HOW TO READ CARDIAC MRI:

1. Open Vitrea (use Wesley login)

2. Find patient- make sure you have Wichita RadPac and MRI picked in the search bar

3. At bottom highlight the SA stack and mitral valve flow at bottom of page and then open the app "CVMR".

4. Hover over the left square (SA stack) and then right click and pick "Q mass"

5. On the top options bar click the "Notepad looking icon" add in the patients height in cm (get patient height in inches from the rec sheet).

6. Now there should be a bunch of rows of squares arranged in rows and columns.

7. Go down the rows and exclude rows on the end that do not completely include both the LV and RV (typically this is both the first and the last row but can be more or less). To exclude a row- right click and "exclude"

8. Now pick a random row in the middle and highlight the whole row. Once you start scrolling this will take you through the columns. We are looking for the column which has the LV the most distended (LV end diastolic) and most compressed (LV end systolic). Right click on each of these columns and label them accordingly (normally this is around columns 10 and 20ish).

9. Now with either the LV ED or SD column highlighted click "auto detect" in the right side of screen options (looks like a target). This will automatically try to outline in the inner and outer margins of the LV and RV.

10. Now use the tools at the bottom of the tool bar (rubber band is good) to adjust the contours the computer made. 

11. Do this for both columns (ED and ES).

12. The computer is using these borders to calculate the Ejection fraction, SV and masses (adjusting your contours will changes the numbers).

13. When satsified hit "save session" in the top right corner. 

14. The report is generated at the tab on the bottom.

15. Go to the report and in the right upper corner hit the export button to Wichita Rad PACs (unclick the default).

16. Then export the a sequence of heart images (this has something to do with tells PACS it is an MRI because we exported a document first). 

HOW TO DO VELOCITY OF A VALVE:

1. In vitrea highlight the "flow" and Series of the valve you want to evaluate.

2. Right click and pick "Q flow"

3. Click in the middle of the open valve and make a small circle

4. Right click and "copy and paste all"

5. Click blue graph button at top, this give the E and A wave

6. Adjust graph, save and export like above. 

WHAT MEASUREMENTS TO MAKE IN PACS:

3-chamber view

• aortic root

• left atrium AP dimension

4-chamber axial view

• long and short axis of RV 

• short axis of the RA

SA stack fiesta Cine

• pick level of LV where papillary muscles start 

• find a point in the cine of end diastole, then measure the LV wall thickness at 11:00 o'clock.

• measure the LV chamber width from 5-11 o'clock (at an angle).

• Then measure the same LV chamber width but now in end systole. 

Cardiac Size Normals

Valve Stenosis and Regurgitation Criteria

Aortic Stenosis

• Aortic jet velocity (m/s)  Mean Gradient (mmHg) AVA (cm2) Indexed AVA (cm2/m2)

  • Normal = less than 2.5 m/s

  • Mild = 2.6–2.9 m/s less than 20 mmHg more than 1.5 sq cm more than 0.85 sq cm per sq m

  • Moderate = 3.0–4.0 m/s 20 to 40 mm of Hg 1.0–1.5 sq cm 0.60–0.85 sq cm per sq m

  • Severe = more than 4.0 m/s more than 40 mmHg less than 1.0 sq cm less than,0.6 sq cm per sq m

Aortic Regurgitation

• Mild = regurgitant volume less than 30 mL/beat, regurgitant fraction less than 30%

• Moderate = regurgitant volume 30 to 60 mL per beat, regurgitant fraction 30-50%

• Severe = more than 60 mL per beat, regurgitant fraction more than 50%

Mitral Stenosis MV area (cm2) Pressure Half-Time (ms)

• Normal = >2.0 cm2

• Mild = 1.5-2.0 cm2 <90ms

• Moderate = 1.0 - 1.5 cm2 90-150ms

• Severe = < 1.0 cm2 >150ms

Mitral Regurgitation fraction= calculated by LV stroke volume - ascending aorta forward flow

                                               (%) Regurgitant volume (ml)

• mild ≤ 15% <30 ml

• moderate = 16-25% 30-50 ml

• moderate-severe = 26-48%

• severe > 48% >50 ml

Pulmonic Stenosis

• Normal = PA velocity is usually less than 1 m/s

• Mild = peak jet velocity is  less than 3 m/s (peak gradient less than 36 mmHg).

• Moderate = peak jet velocity of 3–4 m/s (peak gradient 36–64 mmHg)

• Severe = peak jet velocity  more than 4 m/s (peak gradient greater than 64 mmHg) 

Pulmonic Regurgitation

• Mild less than 20%, RV size is normal

• Moderate 20-40%, RV size is normal or dilated

• Severe more than 40%, RV size is dilated

Tricuspid Stenosis

No one cares...

Tricuspid Regurgitation   

• Mild less than 30 mL:, RV and RA size usually normal, IVC is normal, less than 2 cm

• Moderate 30 to 44 mL, RA and RV size, normal or mild dilatation, IVC is normal or mildly dilated (2.1 through 2.5 cm)

• Severe more than equal to 45 mL, RA and RV size usually dilated, IVC usually dilated more than 2.5 cm

ARVD

ARVD  criteria:

Arrhythmogenic right ventricular cardiomyopathy.

ARVC task force criteria

Regional contraction  abnormality

AND

RV enlargement (more than 110 mL per meter squared) or RV dysfunction (RVEF less than 40 percent)

European heart Journal 2010; 31 (C7): 806-814

Delayed enhancement has been described with ARVC in up to 35 percent of the patients, however, is not a diagnostic criteria, but indicates worse prognosis.

Accordion sign has been described with ARVC, along the inner margin of the lateral free wall of the right ventricle.

Fatty infiltration in the lateral free wall of the right ventricle is a nonspecific and can be seen in asymptomatic people.

Focal aneurysm can be seen with ARVC.

Cardiac MRI is the most sensitive diagnostic imaging modality. 

Major cardiac MRI diagnostic criteria are:

regional RV akinesia or dyskinesia or dyssynchronous RV contraction and 1 of the following:

ratio of RV end-diastolic volume to BSA ≥110 mL/m2 (male) or ≥100 mL/m2 (female)

RV ejection fraction ≤40%

Minor cardiac MRI diagnostic criteria are:

regional RV akinesia or dyskinesia or dyssynchronous RV contraction and 1 of the following:

ratio of RV end-diastolic volume to BSA ≥100 to <110 mL/m2 (male) or ≥90 to <100 mL/m2  (female)

RV ejection fraction >40% to ≤45%

MRI may show fatty infiltration in the right ventricle (and occasionally in the left ventricle) 8, but this can also be seen in normal myocardium 3 and is no longer part of the diagnostic criteria 9. A corrugated pattern to the right ventricular wall may be seen, known as the “accordion sign.”