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With mounting data on its accuracy and prognostic value, cardiovascular magnetic resonance (CMR) is becoming an increasingly important diagnostic tool with growing utility in clinical routine. Given its versatility and wide range of quantitative parameters, however, agreement on specific standards for the interpretation and post-processing of CMR studies is required to ensure consistent quality and reproducibility of CMR reports. This document addresses this need by providing consensus recommendations developed by the Task Force for Post-Processing of the Society for Cardiovascular Magnetic Resonance (SCMR). The aim of the Task Force is to recommend requirements and standards for image interpretation and post-processing enabling qualitative and quantitative evaluation of CMR images. Furthermore, pitfalls of CMR image analysis are discussed where appropriate. It is an update of the original recommendations published 2013.

This document is an update to the 2013 publication of the Society for Cardiovascular Magnetic Resonance (SCMR) Board of Trustees Task Force on Standardized Protocols. Concurrent with this publication, 3 additional task forces will publish documents that should be referred to in conjunction with the present document. The first is a document on the Clinical Indications for CMR, an update of the 2004 document. The second task force will be updating the document on Reporting published by that SCMR Task Force in 2010. The 3rd task force will be updating the 2013 document on Post-Processing. All protocols relative to congenital heart disease are covered in a separate document.The section on general principles and techniques has been expanded as more of the techniques common to CMR have been standardized. A section on imaging in patients with devices has been added as this is increasingly seen in day-to-day clinical practice. The authors hope that this document continues to standardize and simplify the patient-based approach to clinical CMR. It will be updated at regular intervals as the field of CMR advances.

Right ventricular (RV) fibrosis is increasingly recognized as the underlying pathological substrate in a variety of clinical conditions. We sought to employ cardiac magnetic resonance (CMR) techniques of strain imaging and longitudinal relaxation time (T1) mapping to better examine the relationship between RV function and structure. Our aim was to initially evaluate the feasibility of these techniques to evaluate the right ventricle. We then sought to explore the relationship between RV function and underlying fibrosis, along with examining the evolution of RV remodeling according to the amount of baseline fibrosis. Echocardiography was performed in 102 subjects with non-ischemic cardiomyopathy. Right ventricular parameters were assessed including: fractional area change (FAC) and longitudinal strain. The same cohort underwent CMR. Post-contrast T1 mapping was performed as a marker of fibrosis with a Look-Locker technique using inversion recovery imaging. Mid-ventricular post-contrast T1 values of the RV free wall, RV septum and lateral LV were calculated using prototype analysis software. Biventricular volumetric data including ejection fraction was measured by CMR using a cine short axis stack. CMR strain analysis was also performed to assess 2D RV longitudinal and radial strain. Simultaneous biochemical and anthropometric data were recorded. Subjects were followed over a median time of 29 months (IQR 20–37 months) with echocardiography to evaluate temporal change in RV FAC according to baseline post-contrast T1 values. Longitudinal data analysis was performed to adjust for patient loss during follow-up. Subjects (62% men, 51 ± 15 years) had mild to moderately impaired global RV systolic function (RVEF = 39 ± 15%; RVEDV = 187 ± 69 ml; RVESV = 119 ± 68 ml) and moderate left ventricular dysfunction at baseline (LVEF 30 ± 17%). Good correlation was observed between mean LV and RV post-contrast T1 values (r = 0.652, p

Background Breath-hold (BH) requirement remains the limiting factor on the spatio-temporal resolution and coverage of the cine balanced steady-state free precession (bSSFP) cardiovascular magnetic resonance (CMR) imaging. In this prospective two-center clinical trial, we validated the performance of a respiratory triggered (RT) bSSFP cine sequence for evaluation of biventricular function. Methods Our study included 23 asymptomatic healthy subjects and 60 consecutive patients from Institute A (n = 39) and Institute B (n = 21) referred for a clinically indicated CMR study. We implemented a RT sequence with a respiratory synchronized drive to steady state (SS) of bSSFP signal, before the commencement of image data acquisition with prospective cardiac arrhythmia rejection and retrospectively cardiac gated reconstruction in real-time. Left (LV) and right (RV) ventricular function and LV mass were evaluated by using RT-bSSFP and conventional BH-bSSFP sequences with one cardiac cycle for SS preparation keeping all the imaging parameters identical. The performance of the sequences was evaluated by using quantitative and semi-quantitative metrics. Results Global LV and RV functional parameters and LV mass obtained from the RT-bSSFP and BH-bSSFP sequences were in good agreement. Quantitative metrics designed to capture fluctuation in SS signal intensity showed no significant difference between sequences. In addition, blood-to-myocardial contrast was nearly identical between sequences. The combined clinical score for image quality was excellent or good for 100% of cases with the BH-bSSFP and 83% of cases with the RT-bSSFP sequence. The de facto image acquisition time for RT-bSSFP was statistically significantly longer than that for conventional BH-bSSFP (7.9 ± 3.4 min vs. 5.1 ± 2.6 min). Conclusions Cine RT-bSSFP is an alternative for evaluating global biventricular function with contrast and spatio-temporal resolutions that are similar to those attained by using the BH-bSSFP sequence, albeit with a modest time penalty and a small reduction in image quality.

