Setting up a Cardiac Magnetic Resonance service in a
District General Hospital: our experience and learning points
Poster No.:
C-1062
Congress:
ECR 2015
Type:
Educational Exhibit
Authors:
D. H. Kim , D. Felmeden , L. J. Archer ; Torquay/UK, Torbay/UK
Keywords:
Education and training, Audit and standards, MR, Management,
Cardiac
DOI:
10.1594/ecr2015/C-1062
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Page 1 of 30
Learning objectives
We aim to present the first six months of providing a new cardiovascular magnetic
resonance (CMR) service in a district general hospital (DGH) serving a population of over
275,000. We will describe the process of setting up this service and provide a template
for establishing CMR in other hospitals. This will be covered in 4 main steps:
•
•
•
•
Step 1: The business plan
Step 2: Equipment
Step 3: Training and accreditation
Step 4: Protocols and reporting
We will then summarise our experience to date in order to describe the types of cases
that could be faced and to illustrate potential workload. We will also discuss the level of
supervision required and the numbers of scans performed.
Background
The demand for CMR is growing in the UK. It is safe and has become the gold standard
in a variety of cardiovascular conditions through the provision of improved prognostic and
diagnostic accuracy in comparison to other imaging modalities [1].
CMR utilises ECG gating to avoid cardiac motion blur. The indications for CMR are wide
and diverse [2]. For example, gradient-echo sequences can be used to acquire multiple
images throughout the cardiac cycle to be displayed as cine loops to assess cardiac
function (Fig. 1 on page 4).
Page 2 of 30
Fig. 1: A 3 chamber cine view demonstrating normal cardiac function.
References: Dr Daniel H Kim, Torbay Hospital, UK 2015.
Gradient-echo sequences can also be used with velocity encoding in the signal phase
to quantify flow, for example across a diseased heart valve [3]. Perfusion and viability
investigation by CMR provides up to 60 times greater spatial resolution than singlephoton emission computed tomography [4]. The use of gadolinium chelate contrast
enhancement, typically in 3 phases (perfusion phase, early and late phases) allows CMR
to be used in a variety of clinical settings including in assessing infarct size, salvageable
myocardium viability and in visualising microvascular obstruction (Fig. 2 on page 5)
[1].
Page 3 of 30
Fig. 2: Two-chamber axial views. There is uniform suppression of signal on delayed
contrast enhanced inversion recovery T1-weighted images. This is a normal study.
References: Dr Daniel H Kim, Torbay Hospital, UK 2015.
Additional indications for CMR include the assessment of congenital heart disease,
cardiomyopathy, valvular heart disease, myocarditis, amyloidosis and pulmonary arterial
hypertension.
Torbay hospital benefits from an active cardiology unit, with 6 cardiology consultants and
cardiac CT capability. Prior to setting up the CMR service, patients requiring CMR were
required to travel to the Bristol Royal Infirmary nearly 100 miles away.
Images for this section:
Page 4 of 30
Fig. 1: A 3 chamber cine view demonstrating normal cardiac function.
Page 5 of 30
Fig. 2: Two-chamber axial views. There is uniform suppression of signal on delayed
contrast enhanced inversion recovery T1-weighted images. This is a normal study.
Page 6 of 30
Findings and procedure details
Setting up a CMR service
Step 1: Business Plan
Formulation of a robust business plan is essential. Coding of CMR currently does not
reflect the complexity of the service and remains unbundled however the British Society of
cardiovascular Magnetic Resonance (BSCMR) and the British Society of Cardiovascular
Imaging have proposed a set of codes and tariffs that can be used as a starting point
for local tariff negotiations [5].
At Torbay, the business plan was formulated by the cardiac radiology consultant in
collaboration with the cardiology consultant and the relevant management team. The
hospital serves an estimated population of 275,000 with a significant additional influx
from holiday makers during the summer months.
Help can be found at the NHS National Innovation Centre which provides template
business plans [6]. Alternatively template CMR business plans are available from the
Society of Cardiovascular Magnetic Resonance (SCMR) although they require a society
membership for access [7].
