Clinic Guide To Cardiac Magnetic Resonance Imaging PDF

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Williamson
A review of the most common cardiac MR imaging planes
More than
McGee
This compact guide to cardiac magnetic resonance imaging

incorporates the most common techniques with easy-tofollow step-by-step protocols. Physicians and technicians
alike get quick access to the information they need at
the point of exam. Features include:
200
with step-by-step protocols
imaging protocols and example cases
A review of the basic physics of cardiac MRI, including pulse sequences and ECG
gating, as well as common imaging artifacts and how to prevent them.
This easy-to-use reference is the most practical guide for accessing information on all
stages of the cardiac MRI exam, from graphical prescription and protocol selection to
imaging troubleshooting and interpretation.
ABOUT THE AUTHORS
KIARAN P. McGEE is Consultant, Department of Radiology, Mayo Clinic,
Rochester, Minnesota; Assistant Professor of Biomedical Engineering and
Radiologic Physics, College of Medicine, Mayo Clinic.
ERIC E. WILLIAMSON is Consultant, Department of Radiology, Mayo Clinic,
Rochester, Minnesota; Assistant Professor of Radiology, College of Medicine,
Mayo Clinic.
PAUL R. JULSRUD is Consultant, Department of Radiology, Mayo Clinic,
Rochester, Minnesota; Professor of Radiology, College of Medicine, Mayo Clinic.
Mayo Clinic Guide to Cardiac Magnetic Resonance Imaging
Descriptions of the most common indications for cardiac MRI, along with typical
Julsrud
An overview of the various physiologic events that make up the cardiac cycle
Mayo Clinic
Guide to Cardiac
Magnetic Resonance Imaging
Kiaran P. McGee, PhD

Eric E. Williamson, MD
Paul R. Julsrud, MD
MAYO CLINIC SCIENTIFIC PRESS
Mayo Clinic
Guide to Cardiac
Mayo Clinic
Guide to Cardiac
Editors
Paul R. Julsrud, MD
AND INFORMA HEALTHCARE USA, INC.
ISBN-13: 978-1-4200-8303-3
Printed in Canada
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2008 Mayo Foundation for Medical Education and Research.
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Library of Congress Cataloging-in-Publication Data
Mayo Clinic guide to cardiac magnetic resonance imaging/edited by Kiaran P. McGee, Eric E. Williamson,
Paul Julsrud.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-1-4200-8303-3 (pb : alk. paper)
ISBN-10: 1-4200-8303-1 (pb : alk. paper) 1. Heart--Magnetic resonance imaging. I. McGee, Kiaran P. II.
Williamson, Eric E. III. Julsrud, Paul. IV. Mayo Clinic. V. Title: Guide to cardiac magnetic resonance imaging.
[DNLM: 1. Heart Diseases--diagnosis. 2. Magnetic Resonance Imaging--methods. WG 141.5.M2
M473 2008]
RC683.5.M35M39 2008
616.1'207548--dc22
2008005368
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Care has been taken to confirm the accuracy of the information presented and to describe generally accepted
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with respect to the publication. This book should not be relied on apart from the advice of a qualified health
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DEDICATION
To those profound sources of love, joy, and happiness: Nancy, Jeff, Max, Cora, & B.V.M.
To my parents, Byrn and Anitafor teaching me the value of high expectations.
Paul R. Julsrud, MD
To my parents for their unconditional love; to my wife and children for their continued
support and affection; and to Drs. Richard Van Pragh, Kenneth Fellows,
and Ivar Enge for their mentorship and for being extraordinary role models
for my career.
FOREWORD
In 2003, magnetic resonance imaging was formally recognized as one of the most important
advances in modern medicine by the awarding of the Nobel Prize in Physiology or
Medicine jointly to Paul C. Lauterbur and Sir Peter Mansfield. Although this recognition
was a coming of age for the field of MRI, in many respects cardiac MRI is still in its
infancy, in part because of the unique technical challenges of acquiring an MR image of an
organ that changes in size, shape, and location. Despite these difficulties, technological
developments in MR scanner hardware and software, as well as postprocessing techniques,
have allowed cardiac MRI to become more available and practical in nonacademic institutions such as community hospitals and outpatient imaging centers. What is needed to
expand this trend is the ability to reliably and reproducibly perform cardiac MRI
examinations in those settings.
The Mayo Clinic Guide to Cardiac Magnetic Resonance Imaging is designed to facilitate
the dissemination of cardiac MRI from academic centers into the broader MR community.
The books content is designed to serve multiple groups: technologists, clinicians, and clinical medical physicists. Its organization is such that any institution should be able to rapidly
develop their own program without having to seek out a variety of medical and technical
texts. Technologists are the target audience of the first chapter, being the ones to acquire
the actual cardiac MR data. In chapters 2 and 3, the text focuses on providing clinicians
with suggested imaging protocols, along with clinical examples of the actual imaging
indication. Finally, chapter 4 provides a more technical review of the underlying physical
principles of the various imaging sequences used in cardiac MRI. Although this final section
is quite technical, the authors have provided a general overview of the various concepts
that encompass the physics of cardiac MRI.
I highly recommend this text to experts and novices alike.
Jerome F. Breen, MD
Chair, Division of Cardiac Radiology
Mayo Clinic
vii
PREFACE
Over the course of the past decade, cardiac magnetic resonance imaging has developed
from a boutique imaging modality to the gold standard for assessment of various functional
and morphologic cardiac diseases. Based on the experience within our own institution in
training physicians, technologists, and physicists alike, it became apparent that there was
an unmet need for a practical users guide to cardiac MR imaging. We also quickly
appreciated that such a text would not only be useful in training within our own walls but
also could serve as a reference guide for others interested in establishing a cardiac MR
imaging program. This was the motivation for creating a practical handbook for cardiac
MR imaging.
The handbook is intended to serve three basic purposes: 1) to develop a standard
methodology to assist the user in prescribing MR sequences in the commonly used cardiac
imaging planes, 2) to provide a set of imaging protocols that address the most common
indications for which a cardiac MR exam would be ordered, and 3) to give the user a basic
overview of the physical principles of cardiac MR imaging, including electrocardiographic
gating, pulse sequence design and types, and typical imaging artifacts and strategies to
correct them.
In many respects, this work is incomplete in that it represents a broad snapshot of the
landscape of cardiac MR in 2008 AD. However, it is our hope that the information contained
within these pages will contribute to the growth and dissemination of cardiac MR imaging
beyond the boundaries of academic medicine into the broader community.

Paul R. Julsrud, MD
ix
ACKNOWLEDGMENTS
The Latin phrase Quasi nanos, gigantium humeris insidentes, ut possimus plura eis et remotiora videre (We are like dwarfs on the shoulders of giants, so that we can see more than
they) aptly describes those pioneering individuals to whom we owe a debt of gratitude.
Without their efforts and contributions this work would not be possible. In particular, we
recognize Jerome F. Breen, MD, Joel P. Felmlee, PhD, and Richard L. Ehman, MD,
whose diligence and hard work have developed a clinical practice that is the genesis of this
text. We also acknowledge all of those colleagues, both internal and external to our institution, who are too numerous to identify individually but whose cumulative efforts have
contributed to the growth of cardiac MR.
xi
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Editor
Production editor
Editorial assistant
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Mayo Clinic Section of Illustration and Design

Karen E. Barrie
David T. Smyrk
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James E. Rownd
Deborah A. Veerkamp
Kevin M. Youel
Art director
Medical animator
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Presentation designer
xiii
AUTHOR AFFILIATIONS
Philip A. Araoz, MD
Consultant, Department of Radiology, Mayo Clinic, Rochester, Minnesota; Assistant
Professor of Radiology, College of Medicine, Mayo Clinic
Matt A. Bernstein, PhD
Consultant, Department of Radiology, Mayo Clinic, Rochester, Minnesota; Professor
of Radiologic Physics, College of Medicine, Mayo Clinic
James F. Glockner, MD, PhD
Paul R. Julsrud, MD
Consultant, Department of Radiology, Mayo Clinic, Rochester, Minnesota; Professor
of Radiology, College of Medicine, Mayo Clinic
Jacobo Kirsch, MD
Fellow in Cardiac Imaging, Mayo School of Graduate Medical Education, and an
Instructor of Radiology, College of Medicine, Mayo Clinic, Rochester, Minnesota.
Present address: Radiology Institute, Cleveland Clinic, Weston, Florida.
Professor of Biomedical Engineering and Radiologic Physics, College of Medicine,
Mayo Clinic
xv
TABLE OF CONTENTS
PREFACE
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix
LIST OF ABBREVIATIONS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xix
CHAPTER 1
Cardiac Anatomy and MR Imaging Planes
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
CHAPTER 2
Cardiac Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
CHAPTER 3
Clinical Indications and Sample Imaging Protocols With Case Examples
. . . . . . . . . . . .37
CHAPTER 4
Pulse Sequence Basics, ECG Gating, and MR Artifacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107
INDEX
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181
xvii
ABBREVIATIONS
2D
two-dimensional
3D
three-dimensional
ARVC
arrhythmogenic right ventricular

cardiomyopathy
AS
aortic stenosis
bpm
beats per minute
ECG
electrocardiography
EDV
end-diastolic volume
ESV
end-systolic volume
FOV
field of view
Gd-DTPA gadolinium diethylenetriamine

penta-acetic acid
R-R
time interval between successive

R-wave peaks in ECG waveform
RCA
right coronary artery
RF
radio frequency
RV
right ventricle
SE
spin echo
T1
longitudinal (spin-lattice) relaxation time
T2
transverse (spin-spin) relaxation

time
TE
echo time
TI
inversion time
GRE
gradient-recalled echo
TR
pulse repetition rate
HR
heart rate
VCG
vector ECG
IR
inversion recovery
VENC
velocity encoding
LAD
left anterior descending artery
VPS
views per segment
LCX
left circumflex artery
LV
left ventricle
MDE
myocardial delayed enhancement
MR
magnetic resonance
MRI
magnetic resonance imaging
NEX
number of excitations or signal

averages
xix
CARDIAC MR ACRONYMS
MANUFACTURER
IMAGING COMPONENT
& TERM
Siemens Medical
Solutions
GE Healthcare
Magnetization Preparation
Phase contrast
PC
PC
Chemical fat saturation
Fat Sat
Fat Sat, Chem Sat
Tagging
Tagging
Tagging
Flow compensation
Flow comp, GMR
Flow comp
Inversion recovery
IR
IR
Phase-sensitive inversion
PSIR
PSIR
recovery
Echo Formation
Gradient echo
Spoiled
Gradient-recalled echo
Spoiled GRE
Fast gradient echo
Fast gradient echo 3D
Volume-interpreted
GRE
Steady state
Balanced steady-state
free precession
Steady-state free
precessionFID
Steady-state free
precessionecho
Spin echo
Gradient and spin echo
Philips Medical
Systems
PC
SPIR, SPAIR
Tagging
Flow comp
IR-TSE
PSIR
GRE
FLASH
TurboFLASH
MPRAGE,
3D FLASH
VIBE
GRE
SPGR
FGRE, FSPGR
3D FGRE,
3D FSPGR
FAME,
LAVA
FFE
T1-FFE
TFE
3D TFE
True FISP
FIESTA
BFFE
FISP
GRASS
FE
PSIF
SSFP
T2-FFE
SE
SE
SE
TurboGSE,
TGSE
GRASE
GRASE
THRIVE
*Imaging terms and corresponding acronyms used by different MR scanner manufacturers.
xxi
MANUFACTURER
IMAGING COMPONENT Siemens Medical
& TERM
Solutions
Data Acquisition
Single-shot spin echo
Multishot (echo train)
spin echo
Number of echoes in
spin-echo echo train
Echo planar imaging

Rapid Imaging
Image based
k-space based
Imaging Mode
Two dimensions
Three dimensions
Single image
Multiframe image
GE Healthcare
Philips Medical
Systems
HASTE
TSE, RARE
SSFSE
FSE
SS TSE
TSE
Turbo factor
ETL
Turbo factor
EPI
EPI
EPI
mSENSE
GRAPPA
ASSET
ARC
SENSE
2D
3D
Static
Cine
2D
3D
Static
Cine
2D
3D
Static
Cine
ARC, autocalibrating reconstruction for Cartesian imaging; ASSET, array sensitivity encoded;
ETL, echo train length; FAME, fast acquisition with multiple excitation; FE, field echo; FFE,
fast-field echo; FID, free induction decay; FIESTA, fast imaging employing steady-state acquisition; FISP, fast imaging with steady precession; FLASH, fast low angle shot; FSE, fast spin
echo; GMR, gradient moment recalled; GRAPPA, generalized autocalibrating partially parallel
acquisition; GRASE, gradient and spin echo; GRASS, gradient-recalled acquisition in the
steady state; HASTE, half Fourier-acquired single-shot turbo spin echo; LAVA, liver acquisition
with volume acceleration; MPRAGE, magnetization prepared rapid acquired gradient echoes;
mSENSE, modified sensitivity encoding; PSIF, reversed fast imaging with steady-state free precession; RARE, rapid acquisition with relaxation enhancement; SENSE, sensitivity encoding;
SPAIR, special attenuation with inversion recovery; SPGR, spoiled gradient-recalled echo;
SPIR, spectral attenuation with inversion recovery; TGSE, turbo gradient spin echo; THRIVE,
T1 high-resolution isotropic volume estimation; TFE, turbo field echo; TSE, turbo spin echo;
VIBE, volumetric interpolated breath-hold examination.
xxii
CHAPTER 1
CARDIAC ANATOMY AND

MR IMAGING PLANES
Chapter 1
CARDIAC ANATOMY AND

MR IMAGING PLANES
Paul R. Julsrud, MD
Introduction
The purpose of this chapter is to provide a step-by-step protocol for acquiring common
cardiac magnetic resonance (MR) imaging planes. The workflow diagrams presented are
not complete in that each represents only one example of a pathway that can be followed
to facilitate consistent cardiac examinations. However, they do provide both a workflow
that facilitates consistent visualization of the most clinically relevant cardiac anatomy and a
method for completing the cardiac examination in a practical time frame for the patient
and imaging department alike.
MAYO CLINIC GUIDE TO CARDIAC MRI
Left Ventricular Imaging

MR imaging of the heart most commonly includes visualization of the left ventricle (LV).
At least three separate imaging planes are acquired routinely, as shown in Figure 1.1; these
include the sagittal localizer, a four-chamber localizer, and a series of so-called short-axis
views. Three additional imaging planes can also be acquired to further characterize the LV
in the long axis.
Figure 1.1 shows the order in which these planes are typically acquired (numbers 1
through 6), as well as their temporal and spatial relationships. Each arrow describes the
relationship between the image used as the prescription and the resultant imaging plane.
For example, the sagittal localizer is used as a prescription image in order to acquire the
four-chamber localizer view. Similarly, the four-chamber localizer acts as the prescription
image for the short-axis views. Solid arrows represent standard imaging planes and dashed
arrows identify optional planes.
Figure 1.1. Imaging planes used to characterize

the LV of the heart. The numbers indicate the
acquisition order. Solid arrows indicate typical
imaging planes; dashed arrows indicate optional
planes used to visualize the left heart.
CHAPTER 1
CARDIAC ANATOMY AND MR IMAGING PLANES
Sagittal localizer (1)
Four-chamber localizer (2)
Short axis (3)
Left ventricle two chamber (4)
Left ventricle three chamber (5)

Left ventricle four chamber (6)
Sagittal Localizer
The first step in prescribing the various imaging planes acquired during a cardiac MR
examination is to obtain a series of straight sagittal images that include the entire volume
of the heart (Figure 1.2). This is an essential first step because all subsequent planes are
prescribed from these data. Prescribe enough slices to cover the entire heart. The graphical
prescription should start roughly at the sternum and cover more than two-thirds of the left
side of the patients thorax. The goal is to obtain slices that include the mitral valve plane
and cardiac apex.
Figure 1.2. Anatomical reference showing

the location of the sagittal localizer with
respect to the heart and chest wall, as well as
the corresponding MR imaging planes. The
localizers start at the position of the sternum
and progress laterally toward the apex of the
heart.
CHAPTER 1
Anatomical reference
Resultant sagittal localizer views
Four-Chamber Localizer
Acquisition of the sagittal localizer allows identification of the four chambers and great
vessels of the heart. Review of these images shows the oblique orientation of the heart
within the thoracic cavity, with the apex lying on top of the diaphragm at the level of the
fifth intercostal space and the base of the heart posterior to the apex at the level of the third
rib. Scrolling from left to right, the sagittal images traverse the left and then right sides of
the heart. These images can be used to acquire a four-chamber localizer view. The resultant
images are not true four-chamber views, but they serve as a reference point from which
short-axis views are acquired.
To obtain a four-chamber localizer image from the sagittal localizer images, perform the
following steps:
Scroll through the sagittal images and find an image in which the apex of the LV can be
clearly identified. This will not necessarily be the first slice that contains cardiac
anatomy. It is most common to identify the slice in which the LV first appears and then
choose the next medial slice.
Continue scrolling through the images, moving medially from the left to the right side
of the heart, until the mitral (bicuspid) valve plane is identified. If the mitral valve is
not clearly identified, the root of the aorta can also be used.
Prescribe an imaging plane that bisects both the apex and mitral valve planes identified
in the two previous images.
Figure 1.3 shows the placement of the imaging plane on each sagittal image (yellow lines).
Angulation of the imaging plane in this manner allows the imaging slice to approximately
bisect all chambers of the heart. The orientation of the imaging plane in relation to the
heart and the resultant image are also shown.
Figure 1.3. Four-chamber localizer. Anatomical

reference image, MR prescription imaging planes
(yellow lines), and the resultant four-chamber
image are shown. The imaging plane bisects the
apex of the LV and the mitral (bicuspid) valve,
providing a view of all four chambers of the heart.
CHAPTER 1
Prescription
Mitral valve
Apex of LV
Resultant four-chamber localizer
10
Left Ventricular Short-Axis Views

Short-axis images of the heart show a view down the barrel of the LV, perpendicular to
the long axis or septum of the heart. Figure 1.4 shows the placement of a short-axis imaging plane in relation to the heart and the resultant anatomical cross-section. Multiple
short-axis images are typically acquired from the cardiac apex to the base of the heart and
are distinguished from one another by the part of the LV imaged (eg, cardiac apex, mid
ventricle, or base of the heart). The base image is closest to the great vessels and includes
the left and right ventricles, whereas the apex image typically includes only the LV.
Acquisition of the four-chamber view provides the anatomical landmarks necessary for
prescribing the various left ventricular short-axis views. Depending on the type of study,
three or more slices will be acquired. If only three slices are used, these should be through
the apex, mid ventricle, and base of the LV.
To prescribe short-axis views of the LV, perform the following steps:
From the four-chamber data set acquired previously, identify the image that is approximately at end diastole. This will be the image in which the heart is relaxed and the
chamber is maximally dilated.
Prescribe an imaging plane that is centered on the LV and is roughly perpendicular to
the septum. The plane should be placed at approximately mid ventricle.
If multiple slices are prescribed, the planes should track roughly parallel to the septum. A
series of images slicing through the base, mid ventricle, and apex of the heart will result.
Figure 1.4 shows the placement of three imaging planes (yellow lines) perpendicular to the
septum on the four-chamber view. The orientation of these planes in relation to the
anatomical orientation of the heart is also shown.
Figure 1.4. Anatomical reference, MR

prescription planes (yellow lines), and resultant
MR images of the left ventricular short-axis
view are shown. The MR imaging planes
should be parallel to the septum of the heart
and centered within the middle of the LV.
CHAPTER 1
Prescription
Resultant left ventricular

short-axis views
11
12
Left Ventricular Long-Axis Views

A second set of long-axis views also can be acquired by prescribing a set of imaging planes
orthogonal to the short-axis images previously acquired. The three prescriptions that
follow (two, three, and four chamber) can all be prescribed off a single short-axis image.
If multiple slices are acquired, long-axis views are typically prescribed off the slice that
corresponds most closely to the mid ventricle.
Left Ventricular Two-Chamber (Vertical Long-Axis) View
A two-chamber long-axis (or vertical long-axis) view bisects the LV through its anterior
and inferior walls, parallel to the interventricular septum. This orientation is commonly
known as a two-chamber view because two chambers (the left atrium and LV) are
visualized.
To prescribe a two-chamber long-axis view of the LV, perform the following steps:
Select the short-axis slice that is approximately at the location of the mid ventricle.
Select the image at this slice location that is approximately at end diastole. This will be
the image in which the heart is relaxed and the chamber is maximally dilated.
Prescribe an imaging plane that is parallel to the interventricular septum and bisects the
LV from the base of the heart to the cardiac apex.
The center of the imaging plane should be at the center of the LV.
Figure 1.5 shows the placement of the two-chamber imaging plane (yellow line). The
prescribed imaging plane is approximately parallel to the interventricular septum. The
orientation of this plane in relation to the anatomical orientation of the heart is also
shown. Placement of the imaging plane at mid ventricle produces the resultant image.

