 Open the real-time protocol (BEAT_IRT) in the Online Editor.

2 Optimize the measurement parameters, if necessary.

3 Plan the measurement using a maximum number of repetitions.

4 For this purpose, select the Infinite measurement checkbox onthe Contrast Dynamic parameter card.

To control the measurement in progress, the protocol needs toremain open in the Online Editor during the measurement. This isensured by starting the measurement with Apply in the programcontrol.

5 Start the localization measurement.

In the Online Editor, the real-time protocol changes from planningto the interactive mode. With the exception of the slice positionand orientation parameters that are controlled interactively, allparameters are dimmed.

6 During the localization measurement, change the slice positionand orientation.

7 For this purpose, use the same tools you normally use for sliceplanning.

The reconstructed images are shown in the Inline Display.

3.2

3.2.1



Transferring slice parameters✓ Slice has been localized

As soon as the requested slice plane has been reached, you can saveit for later use (e.g., other imaging strategy). For this purpose, youcan continue, pause, stop, or end the measurement.

◆ In the Inline Display: Save the requested image.

You are able to locate and save several orientations during themeasurement.

Pausing the measurementPrior to saving the image orientation, you can pause themeasurement. This pause may be used for example, to give breathingcommands in order to optimize the orientation.1 In the Inline Display: Pause the localization measurement.

2 To continue the measurement, click Pause again.

3.2.2



Stopping the measurement1 In the program control: Stop the localization measurement.

The real-time protocol changes again from interactive to planningmode in the Online Editor. If necessary, you are now able tooptimize the protocol again.

2 In the program control: End the localization measurement.

The real-time protocol is closed and, if available, the next protocolopens.

Helpful hintsIn the following example, a typical setting for an interactive heartlocalization measurement is explained.

✓ Protocol has been selected

1 Select Edit Properties… from the context menu (right-click withthe mouse).

The Step properties dialog window opens.

2 Select the Auto load subtask card.

3 Select the Load images to graphic segments checkbox.

3.2.3



The images measured interactively are automatically loaded into asegment of graphic slice positioning. You can continue localizinginteractively in real time on these images.

4 Select the Execution subtask card.

5 Select the Auto open inline display checkbox.

When starting the protocol, Inline Display opens automaticallywith the display options last used.

6 Select the Auto close inline display checkbox.

At the end of the measurement, Inline Display closesautomatically.

On the Image Management subtask card: Select the Auto storeimages option only, if you want to view several measurementssimultaneously (e.g., motion studies). In this case, ensure thatMultiple series is deselected (see also next hint).



To minimize the number of series: Deselect the Multiple seriesoption on the Contrast Dynamic parameter card.In this case, the images will be automatically loaded into graphicslice positioning only after completion of the protocol.However, you are able to manually load unfinished series intoimage segments during the measurement.

Changing between different slice orientations◆ Load the images into stamp segments.

Automatically duringthe measurement

The Load images to stamp segments andMultiple series options are selected.

Automatically afterthe measurement

The Load images to stamp segmentsoption is selected and the Multiple seriesoption is deselected. In this case loadingimages may take a long time in case oflarge data volumes.

Manually You can drag the image icon from themeasurement queue to an image stampsegment at any time.

Subsequently, you are able to select from the images during themeasurement (Copy image position in the graphic slicepositioning context menu).

Automatic windowingIf the windowing of the first images of the localization measurementis not optimal, do not transfer the window values to the followingimages. In that case:◆ Deselect Window On Succeeding On (from the Inline Display

context menu).

Adjustment volumeIf the adjustment volume (green rectangle) covers the slice duringgraphic slice positioning:◆ Switch off the display of the adjustment volume (View >

Adjustment Volume on/off menu).



– or –

Select the adjustment volume large enough so it covers the entiredisplay area.

Displaying standard viewsAccurately determined standard views constitute an important basisfor many examinations.2-chamber view, left ventricle: The 2-chamber view of the leftventricle (LV) shows:

◾ Left ventricle◾ Front and back wall LV◾ Left atrium◾ Mitral valve2-chamber view, right ventricle: The 2-chamber view of the rightventricle (RV) shows:

◾ Right ventricle◾ Front and back wall RV◾ Right atrium◾ Tricuspid valve4-chamber view: The 4-chamber view shows:

◾ Atrial septum◾ Intra-ventricular septum◾ Ventricular lateral walls of LV and RV◾ Mitral and tricuspid valves3-chamber view: The 3-chamber view (left ventricular inflow andoutflow tract) shows:

◾ Left ventricle◾ Left atrium◾ Anterior septum

3.3



◾ Back side wall of left ventricle◾ Aortic and mitral valvesShort-axis views: The short-axis views simultaneously show bothventricles at a right angle to the septum, including all cardiac walls.The post-processing software Argus requires this view for analyzingthe LV or RV functional values. ( Page 136 Ventricular Analysis)Left ventricular outflow tract with aortic valve: The image of the leftventricular outflow tract with aortic valve (LVOT) shows:

◾ Left ventricle◾ Outflow tract LV◾ Aortic valve◾ Aortic bulb◾ Ascending aortic arch

Displaying the 4-chamber viewHigh-resolution standard views are generated on the basis of thelocalizers.

✓ Localizers have been measured

On the short-axis localizers1 Position the slice vertically on the septum through the largest

expansion of the right and left ventricle.

2 Ensure that the planned slice is not crossing the aortic root byscrolling to the base of the heart.

On the 2-chamber localizer◆ Position the slice through the mitral valve and the apex of the

heart.

On the 4-chamber localizer◆ Adjust the size of the FoV, position, and inline rotation.

The 4-chamber view shows the left and right ventricles in theirentire length as well as both atria.

3.3.1



Positioning and 4-chamber view.

(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



2-chamber view, displaying the left ventricleOn the short-axis localizers◆ Position the slice parallel to the connection line between the back

and front connection points of the right ventricle and shift the sliceinto the center of the left ventricle.

On the 4-chamber view◆ If required, turn the slice into the apex of the heart.

On the 2-chamber localizer◆ Adjust the size of the FoV, position, and inline rotation.

3.3.2



Positioning and 2-chamber view LV.

(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



Displaying the 3-chamber view (LV inflow andoutflow tract)On the basal short-axis localizers◆ 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◆ Adjust the slice in the 4-chamber view so that it passes through the

apex of the left ventricle.

Positioning and 3-chamber view.

(1) Left ventricle(2) Left atrium(3) Right ventricular outflow tract(4) Mitral valve

3.3.3



(5) Papillary muscle(6) Aortic valve(7) Apex of the heart(8) Anterior septum(9) Aorta(10) Pulmonary artery

Displaying short-axis viewsOn the 4-chamber view◆ Position the slice(s) vertically on the 4-chamber view,

approximately at a right angle to the septum and parallel to thecardiac valves.

On the 2-chamber view◆ Adjust the slices, if necessary, so that they run parallel to the mitral

valve.

On the short-axis localizer◆ To avoid aliasing artifacts in the read-out direction, adjust the FoV.

When planning slices, please factor in cardiac motion andlocation as a function of the cardiac cycle. Use CINE images foraccurate slice positioning. ( Page 58 The CINE technique)

If you cover the entire heart with short axes for a volumetricmeasurement, please ensure that all slices are measured with thesame slice orientation.

3.3.4



Positioning and short-axis view.

(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



2-chamber view, displaying the right ventricleOn the short-axis localizers◆ Position the slice approximately parallel to the 2-chamber view LV.

On the 4-chamber view◆ 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 thetricuspid valve and the pulmonary valve.

3.3.5



Positioning and 2-chamber view RV.

(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



Displaying the left ventricular outflow tract withaortic valve (LVOT)On the 3-chamber view◆ 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 58 TheCINE technique)

Arms frequently lead to overfolding artifacts. However, these areusually located outside the structures of interest.

3.3.6



Positioning and outflow tract LV.

(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



Views of the heart valvesThe position of the heart valves changes as a function of the phase ofthe cardiac cycle. As a result, their display during the systole requiresa different slice position than during the diastole.In case of stenosing valves, the leaflets or atrioventricular valves nolonger open uniformly. For slice positioning it is helpful to know themain orientation of the blood flow through the valve ring.FLASH versus TrueFISP: The FLASH sequence is especially suitablefor displaying valve openings due to its characteristics of displayinginflowing blood as bright in color. Equally, FLASH provides forexcellent displays of jets (blood flow in the wrong direction and/orturbulent flow in case of stenoses).Inflowing blood is not as bright ina TrueFISP sequence, however, the valve rings are clearly shown.Evaluation: The size of the valve opening is evaluated by drawing inthe valve margins and/or evaluating the bright blood flow as afunction of the cardiac phase.

Inflow through a normal (top) and stenosing mitral valve (bottom) during earlyand late diastole.

3.4



Displaying the aortic valveThe slices for imaging the aortic valve ring are easily positioned onthe displays of the 3-chamber view or LVOT.1 Depending on the cardiac phase to be examined, determine the

position of the valve on the CINE images as a function of the timeafter the trigger pulse.

2 To show the valve in full, generate several slices running in parallelto the valve plane.

3 Position the slice vertically to a 3-chamber and LVOT view on theaortic valves.

Shifts in the valve plane are less noticeable with sclerosing valvesor older patients.

The aortic valve is open during the systole. The opening is usuallyshown as a bright triangle. In 3-chamber and LVOT views, stenosesare indicated by jet effects in the blood flow direction. Ascompared to stenoses, insufficiencies are indicated by a jet effectin the opposite direction of the blood flow.

3.4.1



Positioning and aortic valve.

(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



Displaying the mitral valveThe mitral valve can be seen on the long axis cuts. The most optimaldisplay is provided with a 3-chamber view.◆ Determine the position of the valve as a function of time after the

trigger pulse.

On the 3-chamber view◆ Position the slice on the mitral valve.

To display the entire valve, measure several parallel slices.

On the 4-chamber view◆ Correct the slice as required and turn it parallel to the valve plane.

3.4.2



Positioning and mitral valve.

(1) Anterior leaflet(2) Posterior leaflet(3) Right atrium(4) Pulmonary valve(5) Vena cava inferior(6) Lungs



Display of the heart and valve functionsThe examination of functions plays an important role withincardiovascular MR. Various programs provide different methods forCINE imaging. In general, the different options enable you tocompromise between temporal and spatial resolution, measurementtime as well as image contrast.As a prerequisite for functional examinations, the complete cardiaccycle must be imaged. This means that the acquisition windowincludes the entire cardiac cycle. Additionally, there is no triggerdelay between triggering and the start of data acquisition.

2-chamber view of the left ventricle during different cardiac phases.

The CINE techniqueCINE: To display the cardiac function, MR images are acquired duringdifferent phases of the cardiac cycle and automatically shown in anendless loop. The viewer has the feeling of watching a video oncardiac activity.The more phases are shown, the better the resolution of cardiacmotion.

3.5

3.5.1



The CINE technique uses gradient echo sequences:

◾ FLASH◾ TrueFISPThe sequences are combined with the following techniques:

◾ Segmentation◾ Phase sharing◾ iPAT (integrated and separated reference lines)◾ tPAT◾ Radial (TrueFISP only)◾ Real time (TrueFISP only)◾ Saturation bands

(1) Mitral valve (FLASH)(2) 4-chamber view (TrueFISP)

Measuring multiple slices per breathholdProtocols for functional examinations enable you to measure severalslices in the same orientation within a breathhold.ConcatenationsThe concatenation parameter determines the number of slices to bemeasured per breathhold. The following applies:Total number of slices/Concatenations = Number of slices perbreathhold

3.5.2



Example: If twelve slices are required to cover the entire heart for anejection fraction examination and six concatenations are selected,two slices per breathhold can be measured.Settings for this example:

◾ On the Physio PACE parameter card select Breath-hold forrespiratory control.

◾ On the Routine parameter card or the Physio Signal 1 or PhysioPACE parameter cards, set the Concatenations to 6.

