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MR Evaluation of Ventricular Function: True Fast Imaging with Steady-State Precession versus Fast Low-Angle Shot Cine MR Imaging: Feasibility Study¹

¹ From the Departments of Diagnostic Radiology (J.B., S.G.R., M.G., J.F.D.) and Cardiology (T.B.), University Hospital Essen, Hufelandstrasse 55, D-45122 Essen, Germany, and Siemens Medical Systems, Erlangen, Germany (G.L.). Received May 2, 2000; revision requested June 29; revision received August 7; accepted September 12. Address correspondence to J.B. (e-mail: joerg.barkhausen@uni-essen.de).

	ABSTRACT

TOP ABSTRACT INTRODUCTION Materials and Methods Results Discussion REFERENCES

 
Short- and long-axis cine magnetic resonance (MR) images were obtained with a standard fast low-angle shot, or FLASH, sequence and a first-generation true fast imaging with steady-state precession (FISP) sequence on a 1.5-T MR imager. Contrast-to-noise ratios and volumetric left ventricular measurements were compared for manual and automatic segmentation. True FISP images were associated with significantly (P < .01) higher contrast-to-noise ratios and allowed better detection of the endocardial border. True FISP images were provided with short acquisition times and excellent contrast between the myocardium and the ventricular lumen.

Index terms: Heart, MR, 51.121416 • Heart, ventricles, 51.92 • Heart, volume, 51.92 • Magnetic resonance (MR), cine study, 51.121416 • Magnetic resonance (MR), pulse sequences, 51.121416 • Magnetic resonance (MR), volume measurement, 51.121416

	INTRODUCTION

TOP ABSTRACT INTRODUCTION Materials and Methods Results Discussion REFERENCES

 
The multiplanar cross-sectional nature inherent to cine magnetic resonance (MR) imaging coupled with high spatial and temporal resolution have been shown to provide highly accurate and reproducible measures of ventricular volume, stroke volume, and ejection fraction (1,2). In fact, several authors have established cine MR imaging as the standard of reference for assessing ventricular function (2,3). Nevertheless, echocardiography has remained the method of choice for assessing most cardiodynamic parameters in clinical practice.

Limited clinical acceptance of cine MR imaging largely reflects heterogeneous image quality, particularly with regard to differentiation of luminal blood signal from surrounding myocardium. Poor contrast between the myocardium and blood flowing in the left ventricular cavity severely impedes the ability to use automatic edge detection algorithms (4). Accordingly, time-consuming and tedious manual tracing of endo- and epicardial contours is the only alternative.

High contrast between myocardium and the intraventricular cavity must thus be considered the key component required for a more widespread use of cine MR imaging in the evaluation of ventricular function. To this end, several authors have advocated the use of intravascular contrast agents capable of reducing the T1 of blood (5,6). An alternative may be MR imaging with a recently developed fast gradient-echo sequence with a very short echo time, true fast imaging with steady-state precession (FISP).

The purpose of this study was to evaluate cine MR imaging with true FISP versus standard two-dimensional fast low-angle shot (FLASH) sequences in the assessment of myocardial function. We subsequently assessed the feasibility of automatic volumetric measurements with commercially available software.

	Materials and Methods

TOP ABSTRACT INTRODUCTION Materials and Methods Results Discussion REFERENCES

 
After giving their informed consent, participants were enrolled in the study in accordance with the regulations of the local institutional review board. The study population included 10 healthy volunteers (eight men and two women; mean age, 31 years; age range, 25–44 years) and 10 consecutive patients (six men and four women; mean age, 56 years; age range, 39–84 years) referred for cardiac MR imaging to evaluate coronary heart disease (n = 4) and cardiac failure (n = 6).