prescription plane (yellow line), and resultant
MR image of the left ventricular two-chamber
vertical long-axis view are shown.
CHAPTER 1
Prescription
Resultant left ventricular two-chamber long-axis view
13
14
Left Ventricular Three-Chamber View

A three-chamber long-axis view bisects the LV through the aortic root and lateral left
ventricular wall at the base of the heart and should extend to the tip of the cardiac apex (to
avoid foreshortening of the LV). This orientation allows visualization of the aortic outflow
tract, as well as the anterior septum and inferolateral wall of the LV.
To prescribe a three-chamber long-axis view of the LV, perform the following steps:
Select the short-axis slice that is approximately at the location of the aortic outflow
tract.
Prescribe an imaging plane through the aortic root, bisecting the LV from the base of
the heart to the cardiac apex.
This imaging plane can also be obtained by copying the prescription from the twochamber acquisition and rotating the imaging plane accordingly.
Figure 1.6 shows the placement of the three-chamber imaging plane (yellow line). The

MR image of the left ventricular three-chamber
long-axis view are shown.
CHAPTER 1
Prescription
Resultant left ventricular three-chamber view
15
16
Left Ventricular Four-Chamber (Horizontal Long-Axis) View

A final, four-chamber, long-axis view of the left and right ventricles can be obtained by
prescribing an imaging plane that is perpendicular to the interventricular septum and
centered on the LV. This is a true four-chamber view of the heart because it is perpendicular to the septum and bisects the left and right chambers of the heart along the long axis.
To prescribe a true four-chamber long-axis view, perform the following steps:
Select the left ventricular short-axis slice that is approximately at the location of the mid
ventricle.
Prescribe an imaging plane that bisects the LV and inferior septum.
This imaging plane can also be obtained by copying the prescription from either the
two- or three-chamber acquisition and rotating the imaging plane accordingly.
Figure 1.7 shows the placement of the four-chamber imaging plane (yellow line). The

MR image of the left ventricular four-chamber
long-axis view are shown.
CHAPTER 1
Prescription
Resultant left ventricular four-chamber view
17
18
Right Ventricular Imaging

Visualization and interpretation of the structure and function of the right ventricle (RV) is
an integral part of a routine cardiac MR examination. Under most circumstances,
adequate visualization can be achieved from the planes used for imaging the LV. Under
certain circumstances, however, additional imaging planes are required. In most of these
cases, the addition of a single, conventional, axial imaging plane will suffice. In other
specific instances, more complex right ventricular views are required, such as for the
diagnosis of arrhythmogenic right ventricular dysplasia or Ebstein anomaly. As with the
previous figures illustrating visualization of the LV, solid arrows indicate commonly
acquired imaging planes and dashed arrows represent optional planes. The color of the
arrow symbolizes the left (red) or right (blue) side of the heart (Figure 1.8). The arrows
also identify the relationship between the prescription and resultant image planes.
Figure 1.8. Imaging planes used to characterize

the RV of the heart. The numbers indicate the
acquisition order. Note that, to image the right
side of the heart, it is necessary to first acquire
several planes used to visualize the left heart.
CHAPTER 1
Conventional axial (3)
19
20
Conventional Axial Right Ventricular View

The sagittal localizer image set provides the anatomical landmarks necessary for prescribing the axial right ventricular cine data. Using the axial plane can facilitate tracing the RV
for calculating RV volumes and ejection fraction. In general, straight axial data sets provide
a more complete and easy-to-identify tricuspid valve plane.
To prescribe conventional axial views, perform the following steps:
From the sagittal localizer image, identify the top of the ascending aorta cranially and
the apex of the heart caudally.
Prescribe a series of straight axial imaging planes that are centered roughly on the
septum of the heart.
Figure 1.9 shows the placement of the axial image planes (yellow lines) on the sagittal
localizer covering the ascending aorta and apex of the heart. The orientation of these
planes in relation to the anatomical orientation of the heart is also shown.

prescription planes (yellow lines), and resultant
MR images of the RV with conventional or
true axial views are shown. Note that these
planes are prescribed as true axial planes that
are orthogonal to the sagittal imaging planes
acquired initially.
CHAPTER 1
Prescription
Resultant conventional axial right ventricular views
21
22
Additional Right Ventricular Views

If additional views of the RV are required, the flow diagram in Figure 1.10 can be
followed.
Figure 1.10. Additional imaging planes

used to characterize the RV of the heart. The
numbers indicate the acquisition order. Solid
arrows indicate typical imaging planes and
dashed arrows indicate optional planes. Most
of these planes are optional.
CHAPTER 1
23
Conventional axial (3)
Right ventricle inflow tract vertical long axis (4)
Right ventricle sagittal outflow tract (5)
24
Right Ventricular Inflow Tract Long-Axis View

Acquisition of the four-chamber localizer view provides the anatomical landmarks necessary for prescribing right ventricular inflow tract views. The right ventricular inflow tract
long-axis view should be oriented parallel with the interventricular septum and centered at
the midventricular point of the RV.
To prescribe right ventricular inflow tract long-axis views, perform the following steps:
From the four-chamber localizer data, identify the image that is approximately at end
diastole. At this point of the cardiac cycle, the heart is relaxed and largest.
Prescribe an imaging plane that is centered on the RV and is parallel to the septum.
The plane should be centered at approximately mid ventricle.
Figure 1.11 shows the placement of a single imaging plane (yellow line) parallel to the septum on the four-chamber localizer view and centered at the middle of the right ventricular
cavity. The orientation of this plane in relation to the anatomical orientation of the heart is
also shown. Placement of the imaging plane at mid ventricle produces the resultant image.

MR image of the right ventricular inflow
tract in the long-axis view are shown.
CHAPTER 1
Prescription
Resultant right ventricular long-axis view
25
26
Right Ventricular Sagittal Outflow Tract View

Acquisition of straight axial images provides the relevant anatomical landmarks necessary
to prescribe a sagittal imaging plane oriented so as to bisect the outflow tract from the RV.
To prescribe a right sagittal outflow tract view, perform the following step:
On the axial data, prescribe a sagittal imaging plane that is centered on the pulmonary
semilunar valve and also bisects the main pulmonary artery. This plane will be slightly
oblique to the anterior-posterior axis of the patient and as such is not a true sagittal
view.
Figure 1.12 shows the placement of a single imaging plane (yellow line) on an axial image
showing the main pulmonary artery. Placement of the imaging plane at mid ventricle
produces the resultant image.

MR image of the outflow tract of the RV in
the sagittal view are shown.
CHAPTER 1
Prescription
Resultant right ventricular sagittal outflow tract view
27
CHAPTER 2
CARDIAC PHYSIOLOGY
Chapter 2
CARDIAC PHYSIOLOGY
Paul R. Julsrud, MD
Introduction
In-depth knowledge of the physiology of the heart is essential to diagnosing and distinguishing the multitude of complex cardiac disease processes. The figures in this chapter
show the relationships among pressure, electrical activity, and associated images throughout the cardiac cycle. As quantitative assessment of cardiac function becomes more important, so too will the need to understand the interrelationships among these various cardiac
events.
31
32
Events of the Cardiac Cycle (Left Heart)

Figure 2.1 shows the various physiologic events of the left heart throughout the cardiac
cycle. The relationships of pressure, volume, and flow to the electrical potential of the
heart as a whole (as measured by electrocardiography [ECG]) are shown. The systolic and
diastolic time intervals denote the portions of the cardiac cycle taken up by each phase and
are defined by the intervals between the black and red, and red and blue lines, respectively,
on the ECG waveform. It is important to note that the percentage values shown for the
time intervals of systole (40%) and diastole (60%) are valid only for the given heart rate
(HR) of 70 beats per minute. As HR increases, the systolic time interval remains relatively
unchanged, while the diastolic interval decreases. This results in a percentage increase in
systole and a percentage decrease in diastole. Consequently, end diastole is the most variable phase of the cardiac cycle.
Figure 2.1. Important cardiac physiologic

waveforms during the cardiac cycle. The bottom
3 traces show the pressure, volume, and flow
curves within the left-sided cardiac chambers
throughout the cardiac cycle, correlated with the
ECG waveform at the top. EDV, end-diastolic
volume; ESV, end-systolic volume. (Modified
from Oh JK, Seward JB, Tajik AJ. The echo
manual. 3rd ed. Philadelphia: Lippincott Williams
& Wilkins; 2006. Used with permission of Mayo
Foundation for Medical Education and Research.)
Electrical potential
CHAPTER 2
Systole
40%
Diastole
60%
QRS
End diastole
120
Aortic pressure
80
Ventricular pressure
Atrial pressure
10
0
Volume (mL)
HR=70
End systole
Pressure (mm Hg)
CARDIAC PHYSIOLOGY
130
EDV
50
ESV
Aortic outflow
Mitral inflow
Flow (mL/s)
500
Isovolumic
contraction
Isovolumic
relaxation
33
34
MR Imaging Characteristics of the Cardiac Cycle

Figure 2.2 shows the relationship between the electrical activity of the heart as a whole and
the corresponding magnetic resonance (MR) images acquired as part of a cine imaging
series in both four-chamber long-axis and two-chamber short-axis views of the left ventricle (LV). Typical cine acquisitions acquire 20 images corresponding to fixed time points or
phases of the cardiac cycle. In this figure, only 10 images for both views are reproduced,
representing every even or odd phase of the cardiac cycle. Viewed as a dynamic display,
these cine loops simulate real-time imaging and are used to interpret the contractility of
the heart. The figure also shows enlarged views of the heart at end systole (red outline) and
end diastole (blue outline). At end systole, the cavity of the LV is smallest, with maximal
thickness of the myocardium; at end diastole, the LV is most relaxed, with maximal chamber volume and minimal myocardial wall thickness.
Figure 2.2. Four-chamber long-axis (top row) and twochamber short-axis (bottom row) cine series corresponding to
the electrical potential trace of a cardiac cycle. Enlarged MR
images at bottom are those acquired at end systole (red outline) and end diastole (blue outline).
CHAPTER 2
CARDIAC PHYSIOLOGY
Four-chamber long axis
Two-chamber short axis
35
CHAPTER 3
CLINICAL INDICATIONS AND

SAMPLE IMAGING PROTOCOLS
WITH CASE EXAMPLES
Chapter 3
CLINICAL INDICATIONS AND

SAMPLE IMAGING PROTOCOLS
WITH CASE EXAMPLES
Jacobo Kirsch, MD
James F. Glockner, MD, PhD
Philip A. Araoz, MD
Paul R. Julsrud, MD
Introduction
The purpose of this chapter is threefold. First, it provides recommended magnetic resonance (MR) imaging protocols for indications in which cardiac MR has been proved to be
clinically useful. Second, it provides example MR images for each indication and the
imaging sequences that most clearly illustrate the associated findings. Third, it provides
descriptions of each disease process and specific recommendations for image interpretation
and analysis. The list of indications is not complete, but it covers a broad spectrum of
cardiac diseases, with specific focus on the conditions that are most likely to be encountered in clinical practice.
Throughout this chapter, we refer to specific pulse sequences and provide examples to
illustrate the appearance of a given disease process or abnormality. It is assumed that the
reader is familiar with these cardiac MR imaging (MRI) techniques. For the interested
reader, in-depth descriptions of all sequences used in this chapter are provided in Chapter
4. For those who are new to cardiac MRI, we recommend reviewing Chapter 4 before
reviewing this chapter.
39
40
Myocardial Perfusion and Viability

Assessment of the delivery of blood to the myocardium is of utmost importance in
patients with ischemic heart disease or the suspicion of it. Regional assessment of myocardial perfusion is performed by administering an exogenous gadolinium-based contrast
agent, followed by pseudoreal-time imaging of the arrival of the contrast into the right
and then left chambers of the heart. Assessment of myocardial perfusion is therefore based
on the first pass of the contrast through the myocardium. Poorly perfused regions show
decreased contrast enhancement and are typically identified as perfusion defects.
Myocardial viability is assessed, following a delay after administration of the contrast
agent, by using T1-weighted inversion recoverybased MRI sequences. The physiologic
basis for this approach relies on the delayed wash-in and wash-out of the contrast agent in
poorly perfused or ischemic myocardium. Nulling of normal myocardium is achieved by
the appropriate choice of inversion time; regions with increased contrast uptake appear
bright because of their contrast-enhanced T1 weighting. Figure 3.1 shows the 17 myocardial segments of the heart and their assigned coronary arteries, as defined by the American
Heart Association. The 17th segment located at the apical tip can be supplied by any one
of the three coronary arteries and has been identified in this figure as being supplied by the
left anterior descending coronary artery.
CLINICAL INDICATIONS AND SAMPLE IMAGING PROTOCOLS
CHAPTER 3
41
Infarct Distributions
Coronary Artery Territories

Short axis
Apical
Mid
Basal
Mid
13
14
Vertical long axis
12
16
15
17
9
11
LAD
10
RCA
LCX
Figure 3.1. Assignment of the 17 myocardial segments to the territories of the left anterior
descending artery (LAD), the right coronary artery (RCA), and the left circumflex coronary
artery (LCX). The image of the heart (top) shows the anatomical location of the three main
coronary arteries, as well as the three parallel planes that correspond to the short-axis slices
shown at bottom. (From Imaging guidelines for nuclear cardiology procedures: part 2. J
Nucl Cardiol. 1999;6[2]:G47-84. Used with permission.)
42
Imaging ProtocolMyocardial Perfusion and Viability
Series
1
Plane
Imaging sequence
Sagittal
Bright blood static

(balanced or spoiled
gradient echo)
Specific
parameters
Time/slice
(s)
Breath hold
Single cardiac phase
20
Localizer scan to identify imaging volume. Prescribe enough

slices to include entire heart. Typical left-to-right range, 200
mm depending on body habitus (120 mm left to 80 mm
right of midline).
2
Four chamber
long axis
Bright blood cine

(balanced gradient echo)
Breath hold
20 cardiac phases
10-16
Single slice through left ventricular apex and mitral valve.

Adjust VPS based on heart rate and breath-hold duration;
minimize breath-hold time for patient comfort.
Short axis
Bright blood cine

Breath hold
20 cardiac phases
10-16
Center each slice on the center of the LV. Ensure that slices
cover the entire ventricle from apex to base. Adjust imaging
parameters (VPS, imaging matrix, NEX) based on breathhold duration and patient compliance.
CHAPTER 3
Series
4
Plane
Vertical and
horizontal
long axis
Imaging sequence
Specific
parameters
Bright blood cine

Breath hold
20 cardiac phases
43
Time/slice
(s)
10-16
Prescription should be based on midventricular short-axis view

with slices bisecting the LV parallel and perpendicular to the
septum.
Short axis
Perfusion
30-40
temporal phases
50 -70
Patient typically needs more than one breath hold to complete.

Coaching is required beforehand to prevent rapid inspiration on
second breath hold. Inject 20 mL gadolinium contrast at 4-5
mL/s and start sequence simultaneously. Instruct patient to hold
his breath for as long as possible and then to do additional
breath holds until the scan is over. After the scan has finished,
may inject an additional 20 mL gadolinium contrast at 2 mL/s
(to improve contrast on delayed enhancement sequence).
44
Series
6
Plane
Short axis
Imaging sequence
Delayed enhancement
Specific
parameters
Breath hold
TI = 100-300 ms
Time/slice
(s)
10-20
TI chosen to null normal myocardium. If imaging sequence

does not provide recommended TIs (phase-sensitive inversion
recovery), a prior multi-inversion time sequence must be run
to determine this value. Imaging performed approximately 10
minutes after administration of first contrast bolus.
7
Long axis
Delayed enhancement
Breath hold
TI = 100-300 ms
10-20

LV, left ventricle; NEX, number of excitations; TI, inversion time; VPS, views per segment.
CHAPTER 3
45
Case Examples
Subendocardial Myocardial Infarction
Figure 3.2. Short-axis perfusion image (left) acquired shortly after the intravenous administration of gadolinium shows a subendocardial area of low signal in the inferior segments,
characteristic of a first-pass myocardial perfusion defect (arrow). A corresponding two-chamber
myocardial delayed enhancement (MDE) image (right) shows persistent subendocardial
hyperenhancement of the inferior wall of the LV, confirming the presence of an infarction (arrow).
Figure 3.3. Four-chamber MDE

image demonstrates persistent subendocardial enhancement along the lateral
wall of the LV.
The rationale behind MDE sequences is that cellular disruption occurring in the infarcted
region causes an increase in vascular permeability and corresponding expansion of the
extracellular space. Injected gadolinium accumulates in the area of infarcted myocardium
and is cleared more slowly from this region than from normal, healthy myocardium.
These two factors result in the characteristic appearance of persistent hyperenhancement
in the region of a myocardial infarction.
46
Transmural Myocardial Infarction
Figure 3.4. Four-chamber MDE image demonstrates full-thickness delayed enhancement,

characteristic of a large LAD distribution infarction. The dark core of the infarction is
believed to represent microvascular obstruction, meaning that the arterial occlusion was
severe enough to prevent any gadolinium from reaching that area.
Figure 3.5. Short-axis balanced gradient echo (left) and MDE (right) images show thinning
of the inferolateral left ventricular wall with corresponding full-thickness enhancement,
characteristic of an underlying infarction in the LCX arterial territory.
CHAPTER 3
47
Figure 3.6. Three-chamber balanced gradient echo image shows focal thinning of the
anterior left ventricular wall, consistent with an LAD distribution infarction.
Myocardial infarction spreads over time, like a wave front, from the endocardium to the
epicardium. In infarcted myocardium, the subendocardial layer should always be affected.
If an area of delayed enhancement spares the subendocardial layer or is not confined to a
single vascular territory, nonischemic myocardial diseases should be considered.
48
Ischemic Cardiomyopathy
Figure 3.7. Four-chamber balanced gradient echo (left) and MDE sequence (right) images
show global dilatation of the left ventricular cavity. Thinning and persistent enhancement of
the mid and apical segments of the LV are consistent with an ischemic dilated cardiomyopathy.
The term ischemic cardiomyopathy is commonly used to refer to congestive heart failure
due to coronary artery disease and resulting myocardial infarction. After a myocardial
infarction, some degree of left ventricular dysfunction is expected; it usually correlates with
the extent and location of myocardial injury. The use of gadolinium-enhanced perfusion
and MDE images for these patients can be important for distinguishing ischemic from
nonischemic causes of dilated cardiomyopathy.
CHAPTER 3
49
Cardiomyopathies
The cardiomyopathies make up a heterogeneous group of disorders characterized by
dysfunction of the cardiac myocytes. This dysfunction leads to a decrease in the ability of
the heart to maintain adequate cardiac output. Depending on the type of cardiomyopathy,
the imaging findings can be variable and relatively characteristic.
Common forms of cardiomyopathy include dilated, hypertrophic, and restrictive
cardiomyopathy. Additional disorders involving dysfunction of cardiac myocytes include
arrhythmogenic right ventricular cardiomyopathy (ARVC), apical ballooning syndrome,
and myocarditis.
50
Imaging ProtocolCardiomyopathies
Series
1
Plane
Imaging sequence
Sagittal
Bright blood static

gradient echo)
Specific
parameters
Time/slice
(s)
Breath hold
20

right of midline).
2
Four chamber
long axis
Bright blood cine

Breath hold
20 cardiac phases
10-16

Short axis
Bright blood cine

Breath hold
20 cardiac phases
10-16
CHAPTER 3
Series
Plane
4 Left ventricular
outflow tract
Imaging sequence
Specific
parameters
Bright blood cine

Breath hold
20 cardiac phases
51
Time/slice
(s)
10-16
Disease-specific imaging plane. See specific diseases for actual

prescription.
Short axis
Perfusion
30-40
temporal phases
50-70
for total study

Coaching is required beforehand to prevent rapid inspiration on
second breath hold. Inject 20 mL gadolinium contrast at 4-5
mL/s and start sequence simultaneously. Instruct patient to hold
his breath for as long as possible and then to do additional
may inject an additional 20 mL gadolinium contrast at 2 mL/s
(to improve contrast on delayed enhancement sequence).
52
Series
6
Plane
Short axis
Imaging sequence
Delayed enhancement
Specific
parameters
Breath hold
TI = 100-300 ms
Time/slice
(s)
10-20

to determine this value. Imaging performed approximately
10 minutes after administration of first contrast bolus.
7
Long axis
Delayed enhancement
Breath hold
TI = 100-300 ms
10-20

