9/22/09 v8 BIDMC Cardiac MR Fellowship Guide 1. Guidelines for CMR Credentialing* Level I: General training in CMR to provide the trainee with a working knowledge of CMR methods and their diagnostic utility, but not the practice of CMR -1 month Level II: Specialized training designed to provide the trainee with the skills necessary to independently interpret CMR imaging studies - 3 months training under the aegis of a Level 2 or Level 3 (preferred) qualified mentor - >50 hours CMR related coursework - supervised interpretation of >150 cases - primary (independent) interpretation >50 cases with the trainee at the scanner, performing the analyses and initial interpretation. - Maintenance of skills: - CME in CMR of at least 20 hours over 2 years - Primary interpretation of >100 cases over 2 years Level III: Advanced training to provide those who ultimately wish to be responsible for the operation of a CMR laboratory and to train others. -12 months training under aegis of a Level 3 mentor - > 50 hours of coursework - supervised interpretation of >300 cases - primary (independent) interpretation >100 cases with the trainee at the scanner, performing the analyses and initial interpretation. - participation in ongoing QA or improvement program - Maintenance of skills: - CME in CMR of at least 40 hours over 2 years - Primary interpretation of >200 cases over 2 years * Kim RJ, de Roos A, Fleck E, Higgins CB, Pohost GM, Prince M, Manning WJ. Guidelines for training in cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2007;9:3-4. 2. EDUCATION/CONFERENCES Attendance and active participation in clinical and research conferences is an integral part of the CMR training program. Each fellow is expected to present their research and/or Journal Club to the group 2x/year – usually in the Fall (presentation of planned project) and Spring (presentation of data). The weekly conference schedule includes: Monday, 8am, Cardiology Clinical Conference – Baker 4 Monday, Noon, CMR/Cardiac CT/Nuclear Cardiology Seminar (September – June) – Baker 4 , Cardiology Library Tuesday,noon – East Campus Cardiology Division Library 9/22/09 v8 1. Summer: weekly CMR Physics (Reza and Dana) 2. September - June 1. 2nd and 4th Tuesday of the month – CMR Research meeting [coordinated by Dana] with presentations by members of the group and local outside speakers (current format). 2. 3rd Tuesday of the month – Journal Club (CMR and CCT papers chosen by the discussant) [coordinated by Reza] 3. 1st Tuesday of the month (after Summer) – General CMR Lab meeting Wednesday, 8am, Echo/Non-invasive Cardiology Conference – EAST Campus, Cardiology Library Friday, 8am, Cardiology Grand Rounds (September – June) – West Campus (CC250 or Deaconess 3) Friday, Noon, monthly, Case Based Non-invasive Imaging Conference – Baker 4. Attendings and fellows present images from Echo, TEE, Nuclear Cardiology, CCT and CMR in a “show and tell” format. CONFERENCE SUMMARY EAST/WEST 8-9am 11-12pm 12-1pm 4-5pm Mon Clin Conf CMR readout CMR/CCT/ Nuclear Teaching Tue CMR readout CMR Lab Mtg CCT Reading Wed Echo Conf CMR readout Thur CMR readout Fri Card GRnds CMR readout 12:30pm Imaging Cases (monthly) CCT Reading Sources of Exposure to Clinical CMR Scans BIDMC Clinical Readout Sessions Clinical CMR Fellow – Independent Analysis BIDMC CMR Center Clinical Case Library (S drive: Cardiac MR) 9/22/09 v8 Fellow Clinical Months 1) Fellows are expected to view the video on the shared drive regarding CMR Safety during their frist CMR rotation a. S:\Cardiac MR\MRI Safety\INTERA Safety-Video.mpg b. Complete the online MRI training program: i. http://research.bidmc.harvard.edu/education/MRMemo.asp 2) CMR Fellow is to be available for all clinical scans (Mon and Friday, 8am5pm; Tuesday and Thursday 8am – 6pm, and Wednesday 8am – 7pm) during months on clinical service. 3) There is a virtual CMR pager which the fellow should sign out to his/her own pager at the start of their CMR clinical rotation. 4) When the fellow is unavailable or in clinic, he/she should arrange coverage for urgent/emergent protocol/interpretations/scanning. 5) CMR Fellow is to be available to review images and be knowledgeable regarding scan set-up and troubleshooting. 6) When possible, CMR fellow is to be at the scanner during clinical months to become familiar/knowledgeable about the scanning process, troubleshooting, etc. Selected opportunities to scan may be available on an individualized basis. 