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Usefulness of Segmented TrueFISP Cardiac Pulse Sequence in Evaluation of Congenital and Acquired Adult Cardiac Abnormalities

¹ Department of Radiology, Northwestern University Medical School, 676 N. St. Clair, Ste. 800, Chicago, IL 60611.
² Siemens Medical Systems, 448 E. Ontario, Ste. 700, Chicago, IL 60611.
³ University of Arizona Health Sciences Center, 1609 N. Warren, Bldg. 112, Tucson, AZ 85724.

Received March 9, 2001; accepted after revision May 11, 2001.

 
Address correspondence to F. S. Pereles.

Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
OBJECTIVE. The purpose of this study is to compare ultrashort TR, segmented trueFISP (fast imaging with steady-state precession) cine MR imaging with segmented FLASH (fast low-angle shot) cine MR imaging for the detection and characterization of congenital and acquired adult cardiac abnormalities.

SUBJECTS AND METHODS. Twenty-five patients with known or clinically suspected cardiac abnormalities were imaged on a 1.5-T scanner. Valve plane movies were obtained in patients with suspected valve morphology or function abnormalities or whose horizontal long-axis images showed jets. For each patient, three radiologists independently compared corresponding matched cine FLASH and trueFISP movies for image quality in evaluating anatomy and function of the great vessels and heart. Image quality was rated on a five-point scale, and data were analyzed using both a Wilcoxon's signed rank test and a repeated-measures analysis of variance.

RESULTS. Image quality ratings of trueFISP and FLASH showed a statistically significant difference (F = 58.67; df = 1, 72; p < 0.0001), with the average rating for the trueFISP images being significantly higher (mean rating, 4.1 ± 0.92) than that for the FLASH images (mean, 3.0 ± 1.0). However, valve architecture in the aortic valves appeared to be better visualized and was more easily measured in valve plane images with FLASH. No statistically significant differences among the ratings of the interpreters (F = 0.018; df = 2, 72; p = 0.9821) were evident, and, therefore, no suggestion of bias was indicated (F = 0.775; df = 1, 2; p = 0.4645). TrueFISP yielded the correct diagnosis prospectively in 13 (100%) of 13 patients, whereas FLASH yielded the correct diagnosis in 12 (92%) of 13 patients.

CONCLUSION. TrueFISP images depict morphologic and functional abnormalities with greater clarity and provide greater diagnostic confidence than FLASH images—and in a fraction of the time. A specific exception is in the assessment of valve leaflet architecture and cross-sectional area calculation (i.e., bicuspid aortic valves); in these evaluations, FLASH maintains a complementary diagnostic imaging role.

Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Segmented trueFISP (fast imaging with steady-state precession) has recently been improved so that it can provide fast, high-contrast MR imaging of the beating heart [1]. However, this modality's clinical performance relative to the more widely available segmented FLASH (fast low-angle shot) techniques has not previously been evaluated. Fast MR imaging with gated, segmented FLASH sequences generally provides good-quality breath-hold images with acceptable temporal and spatial resolution [2]. Spoiled gradient-echo sequences, like FLASH, rely on inflow enhancement to generate blood—myocardium contrast, and so the tendency toward blood saturation that occurs when the TR is decreased limits the lowest useful TR parameter that can be applied, even in high-performance gradient systems. Thus, sequences of this type may limit acquisition speed and achievable spatial and temporal resolution. TrueFISP is a steady-state technique that recycles coherent transverse magnetization, and the steady-state signal is determined by the T2-to-T1-signal ratio [1]. Because blood has a significantly higher T2-to-T1 ratio than the myocardium and because trueFISP uses the available blood signal very efficiently, trueFISP excellently differentiates the blood, myocardium, and epicardial fat [3]. In this study, we compared trueFISP and FLASH gradient-echo techniques in the evaluation of cardiac anatomy, myocardial wall motion, valve disease, and other cardiac functional abnormalities in 25 patients. The relative clinical performance of these techniques with respect to contrast material effects and image degradation attributable to artifacts was assessed.

Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion References

 
All imaging was performed on a Magnetom Sonata 1.5-T scanner (Siemens Medical Systems, Erlangen, Germany). We evaluated 25 consecutive patients referred for cardiac abnormalities suspected at physical examination or echocardiography. These abnormalities included shunts, right ventricular dysplasia, left-sided heart failure, valvular dysfunction, and pericardial thickening (Table 1). Thirteen patients with abnormalities had undergone one or more corroborating imaging examinations or surgeries, including echocardiography (n = 7), cardiac catheterization (n = 2), and surgery (n = 6) (Table 1). MR imaging of the heart was performed using segmented FLASH and a new segmented trueFISP technique [1]. Scanning parameters used for the trueFISP sequence were TR/TE, 3.0/1.6; flip angle, 50-70°; bandwidth, 975 Hz/pixel; field of view, 280 x 350; matrix size, 128 x 256; pixel size, 2.3 x 1.4 mm; and slice thickness, 6 mm. For the FLASH sequence, the scanning parameters used were 8/4; flip angle, 15-20°; bandwidth, 230 Hz/pixel; field of view, 280 x 350; matrix size, 128 x 256; pixel size, 2.3 x 1.4 mm; and slice thickness, 6 mm. For both sequences, temporal resolution of approximately 40 msec was achieved for all cine movies.

To achieve the proper imaging orientations, axial scout images were obtained through the patient's chest. From an axial image obtained at the level of the ventricles, an image then was produced of the region through the left atrium and left ventricle parallel to the interventricular septum. This two-chambered vertical long-axis scout image was used to generate the double-oblique cine series through the horizontal long-axis image of the heart, as described in detail by Boxt [4]. Horizontal long-axis cine FLASH and trueFISP movies for each patient were compared independently for image quality by three radiologists. For each suspected abnormality, between one and four additional matched cine angiographic movie pairs of FLASH and trueFISP were also compared. Movies were evaluated for cardiac and great-vessel anatomy and function, including chamber size, wall thickness and motion, valve morphology, and leaflet mobility. In patients with a clinically suspected abnormality of valve morphology or function or with jets visible on the horizontal long-axis image, cine movies in the valve plane were also obtained. To obtain valve plane images, the horizontal long-axis cine movie images were used as scout images to obtain a coronal—oblique cine series through the aortic outflow tract (Fig. 1A,1B,1C). Subsequently, using the outflow tract cine series images as a scout view, valve plane cine series images were generated (Fig. 1A,1B,1C).

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —Technique for obtaining valve plane images depicted in images of 66-year-old female patient. Horizontal long-axis trueFISP MR image (TR/TE, 3.0/1.6) shows image orientation through aortic outflow tract.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —Technique for obtaining valve plane images depicted in images of 66-year-old female patient. Outflow tract image shows image orientation through aortic valve plane.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —Technique for obtaining valve plane images depicted in images of 66-year-old female patient. Resultant aortic valve plane image.

Matched cine trueFISP and FLASH images were displayed side—by—side on a workstation (Pathspeed 8.0 PACS; General Electric Medical Systems, Milwaukee, WI) and reviewed independently by three radiologists unaware of patient names and histories. All three radiologists were experienced with cardiac MR imaging examinations and the use of the PACS work-stations. The radiologists were able to manipulate viewing parameters for the cine movies (i.e., brightness and contrast, frame rate and direction, and magnification) in any way they desired. The reviewers were asked to use a five-point scoring method for assessing image quality (5 = excellent; 4 = good; 3 = fair; 2 = poor; and 1 = poor—nondiagnostic). Excellent images were defined as those that had good blood—myocardium contrast, high structural definition, and low artifact.

The data were analyzed in two ways. A Wilcoxon's signed rank test was performed to determine if the paired sets of FLASH and trueFISP data were rated differently (e.g., to test whether trueFISP was consistently rated higher in quality than FLASH, or vice versa). An analysis of variance was also performed on the data to examine the average ratings. We believe that it is noteworthy that the ratings provided by the radiologists were based on image quality, not diagnostic confidence, so these data are not appropriate for a receiver operating characteristic analysis.

Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Overall Comparisons
In 60 of the 75 comparisons (25 patients x 3 radiologists = 75 comparisons), trueFISP cine movies received higher ratings than the FLASH comparison movies (Wilcoxon's signed rank test, z = -5.569, p < 0.0001). For the overall comparison of image quality, analysis of variance also found a statistically significant difference in ratings (F = 58.67; df = 1, 72; p < 0.0001), with the average rating for the trueFISP images being significantly higher (range, 2-5; mean, 4.1 ± 0.92) than for the FLASH images (range, 1-5; mean, 3.0 ± 1.0). Average ratings for each radiologist were also significantly greater (p < 0.01) for trueFISP (radiologist 1, 4.0; radiologist 2, 4.0; and radiologist 3, 4.2) than for FLASH (radiologist 1, 3.1; radiologist 2, 3.0; and radiologist 3, 2.8). In seven of the 75 comparisons, both trueFISP and FLASH received the same rating, whereas in eight of the 75 comparisons FLASH received higher ratings than the trueFISP.