Number of concatenationsThe concatenations have to be adjusted to the length of thebreathhold that is not difficult for the patient to handle.A small number of concatenations divides the measurement into onlyfew but long breathholds. A large number of concatenations dividesthe measurement into many short breathholds. The length of thebreathhold can be displayed by holding the mouse pointer over thetotal measurement time displayed.

FLASH sequencesArea of application◾ 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 TrueFISPNone-segmentedOnly one raw data line is measured per cardiac cycle. Themeasurement time is too long for breathhold technique.To reduce motion artifacts, the data are acquired repeatedly andsubsequently averaged. Today this method is rarely used.SegmentedSeveral raw data lines are measured per cardiac cycle. Themeasurement can be performed within a breathhold.The number of segments limits temporal resolution. If you increasethe number of segments, temporal resolution as well as the entiremeasurement time are reduced (and vice versa).

3.5.3



Phase sharingEach phase acquires several previously measured raw data lines fromadjacent phases. As a result, fewer raw data lines have to bemeasured per phase.The number of segments can be increased and the measurementtime reduced, or the repetition time TR can be reduced and thenumber of phases increased for the same amount of segments andmeasurement time.PATParallel data acquisition techniques allow for faster measurementtimes or increases in the temporal or spatial resolution.

TrueFISP sequencesTrueFISP sequences are highly suitable for displaying the beatingheart with high temporal and spatial resolution.AdvantagesAs compared to FLASH, the advantages of TrueFISP are:

◾ Blood displayed at higher signal intensity◾ Improved blood-tissue contrast◾ Higher temporal resolution is possible◾ Combinations with real time and radial are possibleSegmentation and phase sharingTrueFISP sequences acquire data either segmented or in a single shot(all raw data lines are measured within one heart beat). As is the casewith FLASH, phase sharing enables even shorter measurement timesor increases temporal resolution (a higher number of phases).PATJust like FLASH, TrueFISP may be used with the different PATtechnologies.

3.5.4



Radial samplingTrueFISP can be combined with radial sampling. In this case, the kspace is not filled line-by-line, but rather through radial projections.The results are very high temporal and spatial resolutions within ashort measurement time.Real timeTrueFISP can also be used to measure in real time.

TrueFISP and image qualityUsing TrueFISP, the best possible image quality is obtained by usingthe shortest possible echo time TE. For this reason, the systemautomatically sets the smallest possible values for TE and TR.Magnetic field homogeneity is the most important prerequisite forgood image quality. Inhomogeneities lead to ribbon artifactsnoticeable as dark stripes in the image.In the majority of cases, image interference is remedied by adjustingthe adjustment volume.

TrueFISP images: Artifacts caused by field inhomogeneity (left, center) andgood image quality by correcting the adjustment volume (right).

TrueFISP parameter—exampleIn the following example, a typical setting for TrueFISP withretrospective gating is explained for the Physio Signal1 parametercard. These settings also apply to the respective FLASH and flowsequences.

3.5.5

3.5.6



TRThe repetition time TR is computed by the system as a function of thenumber of segments and echo spacing time.To shorten TR you can reduce the number of segments.

Select the number of phases so that one phase does notcorrespond to more than double the temporal resolution of TR.This means that not more than 40 phases should be computed ata TR of 40 ms and an average cardiac cycle of 800 ms.

It is recommended to adjust temporal resolution to the cardiaccycle.This may be especially important for stress examinationswith short cardiac cycles.

Real-time measurementsUsing TrueFISP sequences, cardiac motion may be displayed in realtime.Real-time measurements may be performed without triggering andbreathhold techniques. This makes real-time measurements anexcellent alternative for examining uncooperative patients or patientswho are unable to hold their breath. The measurement is fast enoughto avoid respiratory artifacts.

3.5.7



PAT: When real-time measurements are combined with various PATtechniques, an improved temporal resolution is obtained.

(1) Real-time measurement(2) High-resolution measurement

Radial sequences: Overfolding effects are eliminated with radialsequences. The FoV can be closely limited to the cardiac area whichresults in high spatial resolution.

It is not possible to combine real-time radial sequences with iPAT.

Preparation pulse: By switching off the preparation pulses (Dummyheartbeats = 0), the total measurement time can be considerablyreduced for real-time measurements, because only half of theheartbeats have to be measured.



Inline function examinationsOverviewIn addition to segmenting and analyzing short-axis images with theArgus ventricular analysis ( Page 136 Ventricular Analysis), anautomatic inline-segmentation of the left ventricle (LV) is possible aswell.Progression: Automatic segmentation is performed across all CINEphases and slices. The results of segmentation are superposed ascolor graphics in the short-axis images.As soon as a complete image stack has been acquired, calculation ofthe most important functional parameters starts (ejection fraction,cardiac output, end- diastolic and end-systolic volumes).The calculated parameters are shown in the Inline Display and savedas their own series in the database (Inline_VF_results).Automatically generated contours can be edited retroactively withArgus.

3.5.8



Automatic segmentation of the left ventricle.

(1) End diastole(2) End systole

Performing Inline function examinationsThe Inline ventricular analysis is performed with a stack of parallelshort-axis images which cover the left ventricle. You activate thefunction on the Inline Cardiac parameter card.

Prerequisites for the measurement:

◾ triggered CINE images◾ Slice positioning: at the end systole, the second slice should be

positioned approximately at the level of the mitral valve (refer tofigure).



(1) Slice positioning in the end diastole(2) Slice positioning in the end systole

Automatic segmentation: During the acquisition, non-contouredimages are displayed immediately in the Inline Display and saved inthe database. As soon as all short-axis images are acquired, automaticsegmentation of the left ventricle is performed. When segmentationis completed, the contoured images and the table of results aredisplayed in the Inline Display and saved as a separate series in thedatabase.

Please be aware that the results calculated in the InlineVentricular Function may differ from those calculated in 2DVentricular Analysis. This is mainly due to improvements to thebase-plane segmentation.

Display of cardiac morphologyA large number of different imaging methods are available forevaluating the morphology of the heart. Where cardiac morphologyrelied on spin echo and Turbo spin echo sequences in the past,additional high-speed techniques, such as TrueFISP and HASTE, areavailable today as well.

Increase in contrast using Dark BloodThe contrast between the myocardium and the blood can beconsiderably increased with the Dark Blood technique. The blood isshown low in signal and appears dark in images.

3.6

3.6.1



Dark Blood preparationDark Blood preparation is obtained via a double preparation pulse.The first pulse inverts the blood and myocardial signal inside as wellas outside the slice to be measured. The subsequent pulse reinvertsthe signal inside the measurement slice only.During the cardiac cycle, blood with an inverted signal flows into themeasurement slice. Blood is shown dark when data acquisition isperformed during the zero crossing of its magnetization.TimingDark Blood measurements must meet two requirements:

◾ During the reinversion pulse, the heart must be in a similar positionas during data acquisition. Otherwise, the tissue of the slice to bemeasured will not be reinverted.

◾ Data acquisition must occur in the diastole and during the zerocrossing of the blood signal.

Both conditions are met when preparation is completed in the latediastole, immediately after the R wave, and the measurement follows600–800 ms later. The time for optimal acquisition is determined byselecting a suitable TR value.

(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



Dark Blood parameter—example (TSE)The settings are either made on the Physio Signal1 parameter cardor on the Physio Cardiac parameter card.

The acquisition window is defined using the Captured Cycle button.A TR of e.g., 700 ms ends the measurement within this time intervalafter the trigger.During a short cardiac cycle, a protocol with a small turbo factorshould be selected for suppressing motion artifacts. This keeps theacquisition time (TR min) as short as possible.



Where there is poor contrast, it usually suffices to vary TR by approx.50–100 ms. This will shift the measurement within the cardiac cycle.T1-weighted: The trigger pulse is at 1. This means one measurementper cardiac cycle.T2-weighted: The trigger pulse is at 2. This means one measurementevery other cardiac cycle. TE is long (70–110 ms) compared to the T1measurement.Dark Blood preparation: The trigger delay is 0, the preparationpulses immediately follow the R wave. The thickness of the selectivepreparation pulse and the flip angle can be changed for themeasurement. With short cardiac intervals, the image quality can beimproved by thickening the selective preparation pulse.

Bright BloodHyperintense blood flowing into the slice is used for obtainingcontrast optimization with Bright Blood techniques.The Bright Blood technique is suitable for combining with TrueFISPand FLASH.TrueFISP: As single shot technique:

◾ Without breathhold technique (for uncooperative patients)◾ One slice per heartbeatSegmented:

◾ 2–3 heartbeats are required per slice◾ For patients with a short cardiac cycle (with breathhold technique)FLASH:

◾ Segmented only◾ One slice per breathhold is measured◾ Usually combined with fat saturation◾ Suitable for localizing coronaries

3.6.2



(1) Bright Blood (FLASH)(2) Bright Blood (TrueFISP)

Display of coronary vesselsAgain, there are several methods available for displaying coronaryarteries. The fine structures of coronary vessels require consistentlygood spatial resolution.2D imaging: 2D imaging may be used to display the proximalsegments of the coronary arteries. Due to the non-isotropic voxelsize, it is not possible to reformat the data sets. Contrast agents arenot used.3D imaging: Usually, the coronaries are shown in the 3D mode. Themeasurement can be taken using the breathhold technique or freebreathing plus the navigator.

Measurement conditionsThe success of the measurement depends on satisfactory localizationas well as planning the specifics of sequence timing. It is also equallyimportant to reduce motion artifacts using the breathhold ornavigator technique.LocalizationImages with different slice orientations are used for localization.HASTE has proved to be highly suitable for many patients. However, ifthe display with HASTE does not meet requirements, TrueFISP orFLASH may be used as an alternative.

3.7

3.7.1



Acquisition windowTo ensure that the fine structures of the coronary arteries aredisplayed, data acquisition must be performed during the low-motionphase of the diastole.A 4-chamber view with a section of the right coronary provides asuitable display. Based on this measurement, the time can be definedwhen the coronary is motionless. Usually, this corresponds to thediastole.Breathhold techniqueThe patient produces the end expiration phase more accurately thanthe end inspiration phase. For this reason, the end expiration phase isbetter suited for displaying the coronary arteries. As the basis for slicepositioning, localization must be performed in the end expirationphase as well. Also, since the navigator-supported protocols measurein the expiration phase, this phase doubles as a constant exposureparameter that ensures comparison and reproducibility of thetechnique.

Right coronary in the 4-chamber view.

Localizing coronary blood vessels1 Measure transverse localizers that cover the entire left ventricle.

2 Select thin slices with a maximum slice thickness of 6 mm and startat the aortic root.

3 If the coronaries cannot be displayed clearly, measure an additionallocalizer in another slice orientation, e.g., orientation of the 4-chamber view or coronal slices.

4 In conclusion, take a CINE series in the 4-chamber view and visuallydetermine the low-motion phase of the coronaries in the images.

3.7.2



Displaying coronary blood vessels1 Search for the course of the blood vessels on the localizers.

You can also include existing, high-resolution images.

2 As soon as you recognize the course, position the slice orientationusing the 3-point mode.

3-point method used with the right coronary artery (example).

3 Adjust the acquisition window and position the exposure with asuitable trigger delay on the low-motion phase.

When setting the trigger delay, factor in sequence andmagnetization-related delays which have to be subtracted. A tooltip for the Trigger delay input field helps to determine the correcttime. The tool tip shows when data acquisition starts with thecurrently set trigger delay. In addition, the measurement timeduring the akinetic phase is shown.

4 Reduce the number of segments for patients with a short cardiaccycle. In this way, you are able to minimize blurring.

5 Start the measurement.

3.7.3



Respiratory control using navigator techniqueNavigator and search windowThe navigator technique detects respiratory motion. Navigator echoesare integrated in the imaging sequence. These echoes allow you todetermine the current respiratory position.Navigator: The navigator signal consists of two slice-selective pulses(90° and 180°). With their help, the motion of the diaphragm can beacquired and displayed continuously in real time.For this purpose, the intersection of the two navigator slices must bepositioned on the dome of the liver.A spin echo profile is generated in the cranial/caudal direction whichdescribes the current respiratory status.Search position and search window: The search position isdetermined using the display of the respiratory position.