7) CMR Fellow is available to cover for the nurse for contrast injection, IV placement. Protocol Development 1. CMR scan requests (forms available on the web) are faxed to the CMR Office (617-975-5480). The request should include the patient’s demographic details, height, weight, insurance information, reason for the exam request, underlying medical condition(s), MRI safety screening, BUN, creatinine, race (for estimated glomerular filtration rate, eGFR). The referring physician and the patient’s PCP information should also be included. Iris will collect the information (including contact of the ordering physician if information is not provided). 2. After collection of these data, Iris creates a paper file that is placed in the “Awaiting Protocols” box. The fellow should check this box several times during the day so as to respond to referral needs. 3. After review of the case, the fellow should protocol the study on the same day. Queries can be made to any of the available CMR attendings. 4. The file is then returned to the “Protocols complete” box. Iris will then contact the patient. Based on the protocol time, she will arrange a date and time for the CMR examination. [Ideally, the study protocol and scheduling should occur on the same day as the exam request. 5. Gd-DTPA use: Reports of nephrogenic systemic fibrosis (NSF) have been described in patients with impaired renal function. Therefore, an estimate of eGFR should be made for all patients before they arrive for scanning and at the time of protocol development, as this may impact the dose (or use of Gd; e.g., for viability – low dose dobutamine may be the only protocol for patients with depressed eGFR and no Gd-DTPA). eGFR can be estimated from a recent BUN, creatinine and knowledge of the patient’s race. For patients 9/22/09 v8 with an eGFR >60ml/min/1.73m2, up to 0.2mmol/kg of Gd-DTPA can be given. For patients with an eGFR of 45-60ml/min/1.73m2, the indication for Gd-DTPA should be reviewed with a CMR staff physician. If Gd-DTPA is deemed necessary, a lower dose should be considered (e.g., 0.1mmol/kg). For patients with eGFR 30-45ml/min/1.73m2 or on dialysis, the indication for Gd-DTPA should be reviewed with the ordering physician and alternatives considered. If on dialysis and Gd-DTPA is deemed necessary, the patient will need a session of hemodialysis within 3 hours and again within 24 hours after Gd-DTPA administration. It is unlikely, however, that gadolinium would be essential for a cardiac MR in a patient on dialysis. Clinical Readout 1. Cases are read out at a combined reading session with staff cardiologist/radiologists. 2. Clinical CMR cases are reviewed and analyses performed by CMR Fellow prior to readout session. The case is then presented with analyzed data to the group (Cardiology/Radiology staff, fellows, residents, students) 3. The CMR fellow sends out an e-mail by 5pm the prior evening alerting the Radiology and Cardiology staff as the number of cases to be reviewed. 4. Daily readout begins at 11am in the CMR fellows’office. CMR Reports: 1.CMR reports are prepared using gender specific Microsoft Word templates. 2. Preliminary reports should be completed on the day that the study is interpreted. a. Preliminary reports are either placed in the attending mailbox (WJM and SBY) or emailed as an attachment (TH, EA, EVG, LF, DO, YH). 3. Corrections are made by the attending and returned to the fellow by the next working day. 4. The fellow e-mails the final report to “CMRI Final Reports” using “Final report(s)” in the subject line. 5. The patient’s attending cardiologist should also be notified by email or telephone. 6. Claire Odom from Radiology is responsible for ensuring the report is then posted to CareWeb. 7. The final report is saved on the S drive (Cardiac MR > BIDMC NEMRI Reports > 2009 CMR Clinical Reports) with the format – Date Patient Surname Patient MRN Indication. [e.g., 01/01/09 Bond 0070070 Aortic Regurgitation]. If there are abnormalities beyond what was in the initial requisition, these should be noted (to allow for searching of the database for specific abnormalities.). 8. The study images (with analyses) are copied to the Radiology PACS and to the hard drive (see APPENDIX). 9. A “scut list” is maintained on the View Forum desk top to keep track of the various steps for each case. This document is also in the appendix to this document. Clinical Teaching Cases/File Preparation and Archiving A teaching file of classic/interesting images is maintained on the S: drive. 