To assess the utility of cardiac magnetic resonance (MR) imaging in the diagnosis of constrictive pericarditis (CP). This study was approved by the institutional review board, with a waiver of informed consent. A total of 42 consecutive patients (mean age, 55 ± 16 years; 3 women, 39 men) with CP treated with pericardiectomy who had undergone cardiac MR before surgery were evaluated retrospectively. An additional 21 patients were evaluated as a control group; of these, 10 consecutive patients received cardiac MR for reasons other than suspected pericardial disease, and 11 consecutive patients had a history of pericarditis but no clinical suspicion of pericardial constriction. MR imaging parameters were analyzed independently and with a decision tree algorithm for usefulness in the prediction of CP. Catheterization data were also reviewed when available. A model combining pericardial thickness and relative interventricular septal (IVS) excursion provided the best overall performance in prediction of CP (C statistic, 0.98, 100 % sensitivity, 90 % specificity). Several individual parameters also showed strong predictive value in the assessment of constriction, including relative IVS excursion (sensitivity, 93 %; specificity, 95 %), pericardial thickness (sensitivity, 83 %; specificity, 100 %), qualitative assessment of pathologic coupling (sensitivity, 88 %; specificity, 100 %), diastolic IVS bounce (sensitivity, 90 %; specificity, 85 %), left ventricle area change (sensitivity, 86 %; specificity, 100 %), and eccentricity index (sensitivity, 86 %; specificity, 90 %; all P

Mesenteric ischemia is a rare disease associated with high morbidity and mortality. Acute mesenteric ischemia is most commonly secondary to embolism followed by arterial thrombosis, nonocclusive ischemia, and less commonly venous thrombosis. Chronic mesenteric ischemia is almost always caused by atherosclerotic disease, with rare causes including fibromuscular dysplasia and vasculitis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Patients with mesenteric ischemia usually present with nonspecific abdominal symptoms and laboratory findings. This document evaluates and rates the appropriateness of imaging to evaluate patients with clinically suspected mesenteric ischemia. While catheter-based angiography has been considered the reference standard and enables diagnosis and treatment, advances in computed tomography have made it a first-line test in many patients because it is a fast, widely available, and noninvasive study. Abdominal radiographs and ultrasound have a limited role in diagnosing mesenteric ischemia but are commonly the first ordered tests in patients with abdominal pain and may diagnose more common pathologies.

Clinical palpation of a pulsating abdominal mass alerts the clinician to the presence of a possible abdominal aortic aneurysm (AAA). Generally an arterial aneurysm is defined as a localized arterial dilatation ≥50% greater than the normal diameter. Imaging studies are important in diagnosing the cause of a pulsatile abdominal mass and, if an AAA is found, in determining its size and involvement of abdominal branches. Ultrasound (US) is the initial imaging modality of choice when a pulsatile abdominal mass is present. Noncontrast computed tomography (CT) may be substituted in patients for whom US is not suitable. When aneurysms have reached the size threshold for intervention or are clinically symptomatic, contrast-enhanced multidetector CT angiography (CTA) is the best diagnostic and preintervention planning study, accurately delineating the location, size, and extent of aneurysm and the involvement of branch vessels. Magnetic resonance angiography (MRA) may be substituted if CT cannot be performed. Catheter arteriography has some utility in patients with significant contraindications to both CTA and MRA. The American College of Radiology Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

The purpose of these guidelines is to recommend appropriate imaging for patients with blunt chest trauma. These patients are most often imaged in the emergency room, and thus emergency radiologists play a substantial role in prompt, accurate diagnoses that, in turn, can lead to life-saving interventions. The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Imaging largely focuses on the detection and exclusion of traumatic aortic injury; a large proportion of patients are victims of motor vehicle accidents. For those patients who survive the injury and come to emergency radiology, rapid, appropriate assessment of patients who require surgery is paramount.