Select the search window (red) so that the entire movement ofthe diaphragm is included as well.

Display of the navigator pulses (turquoise) and diaphragm position in thesearch window (red).

(1) Lungs(2) Liver

Acceptance windowDuring free breathing, the acceptance window is positioned on theend expiration phase of the patient.The data are used for image reconstruction only when the diaphragmis located within the acceptance window.

3.7.4



If the diaphragm lies outside this position, the data are discarded.During measurements in breathhold technique, the acceptancewindow is selected large enough to cover the entire respiratory cycle.Size of the acceptance window: A large acceptance window enablesdata acquisition during a longer phase (shorter overall measurementduration), a smaller window limits data acquisition (strongerrespiratory motion suppression).

Acceptance window (green) and search window (red).

Slice correction with the navigatorGate and Follow: During the slice following mode, the exact positionof the diaphragm in the acceptance window is evaluated andcorrected.Tracking factor: The correlation between the current changes in thediaphragm position and the slice shift to be performed is determinedby the tracking factor.The connection between respiratory motion and cardiac position isnot linear, instead it is based on three-dimensional movement. Forthis reason, slice alignment is useful within limits.

Avoid selecting an acceptance window that is too large.

During imaging in the breathhold technique, a large acceptancewindow must be selected. All data are accepted.Slice alignment may have a corrective effect when respiration isstarted prematurely.



Respiratory motion adaptation: During free breathing examinationsthe patient may breath differently. The acceptance window, whichhad been defined at the beginning of the exam, might therefore notfit any longer to these changing conditions.By enabling Resp. Motion Adaptation, the system will adapt theacceptance window automatically to the different expiration states.Thus, the measurement can be continued and must not be started allover again, even under these circumstances.Navigator parameter free breathing—exampleThe navigator parameters are set on the Physio PACE parametercard. The example shows the parameters of a measurement with slicealignment.

Respiratory control is set to Gate & Follow. Data are used for imagereconstruction when the diaphragm position is located within theacceptance window and slice alignment is performed within theacceptance range.The Navigator mode can be changed via the Respiratory controloption in the Physio PACE parameter card. Using Gate, dataacquisition is performed in the acceptance window without slicealignment.By activating the scout mode, the individual diaphragm position ofthe patient can be determined prior to the measurement.



By selecting suitable parameters, the Search position and Acceptposition are set to the end expiration phase.The size of the acceptance window can be enlarged to obtain ashorter overall measurement time. However, it can be also reduced insize for improved motion suppression. The value corresponds to thetolerance range used to expand the search position during dataacquisition.Navigator parameter breathhold technique—exampleThe example shows the parameters of a measurement with slicealignment.

Respiratory control is set to Gate & Follow. Search position andSearch window as well as the Acceptance position and Acceptancewindow cover the entire respiratory cycle.The Navigator mode can be changed via the Respiratory controloption in the Physio PACE parameter card. Using Gate, dataacquisition is performed in the acceptance window without slicealignment.By activating the scout mode, the individual diaphragm position ofthe patient can be determined prior to the measurement.

You must select a very large Search window and Acceptancewindow. All data have to be accepted. Otherwise, the breathholdcycle is too long.



If the patient begins to breathe at the end of the measurement, itmay be possible to use slice alignment for correction. However,should the picture continue to be blurry, shorten themeasurement time or switch to free breathing.

Myocardial mappingIn recent years, the measurement of tissue relaxation times hasbecome increasingly important in the assessment of a range ofcardiovascular diseases. Myocardial mapping generates pixel maps ofthe T1, T2 and T2* relaxation times in MR imaging examinations ofthe heart. Thus, the relaxation times, estimated using imagingsequences gated to the cardiac cycle, are encoded, in milliseconds, ineach image pixel.Optimized protocols are provided in the Siemens tree under heart/MyoMaps and in the Cardiac Dot Engine library ( Page 117 Adaptingstandard views (Cardiac Standard)).

Caution

Evaluated T1, T2 and T2* values are only estimated!Wrong diagnosis◆ Note that the relaxation times determined using the

MyoMaps software may differ to those obtained using otherMR acquisition techniques. Furthermore, variations inprotocol parameters may influence the estimated relaxationtimes. You are responsible for the interpretation of theparametric maps.

3.8



T1 mappingThere are a number of ways of obtaining estimates of T1 relaxationtimes. These include inversion recovery and saturation recovery pulsesequences, in addition to spoiled gradient echo imaging at twodifferent flip angles. T1 mapping with MyoMaps can be performedusing an inversion recovery-based pulse sequence. The softwareprovides a flexible interface to enable the evaluation of myocardialtissue T1 relaxation times. The so-called native T1 values ofmyocardial tissue may be estimated using “long T1” protocolsprovided in the Siemens tree.

For further information and recommendations, please see “Moonet al.: Myocardial T1 mapping and extracellular volumequantification: a Society for Cardiovascular MagneticResonance (SCMR) and CMR Working Group of the EuropeanSociety of Cardiology consensus statement. Journal ofCardiovascular Magnetic Resonance 2013 15:92.”

Measurement techniqueT1 mapping is performed using an ECG-triggered inversion recovery-based imaging technique. This technique involves the acquisition ofsingle-shot TrueFISP images at different inversion times (TI) followingan inversion pulse. The acquisitions are gated to the same cardiacphase, thereby enabling a pixel-based T1 value estimation in themyocardium.After the inversion, the magnetization following the T1 relaxationcurve is repetitively sampled over several heartbeats, followed by anumber of recovery heartbeats to allow for the magnetization torecover. For consistency, gradients are played out during theserecovery periods without acquiring data. By combining several(typically 2–3) inversions with slightly shifted TI times within oneimaging protocol, the relaxation curve is sampled in an interleavedmanner, resulting in a sufficient number of points for estimating T1values within a single breathhold.T1 mapping is typically performed during a breathhold and the use ofnavigator gating is not supported.Motion correction: An optional fast and fully automatic non-rigidregistration algorithm is utilized to compensate for in-plane motionbetween the images.

3.8.1



If the detected frame-to-frame motion is too large, imageregistration may fail. In such cases, repeat the scan.

At 3 T perform shimming to minimize non-uniformities.

Adjust the timing with respect to the cardiac cycle, for example,time the acquisition to diastole.

The following figure shows an example timing diagram where twoinversion pulses are applied, followed by sampling over five and thenthree heartbeats, respectively. The two sampling periods areseparated by a recovery period of three heartbeats. Pixel-wise curvefitting is performed using a three-parameter phase-sensitive approachto generate T1 pixel maps. The curve fitting and map generation arecompleted inline, and require no user interaction.

Timing diagram for a T1 mapping protocol comprising five acquisitionheartbeats, three recovery heartbeats, then three acquisition heartbeats. TD isthe trigger delay; ΔTIA and ΔTIB are calculated automatically to ensure an evendistribution of samples (TI1 to TI8 in this case) over the T1 recovery curve.

(1) Sampling duration 1(2) Recovery duration



(3) Sampling duration 2(4) Inversion recovery preparation pulses(5) Longitudinal magnetization Mz

(6) ECG(7) Gradients(8) Readout

T2 mappingT2 mapping is utilized to assess pathologic conditions which alter themyocardial water content and consequently prolong the T2 relaxationtimes.Measurement techniqueThe T2 mapping technique uses a T2-prepared sequence combinedwith either TrueFISP or gradient-echo readout to produce single-shotT2-weighted images, each with a different T2 preparation time. Thesequence will wait for several recovery heartbeats between eachpreparation to allow for full T1 regrowth. Gradients are played outduring these recovery periods without acquiring data to ensure aconsistent sound pattern.Motion correction: An optional fast and fully automatic non-rigidregistration algorithm is utilized to compensate for in-plane motionbetween the images.

If the detected frame-to-frame motion is too large, imageregistration may fail. In such cases, repeat the scan.

The following figure shows an example timing diagram. Two-parameter fitting to the signal decay curve is used to estimate T2 foreach pixel. The curve fitting and map generation are completedinline, and require no user interaction.

3.8.2



Timing diagram portraying a typical T2 mapping sequence, where three single-shot images are acquired, each with a different T2 preparation time. Arecovery period of four heartbeats is inserted between each acquisition toallow for full T1 recovery. TD1, TD2, and TD3 are adjusted to ensure eachreadout occurs in the same cardiac phase.

(1) Image 1 (without T2 preparation, TE = 0 ms)(2) Recovery duration(3) Image 2 (with T2 preparation, TE = 25 ms)(4) Image 3 (with T2 preparation, TE = 55 ms)(5) ECG(6) Gradients(7) T2 non-selective preparation pulses(8) Readout

T2* mappingMyocardial T2* measurements are a valuable tool for non-invasiveassessment of iron overload, and are clinically employed for planningand monitoring iron-chelating treatments for transfused thalassemiamajor patients.

T2* protocols are only available for 1.5 T systems.

3.8.3



Measurement techniqueImage acquisition typically involves the combination of black-bloodpreparation with a segmented gradient-echo readout for a range ofecho times.To generate an inline T2* map, the MyoMaps software performspixel-wise T2* estimation using a robust fitting technique, in whichthe signal at each TE is iteratively weighted to reflect its fidelity to amonoexponential decay curve. Signal points farther from the idealrelaxation curve are weighted lower, reducing their influence on thefit. The weights of outlier points can be completely zero, eliminatingtheir negative impact on the fit. As all echoes are acquired in a shorttime after an RF pulse, all multi-echo images are intrinsicallyregistered. The curve fitting and map generation are completedinline, and require no user interaction.The following figure shows the sequence timing and an example of aT2* mapping sequence with eight echoes acquired during the T2*decay.

Segmented multi-echo gradient echo readout used for T2* mapping. Imagingis typically performed during diastole.

(1) ECG(2) Gradients(3) Multi-echo readout



Generating T1 maps✓ T1 mapping protocol has been opened

1 Use Cardiac shim as appropriate to minimize non-uniformities.

2 Open the Inline Cardiac parameter card.

3 From the Inline Evaluation list: Select T1 map.

The T1 map is generated from a series of images acquiredfollowing magnetization preparation with a non-selectiveinversion pulse. The estimated T1 values are encoded in theintensity of each pixel.

4 From the Magn. preparation list: Select Non-sel. IR T1 map.

The data acquisition is preceded by a non-selective inversionpulse, thus inverting the magnetization in the entire volume. Thenon-selective inversion recovery pulse is optimized for the T1mapping application with an improved inversion efficiency for theoperating range of interest.

5 Num. of preps: Enter the number of inversion preparation pulses.The tooltip shows the TI start and the TI increment.

6 Sampling duration: Enter the number of images (samples)acquired with different inversion times following a preparationpulse.

3.8.4



The number of input images used to generate a given T1 map isdetermined by the sum of the sampling duration values. Forexample, for Num. of preps = 3 and Sampling duration 1 = 5,Sampling duration 2 = 3 and Sampling duration 3 = 3, a total of5 + 3 + 3 = 11 images (or samples) are acquired each with adifferent inversion time TI.

7 Recovery duration: Enter the recovery duration following eachsampling episode.

8 Motion Correction: Select Standard if a correction of in-planemotion between successive images acquired with single-shotacquisition techniques should be performed.

9 Use Captured cycle or modify the acquisition window and triggerdelay manually to adjust the timing of the acquisition within thecardiac cycle.


Result images:

◾ A series containing the original input images.◾ A series containing a “T1 map” image for each acquired slice. A

color bar scale is displayed within the T1 map ranging from0 ms to 2000 ms.

◾ If motion correction was enabled, an additional series ofmotion-corrected input images is provided. This image seriesname contains the label “_MOCO”.

Example: Amyloidosis with MyoMaps; T1 map courtesy of Peter Kellman,National Institutes of Health, Bethesda, USA.