9/22/09 v8 1. These electronic folders include the final clinical report, pertinent CMR images/cines, and other pertinent images (i.e. coronary angiograms, electrocardiograms, echocardiograms, or nuclear images). ‘Soapbubbled’ coronary MRI images (a reconstruction format. Soapbubble is a reconstruction program created by Rene Botnar and Mathias Stuber) are the preferred method for saving coronary MR angiograghic data. 2. Once assembled, the files are saved in the S Drive (Cardiac MR > BIDMC CMR Cases) with the format of the Patient MRN followed by the reason they are of interest [e.g., 0070070 Bicuspid Aortic Valve with Mild Coarctation]. IV Placement and Intravenous Gadolinium-DTPA Injections (see Protocol Development section above on Gd-DTPA guidelines). 1. Most patients receive 0.2 mmol/kg IV using the power injector or manual injection. 2. For delayed IR imaging, use a quarter (e.g., 0.05 mmol/kg) for resting ‘firstpass’ perfusion imaging followed by an additional 0.15mmol/kg to completed the standard delayed enhancement dose. 3. Use 0.2 mmol/kg for pulmonary vein angiography with a test dose of 1-2 cc for timing assessment. 4. Strong preference is for a 20g IV in an antecubital vein. If Kraig or Lois cannot place an IV, they will usually contact the fellow first to attempt before asking the IV nurse. Subject Monitoring During CMR studies 1. Patients are monitored via verbal communication, continuous heart rate, blood pressure, and respiratory rate, and pulse oximetry. Stress CMR imaging - Viability 1. Low dose dobutamine stress CMR should be considered for all patients with a resting wall motion abnormality for whom viability assessment is desired (but not routinely as part of a general cardiomyopathy evaluation). 2. After baseline functional images are obtained, dobutamine, 5 mcg/kg/min IV is given for 5 minutes followed by repeat of the functional/cine images (4-chamber, 2-chamber, and short axis stack functional/cine images while the dobutamine infusion running (generally 20 mins or so). No flow data are acquired. c. The elimination half life of dobutamine is 2 minutes. Therefore, it will take 1015 minutes for active metabolites to be out of the patient’s system – so if we do the rest images after the dobutamine images, it will need to be > 15 mins after. 3. The fellow should be present for the entire period during which the patient is receiving dobutamine and for at least 10 minutes after cessation of dobutamine.. 4. Analysis includes tracing of the LV and RV endocardial borders (NOT epicardial borders) on the post dobutamine images to assess for change in ventricular volumes and EF b. Use the 2nd study report template when you do your report – that way you can use 2 columns called “ Baseline” and “With 5mcg/ kg/min 9/22/09 v8 Suggested Reading (s) MR Physics MRI Physics Made Easy – Berlex Vivian Lee text Clinical CMR Manning and Pennell Text (2010 edition expected soon) Higgins and deRoos Text Manning CMR Atlas text Online tutorials There are multiple on-line lectures and Powerpoint presentations available on the S drive. Check the folders named CMR Physics, CMR physics course 06, MRI training. There are also lecture series available on CD-ROM in the Cardiac MR fellows’ office and links via the Cardiac MR folder and the Cardiology fellowship folder on the CMR website. Seminal Article Bibliography* *will be provided upon starting fellowship Review teaching file cases on the S drive Hands-on Scanning KVK Scanning Manual (read before scanning) Dedicated time on volunteer Scanning subjects Troubleshooting First Wed of the month, 5-7pm is reserved for fellow scanning experience. CMR reporting There is a gender specific template for CMR reporting in the Cardiac MR folder. We are currently at version 10 – versions are updated as scanning protocols are modified. Thanks to Jason Ryan, there is now an excel spreadsheet on the ViewForum and also in the Cardiac MR folder. By filling in the values on this spreadsheet the relevant boxes on the report are automatically populated – saving a lot of time!! There are plans to develop an ENCOR template for CMR reporting. Aids/Reference Charts/CMR Forms/CMR Center Directions Found on: BIDMC CMR Center Webpage – www.home.caregroup.org, Clinical – BIDMC, Cardiac MR Center Normative Value Chart (Salton et al for LV, Plein et al for RV, Hughes et al for valvular regurgitation, 2-D echo parameters) Inversion Time Charts