cardiac mri protocols by indications




HISTORY: []yo [M/F] with [indication]. Patient’s height and weight are []lbs and []in respectively.  Cr of [] and estimated GFR of [] on [date].


TECHNIQUE: EKG-gated cardiovascular MRI was performed on a 1.5/3.0T magnet [tailored for/utilizing x protocol]. A total of []cc of intravenous Gadolinium [Magnevist/Multihance] at [2-3]cc/s was given. 

Sequences include:
___ [plane] [T1/T2] [Double/Triple] IR FSE dark blood [with chemical FS]
___ [plane] T1 dual echo in/out of phase
___ Cine SSFP bright blood in [short and long axis]
___ 1st pass perfusion at rest with Gad [SR (saturation recovery) prepared SPGR] at rest [in short axis] with Gad
___ Stress perfusion with Gad during during 0.14mg/kg/min Adenosine IV infusion (with continuous monitoring) [SR (saturation recovery) prepared SPGR]
___ Low-dose Dobutamine stress cine SSFP imaging [in short and long axis] performed during []mcg/kg/min IV infusion including []mg Atropine IV (with continuous monitoring) for myocardial contractile reserve assessment
___ Delayed myocardial enhancement [10]min after Gad using TI of [175-225]ms in short/long axis [IR (inversion recovery) prepared SPGR]
___ [Thru-plane] Phase contrast imaging at [MPA and Aortic root] with VENC of [150 and 250cm/s respectively] along with water phantom correction of phase offset error 
___ 3D SSFP with FS for coronary arteries origins
___ Axial/coronal/candy-cane 2D SSFP imaging of thoracic aorta
___ Multiphase post-Gad 3D GRE FS MRA imaging of thoracic aorta [from aortic root to the level of renal arteries] using fluoro trigger
___ Dynamic real-time contrast-enhanced imaging with valsalva maneuver for PFO detection
___ Dynamic real-time imaging of interventricular septum

[Given patient’s estimated GFR of [], a written informed consent was obtained before Gad administration]. Images were post-processed and analyzed [(including flow measurements)] on a dedicated, stand-alone cardiac MR workstation by physician.

STRESS PROTOCOL:  12-lead EKG before and after the MR exam demonstrates [no arrhythmia or ischemic changes].

Adenosine: 140mcg/kg/min IV infusion for a total of [4-6min] with [0.05-0.075mmol/kg IV at 4cc/s] Gad injection performed at [2-4min] for stress perfusion imaging in short axis.  Patient’s vitals were monitored during and after the infusion with [no symptoms or adverse affects].   Rest imaging in short axis was subsequently performed after [10-15min delay] with additional [0.05-0.075mmol/kg IV at 4cc/s] Gad injection.     

Dobutamine: low dose Dobutamine infusion performed for a total of [20]mcg/kg/min IV.  3 short axis and a single 4chamber cine SSFP imaging was performed at rest and during Dobutamine stress at every 3min dose increment for contractile reserve assessment.  Patient’s vitals were monitored during and after the infusion with [no symptoms or adverse affects].  []mg Atropine IV was given for HR response.  Patient achieved []% of age-predicted max HR with resting BP of [] and max BP of [].

FINDINGS:  [Exam Quality/Limitations].

Ventricular Function and Volume:
Left ventricular EF of []%, EDV of []cc, ESV of []cc, SV of []cc/beat, and CO of []L/min. 
Right ventricular EF of []%, EDV of []cc, and ESV of []cc.
Index values are normalized to a BSA of []m2.

Chamber Morphology: 
LV chamber dimension of []cm in ED.  LV myocardial mass of []g or []g/m2.  LV ED anteroseptal wall thickness of []cm and inferolateral wall thickness of []cm.   [No LV dilation or hypertrophy.] 

RV chamber major and minor dimensions of []cm and []cm respectively [with RV free wall thickness of Xcm].  [RV is normal is size.]
LA AP dimension of []cm.  [No LA or RA enlargement]. [No left atrial appendage clot].    

Wall motion: Qualitative assessment of LV regional wall motion using AHA 17-segment model demonstrated [no regional LV wall motion abnormality]. []wall (segments []) [hypokinesis/akinesis/dyskinesis/tardykinesis/paradoxical motion] [with associated wall thinning to Xcm measured on end-diastole].  [RV wall motion is grossly normal.]

Stress and Rest Perfusion: Pharmacological stress was performed with 0.14mg/kg [Adenosine] IV infusion over [4-6]min.  [0.05-0.075]mmol/kg Gad was injected IV at rate of []cc/s before rest and stress imaging for a total of []cc.

[]wall stress perfusion defect with normal rest perfusion and no delayed enhancement consistent with ischemia.
[]wall stress and rest perf defect which is [similar in size][larger than] delayed enhancement consistent with [infarct][peri-infarct ischemia].
[]wall stress and rest perf defect without delayed enhancement most likely represents artifact. 