CHAPTER 3
53
Case Examples
Dilated Cardiomyopathy
Figure 3.8. Four-chamber long-axis (top

left) and midventricular short-axis (top
right) balanced gradient echo images show
marked left ventricular dilatation. A twochamber long-axis MDE image (bottom)
shows no evidence of myocardial infarction.
The most common form of cardiomyopathy, dilated (congestive) cardiomyopathy, is characterized by enlargement of the cardiac chambers and decreased contractile function in the
absence of ischemic causes. Although most commonly idiopathic, dilated cardiomyopathy
can be due to viral infection or exposure to toxic substances (eg, alcohol) or can be associated with pregnancy (peripartum cardiomyopathy).
54
Hypertrophic Cardiomyopathy
Figure 3.9. Hypertrophic obstructive cardiomyopathy. Three-chamber long-axis (top) and

midventricular short-axis (bottom) balanced gradient echo images demonstrate asymmetric
septal hypertrophy, characteristic of hypertrophic obstructive cardiomyopathy. The low signal
flow void seen in the left ventricular outflow tract (top) is consistent with obstructive physiology.
Cine images in this case showed systolic anterior motion of the anterior leaflet of the mitral
valve, which is thought to contribute to the outflow tract obstruction.
CHAPTER 3
55
Figure 3.10. Hypertrophic cardiomyopathy. Two-chamber long-axis balanced gradient echo

(top) and midventricular short-axis MDE (bottom) images. Symmetric left ventricular
hypertrophy with mitral regurgitation (top) is most likely due to outflow obstruction. MDE
image (bottom) demonstrates characteristic small foci of hyperenhancement at the junction
points between the right ventricle (RV) and the interventricular septum.
The second most common form of cardiomyopathy, hypertrophic cardiomyopathy, is

characterized by thickening of the LV wall, which can be focal or diffuse and symmetric.
In a subtype of the disorder, hypertrophic obstructive cardiomyopathy, the wall thickening can
cause obstruction of the normal flow of blood, at either the left ventricular outflow tract
(Figure 3.9) or the midventricular level. In the case of obstruction, flow dephasing can be
observed using bright blood cine or phase-contrast images. When left ventricular outflow
tract obstruction is present, it can be associated with systolic anterior motion of the anterior
mitral leaflet (Figure 3.9), which typically results in mitral regurgitation (Figure 3.10).
56
Restrictive Cardiomyopathy
Figure 3.11. Cardiac amyloidosis. Fourchamber long-axis balanced gradient echo (top
left), two-chamber long-axis MDE (top right),
and midventricular short-axis MDE (bottom)
images of cardiac amyloidosis. Long-axis
images show signs of increased cardiac filling
pressures, with atrial dilatation (top left and
right) and normal-thickness pericardium (top
left). MDE images demonstrate heterogeneous,
patchy-appearing myocardial signal with poor
nulling regardless of the inversion time.
Restrictive cardiomyopathy is a less common form of myocardial dysfunction which can

be idiopathic or can occur as a result of systemic diseases (eg, amyloidosis or sarcoidosis).
The imaging findings in restrictive cardiomyopathy predominantly result from restricted
filling in diastole and include decreased diastolic volume of the ventricles and dilated atria
in the presence of preserved systolic function. A few causes of restriction have specific imaging findings on MRI that can be helpful in making the diagnosis (Figures 3.11 and 3.12).
CHAPTER 3
57
Eosinophilic Cardiomyopathy
Figure 3.12. Eosinophilic cardiomyopathy.

Four-chamber long-axis balanced gradient
echo (top left and right) and two-chamber
long-axis MDE (bottom) images of
eosinophilic cardiomyopathy. Four-chamber
images show signs of increased cardiac filling
pressures, with atrial dilatation (top left and
right) and normal-thickness pericardium
(top right). The MDE image shows diffuse
endocardial thickening and hyperenhancement not corresponding to a vascular
distribution. Thickening of the mitral
valve leaflets and obliteration of the left
ventricular cavity also have been described
for eosinophilic cardiomyopathy but neither
is seen in these images.
58
Arrhythmogenic Right Ventricular Cardiomyopathy
Figure 3.13. Four-chamber balanced gradient echo images of ARVC at end diastole (left)
and end systole (right) demonstrate a small outpouching of the free wall of the RV during
systole (paradoxical motion). The RV is mildly enlarged.
ARVC is characterized pathologically by fatty or fibrous fatty tissue replacement of the

right ventricular myocardium. The most commonly affected locations include the right
ventricular apex, pulmonary infundibulum, and subtricuspid region. The involved
myocardium can evoke ventricular arrhythmias originating in the RV that induce syncope
and that have been linked to an estimated 5% of sudden deaths in persons younger than
35 years in the United States. MRI has been considered the ideal imaging technique to
detect fatty tissue infiltration in the RV among patients with typical ARVC. Other features
such as trabecular disarray, wall thinning, regional akinesis/dyskinesis, and, most importantly, an increased right ventricular volume can also be fairly easily detected by MRI.
However, care should be taken because many healthy patients can have focal fatty infiltration along the RV free wall or focal akinesis at the attachment site of the moderator band
on the free wall of the ventricle.
CHAPTER 3
59
Apical Ballooning Syndrome
Figure 3.14. Systolic two-chamber longaxis balanced gradient echo image (top left),
and two-chamber long-axis (top right) and
apical short-axis (bottom) MDE images.
Long-axis images demonstrate systolic dilatation of the left ventricular apex with no evidence of delayed hyperenhancement (top right
and bottom) to suggest myocardial infarction.
Apical ballooning syndrome is a potentially reversible clinical syndrome in which patients

typically present with elevated troponin levels and electrocardiographic changes that can
be indistinguishable from an acute coronary syndrome. The syndrome occurs most frequently among postmenopausal women and consists of transient hypokinesis, akinesis, or
dyskinesis of the LV, typically involving more than one vascular distribution. The wall
motion abnormalities seen in apical ballooning syndrome should resolve within days to
weeks, and MDE MR images in these patients should not show delayed hyperenhancement in any phase of the disease. Cardiac MRI is therefore an excellent tool for distinguishing between apical ballooning syndrome and myocardial infarction.
60
Myocarditis
Figure 3.15. Two-chamber long-axis MDE

(top left), midventricular short-axis triple
inversion recovery (top right), and midventricular short-axis MDE (bottom) images
showing scattered focal areas of subepicardial
delayed hyperenhancement (left) and edema
(right) consistent with acute myocardial
inflammation. Findings are characteristic
of acute myocarditis. Follow-up images after
treatment can show a decrease in regional
edema; however, delayed hyperenhancement
usually persists and is thought to represent
irreversible myocardial injury.
Acute myocarditis comprises a wide variety of infectious, toxic, and autoimmune causes of
myocardial inflammation, which can progress to widespread myocardial damage and even
to cardiomyopathy. Unfortunately, clinical symptoms are nonspecific, and the diagnosis of
myocarditis can be difficult to establish. Cardiac MRI is a powerful tool that can provide
an assessment of regional inflammation and edema, cardiac function, and disease progression. Initial findings of edema and delayed hyperenhancement are believed to represent
acute inflammation with myocyte injury, whereas persistence of hyperenhancement after
resolution of acute symptoms suggests myocyte necrosis and subsequent fibrosis.
CHAPTER 3
61
Valvular Disease
MRI is currently gaining acceptance as a noninvasive method of evaluating the cardiac
valves. The high spatial resolution of MRI, along with its inherent ability to distinguish
between cardiac structures and the adjacent blood pool without the need for intravenous
contrast agents, makes this an excellent means of assessing cardiac valvular anatomy.
Additionally, flow-sensitive techniques allow for detection of the turbulent jets typically
seen with valvular stenosis and regurgitation. By combining cine images used for the determination of ventricular volumes and phase-contrast images for the quantitation of flow,
cardiac MRI can be used as a comprehensive, noninvasive method for assessment of
valvular disease.
62
Imaging ProtocolValvular Disease
Series
1
Plane
Imaging sequence
Sagittal
Bright blood static

gradient echo)
Specific
parameters
Time/slice
(s)
Breath hold
20

right of midline).
2
Four chamber
long axis
Bright blood cine

Breath hold
20 cardiac phases
10-16

Adjust VPS based on heart rate and breath hold duration;
Short axis
Bright blood cine

Breath hold
20 cardiac phases
10-16
CHAPTER 3
Series
4A
Plane
Imaging sequence
Long axis
Bright blood cine
left ventricle,
left atrium (mitral
regurgitation)
Specific
parameters
Breath hold
20 cardiac phases
63
Time/slice
(s)
10-16
Slices should be prescribed from the short-axis slice containing

the base of the heart. Views should be prescribed in 45
increments about the center of the LV. These views should
contain the mitral valve and regurgitant jet.
4B
Oblique long
Bright blood cine
axis aortic
outflow tract
(aortic insufficiency)
Breath hold
20 cardiac phases
10-16
The slice should be prescribed from the short-axis slice containing

the base of the heart. This view should show the regurgitant jet.
64
Series
5
Plane
Imaging sequence
Oblique slice
Cine phase contrast
through aortic
region of interest
ascending,
descending
Specific
parameters
Breath hold
20 cardiac phases
VPS = 4-8
VENC = 250-300
Flow sensitization
direction = slice
Time/slice
(s)
10
For aorta: Slice should be through proximal ascending aorta,

valve to coronary ostia, and perpendicular to the aorta for
accurate flow measurements. Set VENC to 500-600 if patient
has history of or evidence for AS (ie, systolic jet in aorta on
three-chamber cine). FOV should be as small as possible to
maximize number of pixels within aorta. An additional in-plane
slice is useful for measuring peak velocities in AS and should
be prescribed oblique to the long axis of the aorta. Most useful
flow-encoding direction is along the slice-encoding axis.
6
Valve plane
Bright blood cine

gradient echo)
Breath hold
20 cardiac phases
10
Imaging plane bisects the valve plane. Good for aortic outflow
tract and aortic valve views; regurgitant jets are often visualized
more clearly with spoiled gradient echo sequence, although
image quality is poor compared with balanced steady-state
acquisition. In general, there also is less turbulent flow artifact.
To increase conspicuity of the flow jet, reduce imaging bandwidth.
AS, aortic stenosis; FOV, field of view; LV, left ventricle; NEX, number of excitations; TI,
inversion time; VENC, velocity encoding; VPS, views per segment.
CHAPTER 3
65
Case Examples
Aortic Stenosis, Aortic Insufficiency
Figure 3.16. Aortic insufficiency. Three-chamber balanced gradient echo cine image in
diastole (left) shows a dark jet of aortic insufficiency extending from the aortic valve toward
the anterior mitral valve leaflet. Transverse diastolic balanced gradient echo cine image
through the aortic valve plane (right) shows a small central regurgitant orifice.
Figure 3.17. Aortic stenosis. Coronal oblique balanced gradient echo cine image (left) reveals a dark
stenotic jet extending from the aortic valve into the proximal aorta. The corresponding valve plane
image (right), also obtained in systole, reveals a bicuspid aortic valve with a very narrow opening.
66
Aortic insufficiency can be caused by primary valve disease or aortic root dilatation. The
most common cause is idiopathic degeneration of a normal valve, with additional causes
including Marfan syndrome, aortic aneurysm, bicuspid aortic valve, rheumatic heart disease,
and endocarditis. Combined aortic insufficiency and stenosis is common. Patients are
often asymptomatic despite severe left ventricular volume overload and may have irreversible LV dysfunction by the time symptoms appear, which limits the value of valve
replacement. For this reason, close monitoring of patients with significant aortic insufficiency is recommended. MRI can be a valuable tool for evaluating patients with aortic
insufficiency. It provides accurate measurements of left ventricular size and function, as
well as visualization of abnormal valve morphology. Qualitative estimation of the severity
of aortic insufficiency by MRI agrees fairly well with that obtained by echocardiography,
and quantitative evaluation can be performed using cine phase-contrast flow measurement
techniques or by noting the difference in stroke volume between the RV and LV.
QUANTIFYING AORTIC INSUFFICIENCY

Regurgitant volume
Mild
Moderate
Moderate/severe
Severe
<30 mL/beat
30-45 mL/beat
46-60 mL/beat
>60 mL/beat
Regurgitant fraction
Mild
Moderate
Severe
15%-20%
21%-40%
>40%
Aortic stenosis most commonly occurs with idiopathic degeneration of a normal valve but
can also be caused by degeneration of a bicuspid valve (typically occurring at a younger age)
or by rheumatic heart disease. Supravalvular and subvalvular stenosis usually are congenital
lesions, but subvalvular functional stenosis also occurs with hypertrophic obstructive
cardiomyopathy. Classic symptoms include dyspnea on exertion, exertional syncope, and
angina. After symptoms occur, the clinical course usually deteriorates rapidly unless the
valve is replaced. Left ventricular hypertrophy is the primary compensatory mechanism.
MRI can directly demonstrate hypertrophy of the LV and provide accurate measurements
of ventricular mass and function. Stenosis can be qualitatively estimated by visualizing flow
jets; quantitative measurements can be obtained either by direct planimetry of the valve or
by applying cine phase-contrast techniques to measure peak velocities across the valve,
which can be used to estimate pressure gradients.
CHAPTER 3
67
QUANTIFYING AORTIC STENOSIS

Aortic valve area
Normal
Mild AS
Moderate AS
Severe AS
Peak systolic velocity

cm2
2.0-4.0
1.1-1.9 cm2
0.75-1.0 cm2
<0.75 cm2
Normal
Mild AS
Moderate AS
Severe AS
1-2.4 m/s
2.5-2.9 m/s
3.0-4.0 m/s
>4 m/s
Analysis of aortic insufficiency and stenosis by MRI:

Useful cardiac MRIderived metrics include:
Regurgitant volume per beat
Regurgitant fraction: regurgitant volume or regurgitant flow divided by positive
volume or flow
Ejection fraction
Cardiac output
End-systolic and end-diastolic volumes, as well as short-axis LV diameter at end systole
and end diastole at the midventricular level (to duplicate standard echocardiographic
measurement)
Flow though the pulmonary artery. (Note: in normal patients this should be identical
to cardiac output; with aortic insufficiency, the cardiac output is increased because of
the regurgitant volume.)
In patients with aortic stenosis:
Peak pressure gradient = 4(Vmax)2
where Vmax is the maximal velocity of the stenotic jet in the proximal aorta.
Mean pressure gradient = (4 [Vmax]2dt)/t
where dt is the time interval for the phase-contrast cine image in which Vmax is measured
and t the interval over which these velocities are summed (typically one R-R interval).
68
This is the time average of Vmax over systole. For this measurement, it is best to choose a
small region of interest that encompasses the highest velocity portion of the flow jet (this
is somewhat arbitrary).
Aortic valve area = AOT(VOT)/Vmax
where AOT is the outflow tract area, VOT the outflow tract maximum velocity, and Vmax
the maximum velocity of the stenotic jet in the proximal aorta. This measurement can also
be performed directly if good cine images have been made through the stenotic valve.
Alternative measurement of regurgitant volume:
Phase-contrast based
= stroke volume in aorta stroke volume in main pulmonary artery
OR
= stroke volume in aorta mitral valve inflow
Short-axis balanced gradient echo based

= LV stroke volume RV stroke volume
CHAPTER 3
69
Mitral Stenosis, Mitral Regurgitation
Figure 3.18. Mitral stenosis. Short-axis balanced gradient echo cine image at base of heart
during diastole (left) and three-chamber cine image (right) show stenotic mitral valve
(arrows) with reduced area and thickened leaflets.
Figure 3.19. Mitral valve prolapse and regurgitation. Diastolic (left) and systolic (right)
images from three-chamber bright blood cine sequence reveal prolapsing mitral valve leaflets
and a small jet of mitral regurgitation (arrow).
70
Mitral stenosis is most often a result of rheumatic heart disease. Symptoms typically
include shortness of breath and fatigue, which are often exacerbated by exercise. A substantial percentage of patients with moderate or severe mitral stenosis eventually have
development of atrial fibrillation, which complicates evaluation with MRI. Elevated left
atrial pressure leads to atrial dilatation, pulmonary edema, and signs of pulmonary artery
hypertension. MRI can visualize stenotic flow jets across the mitral valve, and mitral valve
area can be estimated by planimetry. Peak velocities can be measured with cine phase-contrast sequences to estimate pressure gradients. Left atrial size, as well as right ventricular size
and function, can be determined.
Mitral regurgitation has many causes, including ischemia and papillary muscle rupture,
infective endocarditis, mitral valve prolapse, hypertrophic obstructive cardiomyopathy,
rheumatic disease, and idiopathic valvular degeneration. Patients with acute mitral regurgitation may present with pulmonary edema and low cardiac output, whereas those with
chronic mitral regurgitation may have symptoms of fatigue and weakness. With significant mitral regurgitation, both the left atrium and LV become dilated. MRI can visualize
jets of mitral regurgitation in the left atrium, which can be qualitatively evaluated.
Quantitative measurement of mitral regurgitant volumes may be obtained by measuring
the difference in left and right ventricular stroke volume, or by the difference in left
ventricular stroke volume and forward flow in the aorta (using cine phase-contrast
sequences). MRI also provides accurate assessment of left ventricular size and function, as
well as left atrial size.
QUANTIFYING MITRAL REGURGITATION

Grade
Grade I/IV
Grade II/IV
Grade III/IV
Grade IV/IV
Regurgitant volume
Mild
Moderate
Moderately severe
Severe
<30 mL
30-44 mL
45-59 mL
60 mL
CHAPTER 3
71
Cine flow analysis of mitral stenosis and regurgitation:

Useful cardiac MRIderived metrics include:
Regurgitant volume per beatcan be calculated by:
1. The difference between flow in the proximal main pulmonary artery and
proximal aorta.
2. Measurement of left ventricular stroke volume by tracing end-systolic and
end-diastolic short-axis images and subtracting flow in the proximal aorta as
measured by phase-contrast flow sequence.
3. Direct phase-contrast flow measurement of regurgitant jet in left atrium: for
accurate quantitation it is important that the VENC is set high enough and
that the slice is oriented perpendicular to the direction of flow.
4. Inflow through the mitral valve plane minus left ventricular stroke volume,
as calculated from phase-contrast images through the proximal aorta.
5. Left ventricular minus right ventricular stroke volumes, as measured from
short-axis cine bright blood images.
Ejection fraction
Cardiac output
Left atrial diameter
End-systolic and end-diastolic volumes, as well as short-axis left ventricular diameter at
the midventricular level at end systole and end diastole (to duplicate standard echocardiographic measurement)
Reversal of flow in pulmonary veins. (This is useful to note, but it is unclear whether
quantitation is important.)
72
Tricuspid Stenosis, Tricuspid Regurgitation
Figure 3.20. End-diastolic (left) and end-systolic (right) frames from four-chamber balanced
gradient echo cine sequence show dilatation of the RV in a patient with pulmonary hypertension. A small jet of tricuspid regurgitation is seen in the right atrium (right).
Tricuspid stenosis is almost always related to rheumatic heart disease and is rarely an isolated
finding; the aortic and mitral valves also are usually involved. Other causes of tricuspid
stenosis include congenital atresia and carcinoid syndrome. Patients typically present with
signs and symptoms of right heart failure: fatigue, abdominal pain, and lower-extremity
swelling.
Tricuspid regurgitation is most commonly a result of dilatation of the RV and tricuspid
annulus rather than a result of intrinsic valvular disease. This is also the most common
valvular lesion among intravenous drug abusers with infectious endocarditis, since leftsided valves are protected by the lungs, which act as a filter.
CHAPTER 3
73
150
150
100
100
50
0
-50
-100
-150
Velocity (cm/s)
Velocity (cm/s)
Pulmonary Stenosis, Pulmonary Regurgitation
50
0
-50
-100
-150
Figure 3.21. Pulmonary regurgitation. Frames from a 3D representation of cine phase-contrast blood flow data across the pulmonary valve during systole (left) and diastole (right) in a
patient with severe pulmonary regurgitation. Note the near-complete flow reversal in diastole.
Figure 3.22. Pulmonary stenosis. Systolic

frame from balanced gradient echo cine
sequence oriented through the right ventricular outflow tract shows incomplete opening
of the pulmonary valve leaflets with slight
doming.
Pulmonary stenosis is almost always due to congenital deformity of the valve. A pressure
gradient develops across the valve, eventually resulting in right heart failure.
Pulmonary regurgitation is most commonly caused by dilatation of the valve ring secondary to pulmonary hypertension. Infective endocarditis is the second leading cause of pulmonary regurgitation.
74
Cardiac Masses
The pathology and etiology of a cardiac mass can be determined by following the cardiac
mass imaging decision tree at right. Examples of various masses, identified according to
the decision tree schema, are given in this section. Characteristic imaging features are presented for each type of mass.
No
Neoplasm
Diagnosis suggested by clinical history?