for Delayed IR (Scar/Infarct/Fibrosis) Imaging Flow Analysis - Velocity Encoding Changes for Stenotic Valve Disease Preliminary data collection form CMR attending schedule 9/22/09 v8 Schedules The schedule for the CMR attendings is on the BIDMC CMR Center Webpage – www.home.caregroup.org and follow the links. The schedule for the CMR fellows is on www.amion.com – password is bicar. Click on “Block” at the top and then use the drop-down menu to “Non-invasive fellows”. Research CMR meetings Current Projects Mentor Funding CMR Center Staff Warren J. Manning, MD, [email protected], pager 31144, x72192 Evan Appelbaum, MD, [email protected], pager 36300, x72034 Loryn Feinberg, MD, [email protected], pager 31692, x72737 Thomas Hauser, MD, [email protected], pager 38219, x74787 Eli V. Gelfand, MD, [email protected], pager 31694, x74811 Yuchi Han, MD - [email protected], pager 39657 David O’Halloran, MD – [email protected], pager 90106 Susan B. Yeon, JD, MD, [email protected], pager 35522, x70479 Reza Nezafat, PhD – [email protected] x7-1747 Dana Peters, PhD, [email protected], x78037 Ivan Pedrosa, MD, [email protected], pager 39016, x42095 Neil Rofsky, MD, [email protected], pager 91446, x72721 Beth Goddu, RT [email protected] Kraig V. Kissinger, RT, [email protected], pager 38293, x70287 Carol Salton, [email protected], x75834 Lois Goepfert, RN, [email protected], pager 32885, x74202 Iris Wasserman, [email protected], x72192 2009-2010 CMR Fellows Francesca Delling – [email protected] Susie Hong-Zohlman – [email protected] Ali Mahajerin – [email protected] Ali Rahami –[email protected] 9/22/09 v8 2008 – 2009 CMR Fellows Jonathan Chan – [email protected] Michael Chuang – [email protected] Airley Fish – [email protected] Joyce Meng – [email protected] 2007 – 2008 CMR Fellows Danya Dinwoodey – [email protected] Alex Morss – [email protected] Greg Piazza – [email protected] Jason Ryan – [email protected] 2006-2007 CMR Fellows: Alisa Rosen, MD Jersey Chen, MD Yuchi Han, MD David O’Halloran, MD Mike Widlansky, MD, PhD (BMC) 2005-2006 CMR Fellows: Kyle Pond, MD Avi Kothavale, MD Eli Gelfand, MD Loryn Feinberg, MD 2004-2005 CMR Fellows Rick Ruberg, MD (BMC) Martin S. Maron, MD (NEMC) Nik Iyengar, MD 2003-2004 CMR Fellows Anita Bhandiwad, MD Sean Hughes, MD Evan Appelbaum, MD Tom Hauser, MD 9/22/09 v8 APPENDIX A: Guide for CMR Fellows Duties 1. Protocol Studies (each question has a specific protocol that may be selected from a list in the back of the CMR request sheet) 2. Data Analysis a. View Forum (VF) Basics i. Logging in ii. Getting to Windows without shutting down View Forum iii. Mouseology in View Forum b. Using the ViewForum i. Finding and loading studies ii. Display modes and navigation iii. Image analysis c. Pulmonary Vein Studies i. Determining PV anatomy and measuring X-sectional areas ii. Volume rendering displays iii. Endoluminal views 3. Report Generation a. Clinical Report – How to Generate b. Electrophysiology Extras c. Sending Reports for Transcription d. Sending Reports to Referring MD e. Backup of Report 4. Data Backup a. Archive on PACS b. Save to Hard Drive c. Burn CD or DVD (only needed if sending images to referring) 5. Readout Sessions a. Emailing CMRI Readout group (a word template with CMRI readout reminder can be found on the desktop) 9/22/09 v8 2a. ViewForum Basics 2a-1. Logging In and starting View Forum (VF) Software Log into workstation (Windows level) as: User: VFUser Password: ViewForum2 Starting View Forum software: double-click on ViewForum icon (left column, 4th down). 2a-2. Getting to Windows without shutting down VF To minimize View Forum (toggle between Windows desktop and View Forum), hit WINDOWSkey-D while in View Forum. 2a-3. Mouseology in View Forum (VF) • Window and contrast – hold down middle mouse key (scroll wheel) and drag Suggest 2000/800 as good windows for LCD projection • Zoom – hold down middle and right mouse keys, drag • Recenter (to drag images around) – hold down left and middle mouse keys, drag 2b. Using the ViewForum 2b-1. Finding and Loading Studies On the VIEWING WORKLIST screen, double click on a specific name to open the entire study. You can also click once on the name, then under the “series” window click on the specific series needed. 