The findings on review of these 25 patients using cine trueFISP and FLASH techniques are listed in Table 1. Thirteen patients with abnormalities had undergone one or more corroborating imaging examinations or procedures, including echocardiography, cardiac catheterization, and surgery. TrueFISP yielded the correct diagnosis prospectively in 13 (100%) of 13 patients who had correlative imaging or surgical confirmations of the diagnosis, whereas FLASH yielded the correct diagnosis in 12 (92%) of 13 patients.

A Bartlett's test for homogeneity of variance indicated that although the variance for the trueFISP ratings was lower than that for the FLASH ratings (0.843 vs 1.013), the difference was not statistically significant (F = 1.20; df = 74; p = 0.4291). No statistically significant differences between radiologists (F = 0.018; df = 2, 72; p = 0.9821) were noted, and no statistically significant interaction between the condition imaged and radiologists (F = 0.775; df = 1, 2; p = 0.4645) was found.

Comparison of imaging times shows that imaging time per cine series is significantly faster (p < 0.0001) for trueFISP (range, 4-8 sec; mean, 6.1 ± 1.1 sec) than for FLASH (range, 8-17; mean, 12.3 ± 2.4 sec). The ratio of FLASH imaging time to trueFISP imaging time per cine series was approximately 2:1.

Subset Comparison (Valve Plane Images)
All eight comparisons in which FLASH received higher scores than trueFISP involved valvular abnormalities. Specifically, valve orifice architecture in normal and bicuspid aortic valves was better visualized and valve orifice area was more easily measured in valve plane images with FLASH than with trueFISP.

Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Evaluation of Morphologic Abnormalities
Differentiation between solid structures (i.e., myocardium) and flow in vascular structures can be achieved with both cine trueFISP and FLASH. However, cine trueFISP has excellent blood—myocardium contrast, resulting in improved cardiac morphologic images compared with such images produced by FLASH (Fig. 2A,2B,2C,2D). In addition, trueFISP takes only half the imaging time of FLASH, resulting in fewer patient-motion and cardiac-gating artifacts. Solid structures, such as papillary muscles and myocardial trabeculae, were judged to be more clearly delineated on trueFISP images than on FLASH images. This finding is, at least in part, due to saturation of slow-flowing blood adjacent to the myocardium on FLASH images, which obscures the blood—myocardium interface. In one patient, the cine trueFISP images (Fig. 3A) showed both a circumflex and right main coronary artery aneurysm, but the matched cine FLASH images (Fig. 3B) showed only the circumflex aneurysm. The presence of the right main coronary artery aneurysm was only identified retrospectively, and it was less obvious than on the trueFISP sequence. Furthermore, this aneurysm was also overlooked at the initial cardiac catheterization and confirmed only after a repeated cardiac catheterization and surgery.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —43-year-old man with normal aortic and mitral valve structure. LA = left atrium, LV = left ventricle. Horizontal long-axis trueFISP MR image (TR/TE, 3.0/1.6) clearly reveals anterior and posterior leaflets (short arrows) of mitral valve, left atrium, left ventricle, and aortic outflow tract (long arrow).

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —43-year-old man with normal aortic and mitral valve structure. LA = left atrium, LV = left ventricle. Horizontal long-axis FLASH (fast low-angle shot) MR image (8.0/4.0) shows poor blood—myocardium contrast and barely visible aortic and mitral valve leaflets.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C. —43-year-old man with normal aortic and mitral valve structure. LA = left atrium, LV = left ventricle. Horizontal long-axis trueFISP MR image (3.0/1.6) clearly reveals closed mitral valve (short arrows), left atrium, left ventricle, and aortic outflow tract (long arrow).

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D. —43-year-old man with normal aortic and mitral valve structure. LA = left atrium, LV = left ventricle. Horizontal long-axis FLASH MR image (8.0/4.0) shows poor blood—myocardium contrast and barely visible aortic and mitral valves.

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —69-year-old man with circumflex and right main coronary artery aneurysms. Axial trueFISP MR image (TR/TE, 3.0/1.6) shows circumflex coronary artery aneurysm (thin arrow) and right main coronary artery aneurysm (thick arrow). Incidentally noted hepatic cyst is visualized on trueFISP image but not seen in corresponding FLASH (fast low-angle shot) image (B).