Known primary
Metastases (variable
appearance)
Tuberous sclerosis
Rhabdomyoma
(multiple masses,
may be low density)
Hypertension
Pheochromocytoma
(very vascular, often
along coronaries)
Immunocompromise Lymphoma (variable
appearance)
enhancement
location (near
area of dyskinesis,
especially the apex
or left atrial appendage)
Thrombus
Typical
Definitive diagnosis from imaging appearance?

Metastases
Visualized masses elsewhere
Myxoma
Narrow stalk (especially if
attached to interatrial septum)
Lipoma
Homogeneous fatty mass
Angiosarcoma Hemorrhagic, vascular,
aggressive mass in
pericardium or right atrium
Fibroma
Large, nonenhancing mass in
myocardium, especially with
calcification
muscle
Trabeculation/papillary
sleeve recess
(low density inferior
and/or posterior to
right pulmonary vein)
Pericardial
hypertrophy
of the interatrial septum
(fat in the interatrial
septum, spares fossa
ovalis)
Normal Variant
Lipomatous
Arising from
inside the heart
lung cancer
Lymphoma
or other
mediastinal mass
Thymoma
Metastases
Primary
Extension from
mediastinum?
carcinoma
Nonaggressive features present?

(Circumscribed, noninvasive,
homogeneous)
Hemangioma (homogeneous,
marked enhancement)
Myxoma without characteristic
narrow stalk (broad base
of attachment, well-circumscribed,
may be heterogeneous)
Adrenocortical
carcinoma
cell carcinoma
Hepatocellular
Renal
Extension from
inferior vena cava?
Invading from
outside the heart
Aggressive features present?

(Invasive, heterogeneous,
associated pericardial effusion)
Primary cardiac sarcoma
(variable appearance)
Metastases (variable appearance)
Cardiac Mass
CHAPTER 3
75
76
Imaging ProtocolCardiac Masses
Series
1
Plane
Imaging sequence
Sagittal
Bright blood static

gradient echo)
Specific
parameters
Time/slice
(s)
Breath hold
20

slices to include entire heart. Typical left-to-right range,
200 mm depending on body habitus (120 mm left to
80 mm right of midline).
2
Four chamber
long axis
Bright blood cine

Breath hold
20 cardiac phases
10-16

Short axis
Bright blood cine

Breath hold
20 cardiac phases
10-16
CHAPTER 3
Series
4
Plane
Oblique based
on mass location
Imaging sequence
Black blood inversion
recovery
77
Specific
parameters
Time/slice
(s)
Breath hold
10-16
Inversion recovery sequence to show cardiac morphology.

There is no fat suppression in this sequence, so nonflowing
fluids and lipids will both have high signal. Short-axis views
are typically used to prescribe these imaging planes. Location
is patient specific.
5
Oblique based
on mass location

recovery with fat
suppression
Breath hold
10-16
Inversion recovery sequence with fat suppression. Acquisition

of identical imaging planes as in series 4 provides a differential
method for determining the likely histologic composition of
the mass. Location is patient specific.
78
Series
6
Plane
Short axis
Imaging sequence
Perfusion
Specific
parameters
30-40
temporal phases
Time/slice
(s)
50-70
entire
volume

Advise patient to avoid rapid inspiration on second breath
hold. Inject 20 mL gadolinium contrast at 4-5 mL/s and start
sequence simultaneously. Instruct patient to hold his breath
for as long as possible and then to do additional breath holds
until the scan is over. After the scan has finished, may inject an
additional 20 mL gadolinium contrast at 2 mL/s (to improve
contrast on delayed enhancement sequence).
7
Short axis
Delayed enhancement
TI = 100-300 ms
10-16

8
Long axis
Delayed enhancement
TI = 100-300 ms
10-16

CHAPTER 3
79
Case Examples
Thrombus
Figure 3.23. Four-chamber balanced gradient echo images in diastole (top left) and
systole (top right) show a large area of dyskinesis at the apex. Within this region can be
seen a mass with a broad attachment to the
myocardium (arrows) which is well circumscribed and shows no discernable invasion.
An MDE image (bottom) shows that the
mass does not enhance.
This combination of features allows for a confident imaging diagnosis of a thrombus.
80
Myxoma
Figure 3.24. Axial balanced gradient echo image (top left) shows a large mass in the left
atrium (arrow). In an MDE image (top right), the mass (arrow) shows heterogeneous
enhancement, indicating that the mass is a neoplasm. In this large mass, no definite attachment
to the wall is visualized; this suggests that it could be a myxoma, which typically attaches by
a narrow stalk. However, for confident diagnosis of a myxoma, direct visualization of a narrow
stalk is required. A computed tomographic image from a different patient (bottom) depicts the
narrow stalk (arrow). (From Araoz PA, et al. CT and MR imaging of benign primary cardiac
neoplasms with echocardiographic correlation. Radiographics. 2000;20:1303-19. Used with
permission.)
Myxomas most frequently arise from the atria, attached to the fossa ovalis, but may occur
anywhere in the heart. Visualization of mobile tumor with a narrow stalk allows a confident diagnosis of myxoma.
CHAPTER 3
81
Figure 3.25. Oblique sagittal double inversion recovery image (left) from a different
patient shows a large, circumscribed mass in the right ventricular outflow tract. The mass
has a large base of attachment. An MDE image (right) shows that the mass has a central
enhancing region. These imaging features suggest a benign neoplasm, most likely a hemangioma or a myxoma without the typical stalk.
This case was a pathologically proven cardiac myxoma that, atypically, had a broad base of
attachment.
82
Metastasis
Figure 3.26. Short-axis MDE image shows a large mass in the lateral wall (arrow). The mass
has a broad attachment, shows no gross invasion of the underlying myocardium, and enhances.
The imaging characteristics of the mass itself do not allow for a confident diagnosis, but
inspection of the liver on this image showed a mass that was a metastasis from a known
carcinoid. The presence of an indeterminate mass with a known primary elsewhere is
strongly suggestive of cardiac metastasis, the most common type of neoplasm in the heart.
CHAPTER 3
83
Hemangioma
Figure 3.27. Short-axis balanced gradient echo image (top) shows a well-circumscribed
mass near the apex. The corresponding MDE image (bottom) shows that the mass has homogeneous bright enhancement, is well circumscribed, and does not appear to grossly invade the
myocardium. These imaging features suggest a benign neoplasm, most likely a hemangioma
or a myxoma without the typical stalk.
This case was a pathologically proven cardiac hemangioma.
84
Lipoma
Figure 3.28. Four-chamber double inversion recovery MR image (top) shows a wellcircumscribed mass (arrow) in the apex of the RV, with diffuse increased signal. The wellcircumscribed appearance suggests it is benign. However, performing triple inversion recovery
(bottom) provides fat saturation.
The signal in the mass decreases uniformly with fat saturation, meaning it is a homogeneous fatty mass and therefore a benign lipoma.
CHAPTER 3
85
Lipomatous Hypertrophy
Figure 3.29. Axial double inversion recovery image (top left) shows a lobulated mass in the
interatrial septum with homogeneous increased signal. An image from the same series at a
slightly lower level (top right) shows that the mass spares the fossa ovalis, which is characteristic
of lipomatous hypertrophy of the interatrial septum. A triple inversion recovery image (bottom)
at the same level as in the top left panel shows that the mass has homogeneously suppressed
signal and is therefore made of fat.
These findings indicate lipomatous hypertrophy of the interatrial septum, which is not
encapsulated, is not a mass or a neoplasm, and is a benign finding.
86
Angiosarcoma
Figure 3.30. Axial double inversion recovery image (left) shows a large, lobulated, invasive
mass centered on the right atrioventricular groove. A triple inversion recovery image (right)
at a lower level with contrast shows that the mass enhances diffusely, clearly invades into the
right atrium, and has an associated pericardial effusion.
The presence of enhancement and invasion into a chamber alone indicate that this is a
malignant neoplasm, and, without a patient history of a primary neoplasm elsewhere,
should represent a primary cardiac neoplasm. However, the location in the right atrium,
bright enhancement, and presence of pericardial effusion are all typical features of
angiosarcoma, the most common primary malignant cardiac neoplasm.
CHAPTER 3
87
Pericardial Disease
The pericardium is a flask-shaped sac composed of two virtually inelastic layers, with a
small amount of fluid between them, surrounding the heart. Its functions are to anchor
the heart in the mediastinum, prevent the heart from dilating to an extreme degree in
acute settings, and potentially act as a barrier to the spread of disease from contiguous
organs. Pathologic changes in the stiffness of the pericardium or in the amount of fluid in
it can alter normal heart function.
88
Imaging ProtocolPericardial Disease
Series
1
Plane
Imaging sequence
Sagittal
Bright blood static

gradient echo)
Specific
parameters
Time/slice
(s)
Breath hold
20

2
Four chamber
long axis
Bright blood cine

Breath hold
20 cardiac phases
10-16

Short axis
Black blood
inversion recovery
10-16
cover the entire ventricle from apex to base. There is no fat
suppression in this sequence, so nonflowing fluids and lipids
will both have high signal.
CHAPTER 3
Series
4
Plane
Short axis
Imaging sequence
recovery with fat
suppression
Specific
parameters
Single cardiac
phase
89
Time/slice
(s)
10-16
Inversion recovery sequence with fat suppression. Acquisition

of identical imaging planes as in series 3 provides a differential
method for diagnosis.
Short axis
Bright blood cine

Breath hold
20 cardiac phases
10-16
Horizontal long
axis
Bright blood cine

Breath hold
20 cardiac phases
10-16

90
Series
7
Plane
Short axis
Imaging sequence
Perfusion
Specific
parameters
30-40
temporal phases
Time/slice
(s)
50-70 for
entire
volume

Coaching is required beforehand to prevent rapid inspiration
on second breath hold. Inject 20 mL gadolinium contrast at
4-5 mL/s and start sequence simultaneously. Instruct patient to
hold his breath for as long as possible and then to do additional
may inject an additional 20 mL gadolinium contrast at 2 mL/s.
8
Short axis
Delayed enhancement
Breath hold
TI = 100-300 ms
10-20

9
Long axis
Delayed enhancement
Breath hold
TI = 100-300 ms
10-20

CHAPTER 3
91
Case Examples
Pericardial Effusion
Figure 3.31. Short-axis balanced gradient echo image near the mid ventricle (notice the
papillary muscles) demonstrates increased pericardial fluid layering in the most dependent
region of the pericardial sac.
The normal pericardium contains only 15 to 50 mL of pericardial fluid. Imaging of pericardial effusion is usually done to assess its severity and to determine the causative insult.
The effusion can be secondary to an inflammatory process such as pericarditis (see next
section) or can be noninflammatory in nature (eg, due to congestive heart failure,
hypothyroidism, or cirrhosis).
92
Pericarditis
Figure 3.32. Axial double inversion

recovery image (top left) and three-chamber
(top right) and short-axis (bottom) MDE
images demonstrate circumferential
pericardial thickening with persistent
enhancement. This constellation of findings
is consistent with active pericardial
inflammation.
Pericarditis is the most common pericardial pathology. It refers to inflammation of the

pericardial layers and can have multiple causesinfectious, postradiation, drug-induced,
or postmyocardial infarctionor can be a manifestation of a systemic disorder. However,
most commonly it is considered to be idiopathic and no cause can be found. In most
cases, some amount of pericardial fluid is present.
CHAPTER 3
93
Pericardial Constriction
Figure 3.33. Four-chamber balanced gradient echo image (left) and short-axis double
inversion recovery image (right) demonstrate circumferentially thickened pericardium with
a trace amount of a pericardial effusion. The interventricular septum in the image at left is
sigmoid shaped, reflecting increased right ventricular pressures.
Figure 3.34. Four-chamber balanced gradient

echo image showing thickened pericardium and
a sigmoid-shaped interventricular septum.
Prominent biatrial enlargement is also seen.
The main characteristic of pericardial constriction is an impairment of the normal cardiac

filling physiology. It is important to distinguish it from a restrictive cardiomyopathy
because the treatments are different. Imaging findings that can help with the diagnosis are
those of pericardial thickening, effusion, inflammation, calcification (best seen on computed
tomography), and findings secondary to the abnormal filling pressures, such as septal
bounce, a D-shaped LV, increased atrial size, and large coronary sinus or inferior vena cava.
94
Pericardial Cyst
Figure 3.35. Axial double inversion recovery (top left) and coronal triple inversion recovery
(top right) images demonstrate a large lobulated cystic structure at the right cardiophrenic
angle in close association with the pericardium. The bottom image shows the axial balanced
gradient echo image for reference.
These pericardial cysts are usually incidental findings, and the vast majority of them are
located in the cardiophrenic angle, most often on the right side. They do not communicate with the pericardial sac.
CHAPTER 3
95
Congenital Disease
Compared with other noninvasive imaging modalities, MRI has unique capabilities that
are of great benefit for evaluating patients with congenital heart disease. This is especially
true for older patients who have undergone attempts at surgical correction. Unlike
echocardiography, which may have difficulty gaining adequate acoustic windows to optimally evaluate these patients, cardiac MRI provides unlimited freedom for selecting the
ideal imaging planes to display the relevant anatomic and physiologic abnormalities in
these often-complex situations. In addition, compared with most other imaging
modalites, MRIs unique ability to both quantitate flow and characterize tissue makes it an
ideal technique to evaluate patients with congenital heart disease.
96
Imaging ProtocolCongenital Disease
Series
1
Plane
Imaging sequence
Specific
parameters
Sagittal
Bright blood static

gradient echo)
Breath hold
Single cardiac
phase
Time/slice
(s)
20

2
Four chamber
long axis
Bright blood cine

Breath hold
20 cardiac phases
10-16

Short axis
Bright blood cine

Breath hold
20 cardiac phases
10-16
CHAPTER 3
Series
4
Plane
Imaging plane
dependent on
pathology
Imaging sequence
recovery
97
Specific
parameters
Time/slice
(s)
Breath hold
10-16
Black blood imaging sequence without fat suppression. For

coarctation, prescribe a sagittal candy cane view of the aorta.
5
Oblique 3D
volume
3D MR
angiography
Breath hold
60-80
Angiography sequence with gadolinium contrast administration

for visualizing disease-specific pathology. A test scan should be
run before administration of contrast agent to verify that the
prescription includes the relevant anatomy.
Imaging plane
dependent on
pathology
Cine phase contrast
Breath hold
20 cardiac phases
Flow direction
sensitization = slice
VENC = 200
10-16
Imaging plane should bisect the anatomical region of interest.

Optional flow quantitation through collateral vessels. Field of
view as small as possible without wraparound artifact superimposing the area of interest. Plane must be perpendicular to the
vessel. Collateral vessels with flow directed below coarctation
indicates physiologically significant coarctation.
LV, left ventricle; NEX, number of excitations; TI, inversion time; VENC, velocity encoding; VPS, views per segment.
98
Case Examples
Tetralogy of Fallot
Figure 3.36. MR images in a patient with tetralogy of Fallot. Short-axis balanced gradient
echo image (top left) at the level of the the left ventricular papillary muscles demonstrates
marked dilatation of the right ventricular outflow tract (*). (See discussion regarding calculations of ventricular volumes and regurgitant fractions on page 66.) Transaxial magnitude
image (top right) of a phase-contrast study at the level of the right pulmonary valve. Phasecontrast images, also at the level of the right pulmonary valve, acquired during systole (bottom
left; note that cephalad flow is dark and caudal flow is bright) and during diastole (bottom
right). In the image at diastole (bottom right), the bright signal in the main pulmonary artery
just above the pulmonary valve is due to retrograde (caudal) flow caused by pulmonary valve
regurgitation.
CHAPTER 3
99
Figure 3.37. Gadolinium-enhanced MR angiography performed postoperatively in a

patient with tetralogy of Fallot who underwent attempted left pulmonary artery angioplasty.
Note the severe residual stenosis (7 mm) and poststenotic dilatation at the origin of the left
pulmonary artery.
100
Transposition Complexes
Figure 3.38. MR images from a patient with D-transposition of the great arteries after an
intraatrial baffle procedure (Mustard operation). Balanced gradient echo MR image in the
transaxial plane at the level of the atrioventricular valves (top; note marked narrowing in
the mid portion of the pulmonary venous pathway [arrow]). Balanced gradient echo MR
image in the sagittal plane (bottom) through the stenotic pulmonary venous pathway (arrow)
demonstrates the anterior (a) and posterior (p) compartments of the surgically created
pulmonary venous atrium.
CHAPTER 3
101
Figure 3.39. Axial balanced gradient echo pulse image at the level just above the aortic
valve in a patient with D-transposition of the great arteries after an arterial switch
procedure, which included placing the pulmonary arteries anterior to the aorta (Lecompte
maneuver). Note mild narrowing of both proximal left and right pulmonary arteries.
a
p
Figure 3.40. Balanced gradient echo MR images from a patient with congenitally corrected
transposition of the great arteries. Oblique sagittal view (left) shows the aorta located anterior
to and originating from the RV (r). Note the left atrium (arrow) connecting with the RV
and the dilated main pulmonary artery (*), which resulted from pulmonary valve stenosis.
Axial view (right) at the level of the bifurcation of the main pulmonary artery (p); note the
aorta (a) anterior and slightly to the left of the pulmonary artery.
102
Partial Anomalous Pulmonary Venous Connections
Figure 3.41. Maximum-intensity projection image from gadolinium-enhanced MR

angiography. Data set demonstrates partial anomalous pulmonary venous connections
of the left upper lobe pulmonary veins to a left vertical vein (arrow).
CHAPTER 3
103
Figure 3.42. Balanced gradient echo pulse sequence in the coronal plane at the level
of the superior vena cava. Image shows partial anomalous pulmonary venous connections
of the right upper (arrow) and right middle (arrowhead) lobe pulmonary veins to the
superior vena cava. This patient also had a sinus venosus atrial septal defect (*).
Figure 3.43. Opposing views of gadolinium-enhanced MR angiography with volume

rendering demonstrate infracardiac partial anomalous pulmonary venous connections
of all the right pulmonary veins. Additional images for this patient (not shown) demonstrated
that the anomalous connection was into the inferior vena cava.
104
Coarctation
Figure 3.44. Gadolinium-enhanced MR angiography with volume rendering demonstrates

severe coarctation at the juxtaductal location. Note the enlarged intercostal and internal
mammary arteries due to collateral blood flow.
The minimum imaging requirements include a scout sequence and 3D MR angiography.