Step 2: Equipment
The prerequisite for a CMR service is an MR scanner with ECG-gating and corresponding
CMR software. The specification and capabilities of each machine will vary and some
software packages may not be suitable for all CMR indications. The authors advise that
the decision over which hardware and software to purchase should not be taken lightly
and that in depth discussion should be held with their reference centre and with other
UK departments where possible. The 'NHS Supply Chain' can help with the procurement
process [8].
At Torbay an Aera MRI Scanner with cardiac capability and 'Syngo via' reporting software
was purchased. Initially the CMR patient workload was such that a weekly dedicated
Friday morning session was started. This was increased to twice weekly sessions after
3 months. The scanner was used to alleviate pressures on other services during the
remainder of the working week.
Page 7 of 30
Step 3: Training and Accreditation
CMR Accreditation is provided by the SCMR and the European Association of
Cardiovascular imaging (EACVI/EuroCMR), and is based on internationally agreed
standards [9,10]. In addition, the BSCMR have published an expansion to this guidance
[11]. Assessment is via examination, case based discussions and direct observation of
procedural skills. In brief, there are currently 3 training levels, as described in Table 1
on page 18.
Table 1: CMR training levels and training requirements as specified by the EACVI and
the SCMR.
References: Dr Daniel H Kim, Torbay Hospital, UK 2015.
At Torbay Hospital, training to level 2 was undertaken by 2 doctors; 1 practising in Clinical
Radiology and the other in Cardiology. Both attended a one week intensive course at
Southampton General Hospital. Training of the radiologist was carried out at the Bristol
Heart Institute, a level 3 accredited centre. Training was arranged to take place over a
one year period. The radiologist then sat the European exam in Cardiac MRI at EuroCMR
(held yearly) and is currently applying for Level 3 competency.
Page 8 of 30
In terms of radiographer training, several observational visits to the Bristol Heart Institute
were made prior to the start of the service. The manufacturer of the scanner also provided
2 days of supervised training. This was followed by several visits from the superintendant
from the level 3 supervising centre designed to improve radiographer technique. Lastly
the radiographer team was sent on the "Cardiac MRI for Radiographers" 1 week intensive
training course at the Southampton General Hospital.
As training is likely to take several months it is advised that this take place in conjunction
with the business plan development and procurement process.
Step 4: Protocols and Reporting
Standardised CMR protocols have been published by the SCMR [12] and the EACVI [13].
It is recommended that these are adhered to with protocol alterations only being made
in conjunction with the level 3 supervising centre.
The SCMR have also published a set of standardised reporting guidelines for CMR [14].
At Torbay, the existing reporting structure at the level 3 supervising centre was adopted.
The multidisciplinary approach of dual reporting with a radiologist and a cardiologist
was particularly effective, and this was the aim wherever possible. The Friday morning
reporting sessions were arranged to coincide with the availability of a level 3 CMR trained
practitioner at the supervising site so that cases could be reviewed immediately when
necessary.
The Torbay Hospital CMR service: progress to date
th
The patient and reporting statistics taken from our CMR service between 9 June 2014
th
and 9 December 2014 are displayed in Table 2 on page 19.
Page 9 of 30
Table 2: Torbay CMR service: patient and reporting statistics.
References: Dr Daniel H Kim, Torbay Hospital, UK 2015.
Studies that were 'Dual Reported' benefitted from collaborative input from both the
Radiology and Cardiology consultants.
Scan indications were varied and are illustrated in Fig. 3 on page 19.
Page 10 of 30
Fig. 3: Indications for CMR studies performed. †Arrhythmogenic right ventricular
cardiomyopathy.
References: Dr Daniel H Kim, Torbay Hospital, UK 2015.
Other indications included investigation for Becker's muscular dystrophy, for Fabry's
disease, family screening for bicuspid aortic valves and for quantification of ejection
fraction following inadequate ultrasound.
The types of diagnosis encountered and their relative frequencies of observation are
illustrated in Fig. 4 on page 20.
Page 11 of 30
Fig. 4: Bar chart illustrating diagnoses made and their relative freqencies.
†Arrhythmogenic right ventricular cardiomyopathy ‡ Left ventricular outflow obstruction.
References: Dr Daniel H Kim, Torbay Hospital, UK 2015.
Cases
In this section we present a selection of some of the more common and interesting cases
observed in our CMR centre so far.
