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MR Imaging of the Heart with Cine True Fast Imaging with Steady-State Precession: Influence of Spatial and Temporal Resolutions on Left Ventricular Functional Parameters¹

¹ From the Department of Diagnostic Radiology, Eberhard-Karls-University, Tübingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (S.M., U.K.); Department of MR Research and Development, Siemens Medical Systems, Chicago, Ill (O.P.S.); and Department of MR Research, Northwestern University, Chicago, Ill (J.C., J.P.F.). Received January 4, 2001; revision requested February 26; final revision received August 10; accepted October 10. Address correspondence to S.M. (e-mail: stephan.miller@uni-tuebingen.de).

	ABSTRACT

TOP ABSTRACT INTRODUCTION Materials and Methods Results Discussion REFERENCES

 
The influence of changes in spatial and temporal resolutions on functional parameters in the left ventricle (LV) were investigated with magnetic resonance (MR) imaging with a modified true fast imaging with steady-state precession, or FISP, two-dimensional sequence that provided temporal resolution of 21–90 msec and spatial resolution of 1–3 mm. MR imaging in the heart was performed in 15 healthy volunteers. A decrease in LV functional parameters was observed with reduced spatial and temporal resolutions. The influence of temporal resolution was more relevant.

© RSNA, 2002

Index terms: Heart, MR, 51.121412 • Magnetic resonance (MR), cine study • Magnetic resonance (MR), image processing • Magnetic resonance (MR), technology, 51.121412

	INTRODUCTION

TOP ABSTRACT INTRODUCTION Materials and Methods Results Discussion REFERENCES

 
Magnetic resonance (MR) imaging has become the standard for evaluation of anatomic and functional parameters of the heart, such as chamber volumes, ejection fraction, mass, and left ventricle (LV) ejection and filling rates (1–5). Currently, cardiac-gated, spoiled gradient-echo sequences (ie, fast low-angle shot, or FLASH) are used for this purpose and are commonly applied with breath holding (6). This approach has been proven to be more accurate than non–breath-hold measurements (7,8). However, the breath-hold period may be limited by the patient’s clinical status and may have to be adapted on an individual basis. Therefore, a compromise is generally made between temporal and spatial resolutions, since a given breath-hold interval for data acquisition cannot be exceeded. Use of very short repetition times could ameliorate this problem, but, with use of standard spoiled gradient-echo techniques, relief would come at the price of reduced contrast between the blood pool and myocardium, which is dependent on flow and repetition time.

Recently, segmented true fast imaging with steady-state precession (FISP) sequences have been introduced that provide high signal intensity and blood-myocardial contrast-to-noise ratio with very short repetition times (9). Spatial and temporal resolutions can be substantially improved with this technique, and acquisition time is decreased. Although it seems intuitively obvious that cardiac frame duration and spatial resolution may influence functional parameters derived from cine MR images (10,11), it is still unclear how the accuracy of these measurements varies as spatial and temporal resolutions are changed.

The purpose of this study was to investigate the influence of spatial and temporal resolutions on the values of LV functional parameters derived with true FISP MR imaging.

	Materials and Methods

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Consecutive MR examinations were performed in 15 healthy volunteers (five women, 10 men; age range, 22–35 years; mean age, 28.3 years ± 0.9 [SD]). Time frame duration (temporal resolution) and spatial resolution were varied in 13 and 12 examinations, respectively. To assess the reproducibility of functional parameters and the intraindividual influence of spatial and temporal resolutions, 10 of the volunteers underwent imaging twice (on different days) with various spatial and temporal resolutions. Inclusion criteria for the examination were no history of cardiac, pulmonary, or other disease. Exclusion criteria were common contraindications (cerebral surgical clip material, pacemaker, claustrophobia) for MR imaging. The investigation was approved by the institutional review board, and informed consent was given by each subject.

MR Imaging
MR images were acquired with a 1.5-T whole-body MR system (Magnetom Sonata; Siemens Medical Systems, Iselin, NJ) by using a quadrature phased-array body coil, prospective electrocardiography triggering, and breath holding. To detect relevant changes in hemodynamic parameters during the examination, blood pressure and heart rate were monitored and documented. The position of the heart was determined with a localizer sequence (single-shot two-dimensional true FISP, repetition time msec/echo time msec of 3.2/1.6, flip angle of 60°, 6-mm section thickness, 350 x 350 field of view, 256 x 256 matrix), and imaging planes were adjusted to obtain standard long- and short-axis views. Subsequently, true FISP cine MR imaging was performed in the LV from the base to the apex, with eight to 12 5-mm-thick sections and 5-mm gap in the short-axis orientation.