Generating T2 maps✓ T2 mapping protocol has been opened


2 From the Inline Evaluation list: Select T2 map.

The T2 map is generated from a series of images acquiredfollowing magnetization preparation with a T2 preparation pulse.The estimated T2 values are encoded in the intensity of each pixel.

3 From the Magn. preparation list: Select T2 prep..A preparation pulse is applied to the entire volume to enhance T2contrast.

The T2 prep. preparation pulse is only available for 1.5 T systems.

– or –

Select T2 prep. adiabatic.

This option works similar to T2 prep.

3.8.5



The main differences are:

◾ Preparation module is more B1-insensitive◾ Leads to better image homogeneity◾ Requires more RF power

4 Num. of preps: Enter the number of preparation pulses.

The number of input images is determined by the number ofpreparations.

5 T2 prep. duration: Enter the duration of the T2 preparation pulsetrain.

6 Recovery duration: Enter the recovery duration following eachsampling episode.

7 Motion Correction: Select Standard if a correction of in-planemotion between successive images acquired with single-shotacquisition techniques should be performed.



Result images:

◾ A series containing the original input images.◾ A series containing a “T2 map” image for each acquired slice. A

color bar scale is displayed within the T2 map ranging from 0 msto 120 ms.

◾ If motion correction was enabled, an additional series of motion-corrected input images is provided. This image series namecontains the label “_MOCO”.



Example: Myocardial edema with MyoMaps; T2 map courtesy of ChristophTillmanns, Diagnostikum Berlin, Germany.

When viewed on non-Siemens platforms, the DICOM imagesencoding the T2 values are multiplied by a factor of 10.

Generating T2* maps✓ T2* mapping protocol has been opened

T2* protocols are only available for 1.5 T systems.


3.8.6



2 From the Inline Evaluation list: Select T2* map.

The T2* map is generated from a series of images acquired using amulti-echo gradient echo sequence. The estimated T2* values areencoded in the intensity of each pixel.

3 Contrasts: Enter the number of images generated with differentT2* weighting within a measurement (number of imagecontrasts).

The number of input images is controlled by the number ofcontrasts.

4 Verify TE and TR, adjust the bandwidth as appropriate.



Result images:

◾ A series containing the original input images.◾ A series containing a “T2* map” image for each acquired slice. A

color bar scale is displayed within the T2* map ranging from0 ms to 80 ms.



Example: Iron overload with MyoMaps; T2* map courtesy of Dudley Pennell,Royal Brompton Hospital, London, UK.

When viewed on non-Siemens platforms, the DICOM imagesencoding the T2* values are multiplied by a factor of 10.

Cardiac Dot Engine

The Dot Engine user interfaces shown in this operator manual areexamples only. The actual guidance texts and the design may beslightly different on your system.

Advantages/Features:

◾ 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

3.9



◾ Automatic calculation of FoV◾ Inline post-processing◾ Adaptive triggering◾ Automatic series re-naming◾ Standardized cardiovascular viewsThe Cardiac Dot Engine offers two workflows.

Workflows Ventricular Func-tion

Ischemic Heart Dis-ease

Measurement steps Localizer

Thoracic overview

AutoAlign Heart Scout

Long-axis localizer

CINE long-axis

Short-axis localizer

n.a. Dynamic test

n.a. Dynamic stress

CINE short-axis

n.a. Dynamic rest

n.a. n.a.

n.a. n.a.

n.a. Tissue characteriza-tion



Planning the heart examination and measuring thelocalizer✓ Electrodes have been positioned

✓ Patient has been registered

✓ Cardiac Dot Engine has been selected

After registration of a cardiac exam, the Patient View opensautomatically. The default examination parameters are loaded. TheGSP changes automatically to the cardio-specific screen layout withan integrated Physiological Display dialog window.

3.9.1



The features of the Physiological Display dialog window are:

◾ 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 24 Physiological

display)◆ Please check the Physiological Display dialog window for

messages.

Adapting the examination to the patientIn the Patient View, you select a suitable examination strategy andadapt the physiological and breathhold parameters to the patient’sneeds. The pending protocols of the measurement queue areupdated with your selection.

You can access the Patient View at any time during the examination.

1 To open the view, click the icon.

2 To confirm the settings and close the view, click the icon.

◆ From the list: Select a suitable Examination Strategy for thepatient.

Breath-Hold For standard measurements.

Realtime Measurements are performed with real-time protocols. Suitable for patients withreduced breathhold capabilities or arrhyth-mia.

Accessing the Patient View

Selecting the examinationstrategy



In the following example, the strategy Breath-Hold is selected.

1 Enter the Breath-hold Capability of the patient.

The number of slices per breathhold for each pending protocol areupdated accordingly.

2 If you want to use Automatic Breath-hold Commands throughoutthe whole examination, activate the checkbox and set the timingand language for the commands.

You are also able to set the breathhold commands individuallyfor each protocol (in the Protocol properties dialog window).

1 Change the Trigger Source, if necessary.

2 The patient’s heart rate may change with the breathhold. Tooverwrite the automatically captured heart rate, open the PatientView again and enter the RR-interval during the breathhold(parameter: Overwrite RR-Interval).

Starting the measurement of the localizer◆ Confirm the patient-specific settings.

The coronal localizer is automatically measured and displayed. Thelocalizer@isocenter protocol opens.

Automatic series re-naming: The series name automaticallyincludes the names of the views acquired. For example, if theprotocol name is CineRetro and the acquired cardiovascular viewis 2-chamber, the series name is CineRetro_2CH.

Setting the breathholdparameters

Adapting the physiologicalparameters



Standardized cardiovascular views: All common cardiovascularMR imaging planes are presented in a consistent manner asshown in the figure below.

Planning the localizer at the isocenterTo ensure the best possible image quality, you first position the heartat the magnet isocenter for all subsequent measurements.

3.9.2



✓ Coronal localizer has been measured

1 Position the heart at the magnet isocenter by shifting the slices andtable position (blue line) to the left ventricle.

You can modify the text and image examples of a guidance viewat any time. ( Page 113 Configuring protocol steps (optional))

2 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.



Inform the patient about potential table movements.


The table automatically moves into the magnet isocenter. Thelocalizer@isocenter is measured.

Measuring thoracic overview images✓ Localizer at isocenter has been measured

1 Open the protocol for thoracic overview images.

2 Position the coronal and transverse slices.


The thoracic overview images are displayed in the GSP.

Measuring the AAHeart_ScoutWithin the measurement step AAHeart_Scout, pseudo short-axisimages are measured. Based on these images, 3D segmentation isperformed and MPRs are generated (not displayed to the user) by thesytem. Based on the MPRs, marker points and slices are calculatedsubsequently.

3.9.3

3.9.4



Please do not use the Localizer_PseudoSAX protocol deliveredwith earlier software versions.

✓ Thoracic overview images have been measured

1 Open the AAHeart_Scout protocol.

2 Check the slice position on the sagittal localizer.

Do not modify any measurement parameters except the sliceshift in the A >> P or F >> H direction, if necessary.


The DefineLongaxis protocol opens and displays the automaticallycalculated 3 long-axis views in the GSP.



If you open the long-axis protocol before the precedingmeasurement has been finished, an overlay window is displayedon top of the protocol parameters. The information from theprevious step is needed for the automatic calculation of the long-axis views. Wait until the previous step is finished and thewindow disappears or close the protocol with Cancel.

If the AutoAlign step was not executed successfully, the icon isdisplayed in the measurement queue.

4 In case of failure, set the marker points manually.( Page 100 Defining the long-axis view manually)

Defining and measuring the long-axis localizerIn order to define the long-axis cardiac views, five markers onanatomical landmarks of the pseudo short-axis views are necessary:

◾ Left atrium◾ Aortic root◾ Right ventricle◾ Left ventricle◾ ApexThese marker points are automatically calculated by the AutoAlignHeart Scout.

✓ AAHeart_Scout has been measured

3.9.5



Checking the long-axis views

◆ Check the position of the slices.

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 manually1 Scroll through the AAHeart_Scout images and select the slice that

best represents the landmark described for each guidance step.

2 Set the marker by clicking the image.

The system automatically jumps to the next guidance view.

3 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.



Measuring the CINE long-axis view◆ Start the measurement of the long-axis localizer.

The optimal FoV for all subsequent long-axis measurements iscalculated and computed, based on the localizer measurementwith a large FoV.

Subsequently, the measurement of the CINE view is startedautomatically. The orientation is preconfigured and copied fromthe preceding step. The physiological parameters are adapted tothe actual heart rate. Breathhold commands are voice outputs thatare applied before and after the measurement. The images areloaded into the GSP and displayed in Movie Mode.

Editing CINE long-axis views (optional)If desired, you can edit the settings of the long-axis views as well asadd or remove additional standard views.Parameters such as FoV, number of slices, and gap can be edited forlong-axis views directly in the GSP, or by opening the parameter cardsof the protocol via the Details view icon in the Exam task card.

Each modification of the protocol parameters is transferred to thesubsequent protocols.

✓ Long-axis localizer has been measured

◆ Open the CINE long-axis protocol.

On the left-hand side, the selected Heart Views measured in thisprogram step are displayed. On the right-hand side, the function-specific parameters are displayed.

In the case of the ischemic heart disease workflow, only the 4-chamber view is available. The 2- and 3-chamber views aremeasured after the CINE short-axis views are acquired.

3.9.6



Adding/removing cardiac views1 Open the Adding/Removing Views dialog window with Add/

Remove.

2 Add or remove the requested cardiac views (via drag&drop of theviews from Available Views to Selectable Views and vice versa).

3 Confirm the changes with OK.

The views displayed in the dialog window are changed accordingly.

For 3T only: Improving image qualityEspecially with the CINE TrueFISP protocols, it may be necessary toadjust the offset frequency to move the TrueFISP banding artifactstypically seen outside the region of interest.1 Select the frequency scout clinical decision point.



2 Start the frequency scout measurement.

Several images of identical geometry, but of different offsetfrequencies are acquired.

3 Locate the image with the best image quality.

4 In the image text: Note the frequency offset value.

5 For the subsequent CINE TrueFISP measurement: Enter thefrequency offset value for the Trufi delta freq parameter.

The same frequency offset is automatically used in all subsequentCINE TrueFISP measurements.

Defining and measuring the short-axis localizer✓ 4-chamber view has been measured

Defining function slicesThe Shortaxis all slices will cover the left ventricle.

◆ Review and adjust the position and orientation of the slices, as wellas the number of slices, if necessary.

3.9.7



Defining a short-axis subset stack (optional)The Shortaxis subset slices are a subset of the function slices andpartially cover the heart. By default, the position of the slices isrelated to the position of the function slices. That is, if you move theshort-axis subset slices, they will snap to an invisible grid of thefunction slices.

1 Review and adjust the position and orientation of the slices, as wellas the number of slices, if necessary.

2 If you want to move the slices independently of the function slices,deactivate the Snap Shortaxis subset Slices to Shortaxis allSlices checkbox.

3 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◆ Start the measurement.

The short-axis localizer stack is measured for all slices. The optimalFoV for all subsequent short-axis measurements is calculated andcomputed, based on the localizer measurement with a large FoV.

Performing dynamic testYou can run the test without any interaction. If you want to changethe settings, please follow the description below.

3.9.8



✓ Short-axis localizer has been measured

1 Open the Dynamic test protocol.

2 Change the scan order, if requested (via drag&drop of the heartviews).

Adaptive triggering: optional heart views are measured only ifthe heart cycle is long enough, otherwise they are skipped(optimal use of time without the risk of missing heart beats.)


The result images are displayed in the GSP.

4 Verify the image quality.

If there are artifacts, repeat the dynamic test with modifiedimage parameters. To make changes to the measurement: Selectthe protocol, then select Repeat & Open from the context menu(right-click with the mouse).

Performing dynamic stressYou can run the dynamic stress measurement without anyinteraction. If you want to change the settings, please follow thedescription below.