2b-2. Display Modes and Navigation There are several image-display modes on the VF. We generally use only two, the TAB view, and the TILED view. 2b-3. Image Analysis (all measurements to be written on worksheet provided in the purple folder) 2b-3a. General measurements (lengths and areas) On the axial T1 weighted images, start from the lowest slice and measure (from bottom to top) the following lengths (use the horizontal arrow/distance icon on the left): abdominal aorta AP diameter, coronary sinus diameter, pericardial thickness, left atrium dimension, and at the level of the bifurcation: ascending/descending aorta AP diameter and pulmonary artery. On the cine SSFP 4ch view measure right and left atrial lengths. On the cine SSFP short axis stack view (at the level just basal to the tips of the papillary muscles), measure the anteroseptal and 9/22/09 v8 inferolateral thickness at end-diastole, and the LV end-diastolic and end-systolic diameters. On the SSFP short axis view at the level of the aortic valve, measure the aortic valve area with the “contour” function on the left. 2b-3b. Volumetric analyses On the SSFP short axis stack view, click on analysis, MR cardiac analysis. Under “available applications”, click on LV analysis, and put your initials in the “new session” window. Click on a mid-level short axis and select the panel on the right (end-systole). Make sure the phase selected is indeed end-systole by going through the different phases with the right/left arrow on the keyboard. Go back to the end-diastole window on the left (usually the first phase), click on the pencil, and start drawing the diastolic (endocardial and epicardial) and systolic contours (endocardial only) (use the up/down arrows on the keyboard to go through the different slices). At the end of your measurements, click on the “analysis results” (looks like a graph) button, and you will see volumes, LVEF, and mass. Repeat the same steps for RV analysis. 2b-3c. Quantitative flow analyses On the QFlow AO view, select analysis, MR cardiac analysis. Under “available applications”, click on Q-flow, and put your initials in the “new session” window. In the left panel, select the best looking flow (brightest lumen) by using the right/left arrows on the keyboard. Click on the pencil, and you’ll obtain a circle that you’ll adjust around the aortic transverse section. The “potato” icon underneath the pencil allows for more precise contours. Click on the central arrows (“propagate contour to all images of current slice”). Once the contours are propagated, click on the graph command and you will obtain a “flow” curve with the flow results. Repeat the same steps for the pulmonary flow. You should take pictures of the flow measurements by clicking on the camera on the bottom left. Name the picture, click on the “hand” icon, and click on all three panels: the flow curve, the actual measurements, and the picture of the contours. 2c. Pulmonary Vein Studies 2c-1. Determining PV anatomy and measuring cross-sectional areas Multiplanar reformat (MPR) is used for quantitative measurements of PV dimensions and areas. 1. Select the PV MRA image set. Under the VISUALIZATION pulldown (lower blue tool bar, second from left) select MPR. This will result in a 3-panel display popping up and an MPR of the pre-contrast scan, which is not what you want, so. 9/22/09 v8 2. Go to VISUALIZATION again and select the VOLUME SOURCE option and pick the second item in the list: this is the immediate post-contrast scan. Now the large left-sided window will display the axial view, while the smaller right-sided windows show sagittal and coronal views. 3. Survey the axial MPR by putting the cursor over the large window. Hold down the left mouse key and drag the mouse forward and back on the desk top, this changes the “cut” of the MPR and will generally let you determine the number of PVs on each side. 4. Prepare to measure the PV cross-sectional areas and dimensions. This is best done by setting the left window to sagittal display and upper right to axial. Use the mouse to select the sagittal (profile of head) icon. This changes the left panel to sagittal. Now place the cursor over the right top panel and right-mouse and select the “feet” icon which represents axial view. The windowing will change dramatically. Use the middle mouse key (scroll wheel) to rewindow. Note that the light blue line in the right upper panel corresponds to the intersection of what is displayed in the left panel with the right upper panel. Measurements are always made in the strict sagittal plane, and NOT perpendicular to a particular PV. Tom Hauser has a paper showing greater reproducibility with the strict-sagittal method [ref]. 