The true FISP pulse sequence is designed to maintain the transverse magnetization in a steady state from one repetition time to the next by rewinding the gradient waveforms on all axes (12). The total gradient area on all axes is zero at every radio-frequency pulse. The polarity of the excitation pulse is alternated by applying a 180° phase shift to every excitation pulse (Fig 1).

View larger version (33K): [in this window] [in a new window] [Download PPT slide]   Figure 1. Schematic depicts the timing module of the basic true FISP pulse sequence. All gradient waveforms (G) are rewound in each repetition time (TR). Phase (Ny) of the excitation pulse () is alternated from one repetition time to the next. Echo time (TE) = TR/2. RF = radio frequency.

To investigate the influence of temporal resolution (frame duration), echo train length for segmented data acquisition was set to seven, 15, 20, and 30 lines, which resulted in frame durations of 21, 45, 60, and 90 msec, respectively. In-plane spatial resolution was kept at a pixel size of 1.5 x 1.5 mm or smaller in a rectangular field of view. Typical parameter settings were approximately 255 x 340-mm field of view with 165 x 256 matrix. Echo sharing was not implemented with true FISP in the current study, and, depending on the individual heart rate, the breath-hold time for data acquisition was 18–24 seconds for temporal resolution of 21 msec, 9–12 seconds for temporal resolution of 45 msec, 6–8 seconds for temporal resolution of 60 msec, and 4–7 seconds for temporal resolution of 90 msec.

To investigate the influence of spatial resolution, the sequence version with an echo train length of 15 lines was chosen (frame duration, 45 msec). Three measurements were started with high spatial resolutions of 1.0–1.2-mm pixel size (spatial resolution 1) with stepwise incrementation by 1 mm to 3.0–3.2-mm pixel size (spatial resolutions 2 and 3, respectively). With this approach, breath-hold time for data acquisition was 15–18 seconds for spatial resolution 1, 7–10 seconds for spatial resolution 2, and 5–7 seconds for spatial resolution 3.

Data Analysis
MR images were analyzed by using commercial evaluation software (Argus; Siemens Medical Systems, Iselin, NJ) with a separate workstation. With use of a midventricular reference image, window and level settings were chosen by one radiologist (S.M.) to optimize contrast between blood pool and myocardium, and they were applied to all images. In all subjects, high image quality with excellent contrast-to-noise ratio between blood pool and myocardium was achieved, which facilitated image segmentation. Endocardial and epicardial contours were manually drawn on end-diastolic and end-systolic short-axis images by the same radiologist. To derive an analysis of LV volume over time, endocardial contours were propagated through the entire stack of images at each section position. Papillary muscles were assigned to the LV lumen and, therefore, ignored. LV volume and mass were calculated as the sum of section volumes, which was determined by summing the section area multiplied by section thickness plus gap. Since both section thickness and gap were set to 5 mm, the LV volume could be calculated as the sum of section (S) areas multiplied by 1 cm: LV volume = ⁿ_i=1(S_i_area x 1 cm).

With this method, end-diastolic volume (EDV), end-systolic volume, ejection fraction (EF), and myocardial mass were determined as absolute values and as index values that were normalized for body surface area. In addition, peak LV filling and ejection flow rates were automatically derived on the basis of a least squares curve fit of the data for LV volume over time. For comparison of different images obtained with various temporal or spatial resolutions, images with maximum temporal resolution (21-msec frame duration) or highest spatial resolution (pixel size of 1.0–1.2 mm, 45-msec frame duration) were considered as the standard of reference.

Statistical Analysis and Reproducibility
Interstudy and inter- and intraobserver reproducibility were determined as the mean ± SD for the parameters EDV index, LV mass index, and EF by means of the Bland-Altmann approach: |M₁ - M₂|/[(M₁ + M₂)/2], where M is measurement.

Interstudy reproducibility was tested in the 10 volunteers who underwent imaging twice on different days by using true FISP cine imaging with a 45-msec frame duration and pixel size of less than 1.5 mm. In these 10 volunteers, sequence parameters for temporal resolution of 45 msec could be kept identical for both branches of the study, a systematic variation of spatial and temporal resolutions. To determine the interobserver variability, 10 examinations obtained with pixel size less than 1.5 mm and 21- or 45-msec frame duration were evaluated by two independent observers. Intraobserver variability was determined by one observer (S.M.) evaluating the data twice for 12 images with 21- or 45-msec frame duration and less than 1.5-mm pixel size.