MR imaging examinations were performed with a 1.5-T imager (Magnetom Sonata; Siemens Medical Systems, Erlangen, Germany) equipped with high-performance gradients (maximum amplitude, 40 mT/m; slew rate, 200 mT/m/msec). Short- and long-axis cine MR images were obtained with the standard FLASH sequence (repetition time msec/echo time msec of 11/6, flip angle of 20°, bandwidth of 195 Hz per pixel) and a true FISP sequence (3.2/1.6, flip angle of 60°, bandwidth of 975 Hz per pixel). An in-plane data acquisition matrix of 126 x 256 for FLASH and 120 x 256 for true FISP imaging was used with a rectangular (6 x 8) field of view of 350 mm², which rendered a pixel size of 2.08 x 1.37 mm for FLASH and 2.19 x 1.37 mm for true FISP imaging. Section thickness was 8 mm for both sequences, and the entire left ventricle was imaged without intersection gaps. Both sequences were prospectively triggered. The true FISP sequence acquires 15 k-space lines per frame and heartbeat, whereas the FLASH sequence acquires only seven lines per frame and per heartbeat. The resulting acquisition time is about nine R-R intervals for true FISP and 19 for FLASH imaging.

The FLASH sequence requires 77 msec to acquire seven lines (7 x repetition time). With use of echo sharing, which generates intermediate temporal phases by means of sharing the data from two temporally adjacent data sets, the effective temporal resolution was reduced to 45 msec. For the true FISP sequence, the temporal resolution was 48 msec (15 x repetition time) without echo sharing.

Contrast-to-noise ratios were based on signal intensity measurements in regions of interest placed in the myocardium, the left ventricular cavity, and an artifact-free area outside the subject. The latter was used to determine noise, defined as the SD of the mean signal intensity inside a region of interest outside the subject. Round regions of interest were standardized in size (8-mm diameter for ventricular cavity and noise, 2-mm diameter for myocardium) and placed in similar positions on images obtained with each evaluated sequence. Measurements were performed in all frames in a cardiac cycle. For short- and long-axis images, the contrast-to-noise ratio (CNR) was calculated from the mean of the signal intensity measurements throughout the entire cardiac cycle by using the following standard formula: CNR = (SI_blood - SI_myo)/noise), where SI_blood is the signal intensity in the left ventricular cavity and SI_myo is the signal intensity in the myocardium. A Student t test was performed to determine the statistical significance of observed differences. Differences with a P value less than .01 were considered to be significant.

To eliminate all operator-related differences, all manual and semiautomatic image analysis procedures were performed by the same experienced investigator (J.B.) with commercially available software (ARGUS; Siemens Medical Systems). The most basal section was defined as the section in which the left ventricular myocardium extended over at least 50% of the circumference on the end-diastolic and end-systolic images.

In a first step, manual segmentation was performed with both sequences. Subsequent analysis was repeated with semiautomatic contour detection. Manual evaluation was performed by drawing the endocardial contours on all end-diastolic and end-systolic images. During manual tracing, the papillary muscles were ignored and included in the left ventricular chamber volume. With semiautomatic segmentation, the contours were drawn on only one section (most basal location), and all other sections were automatically segmented. None of the automatically drawn contours were corrected or redrawn.

The results of the four cardiodynamic measurements (FLASH manual segmentation, FLASH semiautomatic segmentation, true FISP manual segmentation, true FISP semiautomatic segmentation) were compared by calculating systematic and random differences and the correlation coefficients. The agreement between manual and semiautomatic assessments of volumetric parameters was illustrated in Bland-Altman graphs (7). The limits of agreement are given as the mean plus or minus the SD, where the mean is the average of the relative differences between data and is ideally zero but may be either a positive or negative value plus or minus the SD.

	Results

TOP ABSTRACT INTRODUCTION Materials and Methods Results Discussion REFERENCES

 
Short-axis true FISP images showed improved contrast between the myocardium and the ventricular cavity (Fig 1). True FISP images compared with FLASH images showed approximately twice the mean signal intensity of the left ventricular cavity. The mean contrast-to-noise ratios for the true FISP sequence was improved by an average of 46% compared with that for the FLASH sequence (Table 1), although noise increased owing to the higher bandwidth.

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 1a. Coronary heart disease in a 64-year-old female patient. Short-axis view: (a) FLASH and (b) true FISP MR images reveal the difference in image quality regarding the ability to delineate myocardial contours. The true FISP image even permits exact delineation of the papillary muscles (arrows).