Perfusion and late gadolinium enhancement imaging sequences are commonly used in cardiac magnetic resonance imaging for the diagnosis of myocardial ischemia and infarction. The available literature has expanded from single-center studies to multiple multicenter studies that have established the clinical applicability of both imaging techniques in routine practice. In this article, these multicenter trials and their clinical implications are discussed, as well as the areas of interest that require further study.

The purpose of this study was to examine the relationship between noninvasive measurements of ventricular-vascular coupling (VVC) with exercise tolerance, and compared the value of VVC versus other traditional determinants of exercise capacity in this population. 43 patients with ischemic CMP (age 59 ± 9 years, mean EF 24 ± 8%) underwent cardiopulmonary exercise testing, echocardiography and cardiac magnetic resonance (CMR). VVC was defined non-invasively by the ratio of ventricular systolic elastance (Ees) to the arterial elastance (Ea), where Ees = end-systolic pressure/end-systolic volume index and Ea = end-systolic pressure/stroke volume index. VVC significantly correlated with baseline heart rate (HR), peak exercise systolic blood pressure, maximum oxygen consumption (MVO2) and peak O2 pulse (MVO2/HR). A higher VVC was associated with higher LVEF and RVEF but showed inverse relation to mitral E wave velocity. Univariate predictors of MVO2 are baseline HR, chronotropic reserve, VVC and aortic distensibility; whilst mitral E wave velocity, LVEF, VVC, Ees significantly correlated with peak O2 pulse. By stepwise multivariate analysis, VVC remained the only independent predictor of peak O2 pulse. Ventricular-vascular coupling at rest may be a clinically important parameter in predicting exercise capacity in patients with advanced heart failure, and may become an additional target for therapeutic interventions.

Background Mitral regurgitation (MR) is common in patients with ischemic cardiomyopathy (ICM) and independently associated with worse mortality. We sought to determine the impact of adverse LV remodeling, total myocardial infarct (MI) size, location and extent of regional MI, and mitral valve geometry on the severity of mitral regurgitation. Methods A total of 494 patients with LVEF ≤ 40% and ≥ 70% stenosis in ≥ 1 epicardial coronary artery and prior history of CABG or PCI were screened. Patients with transthoracic echocardiogram and CMR studies within 7 days were selected. Forty-two patients (9%) were excluded either due to prior mitral valve surgery, unavailable studies or organic mitral valve disease. Other 42 patients were excluded because of no mitral regurgitation noted on their study. Mitral regurgitation was assessed using semi-quantitative vena contracta method from a parasternal long axis zoomed view obtained of the mitral valve. LV volumes and EF were calculated from cine short axis CMR images. Mitral valve geometry was measured on end-systolic 2, 3, and 4 chamber cine views. LV scar was measured 10-15 minutes after gadolinium injection and using phase-sensitive inversion recovery sequence. Results The mean age of the cohort (n = 410) was 63 ± 11 years and males represented 75%. LVEF, LV end-systolic volume index, mean total infarct size, MV annulus index, MV tenting area index, and MV displacement index were: 23 ± 0.5%, 115 ± 2 ml/m2, 31 ± 17%, 1.7 ± 0.5 cm2/m2, 0.88 ± 0.48 cm2/m2, respectively. Mean inferior, lateral, anterior infarct size were: 27 ± 21%, 25 ± 20%, 37 ± 23%. MR was classified as: mild (63%), moderate (22%) or severe (15%). The mean vena contracta was 0.33 ± 0.24 cm. Multiple variable linear regression (R2 = 0.23) revealed that male gender, worsening GFR, increase extent of inferior LV scar, LV ESVi and MV tenting area index were independent predictors of MR severity, whereas overall scar extent, anterior or lateral location were not. (Figure 1). Conclusions Global LV remodeling, regional inferior myocardial scarring, and mitral valve geometry are more important predictors of worsening MR than total infarct size in patients with advanced ischemic cardiomyopathy. Funding None.