5. Measure right PVs. Left-mouse hold and drag over the left panel until you see the point at which the right PVs just separate from the body of the left atrium. This is the level to measure. Select the free-form shape icon from the left toolbar and click around each PV to generate a closed contour. Double click to close the contour. You can readjust the contour after it is closed. This gives a cross-sectional area. Write it down on the worksheet. Now use the caliper tool to measure maximal linear dimension and its perpendicular. Write these down. Repeat for the other right PV(s). 6. Save an image of the PV measurements. Hold the cursor over the left panel and right click to bring up a list of options. Select CAPTURE CONTENTS near the bottom. To see what you captured, go the top toolbar and select the camera icon on the right. This pops up a small window. Each panel of the display will be in the camera buffer. We only need the sagittal display, so delete the axial and coronal views. Do this by displaying the thing-to-be-deleted in the camera window and click once on the stack with the small X. (The large X deletes all the images in the buffer.) Rename the remaining image “RPVs” and click save, then dismiss the camera display. 7. Repeat these measurements for the left PVs and save the measurements as before. It helps to delete the RPV measurements before doing the left measurements, as visual clutter is reduced. 2c-2. Volume-rendering (shaded surface) display This is used to generate a 3D “outside” display of the left atrium and PVs. You will take several screen shots and save an AVI movie of this step. First, go back to the VISUALIZATION pulldown and select VOLUME RENDERING VIEW. Second, go to VISUALIZATION again and select the VOLUME SOURCE option and pick the second item in the list. The mouse/cursor has multiple options, but the default is “roll” which is depicted by two curved arrows sort of resembling a Bohr atom diagram. Holding down the left mouse key in roll mode turns/tumbles the surface rendering along one axis. If you want to turn it along the other axis, release the left mouse key, then press and hold and move the mouse in the other axis on the desktop relative to what you were doing prior. 9/22/09 v8 Sometimes the rendering looks patchy or “ratty” with areas of dropout. You can improve this slightly by changing levels and opacity. Right click and under INTERACTION pick OPACITY LEVEL & WIDTH. This changes the cursor from the Bohr atom to an icon that looks like a graph. Hold down left mouse and drag cursor around until you get a display that you like (i.e. surface fills in better). Right mouse again to go back to INTERACTION and the “roll” mode. Now you will crop away all the parts that are not posterior left atrium and PVs. This means the aorta, left ventricle and other bits such as pulmonary vessels. This takes practice so don’t be too frustrated. Under VISUALIZATION pick the EDIT SEGMENTATION option. This pops up a little window with several icons on it. Generally speaking, there are “seed” options and “lasso” options. Each of these comes in “include” and “exclude” flavors. Placing an “exclude seed” on a structure causes it to turn red, meaning that it will be deleted from the final volume rendering. Note that anything contiguous to the spot you placed the seed will turn red. The exclude seed is usually only useful for the aorta. Try it. If you do not like the result you can always undo the step (a list of operations will appear in the window) by selecting the particular step and clicking on the pink “X” in the options bar. The exclude lasso option lets you click points to define a region. Once you close the contour by double clicking the inside of the contour turns red. To see what the final result is (without all the red parts), close the EDIT SEGMENTATION dialog box. When you reopen it the red parts will reappear and you can continue from the last step (i.e. you do NOT lose your prior work or the ability to edit the individual steps by closing the box). When everything is cropped as best you can, orient the rendering so that the “H” (for head) direction is pointing up and the “R” key is pointing right (the view is as if you are looking through the person from the rear. The final step is to make screen shots and the movie. You will make RPV and LPV screen shots. To make screen shots, rotate the display until it is oriented so as to best show the PVs of interest. Hit the PRINT SCREEN key (upper right) to grab the screen contents (sometimes it helps to zoom the display of the surface rendering before you do this). Then open Powerpoint and on the appropriate slide (see section 3b below), hit CONTROL-V to paste the buffer contents (i.e. the screen grab). Do this for the RPVs and LPVs. To make the movie, first select MOVIE PRESETS (4th icon from the bottom left) then pick 3D coro shake. Select STORE movie (last icon , bottom left), save as AVI and select the “Powerpoint compatible” option. Save the movie by clicking on “save”. You will find these movies in the “Movies” folder on the desktop. 