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 1b. Coronary heart disease in a 64-year-old female patient. Short-axis view: (a) FLASH and (b) true FISP MR images reveal the difference in image quality regarding the ability to delineate myocardial contours. The true FISP image even permits exact delineation of the papillary muscles (arrows).

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 2a. Coronary heart disease and reduced ventricular function (ejection fraction, 39%) in a 45-year-old male patient. Long-axis view: (a) end-diastolic and (b) end-systolic FLASH cine MR images compare unfavorably with (c) end-diastolic and (d) end-systolic true FISP images. Insufficient visibility of the endocardial border (arrows) on the end-systolic FLASH image reflects slow flow within the ventricular lumen.

View larger version (114K): [in this window] [in a new window] [Download PPT slide]   Figure 2b. Coronary heart disease and reduced ventricular function (ejection fraction, 39%) in a 45-year-old male patient. Long-axis view: (a) end-diastolic and (b) end-systolic FLASH cine MR images compare unfavorably with (c) end-diastolic and (d) end-systolic true FISP images. Insufficient visibility of the endocardial border (arrows) on the end-systolic FLASH image reflects slow flow within the ventricular lumen.

View larger version (125K): [in this window] [in a new window] [Download PPT slide]   Figure 2c. Coronary heart disease and reduced ventricular function (ejection fraction, 39%) in a 45-year-old male patient. Long-axis view: (a) end-diastolic and (b) end-systolic FLASH cine MR images compare unfavorably with (c) end-diastolic and (d) end-systolic true FISP images. Insufficient visibility of the endocardial border (arrows) on the end-systolic FLASH image reflects slow flow within the ventricular lumen.

View larger version (126K): [in this window] [in a new window] [Download PPT slide]   Figure 2d. Coronary heart disease and reduced ventricular function (ejection fraction, 39%) in a 45-year-old male patient. Long-axis view: (a) end-diastolic and (b) end-systolic FLASH cine MR images compare unfavorably with (c) end-diastolic and (d) end-systolic true FISP images. Insufficient visibility of the endocardial border (arrows) on the end-systolic FLASH image reflects slow flow within the ventricular lumen.

View larger version (105K): [in this window] [in a new window] [Download PPT slide]   Figure 3a. Short-axis MR images obtained in a 29-year-old male volunteer. All contours were semiautomatically segmented. In the posterior section, the contour detection failed on (a), the end-diastolic FLASH image whereas the endocardial boundary is depicted correctly (b) on the end-diastolic true FISP image. Automated segmentation results in overestimation of the left ventricular volume on (c) the end-systolic FLASH image owing to poor contrast between ventricular volume and the myocardium. (d) On the end-systolic true FISP image, the ventricular volume is slightly underestimated owing to exclusion of the papillary muscle (arrow).

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 3b. Short-axis MR images obtained in a 29-year-old male volunteer. All contours were semiautomatically segmented. In the posterior section, the contour detection failed on (a), the end-diastolic FLASH image whereas the endocardial boundary is depicted correctly (b) on the end-diastolic true FISP image. Automated segmentation results in overestimation of the left ventricular volume on (c) the end-systolic FLASH image owing to poor contrast between ventricular volume and the myocardium. (d) On the end-systolic true FISP image, the ventricular volume is slightly underestimated owing to exclusion of the papillary muscle (arrow).

View larger version (94K): [in this window] [in a new window] [Download PPT slide]   Figure 3c. Short-axis MR images obtained in a 29-year-old male volunteer. All contours were semiautomatically segmented. In the posterior section, the contour detection failed on (a), the end-diastolic FLASH image whereas the endocardial boundary is depicted correctly (b) on the end-diastolic true FISP image. Automated segmentation results in overestimation of the left ventricular volume on (c) the end-systolic FLASH image owing to poor contrast between ventricular volume and the myocardium. (d) On the end-systolic true FISP image, the ventricular volume is slightly underestimated owing to exclusion of the papillary muscle (arrow).