Data analysis was conducted on subsets of data in which every subject had only one contribution. Therefore, differences in functional parameters for spatial and temporal resolutions were tested by means of analysis of variance. The trend of data was analyzed with the Jonkheere-Terpstra method. Differences with a P value of less than .05 were considered significant.

	Results

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Altogether, 88 MR images were obtained in the heart. Heart rates ranged from 54 to 83 beats per minute. The individual changes in heart rate and blood pressure were in the range of 4%–7% (mean, 4.3% ± 1.1) and typically occurred during the first 10 minutes of the MR examination. A summary of the results of deriving LV functional parameters from true FISP cine MR images is given in Tables 1 and 2.

View larger version (26K): [in this window] [in a new window] [Download PPT slide]   Figure 2. Scatterplot compares EDV index for different values of temporal resolution (T45 = 45 msec, T60 = 60 msec, T90 = 90 msec). The x-y plot of EDV index for different values of temporal resolution shows good correlation (r = 0.98-0.99; slope, 0.79-1.08; P < .001). The graph demonstrates that there is no influence of temporal resolution on EDV index.

View larger version (14K): [in this window] [in a new window] [Download PPT slide]   Figure 3. Bar graph depicts influence of temporal resolution of 21-90 msec (T21, T45, T60, T90) on EF, with mean EF values and error bars that indicate SD. EF decreases with reduction in temporal resolution. The P values are given in comparison with temporal resolution of 21 msec.

View larger version (15K): [in this window] [in a new window] [Download PPT slide]   Figure 4a. Bar graph depicts influence of temporal resolution of 21-90 msec (T21, T45, T60, T90) on ejection and filling rates, with mean values and error bars that indicate SD. P values are given in comparison with temporal resolution of 21 msec. (a) Ejection and (b) filling rates decrease with reduction of temporal resolution.

View larger version (15K): [in this window] [in a new window] [Download PPT slide]   Figure 4b. Bar graph depicts influence of temporal resolution of 21-90 msec (T21, T45, T60, T90) on ejection and filling rates, with mean values and error bars that indicate SD. P values are given in comparison with temporal resolution of 21 msec. (a) Ejection and (b) filling rates decrease with reduction of temporal resolution.

Table 3 summarizes the effect of spatial and temporal resolutions on LV functional parameters and the corresponding level of significance. Four curves that demonstrate LV volume over time that depict the measurement points and adapted curve for different temporal resolution values are provided in Figure 5. Images obtained with spatial resolutions 1–3, with and without contours, are shown in Figure 6.

View larger version (32K): [in this window] [in a new window] [Download PPT slide]   Figure 5. Curves for LV volume over time for temporal resolutions (T) of 21-90 msec. The y axes indicate volume (milliliters), and the x axes indicate time (milliseconds). End systole is not detected with temporal resolutions of 60 () and 90 () msec compared with temporal resolutions of 21 () and 45 () msec. Ejection and filling rates decrease with increasing time frame duration.

View larger version (131K): [in this window] [in a new window] [Download PPT slide]   Figure 6a. End-diastolic and end-systolic short-axis MR images (electrocardiography-triggered cine true FISP two-dimensional sequence, 45/1.5, effective repetition time of 3 msec, flip angle of 50°, 5-mm section thickness) were obtained with different spatial resolutions. Imaging was performed in identical section positions, with and without contours. Increased pixel size is associated with increased partial volume effects and blurring of contours. (a) End-diastolic and (b) end-systolic images were obtained with spatial resolution 1 (pixel size, 1 x 1 mm). (c) End-diastolic and (d) end-systolic images were obtained with spatial resolution 2 (pixel size, 2 x 2 mm). (e) End-diastolic and (f) end-systolic images were obtained with spatial resolution 3 (pixel size, 3 x 3 mm).

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   Figure 6b. End-diastolic and end-systolic short-axis MR images (electrocardiography-triggered cine true FISP two-dimensional sequence, 45/1.5, effective repetition time of 3 msec, flip angle of 50°, 5-mm section thickness) were obtained with different spatial resolutions. Imaging was performed in identical section positions, with and without contours. Increased pixel size is associated with increased partial volume effects and blurring of contours. (a) End-diastolic and (b) end-systolic images were obtained with spatial resolution 1 (pixel size, 1 x 1 mm). (c) End-diastolic and (d) end-systolic images were obtained with spatial resolution 2 (pixel size, 2 x 2 mm). (e) End-diastolic and (f) end-systolic images were obtained with spatial resolution 3 (pixel size, 3 x 3 mm).