Balanced steady-state sequences are useful for demonstrating left ventricular hypertrophy
or dysfunction, as well as a bicuspid aortic valve. A phase-contrast sequence is also valuable
to document flow reversal in collateral vessels.
CHAPTER 3
105
Ebstein Anomaly
a
r
Figure 3.45. Balanced gradient echo images in a patient with Ebstein anomaly. Axial view
(top) at the level of the atrioventricular valves shows displacement of the tricuspid valve
toward the right ventricular apex (arrow). Oblique sagittal view (bottom) through the right
atrium and RV shows the large sail-like anterior leaflet (arrow) of the apically displaced
abnormal tricuspid valve. a, atrialized right ventricle; r, residual trabeculated portion of the
right ventricle; arrowhead, right atrioventricular groove.
106
Ventricular Noncompaction
Figure 3.46. Balanced gradient echo images in a patient with myocardial noncompaction.
Short-axis view (top) near the apex demonstrates the thickened left ventricular wall, which
is composed primarily of trabeculated myocardium containing numerous sinusoidal spaces.
Four-chamber view (bottom) demonstrates noncompaction of the left ventricular myocardium.
CHAPTER 4
PULSE SEQUENCE BASICS,

ECG GATING, AND
MR ARTIFACTS
Chapter 4
PULSE SEQUENCE BASICS,

ECG GATING, AND MR ARTIFACTS
Matt A. Bernstein, PhD
Introduction
The purpose of this chapter is to provide an overview of some of the more technical
aspects of cardiac magnetic resonance (MR) imaging. To this end, three broad topics are
covered: pulse sequence basics, electrocardiographic (ECG) gating, and common imaging
artifacts. Cardiac pulse sequences are described by grouping individual imaging options
into five broad categories: magnetization preparation, echo formation, data acquisition,
rapid imaging, and imaging mode, with the resultant image being described by the blood
pool signal. Using this nomenclature, individual pulse sequences are described, and
sequence-specific variables, recommended values, and example images are provided. Pulse
sequences are also distinguished according to their applicationimaging of morphology
or function. The sections on ECG gating include information on the biophysical origin of
the ECG signal, strategies for successful gating in MR imaging (MRI), and a list of ECG
artifacts encountered in the MR environment and recommendations to reduce or eliminate them. Finally, examples of several commonly seen imaging artifacts are provided,
along with a discussion of their sources and preventive or corrective measures.
109
CHAPTER 4
PULSE SEQUENCE BASICS, ECG GATING, AND MR ARTIFACTS
111
Anatomy of a Cardiac MRI Pulse Sequence

Conceptually, a cardiac MRI pulse sequence can be broken down into five constituent categories (boxes 1-5 below). Each category contains multiple components that can be combined in various ways to provide the full range of image contrasts and applications (eg,
studies of function or morphology). The scheme below shows these five categories and the
resultant image (box 6), as defined by the blood pool signal. This section describes each
category and gives a list of components that make up each one.
Magnetization
preparation
Echo
formation
Data
acquisition
Rapid
imaging
Imaging
mode
Blood
pool
Magnetization Preparation
Magnetization preparation involves the application of radio frequency (RF) and gradient
pulses to prepare the MR signal and, hence, image contrast before data acquisition.
Saturation Recovery Application of a series of 90 RF pulses to convert longitudinal into transverse magnetization. Recovery of the longitudinal magnetization will occur as
a result of spin-lattice (ie, T1) relaxation effects. By choosing the appropriate delay between
the RF pulses (ie, the pulse repetition rate [TR]), suppression of specific tissues can be
achieved.
Inversion Recovery Application of a 180 RF pulse, followed by a delay time.
Tissue suppression is achieved by selection of the delay between the 180 pulse and the
commencement of the imaging sequence, such that the signal of the tissue to be
suppressed is zero because of T1 recovery.
Fat Saturation Application of an RF pulse spectrally tuned to the resonant
frequency of lipids, followed by gradient-induced spoiling. This RF pulse only dephases
the magnetization of lipids, unless the main magnetic field is very inhomogeneous. Fat
saturation can also be achieved by application of multiple inversion pulses as part of the
magnetization preparation phase of the imaging sequence.
112
Tagging Application of an RF pulse to create transverse magnetization, followed

by gradient-induced spatial modulation and a second RF pulse of equal amplitude but
opposite flip angle. This creates a modulation of the MR signal that is spatially dependent,
which can then be used to track motion by following the banding pattern in the images.
Phase Contrast (Flow Encoding) Application of gradient waveforms before data
acquisition to encode the velocity (ie, speed and direction) of moving tissues into the
phase of the MR image. This is typically used for quantifying blood flow but also can be
used to track bulk motion, such as in the heart. A specific range of velocities is mapped to
the minimum and maximum values of the phase (180 to +180). Unlike the other
entries for magnetization preparation listed here, flow encoding is applied after the RF
excitation pulse, so it affects transverse rather than longitudinal magnetization.
Echo Formation
Echo formation refers to the method by which the MR signal is generated. With application of appropriate spatial encoding gradients, these echoes encode the spatial frequency
or k-space representation of the MR image. Fourier transformation of these data produce
the final MR image.
Spin Echo Formation of the k-space signal by application of two RF pulses (90
and 180). The formation of the signal (echo) occurs at a time equal to twice the interval
between the two pulses. For a standard spin echo, each TR consists of a single 90180
RF pulse pair. Multiecho spin echoes are formed by repetition of the 180 pulse.
Gradient Echo Formation of an echo signal and subsequent image by application
of an RF pulse with a flip angle typically much less than 90 (<45). Immediately after the
RF pulse, the transverse magnetization is dephased by application of a negative-polarity
gradient along the readout direction, followed by a contiguous positive-polarity gradient
that reverses the effect of the negative gradient and results in the formation of the image
echo. Additional gradient fields are added for slice selection and phase encoding, necessary
to complete the image acquisition sequence. Short image echo times, on the order of 1
millisecond, can be achieved with high-performance gradient systems on most high-field
imaging systems. Gradient echo imaging sequences are typically used for fast imaging
applications such as MR angiography or cine imaging sequences.
In all types of gradient echo imaging, the longitudinal component of the magnetization reaches a dynamic equilibrium as a result of the trade-off between magnetization loss
CHAPTER 4
113
from the application of RF pulses and gain from T1 recovery. The two most commonly
used types of gradient echoes in cardiac imaging are spoiled and balanced, which will be the
focus in this chapter. Other types of gradient echo imaging include coherent gradientrecalled echo and reversed steady-state free precession.
Spoiled Residual transverse magnetization is eliminated (spoiled) by either
varying the phase of the RF pulses or applying additional gradient lobes. A spoiled gradient echo is typically T1 weighted but can show bright blood signal as a result of inflow.
Balanced Residual transverse magnetization is maintained and strongly contributes to the net signal. As shown in Figure 4.1, the net gradient area on each axis is
nulled (balanced) in each TR interval. Maintaining zero net phase accumulation along all
spatial encoding axes provides a steady-state balanced gradient echo. For these types of
sequences, the phase of the RF pulses follows a simple pattern (like sign alternation) from
one TR to the next. A steady-state balanced gradient echo produces contrast that is proportional to the ratio of T2 (transverse relaxation) to T1 (T2/T1), with fat and fluid being
bright. This type of gradient echo is highly susceptible to gradient balancing errors and
magnetic field inhomogeneities. These effects are manifested as banding (bright to dark
transitions) within the image.
Data Acquisition
Data acquisition refers to the method by which echoes, either spin or gradient, are collected as part of the process of acquiring the k-space data necessary for image reconstruction.
Single Echo Acquisition of a single line of data per repetition (TR) of the imaging
sequence. The total imaging time for a single-echo imaging sequence is equal to the product of the TR and the number of phase-encoding steps performed by the sequence, unless
rapid imaging techniques are used.
Echo Train Acquisition of more than one image echo or line of data per TR by the
application of additional RF (eg, fast or turbo spin-echo sequences) or gradients (for
multi-echo gradient echobased sequences). The total imaging time is equal to the product of the TR and the phase-encoding steps, divided by the number of lines of data
acquired per TR (echo train length). The acquisition time of echo train methods can be
further shortened with use of rapid imaging techniques.
Single Shot Extension of the echo train concept, whereby all of the lines of data are
acquired within a single TR or shot. (Note that certain gradient-echo sequences [balanced steady-state free precession] are sometimes classified as single-shot sequences but
114
180
Spin Echo
90
RF pulse
Slice-selection
gradient waveform
Phase-encoding
gradient waveform
Frequency-encoding
gradient waveform
MR signal
Spoiled Gradient Echo

RF pulse
Slice-selection
gradient waveform
Phase-encoding
gradient waveform
Frequency-encoding
gradient waveform
MR signal
Balanced Gradient Echo

RF pulse
Slice-selection
gradient waveform
Phase-encoding
gradient waveform
Frequency-encoding
gradient waveform
MR signal
CHAPTER 4
115
apply an RF pulse for each echo or line of data. Image data are acquired sequentially and
thus considered as from a single shot.)
Multishot An echo train that requires more than one repetition (shot) to acquire
all of the raw data for an image. The number of shots required per image is equal to the
number of lines of data divided by the number of lines in each echo train.
Segmented Data Acquisition The acquisition of a limited number of lines (views)
of image data at a given phase (segment) of the cardiac cycle. Acquisition of the total number of views of a single image occurs over multiple cardiac cycles. Acquisition of a limited
number of views reduces the temporal footprint or width (tens of milliseconds) of the
data acquisition window within the cardiac cycle, resulting in a static image at each cardiac phase. Repetition of the acquisition process at differing segments results in a multiphase or cine data set, allowing visualization of the motion of the heart. The number of
image echoes (lines) acquired per segment is known as the views per segment (VPS). The
VPS is adjusted on the basis of heart rate to maintain sufficient temporal resolution of
each image in the cine series.
View Sharing Lines of k-space are shared between images representing adjacent
phases of the cardiac cycle, thereby reducing the number of R-R intervals over which the
data are collected but reducing temporal resolution of the image. Most commonly used in
cine cardiac sequences.
Rapid Imaging
Rapid imaging comprises a group of imaging techniques designed to reduce the total
acquisition time by undersampling of the k-space data, followed by image reconstruction.
Image-Based Parallel Imaging (SENSE) Decreasing the number of phase encodings acquired in a standard acquisition to intentionally induce aliasing (wrap) in the phaseencoded direction, followed by unwrapping (unaliasing) to produce an image with an
effectively larger field of view (FOV). (In a three-dimensional [3D] acquisition, decreasing
the number of phase encodings along the two phase-encoding directions sometimes is
Figure 4.1. Pulse sequence diagrams for the three basic pulse sequence types used in cardiac
MRI: spin echo, spoiled gradient echo, and balanced gradient echo. Each sequence shows the
RF pulse(s) and spatial encoding gradients used to create a single image echo. Repetition of
this sequence generates the k-space data necessary for image reconstruction. Multiple gradient
waveforms are shown on the phase-encoding axis.
116
possible for further acceleration.) Differences in spatial sensitivity of the elements of a

phased-array coil are used to mathematically map the unwrapping. Reduction in imaging
time is equal to the fractional reduction in phase encodings. Calibration data are also
required to map the spatial coil sensitivities and can be performed as part of the imaging
sequence or as a separate scan.
K-SpaceBased Parallel Imaging (SMASH and GRAPPA) Undersampling of the
k-space data in the phase-encoding direction, followed by reconstruction of the missing
data using the elements of a phased-array coil and the harmonic nature of the phaseencoding process.
Hybrid (Spatial-Temporal) Techniques to improve the speed of a time series (cine)
data set. UNFOLD is a method of decreasing aliasing artifacts by identification of temporal harmonics of the image data. kt-BLAST and TRICKS are additional rapid imaging
techniques that apply related concepts.
Partial Fourier Not all of the lines of k-space are acquired, thereby decreasing the
number of TRs and, hence, total imaging time. The missing data can be synthesized by applying a homodyne reconstruction technique or simply setting those data to zero (zero filling).
Rectangular-Phase FOV The spacing between k-space lines is inversely proportional
to the FOV. Decreasing the FOV increases the spacing between k-space lines; consequently,
fewer lines are required to cover the same k-space range in the phase-encoding direction.
Acquisition of fewer k-space lines means fewer TRs and, hence, shorter acquisition times.
Imaging Mode
Imaging mode defines the type of data set acquired.
Single Frame Acquisition of a single imaging plane, set of slices, or volume at a
single time point, without any temporal information.
Cine Acquisition of multiple images of the same anatomical location (prescription) but over a given time interval. For the large majority of cardiac acquisitions, the time
interval over which a cine series is acquired is the ECG R-R interval, or multiples thereof.
2D A plane of data whose orientation can be defined by any three points in physical space. A matrix of data points (pixels) fills the plane. The size of the two-dimensional
(2D) image equals the number of frequency encodings and phase encodings plus any zero
filling of the data (eg, 256 192 OR 256 [192 + 64], where 64 lines are zero filled).
These can be thought of as the number of rows and columns, respectively, in the image
matrix (or columns and rows, depending on the orientation of the image). Multiple 2D
CHAPTER 4
117
planes can be acquired with or without gaps to cover an imaging volume.

3D A volume of data with any arbitrary orientation in physical space. The 3D volume can be considered as consisting of a series of contiguous (zero or negative gap) 2D
imaging planes. The term 3D is reserved for acquisitions in which the imaging volume
is excited with a single RF pulse; typically the data are phase encoded in two different
directions. Matrix sizes are defined by the number of rows and columns of each plane and
the number of planes that define the third dimension of the volume.
Blood Pool
Blood pool refers to the intensity of the blood pool signal in the final MR image.
BrightExogenous Contrast Agent Blood pool has the highest signal in the image
and arises from the use of T1-shortening gadolinium-based contrast agents. Most commonly used in conjunction with short echo time (TE) and TR gradient echo pulse
sequences.
Bright Blood pool provides the highest signal in an image. For cardiac applications, high blood pool signal (ie, bright blood) is most commonly achieved with gradient
echo sequences (spoiled and balanced).
Dark Blood pool is suppressed and has intensity approximately equal to the background signal (zero). Blood pool signal suppression is typically achieved by application of
an inversion pulse, followed by a spin echo or a gradient echo imaging sequence.
118
Pulse Sequences for Imaging Cardiac Morphology

Balanced Gradient Echo (Balanced Steady-State Free Precession) Cine
This method is the most common sequence used for assessment of cardiac function.
Image contrast is roughly proportional to the ratio of the two relaxation parameters
(T2/T1), and as such, fluid is bright despite the short TE and TR values used. This
sequence provides high blood poolto-myocardial contrast.
Imaging Components
1
Magnetization
preparation
Echo
formation
Data
acquisition
Rapid
imaging
Imaging
mode
Blood
pool
2D, cine
Single shot
SENSE,
SMASH,
hybrid,
partial
k-space,
fractional
phase FOV
Phase
contrast
Inversion
recovery
Spin echo
Inversion
recovery, fat
saturation
Balanced
gradient
echo
Multishot
Saturation
recovery
Spoiled
gradient
echo
Single echo,
segmented
Bright
contrast
agent
2D, static
Bright
3D, cine
Dark
Full
acquisition
3D, static
Tagging
Sequence-Specific Variables
Views per segment
The number of lines of k-space sampled per cardiac phase; it determines the temporal
resolution of each cardiac phase of the cine sequence. VPS is based on the patients heart
CHAPTER 4
119
rate (in beats per minute [bpm]). A decrease in the VPS will increase imaging time. Thus,
a compromise is often struck between sufficient temporal resolution and breath-hold
duration. To keep imaging times within normal breath-hold times (<20 seconds) for low
VPS values, several strategies can be used, including decreasing the number of phaseencoding steps, partial-phase FOV, or parallel imaging techniques.
T YPICAL VPS VERSUS HEART RATE

Heart Rate (bpm)
VPS
60
61-95
96-125
126-155
156
10-12
8-10
6-8
4-6
<4
Cardiac phases
The number of images reconstructed across the cardiac cycle. Each image is at a specific
time point or phase of the cardiac cycle. The larger the number of cardiac phases the higher the temporal resolution of the cine series. Twenty cardiac phases are most commonly
reconstructed for cine sequences.
Balanced gradient echo short-axis view
120
Spoiled Gradient Echo Cine

This has a lower signal than a balanced gradient echo sequence, but it also is less susceptible to magnetic field inhomogeneity artifacts. Fluid is dark, except for blood that flows
into the slice or has contrast agent on board.
Imaging Components
1
Magnetization
preparation
Echo
formation
Data
acquisition
Rapid
imaging
Imaging
mode
Blood
pool
2D, cine
Single shot
SENSE,
SMASH,
hybrid,
partial
k-space,
fractional
phase FOV
Phase
contrast
Inversion
recovery
Spin echo
Inversion
recovery, fat
saturation
Balanced
gradient
echo
Multishot
Saturation
recovery
Spoiled
gradient
echo
Single echo,
segmented
Bright
contrast
agent
2D, static
Bright
3D, cine
Dark
Full
acquisition
3D, static
Tagging
Views per segment
The number of lines of k-space sampled per cardiac phase; it determines the temporal resolution of each cardiac phase of the cine sequence. VPS is based on the patients heart rate.
A decrease in the VPS will increase imaging time. Thus, a compromise is often struck
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121
between sufficient temporal resolution and breath-hold duration. To keep imaging times
within normal breath-hold times (<20 seconds) for low VPS values, several strategies can
be used, including decreasing the number of phase-encoding steps, partial-phase FOV, or
parallel imaging techniques.

Heart Rate (bpm)
VPS
60
61-95
96-125
126-155
156
10-12
8-10
6-8
4-6
<4
Cardiac phases
time point or phase of the cardiac cycle. The larger the number of cardiac phases the higher the temporal resolution of the cine series. Twenty cardiac phases are most commonly
reconstructed for cine sequences.
Spoiled gradient echo short-axis view
122
Myocardial Delayed Enhancement

This method comprises inversion recovery, single-shot, or multishot spoiled gradient echo.
Myocardium inversion time (TImyo) is chosen so that signal from normal myocardium is
suppressed and the signal from gadolinium contrast-enhanced infarcted myocardium is
maximized.
Imaging Components
1
Magnetization
preparation
Echo
formation
Data
acquisition
Rapid
imaging
Imaging
mode
Blood
pool
2D, cine
Single shot
SENSE,
SMASH,
hybrid,
partial
k-space,
fractional
phase FOV
Phase
contrast
Inversion
recovery
Spin echo
Inversion
recovery, fat
saturation
Balanced
gradient
echo
Multishot
Saturation
recovery
Spoiled
gradient
echo
Single echo,
segmented
Bright
contrast
agent
2D, static
Bright
3D, cine
Dark
Full
acquisition
3D, static
Tagging
CHAPTER 4
123
Myocardium inversion time
The delay time from the application of the RF inversion pulse to data acquisition. TImyo is
chosen so that the longitudinal magnetization of normal myocardium is zero at the time
of data collection. The choice of TImyo is based on the delay between administration of
contrast agent and initiation of delayed enhancement imaging, as well as the wash-in and
wash-out kinetics of the contrast agent within the myocardium. For single-shot and multishot sequences that acquire multiple lines of data for a single inversion pulse, TImyo is the
time delay from the RF inversion pulse to the acquisition of the center of the data acquisition window.
Typical TImyo = 100-300 milliseconds
Example images
Images show myocardial delayed enhancement images of normal (left) and infarcted
(right) myocardium. The blood pool is bright, identifying a high concentration of contrast
agent, whereas the signal from normal myocardium is suppressed and appears dark.
Regions of infarction are bright due to delayed uptake of the contrast agent.
124
Double Inversion Recovery

This is an inversion recovery pulse sequence that applies an inversion pulse to the entire
imaging volume, a slice-selective reverse inversion pulse, and a spin echo, echo train imaging sequence. The time between the first inversion pulse and the spin echo readout is
known as the blood inversion time (TIblood) and is chosen so that the blood signal is
nulled at the time of the imaging sequence. This is not a fat-suppressed imaging sequence.
Imaging Components
1
Magnetization
preparation
Echo
formation
Data
acquisition
Rapid
imaging
Imaging
mode
Blood
pool
Phase
contrast
Inversion
recovery
Spin echo
Inversion
recovery, fat
saturation
Balanced
gradient
echo
Multishot
Saturation
recovery
Spoiled
gradient
echo
Single echo,
segmented
Single shot
SENSE,
SMASH,
hybrid,
partial
k-space,
fractional
phase FOV
2D, cine
Bright
contrast
agent
2D, static
Bright
3D, cine
Dark
Full
acquisition
3D, static
Tagging
CHAPTER 4
125
Blood inversion time
The time delay between the RF inversion pulse and data acquisition. A nonslice-selective
(hard) RF pulse is applied in order to invert the MR signal from all of the blood within
the imaging volume. It is important to note that this value is field strength dependent.
Typical TIblood = 650 milliseconds at 1.5T field strength and HR = 60 bpm
(For more information, see Simonetti et al in Selected References.)
Double inversion recovery image (short-axis view)
126
Triple Inversion Recovery

This is an inversion recovery with three inversion pulses, followed by an echo train spin
echo imaging sequence. This sequence is very similar to the double inversion recovery
sequence but with the addition of the third inversion pulse before the echo train spin echo
imaging sequence to suppress fat signal. The time between the imaging sequence and the
third RF pulse is known as the fat inversion time (TIfat).
Imaging Components
1
Magnetization
preparation
Echo
formation
Data
acquisition
Rapid
imaging
Imaging
mode
Blood
pool
2D, cine
Single shot
SENSE,
SMASH,
hybrid,
partial
k-space,
fractional
phase FOV
Phase
contrast
Inversion
recovery
Spin echo
Inversion
recovery, fat
saturation
Balanced
gradient
echo
Multishot
Saturation
recovery
Spoiled
gradient
echo
Single echo,
segmented
Bright
contrast
agent
2D, static
Bright
3D, cine
Dark
Full
acquisition
3D, static
Tagging
CHAPTER 4
127
Blood inversion time
The time delay between the RF inversion pulse and data acquisition. A nonslice-selective
(hard) RF pulse is applied in order to invert the MR signal from all of the blood within the
imaging volume. This value is field strength dependent.
Fat inversion time
Time delay between the application of a spatially selecive RF pulse and data acquisition.
This inversion time is shorter than TIblood and is placed after the RF pulse and before data
acquisition.
Inclusion of both inversion pulses allows complete suppression of signal from blood and
lipids (fat). Note that both TIblood and TIfat values vary with field strength. When imaging
at higher field strengths (3.0T) it is advisable to check these values.
Typical TIblood = 650 milliseconds at 1.5T field strength and HR = 60 bpm
Typical TIfat = 150 milliseconds at 1.5T field strength
(For more information, see Simonetti et al in Selected References.)
Triple inversion recovery image (short-axis view)
128
Spin Echo T1-Weighted