3.9.9



✓ Dynamic test has been performed

1 Open the dynamic stress protocol.

2 Change the scan order, if requested (via drag&drop of the heartviews).


In addition to the original images, motion-corrected images andparameter maps are calculated.

Measuring CINE short-axis viewsThe following measurement can be performed without anyinteractions.◆ If you want to change the settings, please follow the descriptions

on the referenced page. ( Page 101 Editing CINE long-axis views(optional))

Each modification of the protocol parameters is transferred to thesubsequent protocols. Therefore, the position of the Shortaxissubset slices may no longer be related to the position of thefunction slices.

3.9.10



Repeating short-axis measurements: Select the short-axisprotocol, then select Repeat & Open from the context menu(right-click with the mouse). Open the Adding/Removing Viewsdialog window and move the requested short-axis view to theSelectable Views list. ( Page 102 Adding/removing cardiacviews)

During the measurement, the images are displayed in the InlineDisplay.

After all short-axis images have been acquired, an InlineVentricular Function (Inline VF) evaluation is performed. Thebase plane of the mitral valve is detected on the long-axis viewsand displayed in the resulting mosaic images. The epicardial andendocardial borders are segmented automatically.

Slices that are repeated in subsequent protocol steps replace thealready measured images. Slices that are added in subsequentprotocol steps extend the Inline VF evaluation. In both cases, anew evaluation is performed.

The Inline VF evaluation produces the following images in thedatabase:

◾ 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



(1) Series with segmented images(2) Result table(3) Long-axis mosaic image(4) Short-axis mosaic image



Performing dynamic restThe following measurement can be performed without anyinteractions.◆ Perform the same steps as with the dynamic stress measurement.

( Page 105 Performing dynamic stress)

Recommendation: For best comparison of the rest and stressdata, leave the protocol settings unchanged.

Performing tissue characterizationYou can run the tissue characterization measurement without anyinteraction. If you want to change the settings, please follow thedescription below.

1 Open the tissue characterization overview protocol.

2 Modify the inversion time TI, if necessary.


The result images are displayed in the GSP.

3.9.11

3.9.12



Performing high resolution tissue characterization(optional)If required, you can add high-resolution tissue characterizationmeasurements of the short and long axes without any interactions.◆ If you want to change the settings, please follow the descriptions

on the referenced page. #Performing tissue characterization(Cardiac Dot)#

Planning additional heart views (optional)You can acquire additional heart views which were not scheduled vialandmarks during localization (e.g., 2-chamber view RV). A guidancetext will support you while planning the requested views.

✓ The system does not know the position and orientation of apreconfigured cardiac view

Duplicating a protocol1 Select an already measured protocol.

2 Select Repeat & Open from the context menu (right-click with themouse).

On the left-hand side, the selected Heart Views measured in thisprogram step are displayed. On the right-hand side, the function-specific parameters are shown.

3.9.13

3.9.14



If you have already set up an additional heart view, you can adaptthe slice positioning by clicking Plan. ( Page 112 Openingguidance for positioning)

Changing the heart view1 Open the Adding/Removing Views dialog window with Add/

Remove.

2 Add the requested cardiac view (e.g., RV 2 Chamber) fromAvailable Views to Selectable Views via drag&drop.

3 Remove the cardiac view not wanted in the same way.

4 Confirm the changes with OK.

The views displayed in the dialog window are changed accordingly.



Opening guidance for positioning1 Open the guidance view with Plan.

2 Position the slices as shown on the guidance view.

3 Complete the planning with Confirm.


The selected heart view is measured and available for allsubsequent measurements.



Configuring protocol steps (optional)Dot Engine Step: The Dot Engine Step defines which strategies,decisions and global parameters are valid for the complete DotEngine workflow examination. For a detailed description, please referto: Operator Manual – Dot Cockpit.Dot add-ins are predefined add-ins for Dot Engine Steps andprogram steps. Depending on the selected Dot add-in, you canconfigure different parameters of the Dot Engine Step.Cardiac Dot add-ins:

◾ Cardiac Patient View◾ Cardiac Basic (= Generic add-in + Cardiac Config)◾ Cardiac Marker Localization◾ Cardiac Standard◾ Cardiac SAX PlanningAdapting the Patient View (Cardiac Patient View)1 In the Program Editor: Select the workflow step.

2 Double-click the step to open the Step Properties dialog window.

3 Open the Dot Add-In Configurator.

◆ Select the Slice Group Guidance card.

3.9.15

Adapting guidance text andexample images



Here, you can define guidance text and example images formultiple cardiac views in the Cardiac Standard add-in supportedsteps.

1 From the heart view list: Select a User View.

2 Click Rename View.

The Enter new name for User view dialog window is opened.

3 Enter the new name.

Labeling your own heart views



4 Confirm with OK.

◆ Select the GSP card.

Here, you can switch the GSP layout to the cardio-specific screenlayout (Cardio UI). In this case, the Physiological Display dialogwindow is displayed and cannot be switched off during theexamination.

Adapting the GSP layout



To ensure that the short-axis dynamic slices match the short-axisCINE slices, select Distance from the Extent Mode selection list.

◆ Select the Queue card.

The Disable Scan Button option is set to On to preventunexperienced users from operation errors (scan button isdimmed during the cardiac workflow).

Adapting protocol settings (all cardiac add-ins)1 In the Program Editor: Select a measurement step.



4 Select the Cardiac Config card.

Adapting the measurementqueue



The settings ensure the heart rate and the breathhold adaptions.

Adapting standard views (Cardiac Standard)The CINE, dynamic and delayed enhancement steps are supported bythe Cardiac Standard add-in.

You may also add myocardial maps (T1, T2, T2*) as availableheart views by dragging the corresponding protocols to theCardiac Standard Add-In. The protocols for myocardial mappingare located in the library of the Cardiac Dot Engine.

1 In the Program Editor: Select a measurement step.



4 Select the Cardiac Standard card.



Different parameter groups can be defined, for example,CineRetrospective.

The guidance text and example images for all available slices aredefined in the Cardiac Patient View and can only be changedthere. ( Page 113 Adapting the Patient View (Cardiac PatientView))

To set up the slices for a dynamic measurement, you can differentiatebetween Guaranteed and Optional slices.1 Select the Dynamic parameter group.

Adapting a dynamic parametergroup



2 Open the Adding/Removing Views dialog window with Add/Remove.

3 Select the requested views from the Selectable Views list.

4 Confirm with OK.

The slices are automatically inserted into the Optional slice group.

You can move any slices via drag&drop to the Guaranteed slicegroup.

Adapting short-axis protocols (Cardiac SAX Planning)1 In the Program Editor: Select a short-axis protocol.





4 Select the Short Axis Config card.

5 Set the Number of "Shortaxis subset" slices which should bepositioned as a subset of all CINE slices.

6 Enter the Slice distance of "Shortaxis all" slices.

A slice thickness of 8 mm and a distance factor of 25%corresponds to a slice distance of 10 mm to match the slicesexactly.

7 Activate the Adapt slice distance for exact coverage checkbox, ifyou want to adapt the slice distance for exact coverage of the leftventricle. If you want to keep the slice distance as configured,deactivate the checkbox.

8 Activate the Snap "Shortaxis subset" slices to "Shortaxis all"slices checkbox.

This option ensures that the short-axis CINE slices and the subset ofshort-axis dynamic slices are measured at the same slice position.

Adapting the DefineLongaxis protocol (Cardiac MarkerLocalization)1 In the Program Editor: Select a long-axis protocol.





4 Select the Marker Localization card.

5 Activate the Measure stacked views in this step checkbox if youwant to measure multi-slice stacks per heart view instead of singleslices.

6 Set the Number of Slices for each standard long-axis heart viewstack (2-, 3-, and 4-chamber view)

The defined long-axis view stacks are available for subsequentmeasurements.



Flow measurements

4.1 Measuring the flow in the heart 124

4

Flow measurements 4


Measuring the flow in the heartMR flow measurements are very suitable for determining the cardiacoutput volume of the ventricle and for determining the differentshunt volumes. To display flow and the encoding of the flow velocity,phase contrast images are used. (For a detailed description of thephase contrast technique, please refer to the MR Basic ManualMagnets, Flows, and Artifacts.) In what follows, the measurementof the blood flow through the aorta ascendens and the truncuspulmonalis are introduced.

For the following examination, experience in MR Cardio is aprerequisite.

Measuring the localizers✓ ECG electrodes have been attached to the patient

( Page 23 Attaching ECG electrodes)

✓ Flow measurement program has been selected

1 Measure orthogonal multislice localizers.

You will be obtaining transverse, sagittal and coronal surveyimages of the heart's location.

2 Position the transverse images on the orthogonal multislicelocalizers such that they cover the area between the aortic arc andthe heart.

Multislice localizers in the transverse, sagittal and coronal orientation.

4.1

4.1.1

4 Flow measurements


Determining the slice position of the aorta✓ Localizers have been measured

1 Position the slice in a way that minimizes measurement errors dueto turbulent flow.

2 Use a suitable transverse localizer, position a slice para-sagittal atthe height of the aortic arc and acquire a CINE image.

3 Use the images to determine the area with turbulent flow.

4 Position the measurement slice vertical to the aorta outside theturbulent flow area.

The optimal slice position is frequently at the height of thepulmonalis since turbulent flow may also be present in the aorticarc.

(1) Slice positioning for determining turbulence(2) Positioning of the measurement slice

Determining the slice position of the pulmonaryartery (pulmonalis)✓ Localizers have been measured

1 Position the slice on a suitable transverse localizer at the height ofbifurcation of the truncus pulmonalis and as much as possibleparallel to the vessel walls.

2 Create a CINE image and determine the area of turbulent flow inthe images.

4.1.2

4.1.3

Flow measurements 4


3 Position the measurement slice vertical to the pulmonalis outsidethe turbulent area.

Ensure that you are as far away from the pulmonary valve aspossible, but prior to the branching of the pulmonary artery(pulmonalis).

(1) Slice positioning for determining turbulence(2) Positioning of the measurement slice

Determining the flow sensitivityTo obtain the optimal measurement result, proceed by firstdetermining the area of maximum flow velocity.

✓ Measurement slice has been determined

1 On the Physio Signal1 parameter card: Adjust the target RR to theaverage cycle.

2 On the Angio Common parameter card: Set the velocity encoding.

Velocity encoding: Aorta 500 cm/s, Pulmonalis 350 cm/s

3 Start the measurement of the velocity localizer.

4 Load the image series into Argus and read the maximum velocity.

5 Calculate the optimal area of flow sensitivity.

4.1.4

4 Flow measurements


venc ≈ vmax × 1.2

Performing the measurement✓ Flow sensitivity has been determined

1 On the Physio Signal1 parameter card: Accept the average heartcycle for the acquisition window.

2 On the Angio Common parameter card: Enter the computed vencinto the velocity encoding window.

3 Ensure that Through Plane is entered in the direction window.

4 Activate the checkbox of the image series you would like to save.

5 Enter the breathhold command and start the measurement.

6 After completing the measurement, enter the command forbreathing.

Please note: The cardiac output volume is smaller withbreathhold technique during inspiration than with freebreathing or breathhold during expiration.

Flow-compensated, flow-encoded, and phase-contrast image of the aorta (1).

4.1.5

Flow measurements 4


Flow-compensated, flow-encoded, and phase-contrast image of thepulmonalis (2).

As an alternative, the measurement can be performed withretrospective gating. The average heart cycle is then accepted inthe target RR window.

Use retrospective gating for determining the shunt volume.

4 Flow measurements


Post-processing

5.1 Argus Viewer 1305.2 Ventricular Analysis 1365.3 4D Ventricular Analysis 1545.4 Flow analysis with Argus 168

5

Post-processing 5


Argus ViewerStarting Argus will launch the Argus Viewer. The Argus Viewer isused to view and compare cardiac images and series. Argus protocolsfor evaluation can be started from the Argus Viewer.