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —69-year-old man with circumflex and right main coronary artery aneurysms. Axial FLASH MR image (8.0/4.0) shows circumflex coronary artery aneurysm (thin arrow) and right main coronary artery aneurysm (thick arrow) seen retrospectively.

Evaluation of Cardiac Functional Abnormalities
TrueFISP showed pericardial thickening constricting right ventricular wall motion in greater detail in one patient than the matched FLASH movies. Constrictive physiology was confirmed with cardiac catheterization in this patient. In the four patients with left ventricular failure, cine trueFISP and FLASH were both diagnostic, subjectively, although trueFISP images had better blood—myocardium contrast. The ventricular wall motion, subsequent localization of ventricular dysfunction, and assessment of its degree were more easily evaluated on trueFISP images than on FLASH images because of the more distinct blood—myocardial interface seen on trueFISP images. Findings of left ventricular failure were corroborated by echocardiography in all four patients.

Visualization of Shunts and Abnormal Communication
In some patients with complicated congenital heart disease, or with restricted acoustic access, intracardiac lesions can be well delineated by MR imaging. These cardiac abnormalities include septal defects, abnormal valve morphology, and abnormal arterial connections [5, 6]. Evaluations of one case each of atrial septal defect (Fig. 4), ventricular septal defect, and patent ductus arteriosus had been performed with both cine trueFISP and FLASH imaging techniques. Both techniques were diagnostic in revealing these shunts and abnormal communications. However, in the one patient with atrial septal defect, the initial cardiac catheterization failed to show the abnormality. It was only at the MR examination that the presence of the atrial septal defect was detected and then confirmed by a repeated cardiac catheterization, echocardiography, and surgery. The ventricular septal defect and patent ductus arteriosus findings were also corroborated at echocardiography and surgical repair. Subsequent imaging procedures performed after this comparison study have shown excellent depiction of shunts by trueFISP imaging alone. These findings have also been substantiated by subsecond MR angiography (Finn JP et al., presented at the meeting of the North American Society for Cardiac Imaging, New Orleans, November 2000).

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4. —80-year-old woman with atrial septal defect with septal aneurysm. Axial TrueFISP MR image (TR/TE, 3.0/1.6) shows septal aneurysm (arrow) bowing from right atrium (RA) to left atrium (LA).

Valvular Heart Disease
MR imaging can provide additional information concerning valve disease when echocardiography is technically limited. Cardiac cine MR angiography allows qualitative assessment of valve regurgitation and stenosis as well as quantitative calculation of the valve orifice area [3]. Seven patients with aortic regurgitation were identified in this study. Two of these patients had both aortic regurgitation and stenosis. Three of the seven underwent echocardiography, and all three echocardiographic examinations corroborated the presence of aortic regurgitation or stenosis or both. One of these patients subsequently underwent an aortic valve replacement. In most image pairs, valvular regurgitation analysis was the same in cine trueFISP and FLASH; however, in one image pair, regurgitant flow was better visualized in the cine trueFISP sequence (Fig. 5A) than in the FLASH sequence (Fig. 5B).

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A. —25-year-old man with aortic regurgitation. Axial trueFISP MR image (TR/TE, 3.0/1.6) reveals aortic regurgitation as flow void (arrows) in left ventricle.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B. —25-year-old man with aortic regurgitation. On axial FLASH (flash low-angle shot) MR image (8.0/4.0), aortic regurgitation is not as clearly seen as on trueFISP image (A).

In the specific circumstance of calculating valve orifice area in normal (Fig. 6A,6B), partially fused (Fig. 7A,7B), and bicuspid aortic valves (Fig. 8A,8B), the valve opening is better visualized and measured in valve plane images with FLASH than with TrueFISP. It is likely that in FLASH, the stagnant blood behind the immobile valve leaflets becomes saturated, resulting in signal loss, whereas the blood flowing through the orifice shows higher signal intensity from the flow-related enhancement. The flow-related contrast allows excellent valve architectural definition. Because TrueFISP is more heavily dependent on T2- and T1-signal characteristic imaging of blood than on a flow-related signal, the blood flowing through the valve has the same signal intensity as the more stagnant blood behind the leaflets, making valve architecture less distinct despite high overall image clarity.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A. —40-year-old man with normal aortic valve structure. Aortic valve plane trueFISP MR image (TR/TE, 3.0/1.6) shows normal aortic valve (arrows). Note poor blood—valve leaflet contrast obtained with trueFISP imaging.