View larger version (116K): [in this window] [in a new window] [Download PPT slide]   Figure 6c. End-diastolic and end-systolic short-axis MR images (electrocardiography-triggered cine true FISP two-dimensional sequence, 45/1.5, effective repetition time of 3 msec, flip angle of 50°, 5-mm section thickness) were obtained with different spatial resolutions. Imaging was performed in identical section positions, with and without contours. Increased pixel size is associated with increased partial volume effects and blurring of contours. (a) End-diastolic and (b) end-systolic images were obtained with spatial resolution 1 (pixel size, 1 x 1 mm). (c) End-diastolic and (d) end-systolic images were obtained with spatial resolution 2 (pixel size, 2 x 2 mm). (e) End-diastolic and (f) end-systolic images were obtained with spatial resolution 3 (pixel size, 3 x 3 mm).

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 6d. End-diastolic and end-systolic short-axis MR images (electrocardiography-triggered cine true FISP two-dimensional sequence, 45/1.5, effective repetition time of 3 msec, flip angle of 50°, 5-mm section thickness) were obtained with different spatial resolutions. Imaging was performed in identical section positions, with and without contours. Increased pixel size is associated with increased partial volume effects and blurring of contours. (a) End-diastolic and (b) end-systolic images were obtained with spatial resolution 1 (pixel size, 1 x 1 mm). (c) End-diastolic and (d) end-systolic images were obtained with spatial resolution 2 (pixel size, 2 x 2 mm). (e) End-diastolic and (f) end-systolic images were obtained with spatial resolution 3 (pixel size, 3 x 3 mm).

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 6e. End-diastolic and end-systolic short-axis MR images (electrocardiography-triggered cine true FISP two-dimensional sequence, 45/1.5, effective repetition time of 3 msec, flip angle of 50°, 5-mm section thickness) were obtained with different spatial resolutions. Imaging was performed in identical section positions, with and without contours. Increased pixel size is associated with increased partial volume effects and blurring of contours. (a) End-diastolic and (b) end-systolic images were obtained with spatial resolution 1 (pixel size, 1 x 1 mm). (c) End-diastolic and (d) end-systolic images were obtained with spatial resolution 2 (pixel size, 2 x 2 mm). (e) End-diastolic and (f) end-systolic images were obtained with spatial resolution 3 (pixel size, 3 x 3 mm).

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 6f. End-diastolic and end-systolic short-axis MR images (electrocardiography-triggered cine true FISP two-dimensional sequence, 45/1.5, effective repetition time of 3 msec, flip angle of 50°, 5-mm section thickness) were obtained with different spatial resolutions. Imaging was performed in identical section positions, with and without contours. Increased pixel size is associated with increased partial volume effects and blurring of contours. (a) End-diastolic and (b) end-systolic images were obtained with spatial resolution 1 (pixel size, 1 x 1 mm). (c) End-diastolic and (d) end-systolic images were obtained with spatial resolution 2 (pixel size, 2 x 2 mm). (e) End-diastolic and (f) end-systolic images were obtained with spatial resolution 3 (pixel size, 3 x 3 mm).

	Discussion

TOP ABSTRACT INTRODUCTION Materials and Methods Results Discussion REFERENCES

The true FISP sequence was chosen because of its superior performance compared with fast low-angle shot MR imaging. At very short repetition time, true FISP offers higher blood-myocardial contrast-to-noise ratio than can be achieved with fast low-angle shot MR imaging, independently of flow and related to the ratio to T2 to T1 (9). This may endow specific advantages in patients with low cardiac output (eg, cardiac failure or dilated cardiomyopathy). Also, increased contrast-to-noise ratio between blood pool and myocardium is helpful for contour tracing algorithms (13,14).

The current study was limited to evaluation of segmented true FISP MR imaging. The use of real-time imaging with the true FISP sequence holds promise for single-breath-hold cine data acquisition in the entire heart with limited spatial and temporal resolutions. In a comparison between different sequence settings, however, initial results suggested that both spatial and temporal resolutions may influence cardiac functional parameters derived from cine MR images (15). With true FISP, therefore, one can take advantage of faster data acquisition by optimizing the balance between spatial and temporal resolutions. For this and other reasons, the effect of spatial and temporal resolutions on measurement of cardiac functional parameters warrants investigation.

