Cardiac MRI Fellowship Guide

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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
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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)
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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
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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.
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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
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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
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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]
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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
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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)
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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
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
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.
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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.
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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
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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.
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