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B. —40-year-old man with normal aortic valve structure. Aortic valve plane FLASH (fast low-angle shot) MR image (TR/TE, 8.0/4.0) shows normal aortic valve (arrows) and good valve architecture definition and valve orifice contrast.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A. —41-year-old man with partially fused anterior commissure of aortic valve. Aortic valve plane trueFISP MR image (TR/TE, 3.0/1.6) shows apparently normal aortic valve architecture because of poor orifice—valve leaflet contrast in trueFISP.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B. —41-year-old man with partially fused anterior commissure of aortic valve. Aortic valve plane FLASH (fast low-angle shot) MR image (8.0/4.0) reveals partially fused anterior commissure (arrows) with good valve architecture definition and valve orifice (O) contrast.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A. —67-year-old woman with bicuspid aortic valve. In aortic valve plane trueFISP MR image (TR/TE, 3.0/1.6), bicuspid aortic valve (arrows) is not clearly seen because of poor orifice—valve leaflet contrast.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B. —67-year-old woman with bicuspid aortic valve. Aortic valve plane FLASH (fast low-angle shot) MR image (8.0/4.0) of bicuspid aortic valve (arrows) shows excellent valve architecture definition and valve orifice (O) contrast.

Artifacts of TrueFISP and FLASH
One must be aware of some limitations and consistent artifacts inherent to each sequence. TrueFISP is very sensitive to magnetic field non-uniformity. Metallic objects such as sternal wires will often result in small eddies in the magnetic field that degrade its homogeneity, resulting in characteristic artifacts. In addition, phase-cancellation artifacts are frequently seen as a dark etched outline at major interfaces between fat and water. These artifacts are easily recognizable and typically do not occur in the field of interest. With adequate shimming, cine series remain of diagnostic quality in most patients. For example, prosthetic cardiac valves have not precluded use of diagnostic cardiac images in our experience. Furthermore, familiarity with these artifacts decreases the likelihood of encountering major problems in clinical practice. One foreseeable limitation in the use of trueFISP is the evaluation of the right ventricular wall in subtle cases of right ventricular dysplasia. The right ventricle is typically very thin, and a chemical-shift artifact could conceivably obscure subtle foci of fatty infiltration.

FLASH images frequently suffer from saturation of signal in the blood pool. In addition, FLASH requires at least 8-17 sec per acquisition. Because FLASH acquisitions generally require twice as long as trueFISP acquisitions, the FLASH images are more likely to suffer from breathing-motion artifacts and cardiac gating artifacts.

Study Limitations
The most important limitations of this study include a relatively small patient population for each abnormality studied. Despite this fact, overall p values for comparison of the two imaging techniques are significant. In addition, because trueFISP images have a significantly different appearance than FLASH images, it would be impossible to keep an experienced radiologist from becoming aware of the type of image he or she is evaluating. Therefore, although the potential for observer bias toward one imaging technique versus another does exist, there was no statistically significant difference in ratings of the three radiologists, and all radiologists independently determined that trueFISP was superior to FLASH.

Segmented trueFISP cine images of the heart show superior overall image quality and can be acquired in half the imaging time required for segmented FLASH images. With the exception of valve orifice architecture and area measurements, trueFISP images better depict anatomic and functional abnormalities of the heart. Therefore, our suggested protocol for MR imaging evaluation of patients with known or suspected cardiac abnormalities includes short- and long-axis cine trueFISP images with complementary FLASH valve plane images for visualization of valve orifice and calculation of the valve area.

References

Top Abstract Introduction Subjects and Methods Results Discussion References

 

1. Carr JC, Simonetti O, Bundy J, Li D, Pereles FS, Finn JP. Segmented trueFISP: a new technique for cine MR angiography of the heart. Radiology 2001 (in press)
2. Atkinson DJ, Edelman RR. Cineangiography of the heart in a single breath hold with a segmented turboFLASH sequence. Radiology 1991;178:357 -360[Abstract/Free Full Text]
3. Zur Y, Wood ML, Neuringer LJ. Motion-insensitive, steady-state free precession imaging. Magn Reson Med 1990;16:444 -459[Medline]
4. Boxt L. Cardiac MR imaging: a guide for the beginner. RadioGraphics 1999;19:1009 -1025[Abstract/Free Full Text]
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This Article Abstract Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pereles, F. S. Articles by Finn, J. P. Search for Related Content PubMed PubMed Citation Articles by Pereles, F. S. Articles by Finn, J. P. Social Bookmarking                      What's this?