2c-3. Endoluminal views From the PV MRA sense view select ANALYSIS and click on VOLUME ANALYSIS. Click on the middle panel. Select the icon with the staring face, click on the sausage shape with an arrow pointing towards its cavity. At this point you will obtain the endo 3D screen. Under CLASSIFICATION click on the blue dot, then on preset, and pick “endo:bright colon”. The pink reconstruction on the bottom left will need to be optimized. Right click, and under “interaction” select the “roll” icon. Roll until the “H” (for head) direction is pointing up and the “L” key is pointing towards you (the view is as If you are looking at the right PV ostia). Under “interaction”click on the zoom icon. Zoom in and “roll” until you find the ostia of the PV. Ideally, the ridges of the PV ostia should be very well visualized, and there shouldn’t be any “black” in the lumen of the 9/22/09 v8 veins. To make the movie, first select “generate a sequence” (movie icon bottom left). Under “stored protocols” select “Nod”. Name the sequence as RPV Nod. Click “generate”. Allow a few seconds for the movie to be generated. Press the PRINT SCREEN key (upper right on the key board) to grab the screen contents. Then open Powerpoint and on the appropriate slide (see section 3b below), hit CONTROL-V to paste the buffer contents (i.e. the screen grab). Return to the endo3D screen with the generated movie, click on OK, accept whatever the “close to” default is (selected view or first empty view). Under “stored protocols” now select “shake”. Name the sequence as RPV Shake. Click “generate”. You will find the movies at the end of ALL the series (to go back to the main screen where the image series are shown click on the “reset to default display protocol” icon (three folders connected by an arrow). To transfer the movies to the “movie folder” click on “Movie presets” (the movie icon) and select “save as AVI”. Repeat all the above steps for the left pulmonary veins. 9/22/09 v8 3a. Clinical Report – How to Generate 1. Open the “JRyan worksheet” Excel file on the desktop and fill in appropriate fields from your handwritten worksheet. (This worksheet is linked to the draft CMR reports. You may change the contents of fields, but do NOT change the structure or layout of the worksheet itself.) 2. Open the appropriate draft report from the “CMR Report Templates” folder on the desktop. If first local CMR study then select “Template Male (or Female) revised 08.” If there was a prior CMR study then select “Template Male2 revised 08” (or Female2). 3. When you open the draft report a dialog box will ask if you want to update links. Hit “yes” and wait for Word to do so. 4. Now immediately do a “save as” and title the file “MMDDYY Surname MRN indication” where MMDDYY are the month, date and 2-digit year of the scanning date, Surname is the patient’s last name and MRN is the 7-digit medical record number. E.g. “010208 Smith 1234567 HCM” 5. Under the EDIT pulldown select “Links” and a window will pop up. Select all the links and hit “Break Links.” 6. Go through the table and delete rows that are not relevant to the study, such as the pulmonary vein dimensions if PVs were not studied. You can select the rows, then go to TABLE pulldown and select DELETE then ROWS. 7. Go through the table with an eye to content.Values above or below reference limits should be marked as deviating in a mild (*), moderate (**) or severe (***) way. Place the asterisks to the LEFT of the numerical value. Use the printout “BIDMC CMR Quantitative Guidelines” as a reference and note that cutoff values are sex-specific. 8. Remove descriptive verbiage (below the tables) that is not relevant to the particular study at hand. 9. Of the remaining text, fields which may need to be changed or deleted are noted with one or more asterisks (e.g. “The coronary sinus dimension was *normal.”), modify these appropriately and remove the asterisks. 