Starting Argus and loading images1 Select Patient > Browser.

2 Select the patient in the Patient Browser.

3 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 ofthe patient are loaded.

(1) Work segments(2) Matrix

You can load additional images later on.

5.1

5.1.1

5 Post-processing


Image area in the Argus ViewerThe image area contains work segments and matrix cells. The worksegments and matrix cells in thr Argus Viewer contain image stacks.Each image stack contains a series of images with differentacquisition times.◆ Browse the image stacks using the dog ears.

Sorting series in the matrix and the image stackThe sorting of images within series (layout in the image stack) isdifferent from the sorting of series (layout in the image matrix).

When you load new images into the Argus task card afterremoving current images, the last sorting scheme is applied.

How to change the sort scheme:◆ Select a scheme from the Image Sorting selection lists.

Layout in the image matrix

Sorting scheme Description

Series No. Layout according to series number

Orientation Arrangement according to the slice posi-tion in the head-feet orientation

Series then Orienta-tion

Identical to series number, then same asorientation

Orientation then Ser-ies

Identical to orientation, then same as ser-ies number

Post-processing 5


Arrangement in the image stack

Sorting scheme Description

Triggered Images of a series are sorted according totheir trigger time, followed by their acquis-ition time and then according to theirimage number

Chronological Images of a series are sorted according totheir acquisition time and then accordingto their image number

Anatomical The images are sorted according to theirorientation and then according to theiranatomical position

Selecting images in the matrixYou select images for the following reasons◾ 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◆ Click an image in the matrix.

The selected image is highlighted with a dashed blue border.

Selecting one or multiple series◆ Press and hold the Ctrl key while clicking the selected series (image

stacks).

All selected images are highlighted with a blue border.

Selecting a complete row or columnYou can select complete rows or columns using the numberedbuttons at the top and left side of the matrix

5.1.2

5 Post-processing


◆ Click the button for the respective row or column.

Selecting the entire matrix◆ Click the icon in the upper left corner of the matrix.

Loading a series into a work segmentThe work segments are used to edit the image display and start moviedisplay.◆ Use the mouse to load the series into a work segment.

The series in the 1st segment is highlighted in the matrix by usinga pink frame. The series in the 2nd segment is highlighted with ayellow frame.

5.1.3

Post-processing 5


(1) Image in 1st segment(2) Image in 2nd segment

Movie displayWith movie display, you can show the images of a series as a movie.The image sequence in the movie is determined by the time ofmeasurement or the slice position, depending on the parameter thatis different.Multiple movie display allows you to view up to eight seriessimultaneously.

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Keys for operating movie displayStart the movie display

Slider to set the speedPause movie display

Single frame return

Single frame advance

Displaying contours drawn (only in 1*1 and 1*2 layouts)

Movie display of single series

Movie display of 2 series in parallel



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Stop movie display

Multiple movie display using different slice positionsFor stress examinations, for example, movie display is useful tocompare images measured with the same sequence, but withdifferent slice positions.1 Select the 2*4 layout from the View card.

2 Select a series and load it into the first work segment.

3 Start the movie display.

Each of the two work segments is divided into 4 sub-segments.

The remaining seven series are loaded into the other sub-segmentsand included in the movie display.

During movie display, you can load other series into any sub-segment using the mouse.

Ventricular AnalysisVentricular Analysis is used to determine important physiologicalcardiac parameters.Ventricular analysis lets you perform Volume Analysis as well asThickening Analysis:◾ Volume analysis

Volume analysis provides information about ventricular volumes,the myocardial mass, and the functional parameters of strokevolume, ejection fraction, and cardiac output.

◾ Thickening analysisThickening analysis lets you assess the change in myocardial wallthickness of the left ventricle.

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Typically, you will evaluate the left ventricle. However, you arealso able to evaluate the right ventricle. In this case, only avolume analysis can be performed.

You need short-axis images for a ventricular analysis.

Loading images1 Select the short axis series of the patient in the matrix.

2 Click the icon in the control area.

The Argus task card is updated. The images in the matrix arerearranged:

◾ Images in a row are from the same slice position.◾ Images in a column are from the same cardiac phase.

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Checking assignment to ED, ES, base, and apexAfter loading the images, the system automatically assigns them tobase, apex, ED, and ES phases.1 Check whether the assignment is correct for this evaluation or has

to be changed.

2 If the automatic assignment is correct and no changes arenecessary, confirm the allocation with the icon on the Drawingsubtask card.

The manual ED/ES or base/apex assignment does not have to beexplicitly confirmed.

The ED/ES and base/apex assignments remain effective whensaving the data set in a new Argus series.

Checking the assignment to the ED phase◆ In most cases you can accept the suggested ED phase (first

column).

Ensure that the image with max. expansion is allocated to the EDphase.

Checking the assignment to the ED baseThe assignment to the base is correct if the image shows thebeginning of the ventricle just below the ventricular plane.1 Load the suggested ED base image into the 1st work segment.

2 Start movie display and check whether the slice is suitable for useas ED base.

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When the image shows most of the myocardium, the outflowtract should be detectable as well.However, if the image shows little of the myocardium, the sliceposition is not suitable as a basis. It will lead to incorrect results.

If the suggested slice cannot be used, define a new ED base imagefrom a suitable slice:

3 Move the base image marker (bar with down arrow) to theselected ED base image using the mouse.

You can use the arrow keys to browse the images when checkingthe ED base.If you want to apply the reassignment to all columns, select theentire row before moving the marker.

Checking the assignment to the ED apexThe assignment to the apex is correct if you can still detect a brightblood signal inside the ventricle.1 Load the suggested ED apex image into the 1st work segment.

2 Start movie display and check whether the slice is suitable for useas an ED apex image.

You can use the arrow keys to browse the images when checkingthe ED apex image.

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If the suggested slice cannot be used, define a new ED apex imagefrom a suitable slice:

3 Move the apex image marker (bar with up arrow) to the selectedED apex image using the mouse.

If you want to apply the reassignment to all columns, select theentire row before moving the marker.

Checking the assignment to the ES phase1 From the suggested ES phase, select an image of the mid-

ventricular slice position and load it into the 2nd work segment.

2 Use the arrow keys to browse all phases of the selected sliceposition and select the image with maximum myocardialcontraction.

3 Move the ES button with the mouse to the column containing theselected image.

The column is now defined as the ES phase.

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Checking the assignment to the ES base1 Load the suggested ES base image into the 2nd work segment.

2 Check the ES base image by following the procedure described forthe ED base image.

The ES base image should be defined in the same column as theES phase.

Checking the assignment to the ES apex1 Load the suggested ES apex image into the 2nd work segment.

2 Check the ES apex image by following the procedure described forthe ED apex image.

Drawing contours in the ED base imageThe next step is to draw the epicardial and endocardial contours inthe ED base image.The tools on the Drawing card are used for this purpose.

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(1) Draw contours(2) Edit contours(3) Propagate contours(4) Select drawing mode (epicardial/endocardial contour;left/ right

ventricle)(5) Confirm definitions and contours

Contours should be drawn and corrected with great care andprecision. The more precisely you draw the contours, the morereliable the results of your cardiac analysis.

Selecting the ED base image for editing◆ Load the ED base image into the 1st work segment.

Activating “Left Ventricle” drawing mode◆ Click the icon.

The mode for drawing the contours of the left ventricle isactivated.

Automatic contouringUse the Auto Adjust tool to draw easily detectable contours.

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◆ Click the icon.

An endocardial contour (red) and an epicardial contour (green) areautomatically drawn in the ED base image.

Manual contouringDifficult contours that cannot be created using the Auto Adjust toolcan be drawn using the Drawing tool.1 Click the icon.

2 Select VF Options > Use Contour Cycling.

The mode for drawing the endocardial contour is activatedautomatically.

3 Drag the tool along the endocardial contour in the active image.

4 Double-click to close the freehand contour.

The endocardial contour is shown in the ED base image.

The mode for drawing the epicardial contour is activatedautomatically.

5 Trace the anatomical contour with the mouse button pressed.

6 Double-click to close the freehand contour.

The epicardial contour is shown in the ED base image in addition tothe endocardial contour.

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Checking/correcting drawn contoursAfter drawing the contours in the ED base image, you correct themusing the contour editing tools (if applicable).

Caution

Ambiguous marking of the heart wall contour!Incorrect ventricular analysis◆ Correct the markings for the heart wall contour.

Correcting with the Splice iconThe Splice icon is used to correct the shape of a completed contour byredrawing a segment.1 Click to select the endocardial or epicardial drawing mode.

2 Click the icon.

3 Click the point of the contour in the active image where you wantto correct the shape.

4 Draw the new contour segment while pressing and holding themouse button.

5 Double-click when the new contour line meets the old contour line.

The contour is corrected accordingly.

6 Double-click to deactivate the tool.

Correcting through Nudging1 Click to select the endocardial or epicardial drawing mode.

2 Select the endocardial or epicardial contour.

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3 Click the icon.

4 Click inside or outside the contour near the contour line and keepthe mouse button pressed.

The mouse pointer takes the shape of a circle.

The size of the circle, i.e., the precision of the tool, depends onhow 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.

5 Move the circular mouse pointer toward the contour.

When the circle touches the line, the contour is pushed in thedirection of the mouse movement.

6 Double-click to deactivate the tool.

Deleting and redrawing contours (if applicable)If you want to redraw the active contour, it has to be deleted first.1 Click the icon.

The active contour is deleted.

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You can use the menu commands under Argus Tools > DeleteAll Contours to delete contours in multiple imagessimultaneously.

2 Redraw the contour in the ED base image.

Propagating contours within the ED phasePropagating contours is not the same as copying them. Instead, theyare fitted to the anatomical contours from image to image.Tools for propagating contours

(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 theother images of the ED phase.◆ Click the icon.

Epicardial and endocardial contours are drawn in the remaining EDphase images.

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Checking/correcting propagated contours1 Check whether the propagated contours match the anatomical

structures.

2 Monitor the propagation in the active segment and stop it with theicon, if necessary.

3 Load all images of the ED phase into a work segment, one by one.

4 Check the propagated contours and correct them with the drawingand editing tools, if necessary.

The propagation applies only to the selected ventricle. If youhave drawn contours for both ventricles, they have to bepropagated separately.

Propagating contours to all columnsAfter all contours in the ED images have been drawn precisely, theyare propagated to the other columns.1 Click the icon.

Epicardial and endocardial contours are drawn in the images of theremaining columns.

If you want to evaluate the ED and ES phase only, you canpropagate the contours from the ED images to the ES images:

2 Click the icon.

3 Check the propagated contours and correct them, if necessary.

4 Check the propagated contours by starting movie display with thecontours showing.

Confirming propagated contoursYou must confirm propagated contours before you can startcalculating the results.

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◆ Click the icon.

If propagated contours are not explicitly confirmed, a warningwill be displayed in the results of the ventricular analysis.

Starting volume analysis1 Click Volume in the Result subtask card.

If the patient data are incomplete, the Patient Info Dialog dialogwindow will be displayed.

2 Enter the heart rate, and the patient height and weight.

3 Click OK.

The calculation results are displayed in graphic and table format.

If the patient information is incomplete, certain results cannot becalculated. The corresponding fields in the result table remainempty.

You can use the dog ears to toggle between the result graph andthe result table.

Result diagrams

Two graphs are displayed for each ventricle evaluated:

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◾ Ventricular volume as a function of time◾ Speed of volume changes as a function of time

Example for diagram (1).

You can choose how the measurement points are connected in thegraph.

4 Select one of the following options under VF Options > Curve FitTypes:

Raw data The measurement points are connected bystraight lines.

Default Cubic Spline The curve between measurement points issmoothed with a spline function.

Manual Cubic Spline The curve type allows you to define theacceptable deviation of the characteristicof the spline function from the measure-ment points in ml.

The newly calculated spline curve is displayed as a dotted greenline in the graph.

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The graph does not show a spline curve if only the ED and ESphases have been evaluated.