Although this study was performed in a small group of healthy volunteers and did not include patients with cardiac disease, the role of spatial and temporal resolutions for different cardiac functional parameters is evident (Table 3). Overall, interstudy and inter- and intraobserver variability were small and comparable with results in prior studies (16–18). For consecutive coverage of the LV, we chose an intersection gap of 5 mm (one section thickness), which could introduce some variation to cardiac functional parameters beyond the variation of spatial and temporal resolutions. This issue has recently been addressed by Cottin et al (19) and found to be negligible for an intersection gap as large as 10 mm. Variation of individual hemodynamic parameters (blood pressure and heart rate) may also be considered as potential sources of variability in our study. However, maximum changes usually occurred at the beginning of the examination (during the first 5–10 minutes in the magnet bore, which include section positioning and image planning), and parameters were stable during the rest of the examination. Therefore, only slight variation of hemodynamic parameters may be assumed throughout the acquisition of subsequent cine images.

An effect of spatial resolution on EDV and EDV index was observed with increasing pixel size. The parameter EDV is calculated on the basis of the definition of the endocardial contours and therefore depends on accurate contour drawing. Overestimation of this parameter could conceivably be due to partial volume effects at the junction of blood pool and myocardium. The EDV values with different settings of temporal resolution reflect interstudy reproducibility, because at normal heart rates the LV volume does not directly change immediately after the R wave but approximately 60–90 msec later. Therefore, to a certain degree, prolongation of the data acquisition window has little effect on this parameter.

One might expect that an increase in LV EDV with increasing pixel size is associated with a decrease in LV mass. This was not observed. As pixel size is increased, therefore, partial volume effects at the endocardial and epicardial borders might compensate for each other.

A significant decrease of EF, cardiac output, cardiac index, and ejection and filling rates was found for increased frame duration (temporal resolution) that was related to the number and width of measurement points that were used for fitting the curve of LV volume over time. The effect may be more important in patients with elevated heart rates (ie, during pharmacologic stress examinations), because a higher sampling rate is required to reproduce the more rapid changes. Clinically, decreased dynamic cardiac parameters such as EF, ejection rates, and filling rates might be erroneously interpreted as impaired myocardial function or ventricular compliance.

Findings in multiple studies have validated the accuracy of cardiac cine MR imaging in various cardiac diseases (20–22). Findings in our study show that with the availability of true FISP for cardiac cine MR angiography, the appropriate balance of spatial and temporal resolutions should be carefully considered. In particular, when functional parameters have to be determined for both primary diagnosis and follow-up studies, the influence of spatial and temporal resolutions will be relevant.

In our study group, there was only a small increment in functional parameters as the frame duration increased from 21 to 45 msec; therefore, a frame duration of 45 msec can be considered sufficient in patients with normal heart rates unless maximum ejection and filling rates are of interest. These parameters, which are relevant in longitudinal studies of patients with cardiomyopathy (23–25), aortic stenosis (26), or chronic myocardial ischemia (27,28), were found to be highly dependent on temporal resolution. In such cases, our results suggest use of maximum temporal resolution, which was 21 msec in the current study.

We conclude that changes in both spatial and temporal resolutions influence LV functional parameters determined with true FISP cine MR imaging and that the influence of temporal resolution is more relevant than the influence of spatial resolution. Maximum accuracy can be obtained for spatial resolutions between 1 and 2 mm and temporal resolutions between 21 and 45 msec. In serial follow-up studies, consistent settings of spatial and temporal resolutions should be used.

	ACKNOWLEDGMENTS

 
We thank Resham Sawlani for her assistance in data evaluation regarding interobserver reproducibility and Michele A. Parker for her advice in statistical analysis.

	FOOTNOTES

 
Abbreviations: EDV = end-diastolic volume, EF = ejection fraction, FISP = fast imaging with steady-state precession, LV = left ventricle

Author contributions: Guarantor of integrity of entire study, S.M.; study concepts and design, S.M., J.P.F.; literature research, S.M.; clinical studies, S.M., J.C.; data acquisition, S.M., U.K.; data analysis/interpretation, O.P.S., U.K.; statistical analysis, S.M., J.P.F.; manuscript preparation, S.M., O.P.S.; manuscript definition of intellectual content, S.M., J.P.F.; manuscript editing and revision/review, J.P.F.; manuscript final version approval, S.M., J.P.F.

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