View larger version (124K): [in this window] [in a new window] [Download PPT slide]   Figure 3d. Short-axis MR images obtained in a 29-year-old male volunteer. All contours were semiautomatically segmented. In the posterior section, the contour detection failed on (a), the end-diastolic FLASH image whereas the endocardial boundary is depicted correctly (b) on the end-diastolic true FISP image. Automated segmentation results in overestimation of the left ventricular volume on (c) the end-systolic FLASH image owing to poor contrast between ventricular volume and the myocardium. (d) On the end-systolic true FISP image, the ventricular volume is slightly underestimated owing to exclusion of the papillary muscle (arrow).

View larger version (52K): [in this window] [in a new window] [Download PPT slide]   Figure 4. Bland-Altman graphs depict agreement between cardiodynamic measurements from manually and automatically segmented contours (solid lines = mean value of the differences, dotted lines = ±2 SDs). The average value of the two measurements is plotted along the x axis; the difference is plotted along the y axis. Agreement of the measurements based on true FISP images (left column: A, C, E, G) is much better compared with agreement based on FLASH images (right column: B, D, F, H). EDV = end-diastolic volume, EF = ejection fraction, ESV = end-systolic volume, SV = stroke volume.

	Discussion

TOP ABSTRACT INTRODUCTION Materials and Methods Results Discussion REFERENCES

The FLASH sequence is a spoiled gradient-echo sequence, whereas FISP imaging involves a steady state built up in both the longitudinal and transverse directions. In FISP imaging, however, only one or two of the gradients are balanced, whereas the true FISP sequence is characterized by balanced gradients in all three directions, which ensures maximum recovery of the transverse magnetization.

Cine MR imaging has long been considered the most accurate clinical method for assessing ventricular volumes (1–3). In contrast to angiographic volumetric analysis, the cross-sectional nature of cine MR imaging makes it independent of geometric assumptions. Thus, all ventricular shapes can be accurately measured—a prerequisite for determining right ventricular data. Lack of radiation or any other harmful side effects coupled with better spatial resolution make cine MR imaging superior to nuclear medicine techniques (2). Operator independence and better distinction between myocardium and the ventricular cavity represent important advantages of cine MR imaging over three-dimensional echocardiography (1).

Early studies used spin-echo techniques (8) for the evaluation of ventricular volumes, but Utz et al (9) described a multisection gradient-echo sequence with continuous data acquisition for cine MR examinations. This non–breath-hold technique acquires one k-space line per section and per heartbeat, resulting in a minimum acquisition time of 128 cardiac cycles with a 128 x 256 matrix. In 1991, Atkinson and Edelmann (10) introduced a segmented turbo FLASH sequence for single breath-hold cardiac cine MR imaging. An optimized version of that sequence can now be considered the standard sequence for cardiac cine MR imaging (11). View sharing, introduced by Foo et al (12), improved the effective temporal resolution by reducing the time between frames without altering image acquisition times. Thus end-systolic and end-diastolic volumes could be more accurately defined.

The true FISP sequence evaluated in this study, compared with the standard FLASH sequence, provides images with shorter acquisition times and improved contrast between myocardium and intraventricular cavities. The contrast on true FISP images proved sufficient for automatic segmentation; cardiodynamic parameters based on manually segmented data correlated well with those based on automatic segmentation. For true FISP images, automatic compared with manual segmentation resulted in a slight underestimation of ventricular volumes. This bias may be caused by partial exclusion of papillary muscles during automatic segmentation; the papillary muscles were included in the left ventricular chamber volume during manual segmentation. Because underestimation was present to the same degree on end-diastolic and end-systolic images, the ejection fraction showed excellent agreement with the results obtained with manual segmentation. To achieve reliable volumetric measurements in all patients, checking and correcting of the automatically provided contours is still necessary. The number of corrections required is very limited, which ensures major time-savings with automatic segmentation as compared with manual segmentation.

This study was performed with a first-generation true FISP cine MR sequence. Off-resonance effects resulted in artifacts in some participants that reduced contrast between myocardium and the left ventricular cavity and thereby hampered the automatic segmentation process. These problems have been resolved with the second generation of true FISP sequences, which have shorter repetition times. We expect that use of more recent true FISP sequences will result in even more accurate automatic segmentation.