This involves a fast spin echo, with TE chosen to allow blood within the imaging slice to
flow out of the volume before data collection begins. This effectively eliminates any signal
from the blood pool.
Imaging Components
1
Magnetization
preparation
Echo
formation
Data
acquisition
Rapid
imaging
Imaging
mode
Blood
pool
2D, cine
Single shot
SENSE,
SMASH,
hybrid,
partial
k-space,
fractional
phase FOV
Phase
contrast
Inversion
recovery
Spin echo
Inversion
recovery, fat
saturation
Balanced
gradient
echo
Multishot
Saturation
recovery
Spoiled
gradient
echo
Single echo,
segmented
Bright
contrast
agent
2D, static
Bright
3D, cine
Dark
Full
acquisition
3D, static
Tagging
CHAPTER 4
129
TE/2
Time between the 90 and 180 RF pulses. This value must be large enough to allow for
blood to flow out of the imaging slice (or volume), thereby not contributing to the signal
within the image.
TR
Time between successive repetitions of the 90 RF pulse or lines of data.
Typical TE = as short as possible and should not exceed 50 milliseconds
Typical TR = one R-R interval and should not exceed 800 milliseconds
Note that slow-flowing blood can be mistaken for pathologies within the cardiac chambers
because the blood does not wash out of the imaging volume during the time TE/2 and
therefore contributes to signal within the chambers in the slice of interest.
T1-Weighted axial image
130
Pulse Sequences for Imaging Cardiac Function

Gradient Echo (Balanced and Spoiled) Cine
See previous section (pages 118-121) for a complete description.
3D MR Angiography
This uses a 3D spoiled gradient echo sequence. The sequence uses an ultrashort TR (5 ms)
and TE (1 ms) to produce a T1-weighted imaging sequence. T1-shortening contrast agent
(eg, a gadolinium chelate such as Gd-DTPA) is administered before initiation of the imaging
sequence to provide maximum contrast between the blood pool and background tissue.
Imaging Components
1
Magnetization
preparation
Echo
formation
Data
acquisition
Rapid
imaging
Imaging
mode
Blood
pool
2D, cine
Single shot
SENSE,
SMASH,
hybrid,
partial
k-space,
fractional
phase FOV
Phase
contrast
Inversion
recovery
Spin echo
Inversion
recovery, fat
saturation
Balanced
gradient
echo
Multishot
Saturation
recovery
Spoiled
gradient
echo
Single echo,
segmented
Bright
contrast
agent
2D, static
Bright
3D, cine
Dark
Full
acquisition
3D, static
Tagging
CHAPTER 4
131
Centric view order encoding
K-space views are acquired based on their radial distance from the center of k-space, starting from the center or the outer limits (reverse centric) of k-space. Data acquisition is typically initiated upon arrival of the bolus peak within the imaging volume.
Sequential view order encoding
K-space views are acquired in a rectilinear, sequential order.
Example images
Maximum-intensity projection images from four different perspectives (rotation angles) of

the imaging volume.
132
Cine Phase Contrast

This involves gradient-recalled echo (coherent or spoiled), with motion-sensitizing gradients added between RF excitation and acquisition of the image data. The velocity of flowing blood is encoded into the phase of the MR signal and is measured by the velocity
encoding (VENC) parameter.
Imaging Components
1
Magnetization
preparation
Echo
formation
Data
acquisition
Rapid
imaging
Imaging
mode
Blood
pool
2D, cine
Single shot
SENSE,
SMASH,
hybrid,
partial
k-space,
fractional
phase FOV
Phase
contrast
Inversion
recovery
Spin echo
Inversion
recovery, fat
saturation
Balanced
gradient
echo
Multishot
Saturation
recovery
Spoiled
gradient
echo
Single echo,
segmented
Bright
contrast
agent
2D, static
Bright
3D, cine
Dark
Full
acquisition
3D, static
Tagging
CHAPTER 4
133
Velocity encoding
The maximum velocity that is mapped to the highest phase value in the image (180 or
=3.14159 radians).
Measurement
Vessel
Internal and common
carotid artery
Typical VENC Values (cm/s)
<120
Thorax
Ascending aorta
Descending aorta
Vena cava
<175 (range, 100-250)

<175 (range, 100-250)
<40
Abdomen
Aorta
<100
Pathologies
Aortic valve stenosis
Valvular insufficiency
<800 (range, 200-800)

<400 (range, 200-400)
Carotids
Prestenotic
Intrastenotic
<50 (range, 5-50)

<500 (range, 100-500)
134
Flow-encoding direction
Direction that is sensitized to flow; often described as along the three imaging axes (frequency, phase, and slice). To obtain the three components of the flow vector, the imaging
sequence must be repeated three separate times. It is most common to choose the flow
direction along the slice-encoding direction. Encoding along all directions requires separate acquisitions or a reduction in temporal resolution for interleaved acquisitions.
Reconstruction type
Phase or complex difference; method by which the phase (velocity) data are reconstructed.
Phase difference calculates the difference in the phase of the two data sets acquired in the
cine phase contrast sequence; complex difference uses magnitude and phase information.
Views per segment
The number of lines of k-space sampled per cardiac phase; it determines the temporal resolution of each cardiac phase of the cine sequence. VPS is based on the patients heart rate.
A decrease in the VPS increases imaging time. Thus, a compromise is often struck between
sufficient temporal resolution and breath-hold duration. To keep imaging times within
normal breath-hold times (<20 seconds) for low VPS values, several strategies can be used,
including decreasing the number of phase encoding steps, partial-phase FOV, or parallel
imaging techniques.

Heart Rate (bpm)
VPS
60
61-95
96-125
126-155
156
10-12
8-10
6-8
4-6
<4
CHAPTER 4
135
Cardiac phases
time point or phase of the cardiac cycle. The larger the number of cardiac phases, the higher the temporal resolution of the cine series. Most commonly, 20 cardiac phases are reconstructed for cine sequences.
Example images
Phase (top) and magnitude (bottom) images of the ascending and descending aorta. The
two directions of flow in the phase image are represented by the bright and dark signal
within the vessel lumen.
136
Perfusion
This uses a saturation recovery preparation pulse, followed by a spoiled or balanced gradient echo readout.
Imaging Components
1
Magnetization
preparation
Echo
formation
Data
acquisition
Rapid
imaging
Imaging
mode
Blood
pool
2D, cine
Single shot
SENSE,
SMASH,
hybrid,
partial
k-space,
fractional
phase FOV
Phase
contrast
Inversion
recovery
Spin echo
Inversion
recovery, fat
saturation
Balanced
gradient
echo
Multishot
Saturation
recovery
Spoiled
gradient
echo
Single Echo,
segmented
Bright
contrast
agent
2D, static
Bright
3D, cine
Dark
Full
acquisition
3D, static
Tagging
Phases per slice
The number of samples (images) over which the perfusion bolus wash-in and wash-out
are measured. Each image represents a separate time point. Total imaging time is proportional to this value, which can be between 20 and 40 seconds (typically 30-40). For larger
phases (40), total imaging time can be >1 minute.
CHAPTER 4
137
Example images
Images show a perfusion sequence at time delays of 0, 5, 13, 20, and 31 seconds, respectively, after administration of a gadolinium-based contrast agent. A bright blood pool indicates the presence of the contrast agent, with the filling of the right ventricle followed by
the left ventricle. Overall contrast diminishes over time as the contrast is diluted into the
blood pool.
138
Tagging
This method involves a tagging preparation sequence before initiation of a spoiled gradient echo imaging sequence.
Imaging Components
1
Magnetization
preparation
Echo
formation
Data
acquisition
Rapid
imaging
Imaging
mode
Blood
pool
2D, cine
Single shot
SENSE,
SMASH,
hybrid,
partial
k-space,
fractional
phase FOV
Phase
contrast
Inversion
recovery
Spin echo
Inversion
recovery, fat
saturation
Balanced
gradient
echo
Multishot
Saturation
recovery
Spoiled
gradient
echo
Single echo,
segmented
Bright
contrast
agent
2D, static
Bright
3D, cine
Dark
Full
acquisition
3D, static
Tagging
Tag spacing
The spacing between the individual tag lines. This parameter is typically stated in millimeters, ranges between 5 and 10 mm, and is dependent on gradient performance.
Tag type
Tags can be defined as a series of lines (1D displacement) or grids (2D displacement).
CHAPTER 4
139
Views per segment

The number of lines of k-space that are sampled per cardiac phase; it determines the temporal resolution of each cardiac phase of the cine sequence. VPS is based on the patients
heart rate. A decrease in the VPS will increase imaging time. Thus, a compromise is often
struck between sufficient temporal resolution and breath-hold duration. To keep imaging
times within normal breath-hold times (<20 seconds) for low VPS values, several strategies
can be used, including decreasing the number of phase-encoding steps, partial-phase FOV,
or parallel imaging techniques.

Heart Rate (bpm)
VPS
60
61-95
96-125
126-155
156
10-12
8-10
6-8
4-6
<4
Cardiac phases
time point or phase of the cardiac cycle. The larger the number of cardiac phases the higher the temporal resolution of the cine series. Most commonly, 20 cardiac phases are reconstructed for cine sequences.
Example images
Tagged short-axis images at systole, mid diastole, and late diastole showing tag fading over
time.
140
ECG Gating
The Einthoven Lead Arrangement
The hearts electrical activity was first measured in 1889 by Augustus Desir Waller, who
measured the electrical potential difference (voltage) across electrode pairs placed at five
separate anatomical locations (two on the arms, two on the legs, and one at the mouth).
Wallers method of measuring the time-varying voltage signals across various electrode
pairs (lead combinations) is commonly referred to as the electrocardiogram (ECG). The
original configuration suggested by Waller was modified by Willem Einthoven in 1908.
The so-called Einthoven configuration or Einthovens triangle required placement of
electrodes at three locations: the left and right arms and the left leg (Figure 4.2). The differences in electrical potential between electrodes are known as limb leads I (potential difference between left and right arms), II (potential difference between right arm and left
leg), and III (potential difference between left arm and left leg).
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VI =
141
Lead I
R
Lead II
Lead III
VII =
VIII =
Figure 4.2. Three-lead ECG configuration and Einthovens triangle. (From Malmivuo J,
Plonsey R. Bioelectromagnetism: principles and applications of bioelectric and biomagnetic
fields. New York: Oxford University Press; 1995. Used with permission.)
142
The Einthoven diagram also shows the electrical model of the hearta dipole (positive
and negative charge separated in space) whose magnitude and orientation vary throughout
the cardiac cycle. This model is also known as the vector ECG (VCG). Measurement of
the time-varying voltage of leads I, II, or III is the mathematical equivalent of the projection of the VCG onto the respective lead. This projection produces the characteristic ECG
waveform (Figure 4.3). This complex waveform can be decomposed into separate waveforms that describe the various phases of the cardiac cycle. Key components of the ECG
waveform include the P wave, which signifies the onset of atrial depolarization, the QRS
complex, which represents ventricular depolarization, and the T wave, which indicates
ventricular repolarization.
R-R
interval
Ventricular
Atrial
repolarization
depolarization
Ventricular
depolarization
P
Q
PR interval
ST segment
Figure 4.3. ECG and components of the cardiac cycle. (From Bernstein MA, et al.
Handbook of MRI pulse sequences. Amsterdam: Elsevier Academic Press; 2004. Used with
permission.)
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143
ECG Gating in MRI

ECG gating is a fundamental part of a cardiac MRI examination. We next describe the
important aspects of ECG gating in the MRI environment along with recommendations
for reproducible and reliable gating.
Why Gate in MRI?
To enable consistent temporal sampling of data throughout the cardiac cycle, which is
necessary for cine acquisitions.
To allow acquisition of static images at a given phase of the cardiac cycle.
For correct sorting of static and dynamic k-space data obtained over multiple R-R
intervals using segmented acquisition schemes.
Patient Preparation
Reliable, trouble-free ECG gating in MRI involves identification of the appropriate
anatomical locations for placement of the ECG electrodes, followed by adequate preparation of the patients skin surface. Identification of the appropriate lead locations is
described in more detail below, but three rules should be observed:
1) Lead locations should be placed farther from rather than closer to the sternum, particularly if the patient has had prior chest surgery and sternal wires are present.
2) For women with large, pendulous breasts, an alternative location along the chest wall
inferior to the breast should be identified. Large amounts of breast tissue can attenuate
the ECG signal.
3) Leads should be placed on the anterior chest surface as opposed to the posterior. The
heart is generally located closer to the anterior chest wall, and the ECG voltage is generally greater there.
After identification of the appropriate lead locations, the patients skin surface should be
prepared. For males, this typically requires shaving the chest around the region of the electrodes. Caution should be exercised if this procedure is performed in the MR scan room
because most disposable razors use steel blades and can represent a projectile hazard if
brought too close to the MR scanner. Commercial abrasive gels are available to remove
keratinized skin from the epidermis, thereby creating a better electrical contact between the
skin and electrode. Fine-grit sandpaper also can be used but is generally not recommended.
The use of a gel has the added advantage of cleaning the skins surface of oil and dirt.
144
When the appropriate electrode locations are identified and the skin has been prepared,
the electrodes can be applied. MR-compatible electrodes should be used at all times. The
vendor of the MR scanner provides the appropriate type of electrode either directly or
through a third-party supplier. These electrodes usually have a small amount of conducting gel on their tips to further improve conductivity.
ECG Lead Placement
A major contributor to a prolonged cardiac examination is the amount of time spent
attempting to optimize lead placement either immediately before or during the cardiac
MR examination. The Division of Cardiac Radiology, Mayo Clinic Rochester, has developed several lead placement configurations (the Mayo configuration) that hold the most
promise for gating success. A second lead placement set is also recommended when the
MR scanner is equipped with VCG gating.
Mayo Configuration
Figure 4.4 describes the four lead placement configurations used at Mayo Clinic. The
Mayo lead placements are variations of the precordial locations used in 12-lead ECG. The
locations have been modified on the basis of those arrangements that have proved successful for the ensemble average of the entire patient population at Mayo Clinic.
CHAPTER 4
Configuration 1
Configuration 2
Configuration 3
Configuration 4
145
Figure 4.4. The Mayo Configuration. The recommended ECG lead placement for male
and female patients. Electrode locations are variations of the precordial locations used in a
12-lead ECG. Lead color coding: black, left arm; green, right leg; red, left leg; white, right
arm.
146
VCG Configuration
VCG gating involves measurement of the ECG dipole projected onto two orthogonal
axes. It has been shown that when the ECG waveform is measured in this way, T-wave
swelling as a result of the magnetohydrodynamic effect can be isolated from the QRST
complex waveform. T-wave swelling can be so large that the amplitude of the T wave is
greater than that of the R wave, resulting in incorrect triggering of the MRI sequence.
Most MR scanners offer a modified form of the original VCG concept. Lead placement
for VCG gating is similar to that for the Mayo configuration, except that lead pairs are
used to measure voltages that are orthogonal to one another. Each MR manufacturer provides general guidelines for lead placement. However, the general lead placement for VCG
gating is shown in Figure 4.5.
Configuration 1
Configuration 2
Figure 4.5. VCG lead placement. The lead placement is based on measurement of the
ECG dipole projected onto two orthogonal axes. Black and white electrodes replace the previous colored electrodes. The black electrodes are equal to the left arm (black) and right leg
(green), and the white electrodes are equivalent to the right arm (white) and left leg (red)
electrodes of the Mayo configuration.
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147
Peripheral Photo-Pulse Sensor

Under certain circumstances, it may not be technically feasible to use an ECG waveform
for gated cardiac acquisitions. For example, irregular heart rates or low ECG voltages can
render the ECG waveform unusable. In other circumstances, a quick and dirty waveform for a gated MR angiography sequence may be sufficient. Under these conditions, a
peripheral photo-pulse waveform can be used as an ECG substitute.
Blood flowing in the capillaries of peripheral tissues (fingers or toes) can be measured by
photoplethysmography. This technology involves applying a light beam (typically within
the infrared region of the electromagnetic spectrum) and detecting the light reflected or
backscattered from the beam as it passes through the epidermal and dermal layers of the
skin. Changes in blood flow in the capillaries modify the optical path length and, hence,
the amount of backscattered light. Typical photo-pulse sensors use independent transmitting and receiving detectors separated by a small distance, which allows simultaneous
transmission and detection of the beam. Because the electrical activity of the heart precedes the flow of blood outside of the left ventricle, the waveform has an inherent delay
from the peak of the R wave of the QRS complex to the peak of the flow profile. For this
reason, peripheral photo-pulse triggering is used less commonly than ECG-based methods. However, this form of triggering is extremely reliable and, as such, is a standard feature on all high-performance cardiac MR scanners. Often, a second peak also can be seen
on the photo-pulse waveform, which corresponds to the left atrial contraction following
left ventricular contraction. Figure 4.6 shows a typical photo-pulse waveform.
Reflected light
Left ventricular contraction
Left atrial
contraction
Time
Figure 4.6. Schematic representation of a pulse profile from a peripheral photo-pulse sensor on the finger.
148
MR-Induced ECG Artifacts

Figure 4.7 shows an ECG waveform of a healthy volunteer. The QRS complex and T
wave are easily distinguished, with the T-wave amplitude being substantially less than the
R-wave peak. Unfortunately, the MR environment is particularly hostile for ECG
measurement. Table 4.1 lists some of the more common sources of interference that exist
in a typical MR environment, along with their amplitude and frequency ranges. The table
also includes, as a reference, a typical ECG waveform.
6,000
ECG signal (relative units)
5,000
4,000
3,000
2,000
1,000
0
-1,000
0
500
1,000
1,500
2,000
Time (ms)
Figure 4.7. ECG waveform from lead II from a normal (healthy) volunteer.
2,500
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149
TABLE 4.1. SOURCES OF ECG NOISE IN MRI

Source
ECG reference signal
Induced Electrical Voltage

(typical range)
Frequency Spectrum
(typical range)
0.2-3 mV
0.05-100 Hz
Magnetohydrodynamic
effect
Several mV; can be greater than

the ECG waveform
<100 Hz
Triboelectric effect: lead

and electrode motion
due to respiration or
other motion
Several mV
Several Hz
RF body coil switching
40-700 mV depending on
RF pulse type, body coil
design, and location within
magnet bore (isocenter
smallest)
2-70 kHz
Gradient switching
100-600 mV depending
on location within MR scanner
(ie, gradient amplitude)
32-125 kHz
Note: The frequencies of induced electric fields from RF pulses are multiple orders of
magnitude greater than those of the ECG waveform and do not contribute substantially to the noise spectrum. (Resonant frequency of scanner is 64 MHz at 1.5T.)
150
Magnetohydrodynamic Effect
Blood is composed of formed elements (45% by volume) and plasma. Plasma is composed of approximately 90% solvent and 10% solute. The solvent is water and the solute
is composed of salts (sodium, potassium, calcium, magnesium, chloride, and bicarbonate),
plasma proteins (albumin, fibrinogen, and globulins), and other substances (nutrients,
waste products, respiratory gases, and hormones). Blood is a conductive mediumpositive and negative charges exist and allow current flow. When moving blood is exposed to a
magnetic field, charge separation occurs, inducing a time-varying electrical dipole signal
that is a function of the magnitude and direction of flow within the field of the MR scanner. This dipole is detected as a time-varying electrical signal superimposed onto the ECG
waveform. This second electrical signal precedes ventricular contraction and consequently
is detected after the QRS complex of the ECG waveform. Ventricular repolarization, as
described by the ST segment, is detected at approximately the same time as the flow of
blood through the aorta and, hence, is often superimposed onto the T wave of the ECG.
This is most commonly known as T-wave swelling (or T-wave elevation) and can
cause the T wave to be of even greater amplitude than the R wave. T-wave swelling often
results in unreliable triggering and poor image quality. Figure 4.8 shows a normal ECG
waveform of a volunteer in the absence of an external magnetic field (ie, non-MR environment) and in the presence of a large external magnetic field (ie, inside an MR scanner).
Effect on ECG Waveform
Increase in amplitude of the ST segment of the QRST complex, also known as T-wave
swelling.
Effect on MR Data Acquisition
If ECG triggering is based on the peak voltage of the waveform, the scanner could trigger
off the T wave or switch between the R-wave and T-wave peaks. Detection-peak switching
can result in a miscalculation of the patients heart rate. If some form of arrhythmia detection is used in the ECG gating algorithm, data collection will not occur during that R-R
interval, thereby resulting in an increase in data acquisition time. Increases in scan time are
unacceptable, particularly for some breath-hold scans. Trigger detection based on the slope
of the QRST complex can decrease false triggering but cannot eliminate it entirely.
Triggering off the T wave also results in imaging at inconsistent phases of the cardiac cycle.
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151
Miscalculation of the R-R interval resulting from false ECG triggers degrades the image
quality because data are collected at a different phase of the cardiac cycle than expected.
This is particularly true for segmented cine data acquisition schemes.
Inside MR scanner
Outside MR scanner
6,000
5,000
4,000
3,000
2,000
1,000
0
-1,000
0
400
800
1,200
1,600
2,000
2,400
Time (ms)
Figure 4.8. ECG waveform from a healthy volunteer, as measured outside (red) and inside
(black) the MR scanner before imaging. The magnetohydrodynamic effect introduces distortion of the ECG waveform, most notably T-wave swelling.
152
Triboelectric Effect
The triboelectric effect is the build-up of static charge due to the rubbing of two different
materials against each other (for example, an ungrounded conductor and the insulator of
the ECG cable).
Introduces a slowly varying change in the baseline voltage (baseline drift) of the ECG signal (Figure 4.9).
Baseline drift results in either positive or negative change of the mean ECG signal. If a
threshold value is used to detect the trigger point, noise spikes can be detected if the drift is
positive, or the R wave can be missed if the drift is negative. Miscalculation of the R-R
interval resulting from false ECG triggers results in degraded image quality because data
are collected at a different phase of the cardiac cycle than expected.
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153
Inside MR scanner
Outside MR scanner
2,000
1,500
1,000
500
-500
-1,000
0
500
1,000
1,500
2,000
2,500
3,000
Time (ms)
Figure 4.9. ECG waveform from a healthy volunteer, as measured outside (red) and inside
(black) the MR scanner before imaging. The triboelectric effect introduces a drift in the
baseline signal. Respiratory motion also induces a similar baseline drift.
154
RF Body Coil Switching