Page 12 of 30
Fig. 5: Two-chamber axial views. There is a diffuse subendocardial heterogeneous
pattern of increased signal on delayed contrast enhanced inversion recovery T1weighted images consistent with amyloidosis.
References: Dr Daniel H Kim, Torbay Hospital, UK 2015.
Page 13 of 30
Fig. 6: Four-chamber cine clip demonstrating apical hypertrophic cardiomyopathy.
References: Dr Daniel H Kim, Torbay Hospital, UK 2015.
Page 14 of 30
Fig. 7: Apical hypertrophic cardiomyopathy in a) diastole and b) systole.
References: Dr Daniel H Kim, Torbay Hospital, UK 2015.
Page 15 of 30
Fig. 8: Four-chamber cine view demonstrating a dilated right ventricle. The wall
is dyskinetic and is hypertrabeculated with microaneurysms. This patient has
arrhythmogenic right ventricular wall cardiomyopathy. The left ventricle also has a thin
inferior lateral wall which is hypokinetic.
References: Dr Daniel H Kim, Torbay Hospital, UK 2015.
Page 16 of 30
Fig. 9: Two-chamber cine view demonstrating a severely dilated and impaired left
ventricle consistent with dilated cardiomyopathy.
References: Dr Daniel H Kim, Torbay Hospital, UK 2015.
Page 17 of 30
Fig. 10: Three-chamber cine views in a) diastole and b) systole. This patient has
septal hypertrophic cardiomyopathy.
References: Dr Daniel H Kim, Torbay Hospital, UK 2015.
Images for this section:
Page 18 of 30
Table 1: CMR training levels and training requirements as specified by the EACVI and
the SCMR.
Table 2: Torbay CMR service: patient and reporting statistics.
Page 19 of 30
Fig. 3: Indications for CMR studies performed. †Arrhythmogenic right ventricular
cardiomyopathy.
Page 20 of 30
Fig. 4: Bar chart illustrating diagnoses made and their relative freqencies.
†Arrhythmogenic right ventricular cardiomyopathy ‡ Left ventricular outflow obstruction.
Page 21 of 30
Fig. 5: Two-chamber axial views. There is a diffuse subendocardial heterogeneous
pattern of increased signal on delayed contrast enhanced inversion recovery T1-weighted
images consistent with amyloidosis.
Page 22 of 30
Fig. 6: Four-chamber cine clip demonstrating apical hypertrophic cardiomyopathy.
Page 23 of 30
Fig. 7: Apical hypertrophic cardiomyopathy in a) diastole and b) systole.
Page 24 of 30
Fig. 8: Four-chamber cine view demonstrating a dilated right ventricle. The wall
is dyskinetic and is hypertrabeculated with microaneurysms. This patient has
arrhythmogenic right ventricular wall cardiomyopathy. The left ventricle also has a thin
inferior lateral wall which is hypokinetic.
Page 25 of 30
Fig. 9: Two-chamber cine view demonstrating a severely dilated and impaired left
ventricle consistent with dilated cardiomyopathy.
Page 26 of 30
Fig. 10: Three-chamber cine views in a) diastole and b) systole. This patient has septal
hypertrophic cardiomyopathy.
Page 27 of 30
Conclusion
Setting up a CMR service at a regional district general hospital is feasible, realistic
and can greatly improve the patient experience by providing improved diagnostic and
prognostic services closer to home. A template has been proposed which may be used
by any department looking to replicate this process. This will be necessary to keep up
with the growing demand for CMR in the UK and to continue to improve the level of care
provided in this country.
Personal information
Dr Daniel H Kim joined Torbay Hospital, South Devon in 2014 as a Radiology Registrar.
Dr Dirk Felmeden joined the Consultant Cardiology team at Torbay Hospital, South
Devon in 2006.
Dr Lesley J Archer joined the Consultant Radiology team at Torbay Hosptial, South Devon
in 2010.
References
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FE, van Rossum AC, Shaw LJ, Yucel EK. Clinical indications for cardiovascular
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unique asset worth optimising. J Cardiovasc Magn Reson. 2007; 9:723-728.
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computed tomography (SPECT) perfusion imaging for detection of subendocardial
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rd
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rd
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