Automatic segmentation of FLASH images resulted in overestimation of systolic volumes and underestimation of ejection fractions. This bias is likely caused by failed delineation of the left ventricular borders on systolic images during automatic segmentation. In FLASH imaging, blood pool versus myocardium contrast is dependent on blood flow, which results in reduced contrast in areas with low velocity caused by saturation (13,14). In true FISP imaging, blood pool versus myocardium contrast is largely dependent on T2 and T1 properties, which remain constant throughout the cardiac cycle. Thus, true FISP imaging is considerably less sensitive to effects of blood flow (13).

Frustrated by the inability to use automatic data segmentation, several authors advocate the use of intravascular contrast agents in conjunction with FLASH cine MR imaging. Their studies demonstrate an improvement in contrast-to-noise ratios on both short- and long-axis images. In the present study, however, the mean contrast-to-noise ratio with the nonenhanced true FISP sequence was superior to published contrast-to-noise ratios determined on contrast material–enhanced FLASH images: 35 versus 32 on short-axis images and 22 versus 16 on long-axis images (5). The true FISP sequence evaluated in this study obviates intravascular contrast agents for cardiodynamic measurements.

Until recently, mainly single-section techniques were used for clinical cardiac cine MR imaging. Alley et al (6) demonstrate the feasibility of three-dimensional cine MR imaging, but, owing to the low intrinsic contrast between the myocardium and left ventricular blood pool, a T1-shortening contrast agent has to be added. A recently developed real-time true FISP sequence can acquire multiple short-axis sections through the entire left ventricle in a single breath hold (13). Early results are promising, although the reduced temporal and spatial resolutions will result in less accurate cardiodynamic measurements than are achieved with single-section sequences.

Technologic developments have resulted in the shortening of acquisition times and improved image quality, but the time-consuming manual segmentation has remained the limiting factor in clinical use of cine MR imaging for assessing cardiodynamic parameters. Different methods have been reported for automatic segmentation of the endocardial border, including region growing, edge detection, adaptive thresholding, and fuzzy logic (4,15–18). Results have remained ambiguous. van der Geest et al (19) conclude that left ventricular functional parameters can be obtained with a high degree of accuracy with semiautomatic contour detection, but Rominger et al (4) report that semiautomatic evaluation is erroneous and manual correction of these contours took more time than manual contour tracing alone. True FISP imaging puts these issues to rest by providing better source data characterized by a virtually flow-independent contrast between the ventricular lumen and surrounding myocardium. Rominger et al (4) found large measurement errors with FLASH imaging data, but the same software provided accurate cardiodynamic measurements when analysis was based on true FISP cine MR images acquired in this study.

We conclude that the presented first-generation true FISP sequence is characterized by shorter acquisition times and improved image quality compared with the standard two-dimensional FLASH cine MR imaging sequence. The contrast between ventricular lumen and myocardium associated with true FISP cine MR imaging is sufficient for commercially available automatic contour tracing tools.

	FOOTNOTES

 
Abbreviations: FISP = fast imaging with steady-state precession, FLASH = fast low-angle shot

Author contributions: Guarantor of integrity of entire study, J.B.; study concepts and design, all authors; literature research, J.B., M.G.; clinical studies, J.B., S.G.R.; experimental studies, G.L.; data acquisition, J.B., T.B.; data analysis, J.B.; statistical analysis, J.B., M.G.; manuscript preparation, J.B., S.G.R.; definition of intellectual content, J.B., J.F.D.; manuscript editing, J.B., S.G.R., J.F.D.; manuscript review, all authors; manuscript final version approval, all authors.

	REFERENCES

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				H. P. Kuhl, E. Spuentrup, A. Wall, A. Franke, J. Schroder, N. Heussen, P. Hanrath, R. W. Gunther, and A. Buecker Assessment of Myocardial Function with Interactive Non-Breath-hold Real-time MR Imaging: Comparison with Echocardiography and Breath-hold Cine MR Imaging Radiology, April 1, 2004; 231(1): 198 - 207. [Abstract] [Full Text] [PDF]

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