The RF body coil functions in one of two states. An on state allows RF current to flow
into the coil, thereby irradiating the patient with RF energy necessary to create a detectable
MR signal. A second or off state effectively detunes or decouples the RF body coil from
the RF circuit, thereby allowing other, more sensitive (eg, surface) coils to be used for MR
signal detection. Switching of the body coil is typically performed by applying oppositepolarity () voltages on the order of several hundred volts to pin diodes within the body
coil circuit.
Degradation Source
On/off switching of the RF body coil before and after RF pulse generation.
All imaging sequences require that RF energy be transmitted into the patient. The RF
body coil is the largest and most commonly used coil for this purpose. For cardiac imaging, it is used almost exclusively in transmit-only mode. The enabling and disabling of the
RF body coil before and after generation of the RF pulse induces a voltage that is superimposed onto the ECG signal.
When an RF pulse is generated, a time-varying electric field (current) can also be generated along the ECG cable at the same frequency as the resonant magnetic field. However,
because the frequency of the electric field is in the megahertz range (64 MHz at 1.5T), this
component can be effectively filtered out of the ECG waveform because the ECG signal
only covers a frequency range of approximately 0 to 100 Hz.
Introduction of noise spikes that can cause false ECG triggers (Figure 4.10).
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155
Imaging
No imaging
2,000
Body coil switching

1,500
1,000
500
-500
-1,000
0
250
500
750
1,000
1,250
1,500
1,750
2,000
Time (ms)
Figure 4.10. Noise spikes in the ECG waveform caused by on/off switching of the body
coil.
156
Gradient Switching
Image formation in MR is achieved, in part, by applying gradient magnetic fields with
amplitudes that vary linearly with spatial position. These fields are zero at the isocenter of
the magnet and greatest near the bore wall or the ends of the magnet. Acquisition of a single image requires these magnetic fields or gradients to be rapidly turned off and on
throughout the imaging sequence.
Exposure of the ECG circuit (patient, electrodes, and cable) to a time-varying magnetic
field induces a time-varying electrical voltage in the ECG circuit. This induced voltage is
greatest when the rate of change of the magnetic field is also at its maximum. This occurs
when the polarity of the gradients is switched and generally increases as the speed of the
imaging sequence increases.
Superposition of additional waveforms (noise) onto the ECG signal. Gradient switching
noise amplitudes can, under certain circumstances, be many times larger than the ECG
voltage (Figure 4.11).
Gradient switchinginduced noise can cause false trigger detection and prolongation of
the scan time or scan failure due to timing out of the data acquisition window.
Figure 4.11. Examples of gradient switching

interference in ECG waveforms from two separate
pulse sequences. The black waveform was
acquired during a gradient-intense imaging
sequence, and the red waveform was acquired
with imaging gradients turned off. The top waveform pair is from a gradient echo perfusion
sequence; the bottom image is from a balanced
steady-state sequence.
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157
Imaging gradients ON
Imaging gradients OFF
600
500
400
300
200
100
0
-100
-200
-300
0
500
1,000
1,500
2,000
2,500
3,000
Time (ms)
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
-2,000
0
200
400
600
Time (ms)
800
1,000
158
Sternal Wires or Clips

Sternal wires used to close the chest cavity after thoracic surgery create conducting loops
that can induce additional electric fields that are superimposed onto the ECG signal during imaging.
The electrical dipole resulting from the time-varying magnetic field through a sternal wire
loop acts as another noise source.
Unless noise from the wires is successfully filtered, the result is false triggering and corrupt
data collection. To minimize this effect, electrodes should be moved away from the sternum. This is most commonly achieved by placing the electrodes along the lateral chest
wall of the patient.
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159
Gating During Chemical Stress

Gating during a chemically induced stress MRI examination can be particularly problematic because of changing heart rate and increased artifacts from physiologic and other
effects. In general, adequate patient preparation and monitoring of the ECG signal
throughout the cardiac examination are sufficient to ensure that the MR scanner can
detect and trigger off the peak of the R wave in the QRS complex. If gating off a particular
ECG lead begins to fail, it is advisable to review the signal from the remaining leads.
Another option is to switch to the peripheral photo-pulse waveform. Therefore, it is a
good idea to place the pulse unit on the finger of the patient before beginning the examination. Because the electrical activity of the heart precedes the flow of blood into the system, the peripheral photo-pulse gating trigger point does not correspond to the peak of
the ECG R wave. Thus, this method of gating should be considered a fallback rather than
the default option.
160
Common Artifacts in Cardiac MR

Artifacts are unavoidable in MRI. Even when the MR scanner is functioning correctly,
specific imaging parameter choices will produce artifacts. This section describes the artifacts seen most commonly in cardiac MRI and proposes solutions for their reduction or
removal.
Gradient Decay or Fall-Off

Source
This artifact occurs as a result of excitation and reception of signal from tissue in the falloff zone of the spatial encoding gradients, particularly in the superior-inferior direction.
Spatial encoding gradient fields decay from their maximum amplitude to zero outside the
physical dimensions of the gradient coil. RF excitation and reception of signal from tissue
within the fall-off zone of these gradient fields results in tissue at an incorrect physical location being mapped onto the reconstructed image. This can also occur when the RF coil
used for excitation is larger than the physical extent of the gradient encoding fields (Figure
4.12).
Solutions
Use receive-only coils that do not extend beyond the anatomical region of interest.
If anatomical coverage is large and multicoil element surface coils are used, only those
coils that cover the region of interest should be selected.
Place saturation bands over those regions in the fall-off zone of the gradient fields.
Use transmit-receive RF coils. For cardiac applications this is usually not practical
because the body RF coil typically must be used for transmission and provides images
with lower signal-to-noise ratio when used as a transmit-receive coil.
For dual gradient systems, switch to the larger FOV gradient set.
Apply any of the solutions listed to solve aliasing as described in the next section.
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161
Figure 4.12. Images show the effect of choice of RF coil. The image at left shows the gradient fall-off artifact resulting from signal reception by the surface coil in the region where the
gradient amplitude is decaying to zero. The image at right shows the effect of selecting a
smaller surface coil whose physical coverage does not include the fall-off region of the gradient fields.
162
Aliasing
Source
Aliasing occurs when the FOV in the phase-encoding direction is smaller than the
anatomy being imaged. The data are undersampled and the image appears to be
wrapped from one side to the other along this direction (Figure 4.13). This can
occur in two directions when 3D data are acquired, but it does not occur along the
frequency-encoding direction.
Solutions
Increase the FOV along the phase-encoding axes. This will solve this problem but at
the expense of decreased spatial resolution.
Increase the phase FOV percentage or enable the no-phase-wrap feature.
Swap the readout and phase-encoding directions, unless this increases flow artifacts to
an unacceptable degree.
Apply parallel imaging techniques to unwrap the artifact. This will solve the problem
but can decrease signal-to-noise ratio in the image.
Reposition the center of the FOV so that the aliased data are not included in the anatomy of interest. Signal-to-noise ratio and resolution are not decreased, but several
attempts may be required to position the aliased tissue outside of the region of interest.
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163
Figure 4.13. Reduced-phase FOV in a four-chamber image of the heart (top) demonstrating aliasing of chest wall and arms into the anatomical region of interest. Full-phase FOV
image of the heart (bottom) with phase- and frequency-encoding directions swapped.
164
RF Zipper
Source
An RF zipper results when RF energy from a source other than the patient is detected by
the RF coil used for imaging. The signal is not spatially encoded and appears as a line
whose intensity varies from bright to dark along the phase-encoding direction (Figure
4.14). The typical source of this noise is (but is not restricted to) a pump or other electromechanical device in the room. Also, any conducting cable that enters the room can act as
an antenna, propagating noise from outside into the scan room. Finally, a leak in the RF
shield of the MR scan room can allow external RF noise to enter. These RF leaks occur
most commonly around doors and windows.
Note that zipper-type artifacts that occur along the frequency-encoding axis arise from
sources internal to the MR scanner such as stimulated echoes and pulse sequence timing
errors.
Solutions
Identify and remove all noise sources within the room.
Have a qualified service engineer check for leaks in the RF shield of the scan room.
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165
Figure 4.14. Four-chamber balanced gradient echo (top), perfusion (bottom left), and
delayed enhancement (bottom right) images showing RF zipper propagating along the phaseencoding direction. The noise source that produced this artifact was an infusion pump inside
the MR scan room. For imaging sequences with low signal-to-noise ratio, such as myocardial
delayed enhancement imaging, the artifact can be particularly prominent.
166
ECG Gating Mistriggers

Source
A poor quality (low-voltage) ECG waveform or an irregular heart rate can degrade cardiac
MR image quality. When the voltage of the QRS complex is nearly the same value as that
of the noise, triggering on noise spikes instead of the R-wave peak causes data to be collected at incorrect phases of the cardiac cycle. The random nature of the noise results in mixing of data from multiple cardiac phases into a single phase and produces motion blurring
and signal loss. ECG-gated MR sequences typically use some type of arrhythmia rejection
to ensure that all data are collected at the correct cardiac phase. Arrhythmia rejection prolongs the data-acquisition period, which results in longer breath-holds for the patient. If
arrhythmia-induced heart rate changes are too great, the scanner may time out, resulting
in no data being acquired. Note that poor ECG gating does not produce respiratoryinduced motion artifacts. If breath-holding throughout the data-collection process is adequate but ECG gating is poor, the heart alone will show motion-induced artifacts and the
chest wall will appear static (Figure 4.15).
Solutions
Check all lead voltage waveforms for optimal ECG signal.
Recheck the placement of electrodes. Check for adequate electrical contact between the
electrode and skin surface by using appropriate skin preparation (eg, abrasive gel).
Decrease the tolerance for ECG arrhythmias. This reduces the range of heart rates over
which data are collected, eliminating the effect of collecting data at different phases of
the cardiac cycle because of irregular heart rates or false ECG triggers. This can increase
the image acquisition time because of the extra time required to complete data acquisition.
Increase the VPS and, if necessary, decrease the number of cardiac phases, which will
decrease the number of R-R intervals over which data are collected and potentially the
amount of mistriggered data.
Check to ensure that the ECG cable travels as closely as possible to the center of the
MR scanner bore as it exits.
Choose peripheral photo-pulse gating.
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167
Figure 4.15. Four-chamber view of heart. Gating mistriggers are shown at top; mixing of
different cardiac views from across the cardiac cycle produces motion blurring of the heart
only. Correctly gated four-chamber view is shown at bottom.
168
Respiratory Motion Artifact

Source
Respiratory motion artifacts occur if patients are unable to hold their breath or resume
breathing during the data-acquisition process. Movement of the heart through the imaging plane due to diaphragm motion induces blurring, ghosting (Figure 4.16), and volume
averaging of the heart. These effects can affect image quality and quantitative measures
such as ejection fraction and myocardial mass. This motion is distinguishable from ECG
gating artifacts because of the presence of chest wall motioninduced ghosting.
Solutions
If possible, decrease the imaging time so that the patient can achieve a breath-hold
throughout the imaging sequence. Parallel imaging techniques are useful in this regard.
Another approach is to decrease the number of phase-encoding steps of the imaging
sequence. If a perfusion sequence is being used, decreasing the number of phases will
also decrease imaging time.
In some instances, the use of navigator echoes or respiratory bellows, which allow free
breathing during data acquisition, may be appropriate, particularly for non-cine
sequences such as T1-weighted black blood imaging.
Use single-shot techniques so that the patient can free breathe during data acquisition.
Coach the patient before the breath-hold acquisition.
Figure 4.16. Short-axis images of the heart

during a free-breathing (top) and a breath-hold
(bottom) ECG gated acquisition. Although the
imaging sequence was able to successfully gate the
ECG of the volunteer, respiratory motion severely
degraded image quality. Movement of the
diaphragm results in movement of the cardiac
anatomy through the imaging slice, producing
blurring and ghosting of the cardiac anatomy.
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169
170
Flow-Related Artifacts
Source
Blood flow into and out of the imaging volume during data acquisition results in modulation of the magnetization of the blood throughout the imaging sequence. This modulation produces replication and blurring of the signal along the phase-encoding direction of
the image (Figure 4.17). This effect is most apparent for balanced steady-state sequences
and is exacerbated at increased TR and higher field strength (3.0T). Longer TR allows
more time for the blood to flow out of the volume and accumulate phase, and higher field
strength increases the susceptibility variation, as measured in hertz.
Solutions
Use the shortest possible TR for balanced gradient echo sequences.
Swap the phase- and frequency-encoding directions to change the direction of artifact
propagation.
Choose a spoiled rather than balanced gradient echo sequence.
Image at a lower field strength (1.5T vs 3.0T)
For non-cine acquisitions, choose a more quiescent portion of the cardiac cycle for data
collection (diastole vs systole).
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171
Figure 4.17. Fully magnetized blood in the aorta is shown entering the imaging slice during a balanced steady-state gradient echo imaging sequence (top). Same slice is shown during
late diastole when flow is at a minimum (bottom).
172
Susceptibility-Induced Signal Loss

Source
Differences in magnetic susceptibility of tissues or implanted materials (metals such as
sternal wires or stents) distort the magnetic field around the tissue interface or object,
thereby producing image distortion and signal loss (Figure 4.18).
Solutions
Use linear or higher-order shimming of the volume around the region of differing tissue susceptibilities; this can improve the main magnetic field homogeneity and sometimes decrease the artifact.
Increase the receiver bandwidth of the imaging sequences or choose spin echobased
sequences for imaging around metal implants when appropriate.
Decrease the TR in balanced steady-state free precession pulse sequences.
Decrease the voxel size (ie, increase the spatial resolution).
Image at lower field strength (ie, 1.5T instead of 3.0T).
CHAPTER 4
Figure 4.18. Multiple short-axis views of the heart showing signal loss and distortion
around sternal wires (arrows).
173
174
Banding on Balanced Steady-State Free Precession Images

Source
Balanced steady-state free precession imaging requires that the net area on each gradient
axis be zero during any TR interval. Spatially varying magnetic field inhomogeneities
introduce net phase accrual and violate this condition. This results in varying bright and
dark bands across the image (Figure 4.19). The source of this inhomogeneity can be due
to the physical design limitations of the main magnetic field or susceptibility-induced field
variations from different tissue interfaces (eg, lung to liver to heart) or implanted devices
(eg, stents).
Solutions
The spatial period of the banding is proportional to the inhomogeneity of the main
magnetic field and the inverse of the TR of the imaging sequence. Decreasing the TR
will increase the separation of the bands. However, decreasing the TR may not be possible if the TR is already at a minimum. Improving the homogeneity of the main magnetic field by linear or higher-order shimming over the localized volume of the heart
can decrease the artifact.
Switch to another type of pulse sequence such as a spoiled gradient echo; however, signal-to-noise ratio may decrease.
The bands can be shifted by changing the resonant frequency of the receiver, thereby
shifting the banding artifact so that the region of signal loss is outside of the critical
anatomical region of interest.
Decrease the field strength (ie, 1.5T instead of 3.0T).
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175
Figure 4.19. Balanced steady-state gradient echo images (left) demonstrating banding and
signal loss due to magnetic field inhomogeneities (arrows). Spoiled gradient echo images are
shown at right.
176
Parallel-Imaging Reconstruction Artifact

Source
For image-based parallel-imaging algorithms (eg, SENSE), it is possible that the RF coil
sensitivity map may not cover the anatomical region being imaged. Because the sensitivity
map is used to define the spatial coil maps for the various coil elements, it does not include
the volume over which the data are collected, and the reconstruction algorithm is unable
to unwrap those regions within the image (Figure 4.20). Regions of low signal such as the
background or lungs produce similar artifacts.
Solutions
Rescan the calibration volume to include the imaging volume. This will reduce this
artifact for subsequent parallel-imaging sequences. So-called autocalibration
sequences such as GRAPPA or ARC that acquire the calibration scan as part of the data
collection process can also decrease this error, at the expense of increased scan time of
the parallel-imaging technique.
Reduce the acceleration factor to improve the signal-to-noise ratio of the reconstruction
process.
Acquire a fully sampled MR data set.
Figure 4.20. Short-axis spoiled gradient echo images acquired

with parallel-imaging (SENSE) techniques (left) and full-acquisition short-axis views (right) for two separate volunteers. Insufficient
coverage of the imaging volume by the calibration scan results in
reconstruction errors in the parallel images (arrows).
CHAPTER 4
177
SELECTED REFERENCES
Anatomy, Physiology, and Biophysics
Hobbie RK, Roth BJ. Intermediate physics for medicine and biology. 4th ed. New York:
Springer; c2007.
Malmivuo J, Plonsey R. Bioelectromagnetism: principles and applications of bioelectric and biomagnetic fields. New York: Oxford University Press; c1995.
Marieb EN. Essentials of human anatomy & physiology. 7th ed. San Francisco: Benjamin
Cummings; c2003.
Cardiac MRI
Bogaert J, et al. Clinical cardiac MRI: with interactive CD-ROM. Berlin: Springer; c2005.
Lee VS. Cardiovascular MRI: physical principles to practical protocols. Philadelphia: Lippincott
Williams & Wilkins; c2006.
Miscellaneous
Cerqueira MD, et al, American Heart Association Writing Group on Myocardial Segmentation
and Registration for Cardiac Imaging. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart: a statement for healthcare professionals from the
Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart
Association. Circulation. 2002;105(4):539-42.
MR Acronyms
Boyle GE, et al. An interactive taxonomy of MR imaging sequences. Radiographics.
2006;26(6):e24.
Brown MA, Semelka RC. MR imaging abbreviations, definitions, and descriptions: a review.
Radiology. 1999;213(3):647-62.
Nitz WR. MR imaging: acronyms and clinical applications. Eur Radiol. 1999;9(5):979-97.
Sprung K. Basic techniques of cardiac MR. Eur Radiol. 2005;15 Suppl 2:B10-6.
MR Physics and Pulse Sequences
Bernstein MA, et al. Handbook of MRI pulse sequences. Burlington (MA): Elsevier Academic
Press; c2004.
Haacke EM, et al. Magnetic resonance imaging: physical principles and sequence design. New
York: Wiley-Liss; c1999.
Simonetti OP, et al. Black blood T2-weighted inversion-recovery MR imaging of the heart.
Radiology. 1996;199(1):49-57.
Vector ECG Gating
Chia JM, et al. Performance of QRS detection for cardiac magnetic resonance imaging with a
novel vectorcardiographic triggering method. J Magn Reson Imaging. 2000;12(5):678-88.
Fischer SE, et al. Novel real-time R-wave detection algorithm based on the vectorcardiogram for
accurate gated magnetic resonance acquisitions. Magn Reson Med. 1999;42(2):361-70.
INDEX
INDEX
MRI analysis, 6768