Result tables

Two tables with volume parameter values are displayed for eachventricle evaluated:

◾ Absolute values and normal range◾ Normalized values and normal rangeNormal range

The normal range is determined from the parameter values ofhealthy patients while considering standard deviations.

The normal range for the various volume parameters depends onthe patient's gender.

Normalized values.

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The normalized values are calculated by dividing the cardiacparameters by different values:

Parameters Normalized parameter

Ventricular volumes Ventricular volume/body surface

Myocardial mass Myocardial mass/body surface

Stroke volume Stroke volume/body surface

Cardiac index Cardiac output/body surface

Peak ejection rate Max. cardiac output/ED volume

Peak filling rate Max. fill rate/ED volume

Time to max. ejectionfraction

Time to max. cardiac output/% systole

Time to max. fill rate Time to max. fill rate/% diastole

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Starting thickening analysisThickening analysis lets you assess the change in myocardial wallthickness of the left ventricle.

The thickening analysis is used for the left ventricle only.

Only the images of the ED and ES phases are required to performthickening analysis.

◆ Click Thickening in the Result subtask card.

On the Result subtask card, you can change the followingsettings for thickening analysis to recalculate the thickeningparameters:◾ Smooth Contours◾ Number of Sectors◾ Orientation of reference line (Angle)

The thickening parameters are calculated using the defaultsettings.

The contours are divided into six sectors by one yellow referenceline and five blue lines.

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Argus calculates the following parameters for all sectors and slices:

◾ 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.

You can browse the individual thickening graphs using the dogears.

Thickening graphic – bull’s-eye

The bull's-eye is a stylized view onto a short axis image. The centerof the circle corresponds to the cardiac apex and the outercircumference to the cardiac base.

One thickening graph is generated for each parameter.

One parameter is displayed for all sectors at the same time. Theparameter value is symbolized by a color shade:

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◾ Values within the normal range are displayed from blue (smallvalues) 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 positionsare indicated by concentric rings.

Result table

One table with thickening parameters is displayed for each sliceposition evaluated.

4D Ventricular AnalysisThe 4D ventricular analysis provides you with the possibility ofanalyzing the functions of the left ventricle with an adjustable 4Dheart model.

Evaluation is limited to the left ventricle.

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The application enables you:◾ 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 4DSequence of 4D ventricular analysis:

◾ Loading images◾ Initializing the heart model by identifying just a few anatomical

landmarks◾ Refining the model as needed by setting control points◾ Correcting, as needed, the spatial offset of individual slices caused

by different breathhold positions◾ Evaluating results

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Loading images

(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 ventricularanalysis.

1 Select the series in the Patient Browser.

2 Click the icon on the toolbar of the Patient Browser.

The Argus task card is displayed in the Argus Viewer mode.

3 Click the icon in the control area.

The Argus task card is updated.

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You need at least 2 short-axis cuts and 1 long-axis cut for the 4Dventricular analysis.Results will be more accurate by using an additional long-axis cutas well as additional short-axis cuts.

Setting landmarksInitialize the 4D heart model by identifying a few anatomicallandmarks.You start by determining the central axis of the left ventricle.Subsequently, you identify the base plane and then the transitionfrom the left to the right ventricle.Setting the apical point of the central axis1 Click the Apical Central Axis in the control area.

As soon as you have selected the Apical Central Axis, the short-axiswork segment shows the ED phase of the apical slice.

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2 Place a point into the center of the left ventricle in the short-axiswork segment.

If you want to change its position, click the point with the leftmouse button and shift it.

Setting the basal point of the central axis1 Click the Basal Central Axis in the control area.

As soon as you have selected the Basal Central Axis, the short-axiswork segment shows the ED phase of the basal slice.

2 Place a point into the center of the left ventricle in the short-axiswork segment.

If you want to change its position, click the point with the leftmouse button and shift it.

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Setting the base plane1 Click Base Plane Points in the control area

As soon as you have selected the Base Plane Points mode, thelong-axis work segment shows the ED phase of the selected slice.

2 Use the time-volume diagram to check the correct allocation of theimages to the ED or ES phase.

3 Place 2 points at the height of the base plane in the ED and ESphase in the long-axis work segment.

4 Check the position of the points in the remaining phases.

If you want to change their position, click the points with the leftmouse button and shift them.

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Determining the transition from left to right ventricle1 Click the RV Insertion Points in the control area.

As soon as you have selected the RV Insertion Points mode, twopurple points are displayed as an automatic suggestion for thetransition from the left to the right ventricle.

At the same time the model is initialized specific to the patient.

2 Check to ensure that the automatically determined transition fromthe 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 leftmouse button and shift it.

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Setting control points1 Click Guide Points in the control area.

The model can be further adapted to the patient's anatomy bysetting additional control points.

2 In the short-axis work segment, you set points to adjust thecontours to the patient's anatomy.

If you want to change its position, click the point with the leftmouse button and shift it.Right-click to delete control points.

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The model can be refined and adjusted further to the patient'sanatomy by setting/editing/deleting control points. The model iscalculated again in real time and the contours are updatedaccordingly.

For a detailed display of the results of the analysis, use the briefsummary in the time-volume diagram.

3 Click the result mode with the left mouse button.

Identical to the classic ventricular function analysis, the results areshown in the form of diagrams and tables. Additional details tohelp interpret these diagrams and tables are included in:( Page 136 Ventricular Analysis)

It is not possible to change the model in the “result” modeinteractively. As soon as the result windows are closed, theprogram changes into the “setting control points” mode and fullinteractivity is available again.

Handling of offset slicesBy measuring the heart during different breathhold positions, anoffset between slices of different acquisitions can occur. The offsethas a negative effect on the accuracy of the evaluation.For this reason, the 4D ventricle analysis provides you with thepossibility to correct the spatial offset between images. In addition,an option is available that eliminates affected slices from theevaluation.

Correcting the offsetThe Registration mode compensates for the offset between slices.1 Click the icon on the View subtask card.

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2 Press the left mouse button and drag the contours within theactive work segment to the desired position.

As soon as you release the left mouse button, the model iscalculated anew and the contours are updated.

The icon is activated through registration.

Cancelling registration◆ Click the icon in the matrix cell shown below the image.

The previously determined spatial offset is cancelled in therespective slice.

Excluding slices with offsetsYou can exclude slices from the evaluation◆ Click the icon in the area of the matrix cells.

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It is not possible to exclude slices when an Apical Central Axis, aBasal Central Axis, Base Plane Points or RV Insertion Pointswere set in these slices.Also, slices cannot be excluded when minimum datarequirements are no longer met.

The respective image data are no longer part of the evaluationcalculation. To inform the user, the associated icon is activated.

Cancelling the exclusion of slices◆ Click the icon in the respective matrix cell.

The previously excluded slice is part of the calculation again.

Evaluating the results

(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

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The times during which the image data measured are availablefor a 4D ventricular analysis are shown via filled circles in thetime-volume graph.Phases where control points were set are shown in color.

◆ Click the respective data point in the graph to read out theconcrete numerical value for one of these magnitudes (e.g. theendocardial ventricular volume).

The numerical value is shown above the data point.

Movie segment sliderThe Movie segment slider shows the time when the current imagesare displayed in the Movie segments.◆ Use the mouse to move the slider to a new position.

The images of the selected phase are shown in the Moviesegments.

While the movie is running, the slider moves synchronously withthe film along the time axis.

Work segment sliderAnalogous to the movie slider, the work segment slider shows thephase of the images displayed in the work segment.◆ Use the mouse to move the slider to a new position.

The work segments with the images of the new phase are updatedaccordingly.

ED and ES sliderThe ED or ES sliders show the end-diastolic or end-systolic phases.◆ 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 notcorrespond to the end-diastole or end-systole of the current time-volume graph, the color of the slider will turn red.

Result display:

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The respective value of the cardiac parameters Ejection Fraction,Myocardial Mass, ED volume and ES volume appears in the resultdisplay.

Each time the model is changed, the values are recalculated.

Image navigatorTo obtain an overview of the spatial relationship of the slice dataduring two-dimensional displays, you can have the position of theshort-axis cuts displayed in the long-axis cuts (or vice versa).◆ 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.

The current slice is shown in red.

You can change the current slice by clicking the enlarged circle-shaped end of the corresponding line with the mouse.

4D viewThe 4D view shows the 3D display of the left ventricle model overtime.

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1 Click the icon in the control area of the View subtask card.

The model is shown in a 1 × 1 layout.

An orientation cube shows the orientation of the heart.

Symbols on the orientation cube:

◾ S: Septal◾ L: Lateral◾ I: Inferior◾ A: Anterior◾ B: Base◾ X: Apex


The endocardial surface is displayed.

3 Click the icon again to hide the endocardial surface.


The epicardial surface is displayed.

By default, the endo- and epicardial surfaces are hidden in the 4Dview. The endo- and epicardial wire mesh models and the baseplane are set by default.

5 Click the icon again to hide the epicardial surface.


The endocardial wire mesh model is displayed.

7 Click the icon again to hide the endocardial wire mesh model.


The epicardial wire mesh model is displayed.

9 Click the icon again to hide the epicardial wire mesh model.

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The base plane is displayed.

11 Click the icon again to hide the base plane.

Showing/hiding slices◆ Click the icon in the area of the matrix cells.

The respective slice is shown/hidden.

Flow analysis with ArgusFlow analysis is used to determine the mean and maximum velocityof blood flow and the vessel cross-sections depending on the triggertime.The following example describes how to perform flow analysis ofthrough-plane data for the ascending and descending aorta. As theanalysis for in-plane data is largely the same, it is not described inwhat follows.

Please note that it is not possible to simultaneously processthrough-plane and in-plane data within the Argus flow analysis.

Preparing the dataLoading the image data

✓ Phase-contrast images and corresponding rephased images areavailable

1 Select the data series to be analyzed in the Patient Browser (usethe Ctrl key for multi-selection).

You may also select magnitude images for loading as additionaldata.

2 Transfer the data to the Argus task card by clicking the Argus icon.

The Argus task card opens in the Argus Viewer mode.

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3 Start flow analysis by clicking the icon.

The image matrix is rearranged:

◾ Images in a row are from the same image reconstruction type.◾ Images in a column are from the same cardiac phase.

(1) Work segments(2) Rephased images (labeled M)(3) Magnitude images (labeled MAG)(4) Phase-contrast images (labeled P)

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Optimizing the image display1 Enlarge the image area showing the ascending and descending

aorta.

2 Window the images to optimize their contrast and brightness.

The grayscale values of the phase-contrast images represent flowvelocities.

If necessary, you can assign a linear color scale instead of thegrayscale in the Color selection list of the View subtask card.

Example: Assignment of the Red to Blue color scale.

You cannot window phase-contrast images in color. However,you can continue to use zooming and panning.

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Defining the evaluation regionsYou draw the contours of the vessel cross-sections to define the ROIsfor flow analysis.All tools for ROI definition are available on the Drawing subtask card.You can draw ROIs into any image. Later during propagation, they arecopied automatically to the images belonging to the same phase.

The rephased images show the edges of the vessels more clearlythan the phase-contrast images. This makes them especiallysuitable for drawing.

Drawing the ROI for the ascending aorta

✓ R1 icon for drawing the 1st ROI is active

1 Load an image containing easily recognizable vessel cross-sectionsinto a work segment.

2 Draw a circular ROI around the cross section of the ascendingaorta.

3 Fit the ROI to the vessel contours of the ascending aorta by clickingthe icon.

Once the ROI is drawn, the result of the statistical evaluation isshown next to it.

The value of the highest flow velocity in the ROI is marked by apoint in the image.

Drawing the ROI for the descending aorta1 To start drawing the second ROI, click the R2 icon.

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2 Draw a circular ROI around the cross section of the descendingaorta.

3 Fit the ROI to the vessel contours of the descending aorta byclicking the icon.

Analyzing low velocities (optional)When analyzing low velocities you have to define a reference ROI.1 Start drawing the reference ROI by clicking the Ref. icon.