Rest Perfusion and Myocardial Viability (Delayed Enhancement):  [0.2mmol/kg] Gad was given IV at []cc/s in two equal doses.  First pass myocardial perfusion was performed at rest only, followed by [10]min delayed enhancement in [short and long] axis.

Perfusion imaging shows [subendocardial/transmural] []wall defect which [does/does not persist].
Delayed enhancement imaging shows [subendocardial/mid-wall/subepicardial/patchy/transmural] []wall enhancement with [<25%/btwn 25-50%/ btwn 50-75%/>75%/full 100%] myocardial extent [and correlates with rest perfusion abnormality].  This represents infarct corresponding to []coronary artery territory. [The pattern of delayed enhancement is not consistent with infarct].  No evidence for no-reflow zone or microvascular obstruction within the infarct].  Using qualitative assessment, LV infarct was determined to be approximately []g or []% of total myocardium.

Valvular function/Shunt evaluation: Thru-plane flow measurements were performed at MPA distal to pulmonic valve and sinotubular jct of aorta using VENC of [250-550cm/s].  Also, phase contrast imaging was performed perpendicular to []valve [regurgitant/stenotic] flow jet.  SSFP planimetry performed for []valve area measurement. Velocity offset error correction was performed with water phantom.
Pulmonary to systemic flow ratio (Qp:Qs) is [] which is [normal].
[valve] regurgitant [jet is seen] with forward flow of []cc/beat and regurgitant fraction of []%. 
[valve] stenotic [jet is seen] with valve area of []cm2 [by planimetry/by continuity equation], peak velocity of []m/s, and peak transvalvular gradient is calculated to be []mmHg.   
[Early E and Late A peak velocities of atrioventricular valve].
[No bicuspid aortic valve].  [No mitral valve prolapse].  [No reduced valvular excursion].

Cardiomyopathy evaluation: [No] cardiomegaly.  [No] global or septal hypertrophy.  [No] LVOT narrowing or SAM of mitral valve.  [Ischemic][non-ischemic] pattern of delayed myocardial enhancement.  [No] regional or global WM abnl.  Peak ejection and peak filling rate of [] and []cc/min respectively. [No] systolic or diastolic dysfunction. 

Coronary origins: 3D imaging of only the proximal segments of the coronary arteries was performed without Gad.  [No anomalous origins of left and right coronary arteries].  This exam is not tailored for stenosis evaluation. 

Thoracic aorta: [multiphase 3D GRE MRA of thoracic aorta to the level of renal arteries was performed with Gad].  Aortic annulus measures []cm, aortic root or SOV measures []cm , sinotubular junction measures []cm, ascending aorta at level of right PA measures []cm, prox transverse aortic arch (btwn innominate and left CCA) measures []cm, distal transverse aortic arch (btwn left CCA and subclavian artery) measures []cm, and descending aorta at level of RPA measures []cm, descending aorta at diaphragm measures []cm.  [No aortic aneurysm or dissection or intramural hematoma].  [Arch vessel origins are also normal].  

Pericardium: [No pericardial thickening or effusion].  [No septal bounce and/or inspiratory flattening/inversion of the interventricular septum during real-time cine imaging].

Mass/Thrombus: Selected [T1/T2] black blood imaging with and without fatsat was obtained thru the lesion. Also, dedicated early and [5-10min] delayed enhancement imaging was performed using longer TI of [500ms].

[size][smooth/irreg/infiltrative margins][pedunculated], [location][multifocal][relationship to chamber/valve/septum]. 
[homogenous/heterogenous][signal compared to myocardium][fatsat].
[perfusion pattern][late Gad enhancement pattern][hyper/hypovascular][central necrosis][motion on cine][prolapse].
[transvenous extension from IVC].

ARVD or RV Cardiomyopathy evaluation: RVEF of []%.  [No global or focal] RV wall thinning or dilation.  [No] localized RV aneurysm. [No global or regional] RV wall motion abnl (akinesis/dyskinesis).  [No/mild/extensive] fatty infiltration of RV [subtricuspid/RVOT/apex/free wall].  [There is normal epicardial fat along RV free wall].  [No] delayed enhancement of RV to suggest fibrosis. [No MR evidence for ARVD or Right Ventricular Cardiomyopathy.] [MRI features are present that have been assoc w/ ARVD or Right Ventricular Cardiomyopathy.] [MRI features are diagnostic of/suspicious for ARVD or Right Ventricular Cardiomyopathy.] [Normal MR does not exclude ARVC].

Peripheral MRA: [stenosis severity should be reported in 25% increments].

PFO: Dynamic contrast-enhanced real-time imaging with valsalva maneuver x3 shows no patent PFO.  Qp:Qs=1.

Misc:  [MPA measures Xcm].  [No LV thrombus].  [No extracardial abnl].

1.  [answer clinical question].
2.  FUNCTION [Normal LV and RV systolic function and volume.] 
3.  ISCHEMIA []   
4.  VIABILITY []  [extent] [wall] infarct with associated [wall motion abnormality] and [myocardial thinning].