quantifying, 67
Apex, four-chamber view, 9
Apical ballooning syndrome, 49, 59
Apical short-axis MDE, apical ballooning
syndrome, 59
Arrhythmogenic right ventricular cardiomyopathy (ARVC), 49, 58
Arrhythmogenic right ventricular dysplasia,
18
Atrial pressure, 33
Autoimmune myocarditis, 60
Axial balanced gradient echo
myxoma, 80
transposition complexes, 100, 101
Axial double inversion recovery
angiosarcoma, 86
lipomatous hypertrophy, 85
pericardial cyst, 94
pericarditis, 92
A
Acquisition protocol, cardiac magnetic
resonance (MR) imaging, 3
Aliasing
artifact, 162, 163
intentional, 115
LV four-chamber localizer, 9
LV four-chamber long-axis, 17
LV sagittal localizer, 7
LV short-axis, 11
LV three-chamber long-axis, 15
LV two-chamber long-axis, 13
RV conventional axial, 21
RV inflow tract vertical long-axis, 25
Angiosarcoma, axial double inversion
recovery image, 86
Aortic insufficiency
causes, 66
MRI analysis, 6768
oblique long axis/aortic outflow tract, 63
quantifying, 66
three-chamber balanced gradient
echo cine, 65
Aortic pressure, 33
Aortic stenosis
causes, 66
coronal oblique balanced gradient
echo cine, 65
B
Balanced gradient echo cine, 118119
Balanced gradient echo signal, 113, 114
Balanced gradient echo MR
Ebstein anomaly, 105
partial anomalous venous connections,
103
183
184
perfusion, 136
transmural myocardial infarction, 46,
47
transposition complexes, 100, 101
ventricular noncompaction, 106
Balanced steady-state free precession cine,
118
Balanced steady-state free precession
images, banding, 174, 175
Black blood inversion recovery
cardiac masses, 77
congenital disease, 97
pericardial disease, 88, 89
Blood flow-related artifacts, 170, 171
Blood inversion time (TIblood), 124
double inversion recovery, 125
Blood pool
definition, 117
signal, 109
Breath-hold
cardiac masses, 7677
cardiomyopathies, 5051
congenital disease, 96, 97
ECG gated acquisition, 169
myocardial perfusion and viability,
4243
normal, 119, 121, 139
pericardial disease, 88, 89, 90
valvular disease, 62, 63, 64
Bright blood
balanced gradient echo, 118
cardiac masses, 76
cardiomyopathies, 50, 51
cine phase contrast, 132
4244
spoiled gradient echo, 120
tagging, 138
Bright blood pool signal, 117
Bright-exogenous contrast agent

blood pool signal, 117
myocardial delayed enhancement, 122
perfusion MR, 136
3D MR angiography, 130
C
Cardiac amyloidosis, 56
Cardiac cycle, 32, 33
ECG waveforms, 142
Cardiac magnetic resonance (MR)
cardiac cycle characteristics, 34, 35
ECG artifacts, 109, 148159
ECG gating, 109, 140147
imaging artifacts, 109, 160177
left ventricular imaging, 417
masses, 7486
4048
pericardial disease, 8794
pulse sequence components, 111117
pulse sequences for function,
130139
pulse sequences for morphology,
118129
right ventricular imaging, 1825
valvular disease, 6173
workflow, 3
Cardiac masses
decision tree, 75
MRI examples, 7986
MRI protocols, 7678
Cardiac phases
congenital disease, 96, 97
INDEX
masses, 76
4243
spoiled gradient echo cine, 121
tagging, 139
Cardiac physiology, 3135
Cardiomyopathies
MRI examples, 5360
MRI protocols, 5052
Centric view order encoding, 3D MR
angiography, 131
Chemical stress, ECG effects, 159
Cine imaging, definition, 116
Cine phase contrast MR, 132135
Coarctation, gadolinium-enhanced MR
angiography, 104
Congenital disease
MRI examples, 98106
MRI protocols, 9697
Congestive heart failure
pericardial effusion MRI, 91
resulting from myocardial infarction, 48
Conventional axial RV view
acquisition, 20, 21
planes, 19
Coronal oblique balanced gradient echo,
aortic stenosis, 65
Coronary artery territories, 41
D
D-transposition great arteries, MR
images, 100, 101
Dark blood pool signal, 117
spin echo T1-weighted, 128
triple inversion recovery, 126
185
Data acquisition
gradient switching ECG waveform
effect, 156, 157
image reconstruction, 113, 115
magnetohydrodynamic ECG waveform effect, 150, 151
RF body coil switching ECG waveform effect, 154, 155
sternal wires/clips ECG waveform
effect, 158
triboelectric ECG waveform effect,
152, 153
Diastole, 33
Dilated cardiomyopathy, 53
Double inversion recovery, 124125
E
Ebstein anomaly, 18
balanced gradient echo images, 105
ECG (electrocardiographic) gating, 109,
143
artifacts, 109, 148159
chemical stress, 159
lead placement, 144
Mayo configuration, 145
mistriggers, 166, 167
MR interference, 148, 149
patient preparation, 143144
VCG configuration, 146
ECG waveform, 142
gradient switching effect, 156, 157
magnetohydrodynamic effect, 150, 151
RF body coil switching effect, 154, 155
sternal wires/clips effect, 158
triboelectric effect, 152, 153
Echo formation, 112113
Echo train, 113
Einthoven lead triangle, 140, 141
Einthoven, Willem, 140
186
End-diastolic volume (EDV), 33

End-systolic volume (ESV), 33
Eosinophilic cardiomyopathy, 57
F
Fat inversion time (TIfat), 126
Fat saturation, 111
Fatty tissue infiltration, RV, 58
Flow encoding, 112
Flow-encoding direction, cine phase
contrast, 134
Four-chamber balanced gradient echo
ARVC, 58
ischemic cardiomyopathy, 48
pericardial constriction, 93
RF zipper, 165
thrombus, 79
tricuspid stenosis and regurgitation,
72
Four-chamber double inversion recovery,
lipoma, 84
Four-chamber horizontal long-axis view
(LV), 16, 17
Four-chamber imaging plane
left ventricle, 5
right ventricle, 19
Four-chamber localizer (LV), acquisition,
8, 9
Four-chamber long-axis balanced gradient
echo, eosinophilic cardiomyopathy,
57
Four-chamber long-axis plane
cardiac masses, 76
dilated cardiomyopathy, 53
LV cardiac cycle correlation, 34, 35
myocardial perfusion and viability, 42
Four-chamber myocardial delayed
enhancement (MDE)
ischemic cardiomyopathy, 48
subendocardial myocardial infarction, 45
transmural myocardial infarction, 46
Four-chamber view, ECG gating mistrigger,
167
FOV (field of view)
enlarging, 115
and k-space, 116
phase-encoding direction, 162, 163
Free-breathing ECG gated acquisition, 169
Function, pulse sequences for, 130139
G
Gadolinium-based contrast agent, 40, 51
Gadolinium-enhanced MR angiography
coarctation, 104
partial anomalous venous connections, 102, 103
tetralogy of Fallot, 99
Gradient decay/fall-off, artifact, 160, 161
Gradient echo signal, 112113
Gradient switching effect, 156, 157
GRAPPA (k-space-based parallel imaging),
116
autocalibration, 176
H
Hemangioma, short-axis balanced gradient
echo image, 83
Horizontal long-axis, pericardial disease, 89
Hypertrophic cardiomyopathy, 5455
INDEX
I
Image ghosting, 168, 169
Image-based parallel imaging (SENSE), 115
reconstruction artifacts, 176, 177
Imaging artifacts, 109, 160177
Imaging modes, 116117
Imaging protocols and sequences
4244
Infarct distributions, 41
Infectious myocarditis, 60
Inversion recovery, 111
cardiac masses, 77
double, 124
triple, 126
Inversion time (TI)
cardiac masses, 78
Ischemic cardiomyopathy, 48
Ischemic heart disease, 40
187
four-chamber localizer, 8, 9
long-axis view, 12, 13
planes, 4, 5
sagittal localizer, 6, 7
short-axis view, 10, 11
three-chamber view, 14, 15
two-chamber vertical long-axis view,
12, 13
Left ventricular imaging, 417
Left ventricular outflow tract, cardiomyopathies, 51
Limb leads I, II, and III, 140, 141
Lipoma, four-chamber double inversion
recovery image, 84
Lipomatous hypertrophy, axial double
inversion recovery image, 85
Long axis
left ventricle, 12, 13
left ventricle/left atrium, mitral
regurgitation, 63
right ventricle, 23
Long-axis delayed enhancement
cardiac masses, 77
K
K-space, 115
and FOV, 116
K-space-based parallel imaging, 116
kt-BLAST rapid imaging, 116
L
Left anterior descending artery (LAD), 41
Left circumflex coronary artery (LCX), 41
Left heart, cardiac cycle, 32, 33
Left ventricle (LV)
four-chamber horizontal long-axis
view, 16, 17
M
Magnetization preparation, 111112
Magnetohydrodynamic effect, 150151
Mayo lead placement configuration, 144,
145
Mediastinum extension, 75
Metastasis, short-axis delayed enhancement, 82
Midventricular short-axis balanced gradient
echo, hypertrophic obstructive
cardiomyopathy, 54
Midventricular short-axis MDE
188
cardiac amyloidosis, 56
hypertrophic cardiomyopathy, 55
myocarditis, 60
Mitral regurgitation
causes, 70
cine flow analysis, 71
long-axis left ventricle/left atrium, 63
quantifying, 70
Mitral stenosis
causes, 70
cine flow analysis, 71
short-axis balanced gradient echo, 69
Mitral valve
four-chamber view, 9
prolapse and regurgitation, threechamber bright blood cine, 69
Morphology, pulse sequences for, 118129
Multishot
echo train, 115
Mustard operation, postsurgical MR
images, 100
Myocardial delayed enhancement
(MDE), 122123
hemangioma, 83
myxoma, 80, 81
pericarditis, 92
RF zipper, 165
thrombus, 79
Myocardial heart segments, AHA, 40, 41
Myocardial infarction, MRI examples,
4548
Myocardial perfusion and viability
MRI examples, 4548
MRI protocols, 4244
Myocarditis, acute, 60
Myocardium inversion time (TImyo),
122, 123
Myxoma, MRI, 80, 81
N
Neoplasm, 75
Noise sources
ECG in MRI, 149
RF zipper, 164
Normal variant masses, 75
O
Oblique based on mass location, cardiac
masses, 77
Oblique long axis/aortic outflow tract,
aortic insufficiency, 63
Oblique sagittal double inversion recovery
image, myxoma, 81
Oblique slice aortic region of interest,
Oblique 3D volume, congenital disease, 97
P
P wave, atrial depolarization, 142
Partial anomalous venous connections,
MR images, 102, 103
Partial Fourier rapid imaging, 116
Partial-phase FOV, 119, 121
Pathology-dependent imaging plane,
Perfusion MR, 136137
RF zipper, 165
Pericardial constriction, four-chamber
balanced gradient echo image, 93
Pericardial cyst, axial double inversion
recovery image, 94
INDEX
Pericardial disease
MRI examples, 9194
MRI protocols, 8890
Pericardial effusion, short-axis balanced
gradient echo image, 91
Pericarditis, axial double inversion recovery
image, 92
Peripartum cardiomyopathy, 53
Peripheral photo-pulse sensor, 147, 159
Phase contrast, 112
cine phase contrast MR, 132
Phases per slice, perfusion MR, 136,
137
Photoplethysmography, 147
Prescription images
inflow tract vertical long-axis, 25
LV planes, 4, 5
LV short-axis, 11
LV three-chamber, 15
Pulmonary regurgitation, cine phasecontrast blood flow data, 73
Pulmonary stenosis, balanced gradient
echo cine, 73
Pulse sequence, 109
components, 111117
Pulse sequences
clinical correlation, 39
for function, 130139
for morphology, 118129
Q
QRS complex
healthy example, 148
ventricular depolarization, 142
189
R
Radio frequency (RF)
body coil switching effect,
154, 155
MR signal, 111
zipper-type artifacts, 164, 165
Rapid imaging, 115116
Reconstruction artifact, parallel imaging,
176, 177
Reconstruction type, cine phase contrast,
134
Rectangular-phase FOV rapid imaging,
116
Respiratory motion artifacts, 168, 169
Restrictive cardiomyopathy, 5657
Resultant image, as blood pool signal,
111
Resultant views
inflow tract vertical long-axis, 25
LV short-axis, 11
LV three-chamber, 15
Rheumatic heart disease
mitral stenosis, 70
tricuspid stenosis, 72
Right coronary artery (RCA), 41
Right ventricle (RV)
conventional axial views, 19, 20, 21
four-chamber localizer, 19, 23
inflow tract vertical long-axis view, 23,
24, 25
outflow tract view, 23
planes, 18, 20, 23
sagittal localizer, 19, 23
Right ventricular imaging, 1825
190
S
Sagittal plane
cardiac masses, 76
LV acquisition, 6, 7
LV localizer, 4, 5
RV localizer, 19
Saturation recovery, 111
perfusion MR, 136
Segmented data acquisition, 115
SENSE (image-based parallel imaging), 115
perfusion MR, 136
reconstruction artifact, 176, 177
tagging, 138
Septum, short-axis view, 10, 11
Sequential view order encoding, 3D MR
angiography, 131
Short-axis balanced gradient echo
hemangioma, 83
mitral stenosis, 69
pericardial effusion, 91
tetralogy of Fallot, 98

Short-axis delayed enhancement
cardiac masses, 77
metastasis, 82
Short-axis double inversion recovery,
pericardial constriction, 93
Short-axis plane
cardiac masses, 76
cardiomyopathies, 50, 52
coronary artery territories, 41
left ventricle, 4, 5, 10, 11
perfusion, 43, 51, 78
tissue susceptibility signal loss, 173
Signal loss/distortion, tissue magnetic
susceptibility, 172, 173
Single echo imaging, 113
Single frame image, 116
Single shot
image echo, 113, 115
perfusion MR, 136
SMASH (image-based parallel imaging)
k-space-based parallel imaging, 116
perfusion MR, 136
tagging, 138
INDEX
Spatial relationship, LV images, 4, 5
Spin echo imaging
T1-weighted, 128
tagging, 138
Spin echo signal, 112, 114
Spin echo T1-weighted, 128129
Spoiled gradient echo cine, 120121
Spoiled gradient echo MR
perfusion, 136
tagging, 138
Spoiled gradient echo, signal, 113, 114
Standard imaging planes, 4, 5
Sternal wires/clips
ECG effects, 158
tissue susceptibility signal loss, 172173
Subendocardial myocardial infarction, 45
Systole, 33
T
T wave
healthy example, 148
ventricular repolarization, 142
Tagging, 112
Tagging MR, 138139
spoiled gradient echo imaging, 138
TE/2 (echo time), spin echo T1-weighted,
128129
Temporal relationship, LV images, 4, 5
Tetralogy of Fallot, MR images, 98, 99
Three-chamber balanced gradient echo
191
Three-chamber bright blood cine, mitral

valve prolapse and regurgitation, 69
Three-chamber imaging plane, LV, 5
Three-chamber long-axis
hypertrophic obstructive cardiomyopathy, 54
left ventricle, 14, 15
3D imaging, 117
3D static
Thrombus, 75
four-chamber balanced gradient echo,
79
Tissue magnetic susceptibility signal loss,
172, 173
Tissue suppression, 111
Toxic myocarditis, 60
Toxic substance, cardiomyopathy, 53
TR (repetition time), spin echo T1weighted, 128-129
Transmural myocardial infarction, 46, 47
Transposition complexes, MR images,
100, 101
Transverse diastolic balanced gradient
echo, aortic insufficiency, 65
Triboelectric effect, 152, 153
TRICKS rapid imaging, 116
Tricuspid stenosis and regurgitation,
four-chamber balanced gradient
echo cine, 72
Triple inversion recovery, 126127
Two-chamber imaging plane, LV, 5
Two-chamber long-axis balanced gradient
echo
apical ballooning syndrome, 59
hypertrophic cardiomyopathy, 55
Two-chamber long-axis MDE
192
apical ballooning syndrome, 59

cardiac amyloidosis, 56
cardiomyopathy, 53
eosinophilic cardiomyopathy, 57
myocarditis, 60
Two-chamber myocardial delayed
enhancement (MDE), subendocardial myocardial infarction, 45
Two-chamber short-axis, LV cardiac cycle
correlation, 34, 35
Two-chamber vertical long-axis, LV, 12, 13
2D cine
perfusion MR, 136
tagging, 138
2D imaging, 116117
2D static
UNFOLD rapid imaging, 116
MRI evaluation, 61
MRI examples, 6573
MRI protocols, 6264
Vector ECG (VCG), 142
lead placement configuration, 146
Velocity encoding (VENC) values, cine
phase contrast, 64, 97, 132, 133.
Ventricular noncompaction, balanced
gradient MR, 106
Ventricular pressure, 33
Vertical and horizontal long-axis,
43
Vertical long-axis, coronary artery
territories, 41
View sharing, k-space lines, 115
Views per segment (VPS)
cardiac masses, 78
definition, 115
tagging, 139
Viral infection cardiomyopathy, 53
Valve plane, valvular disease, 64

Valvular disease
Waller, Augustus Desir, 140

Waveforms, cardiac cycle, 32, 33
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A review of the most common cardiac MR imaging planes
More than
McGee
This compact guide to cardiac magnetic resonance imaging

incorporates the most common techniques with easy-tofollow step-by-step protocols. Physicians and technicians
alike get quick access to the information they need at
the point of exam. Features include:
200
with step-by-step protocols
imaging protocols and example cases
A review of the basic physics of cardiac MRI, including pulse sequences and ECG
gating, as well as common imaging artifacts and how to prevent them.
This easy-to-use reference is the most practical guide for accessing information on all
stages of the cardiac MRI exam, from graphical prescription and protocol selection to
imaging troubleshooting and interpretation.
ABOUT THE AUTHORS
KIARAN P. McGEE is Consultant, Department of Radiology, Mayo Clinic,
Rochester, Minnesota; Assistant Professor of Biomedical Engineering and
Radiologic Physics, College of Medicine, Mayo Clinic.
ERIC E. WILLIAMSON is Consultant, Department of Radiology, Mayo Clinic,
Rochester, Minnesota; Assistant Professor of Radiology, College of Medicine,
Mayo Clinic.
PAUL R. JULSRUD is Consultant, Department of Radiology, Mayo Clinic,
Rochester, Minnesota; Professor of Radiology, College of Medicine, Mayo Clinic.
Mayo Clinic Guide to Cardiac Magnetic Resonance Imaging
Descriptions of the most common indications for cardiac MRI, along with typical
Julsrud
An overview of the various physiologic events that make up the cardiac cycle
Mayo Clinic
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Paul R. Julsrud, MD

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A review of the most common cardiac MR imaging planes

This compact guide to cardiac magnetic resonance imaging

with step-by-step protocols

imaging protocols and example cases

Mayo Clinic Guide to Cardiac Magnetic Resonance Imaging

Kiaran P. McGee, PhD

Kiaran P. McGee, PhD

Mayo Clinic Section of Illustration and Design

arrhythmogenic right ventricular

beats per minute

Gd-DTPA gadolinium diethylenetriamine

time interval between successive

right coronary artery

longitudinal (spin-lattice) relaxation time

transverse (spin-spin) relaxation

pulse repetition rate

left anterior descending artery

views per segment

left circumflex artery

myocardial delayed enhancement

magnetic resonance imaging

number of excitations or signal

*Imaging terms and corresponding acronyms used by different MR scanner manufacturers.

Echo planar imaging

CARDIAC ANATOMY AND

CARDIAC ANATOMY AND

MAYO CLINIC GUIDE TO CARDIAC MRI

Left Ventricular Imaging

Figure 1.1. Imaging planes used to characterize

CARDIAC ANATOMY AND MR IMAGING PLANES

Sagittal localizer (1)

Four-chamber localizer (2)

Short axis (3)

Left ventricle two chamber (4)

Left ventricle three chamber (5)

MAYO CLINIC GUIDE TO CARDIAC MRI

Figure 1.2. Anatomical reference showing

CARDIAC ANATOMY AND MR IMAGING PLANES

Resultant sagittal localizer views

MAYO CLINIC GUIDE TO CARDIAC MRI

Figure 1.3. Four-chamber localizer. Anatomical

CARDIAC ANATOMY AND MR IMAGING PLANES

Resultant four-chamber localizer

MAYO CLINIC GUIDE TO CARDIAC MRI

Left Ventricular Short-Axis Views

Figure 1.4. Anatomical reference, MR

CARDIAC ANATOMY AND MR IMAGING PLANES

Resultant left ventricular

MAYO CLINIC GUIDE TO CARDIAC MRI

Left Ventricular Long-Axis Views

Figure 1.5. Anatomical reference, MR

CARDIAC ANATOMY AND MR IMAGING PLANES

Resultant left ventricular two-chamber long-axis view

MAYO CLINIC GUIDE TO CARDIAC MRI

Left Ventricular Three-Chamber View

Figure 1.6. Anatomical reference, MR

CARDIAC ANATOMY AND MR IMAGING PLANES

Resultant left ventricular three-chamber view

MAYO CLINIC GUIDE TO CARDIAC MRI

Left Ventricular Four-Chamber (Horizontal Long-Axis) View

Figure 1.7. Anatomical reference, MR

CARDIAC ANATOMY AND MR IMAGING PLANES