2 Draw a small reference ROI in an area with stationary tissue nearthe vessel of interest (e.g., in the chest wall or the spine).

The flow parameters of the reference ROI are used for subsequentbaseline correction.

Please note that if the background signal in the reference regiondiffers significantly from the vessel region, the correction by thereference ROI might not be valid!

Propagating the vessel contours to other cardiac phasesDuring propagation, the contours of the ROIs are fitted to theanatomy. The contour of the reference ROI is copied without fitting.1 Select all vessel cross-section ROIs that were drawn by clicking the

icon.

2 Start the propagation by clicking the icon.

3 Select the reference ROI with the Ref. icon.

4 Copy the reference ROI by clicking the icon.

The ROIs are drawn into the remaining images of the matrix row.

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Confirming the propagated vessel contours

◆ View the images in a work segment one by one by scrollingthrough them with the arrow keys of the keyboard.

– or –

Display the images using the movie display function of the Viewsubtask card with Graphics On.

If ROIs are misaligned, you correct them with the drawing and editingtools.1 Change the size and the position of the ROI with the Move tool.

2 Correct the shape of the ROI with the Nudge tool.

3 Redraw a segment of the ROI with the Splice tool.

4 To apply the correction to the other series of this phase, browsethrough the images with the arrow keys or click the icon on theDrawing subtask card.

If propagated ROIs are not explicitly confirmed, a warning will bedisplayed in the results of the flow analysis.◆ Accept the contours by clicking the icon.

Checking the ROIs

Correcting the ROIs

Confirming the ROIs

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Evaluating the vesselsAll tools for evaluation are available on the Result subtask card.You can graph the following parameters as a function of time:

Velocity Mean velocity within the ROI

Peak Velocity Peak velocity within the ROI

Flow Product of mean velocity andsurface area

Net Flow Difference between forward andreturn flow

Area Cross-section of the vessel

During the analysis of in-plane data, it is physically not useful tocompute the (net) flow because the vessels are merely truncated.As a result, it is not possible to reliably determine the blood flowthrough the vessel. For this reason, only the velocity as well asthe cross-sectional area of the ROI are determined with in-planedata.

Calculating results with standard settings

If the patient data are incomplete, the Patient Informationdialog window is displayed when starting the calculation.

1 Select the vessels with the R1, R2, and Ref. icons.

2 Start the calculation by clicking the respective parameter icon.

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The results for each ROI are displayed in graphic format.

3 To smooth the curve characteristic using a spline function, selectFlow Options > Fit Curve as Cubic Spline.

The spline curve is displayed in the graph as a dotted line.

4 Display the result tables by clicking Summary.

Limiting the time rangeBy default, the time between the first and last trigger time is used forevaluation.1 Change the time range by overwriting the start and end values in

the Result subtask card.

2 Start the recalculation with the Enter key.

Performing baseline correction

✓ Reference ROI has been defined

◆ Apply baseline correction with Flow Options > Use BaselineCorrection.

A baseline is calculated from the flow parameters of the referenceROI and subtracted from the result curve.

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Baseline correction is indicated in both the image text and theresult tables.

Correcting phase aliasingFlow velocities that exceed the defined flow sensitivity are shownwith an incorrect grey value, resulting in phase aliasing. Anexceedingly high positive velocity is shown as a high negative flowvelocity (black) and vice versa (“phase reversals”).

Phase aliasing can be corrected, as long as the maximum flowvelocity does not exceed double the value set as flow sensitivityduring the measurement.

Examples:

(1) Blood flowing too fast causes dark spots in the region of theascending aorta and bright spots in the region of the descendingaorta.

(2) Phase reversals can be identified by the local minimum in thesystolic phase. The highest velocities are much smaller thanexpected.

Caution

Incorrect selection of the range of velocity for a specific organ(preset range of velocity is lower than physiological range ofvelocity)!Incorrect flow and volume values◆ Correct the parameter range for the organ to be examined.

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You adjust the curves by retroactively changing the velocity range(flow sensitivity) which is set to symmetrical by default.1 Open the Venc Adjustment dialog window with the corresponding

button.

2 Change the velocity range numerically or with the scroll bar.

3 Confirm the new velocity encoding with Update Results.

The actual flow velocity cannot be determined with thiscorrection. It would require a new measurement.

Applying correction

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1,2,3 …2-chamber localizer 332-chamber view

Displaying the left ventricle 44Displaying the right ventricle 49

3-chamber viewDisplaying LV inflow andoutflow tract 46

4-chamber localizer 344-chamber view

Displaying 424D Ventricular Analysis 154

4D view 166Correcting the offset 162Evaluating the results 164Loading images 156Offset slices 162Setting landmarks 157

4D view 166

AAAHeart_Scout

Dot Engine 97Acceptance window 74Acquisition window

Coronary vessels 72Additional heart views

Dot Engine 110Aorta

Flow measurements 125Aortic valve

Displaying 54Argus flow analysis 168

Analyzing low velocities 172Ascending aorta 171Calculating results 174Confirming contours 173Correcting phase aliasing 176Correcting ROIs 173Defining evaluation regions 171Descending aorta 171Drawing ROIs 171, 171, 172Evaluating vessels 174Limiting the time range 175

Loading images 168Optimizing image display 170Performing baselinecorrection 175Propagating vessel contours 172

Argus Viewer 130Image area 131Image matrix 131Image stack 132Loading a series into a worksegment 133Loading images 130Movie display 134Selecting images 132Sorting series 131

Arrhythmia detection 30

BBattery status

PERU 25Breathhold technique

Coronary vessels 72Navigator parameters 77

Bright Blood 70

CCardiac Dot Engine

Refer to Dot Engine 90CINE long-axis views

Dot Engine 101CINE short-axis views

Dot Engine 106CINE technique 58Concatenations 59

Number of concatenations 60Coronary vessels

Acquisition window 72Breathhold technique 72Displaying 71, 73Localization 71, 72Navigator 74

DDark Blood 67

Parameters 69Preparation 68Timing 68

Display ratePhysiological Display 26

Displaying4-chamber view 42Aortic valve 54Coronary vessels 71, 73Heart functions 58Heart valves 53Left ventricle 44LV inflow and outflow tract 46LVOT 51Mitral valve 56Morphology 67Right ventricle 49Short-axis views 47Standard views 41Valve functions 58

Dot add-inCardiac Basic 116Cardiac Marker Localization 120Cardiac Patient View 113Cardiac SAX Planning 119Cardiac Standard 117

Dot Engine 90AAHeart_Scout 97Additional heart views 110CINE long-axis views 101CINE short-axis views 106Configuring protocol steps 113Dynamic rest 109Dynamic stress 105Dynamic test 104Examination strategy 93High-resolution tissuecharacterization 110Localizer at isocenter 95Long-axis localizer 99Measuring the localizer 94Short-axis localizer 103Thoracic overview images 97Tissue characterization 109

Dynamic restDot Engine 109

Dynamic stress

Index


Dot Engine 105Dynamic test

Dot Engine 104

EECG signal

Checking 28Electrodes

Attaching 23Positioning 22Procurement addresses 24

Examination strategyDot Engine 93

FFLASH

Area of application 60Functional examinations 60None-segmented 60PAT 61Phase sharing 61Segmentation 60

Flow analysis with argusRefer to Argus flow analysis 168

Flow measurements 124Determining the flowsensitivity 126Determining the slice position ofthe aorta 125Determining the slice position ofthe pulmonary artery 125Measuring localizers 124Performing 127

Flow sensitivity 126Free breathing

Navigator parameters 76Functional examinations

CINE technique 58Concatenations 59FLASH 60Inline 65Measuring multiple slices 59Number of concatenations 60TrueFISP 61

HHeart functions

Displaying 58Heart valves

Displaying 53Helpful hints

Real-time localization 38High-resolution tissuecharacterization

Dot Engine 110

IInline function examinations 65

Performing 66

LLocalization 32

2-chamber localizer 334-chamber localizer 34Coronary vessels 71, 72In real time 36Orthogonal multi-slicelocalizers 32Short-axis localizer 34

LocalizerDot Engine 94Flow measurements 124

Localizer at isocenterDot Engine 95

Long-axis localizerDot Engine 99

LVOTDisplaying 51

MMitral valve

Displaying 56Morphology

Bright Blood 70Dark Blood 67Displaying 67

Movie displayArgus Viewer 134

Multiple slices

Functional examinations 59Myocardial mapping 78

T1 mapping 79T2 mapping 81T2* mapping 82

NNavigator 74

Slice correction 75Navigator parameters

Breathhold technique 77Free breathing 76

Non-segmented FLASH sequences 60

OOrthogonal multi-slice localizers 32

PParameters

Dark Blood 69Prospective triggering 29Retrospective gating 30TrueFISP 62

PATFLASH 61TrueFISP 61

PERUPositioning 22

Phase sharingTrueFISP 61

Phase SharingFLASH 61

Physiologcial DisplaySelecting the physiologicalsignal 26

Physiological control 22Physiological display 24

Battery status 25Display of trigger events 25Displaying controls 25Displaying signal values 25

Physiological DisplayDisplaying time ranges 27Selecting the trigger method 27

Index


Setting the display rate 26Setting the number of signaltracks 26

Physiological signalPhysiologcial Display 26

PositioningElectrodes 22PERU 22

Procurement addressesElectrodes 24

Prospective triggeringSetting the parameters 29

Protocol steps (Dot Engine)Configuration 113

Pulmonary arteryFlow measurements 125

RRadial sampling

TrueFISP 62Real-time localization 36

Helpful hints 38Transferring slice parameters 37

Real-time measurementsTrueFISP 63

Retrospective gatingSetting the parameters 30With arrhythmia detection 30Without arrhythmiadetection 30

SSearch window 74Segmentation

FLASH 60TrueFISP 61

Short-axis localizer 34Dot Engine 103

Short-axis viewDisplaying 47

Signal tracksPhysiological Display 26

Standard viewsDisplaying 41

StrategyDot Engine 93

TT1 maps 79

Generating 84Measurement technique 79

T2 maps 81Generating 86Measurement technique 81

T2* maps 82Generating 88Measurement technique 83

Thickening analysis 152Thoracic overview images

Dot Engine 97Time ranges

Physiological Display 27Tissue characterization

Dot Engine 109Trigger events

Physiological display 25Trigger method

Physiological Display 27TrueFISP

Advantages 61Functional examinations 61Image quality 62Parameters 62PAT 61Phase sharing 61Radial sampling 62Real-time measurements 63Segmentation 61

VValve functions

Displaying 58Ventricular Analysis 136

Assigning the apex 138Assigning the base 138Assigning the ED phase 138Assigning the ES phase 138Checking contours 144

Checking propagatedcontours 147Confirming propagatedcontours 147Correcting contours 144Correcting propagatedcontours 147Drawing contours in the ED baseimage 141Loading images 137Propagating contours to allcolumns 147Propagating contours within theED phase 146Starting thickening analysis 152Starting volume analysis 148

Volume analysis 148


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Manufacturer’s note:

This product bears a CE marking in accordance with theprovisions of regulation 93/42/EEC of June 14, 1993 formedical products.

The CE marking applies only to medico-technical products/medical products introduced in connection with the above-mentioned comprehensive EC regulation.

Global Business UnitSiemens AGMedical SolutionsMagnetic ResonanceHenkestr. 127DE-91052 ErlangenGermanyPhone: +49913184-0www.siemens.com/healthcare

Global Siemens HeadquartersSiemens AGWittelsbacherplatz 280333 MuenchenGermany

Global Siemens HealthcareHeadquartersSiemens AGHealthcare SectorHenkestraße 12791052 ErlangenGermanyPhone: +49 9131 84-0www.siemens.com/healthcare

Legal ManufacturerSiemens AGWittelsbacherplatz 2DE-80333 MuenchenGermany

Print No. MR-05015.630.10.02.24 | © 2014, Siemens AG

www.siemens.com/healthcare

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