10. Generally leave the “additional findings” field unchanged in the draft (don’t delete), as the Radiology reader may have comments for you during the readout session. 11. The names of all physicians likely to be present are listed, after readout get rid of the people who weren’t actually there, and add the names of the MDs who showed up but are not listed. The Cardiology attending’s name should always be last. 12. Print a copy of your draft report, and write “DRAFT” or otherwise notate draft status and place in the purple folder to await readout. 13. After readout, incorporate the Cardiology and Radiology attending comments and email the draft to the Cardiology attending. (For Warren please print a hardcopy report, label as “draft” and place it, with/inside the entire purple folder, in his mailbox. 14. Cardiology attending will return email (or put in your mailbox if Warren) the corrected report. Go through it and “accept changes” as appropriate then save. 9/22/09 v8 3b. Electrophysiology Extras For prePVI studies, a slide show needs to be made prior to the PVI (i.e. if the PVI is the morning after you read the study, but official readout with an attending has not happened yet, you still need to make the slide show). There is a power point template on the desktop named “PVI template”. “Save as” your patient’s name before modifying this template. The slides will include: 1. “Screen grab” of a T1 weighted series (or if poor quality, a LGE view of the left atrium can also be used) at the level of the left atrium with the left lower pulmonary vein and esophagus in view. 2. “Screen grab” of volume rendering (3D reconstructions) of RPVs and LPVs (on separate slides) (described in section 2c-2). 3. “Screen grab” of endoluminal views of RPVs and LPVs (on separate slides) (described in section 2c-3). Each prePVI will have a specific folder (under “EP folders” on the desktop). This will need to contain DICOM data (transferred by Kraig or Beth from the control room by the scanner), the power point presentation described above, and the 3D coro shake and the nod/shake endoluminal views movies. You can transfer these movies from the “Movie” folder on the desktop. Because the final report is usually not available to the EP team when the PVI is scheduled the day after a prePVI CMR is performed, an e-mail with the number of PVs and cross-sectional area measurements should be sent to the EP fellow/attending involved in the case the day before the procedure. 3c. Sending CMR Reports to Transcription 1. Ensure that the cardiology attending has finalized the report. 2. Email to “CMRI Final Reports” in the BIDMC email system as an attachment. 3d. Sending CMR Reports to Referring MD 1. Ensure that the cardiology attending has finalized the report. 2. Email to referring MD if in BIDMC system or you have their email address. If not available, Iris can help send the report for you (e.g. by fax). 3e. Backing Up CMR Reports 1. Save a copy on the shared “S Drive.” There is a link to the appropriate folder on the desktop. It is called “Shortcut to 2009 CMR Clinical Reports.” 9/22/09 v8 4a. Archiving on PACS 1. In View Forum, select the yellow-tabbed “Viewing Worklist” display. This has three stacked windows called (top to bottom): Worklist, Examinations and Series. 2. Left-click (once) on the name of the person to archive in the Worklist window. This will automatically update the Examinations and Series windows. 3. Select only the images you generated in Viewforum. Kraig or Beth will have already sent the unprocessed images.. 4. Click left on the transfer icon (large and small computer screens linked together) in the SERIES window. A pop-up will appear. Make sure the From field has “DataBase on VF1” while the To field has “BIDMC_PACS_SECONDARY” and hit OKAY. 5. A “Status of background tasks” window will pop up. Check in on this to make sure the job was done (Status field reads “complete”). Sometimes it fails for unclear reasons, in which case try again. 4b. Sending to hard drive Under the WORKLIST screen, click once on the study to send. Then select the “copy” icon (large and small computer screens linked together) on the left hand side. A pop-up will appear. Make sure the From field has “DataBase on VF1” while the To field has “SHARED DATA FOLDER (as DICOM)”. Folder: G:\2009Clinical CMR\ScanDate_PatientName_MedicalRecord. Hit OKAY.