Background Tetralogy of Fallot (TOF) repair and pulmonary valvotomy for pulmonary stenosis (PS) lead to progressive pulmonary insufficiency (PI), right ventricular enlargement and dysfunction. This study assessed whether pulmonary regurgitant fraction measured by cardiovascular magnetic resonance (CMR) could be reduced with inhaled nitric oxide (iNO). Methods Patients with at least moderate PI by echocardiography undergoing clinically indicated CMR were prospectively enrolled. Patients with residual hemodynamic lesions were excluded. Ventricular volume and blood flow sequences were obtained at baseline and during administration of 40 ppm iNO. Results Sixteen patients (11 with repaired TOF and 5 with repaired PS) completed the protocol with adequate data for analysis. The median age [range] was 35 [19–46] years, BMI was 26 ± 5 kg/m2 (mean ± SD), 50% were women and 75% were in NYHA class I. Right ventricular end diastolic volume index for the cohort was 157 ± 33 mL/m2, end systolic volume index was 93 ± 20 mL/m2 and right ventricular ejection fraction was 40 ± 6%. Baseline pulmonary regurgitant volume was 45 ± 25 mL/beat and regurgitant fraction was 35 ± 16%. During administration of iNO, regurgitant volume was reduced by an average of 6 ± 9% (p=0.01) and regurgitant fraction was reduced by an average of 5 ± 8% (p=0.02). No significant changes were observed in ventricular indices for either the left or right ventricle. Conclusion iNO was successfully administered during CMR acquisition and appears to reduce regurgitant fraction in patients with at least moderate PI suggesting a potential role for selective pulmonary vasodilator therapy in these patients. Trials registration ClinicalTrials.gov, NCT00543933

Methods Velocity encoded MRI was performed in 80 HCM and 35 normal control subjects. PWV was determined between the mid ascending and descending thoracic aorta. Delayed enhancement MRI was acquired for identification of myocardial fibrosis. Quantitative analysis of the scar was performed using advanced software package (Philips, The Netherlands). LV mass was evaluated by drawing endocardial and epicardial contours in cine-SSFP images. Diastolic function and LVOT gradients were evaluated by echocardiography. Diastolic function was graded from 03 and LVOT gradient was significant if > 30 mm Hg.

These reporting guidelines are recommended by the Society for Cardiovascular Magnetic Resonance (SCMR) to provide a framework for healthcare delivery systems to disseminate cardiac and vascular imaging findings related to the performance of cardiovascular magnetic resonance (CMR) examinations.

Methods 349 patients (24% women) with severe ICM >/= 70% stenosis in >/= 1 epicardial vessel on angiography and mean LV ejection fraction (EF) 23%], that underwent DHE-MRI (Siemens 1.5 T scanner, Erlangen, Germany) from 2003– 6 were studied. DHE-MR images were obtained in standard long and short axis orientations (covering the entire LV), after injection of Gadolinium dimenglumine using an inversion recovery spoiled gradient echo sequence: TE 4 msec, TR 8 msec, flip angle 300, bandwidth 140 Hz/ pixel, 23 k-space lines acquired every other RR-interval, field of view (varied from 228–330 in the x-direction and 260–330 in the y-direction) and matrix size (varied from 140–180 in the x-direction and 256 in the y-direction). For DHE-MRI analysis, a custom analysis package (VPT software, Siemens, Erlangen, Germany) was used to manually delineate endocardial and epicardial myocardial edges. Scar was defined (as % of myocardium in a 17-segment model on custom software, Siemens Research) on DHE-MR images, as intensity > 2 standard deviation above viable myocardium. Transmurality score was recorded in all segments as follows: 0 = no scar, 1 = 1– 25% scar, 2 = 26–50%, 3 = 51–75% and 4 = > 75%. Global LV scar burden was calculated as transmurality score for all segments/17. LV volumes, EF, demographic/clinical data, history of cardiac transplantation and all-cause mortality were recorded.

Methods 349 patients with severe ICM >/= 70% coronary artery disease in >/= 1 epicardial vessel on angiography, mean LV ejection fraction (EF) of 24%] that underwent DHE-MRI (Siemens 1.5 T scanner, Erlangen, Germany) from 2003– 6 were studied. (Siemens, Erlangen, Germany) from 2005–6. DHE-MR images were obtained in standard long and short axis orientations (covering the entire LV), after injection of Gadolinium dimenglumine using an inversion recovery spoiled gradient echo sequence: TE 4 msec, TR 8 msec, flip angle 300, bandwidth 140 Hz/pixel, 23 kspace lines acquired every other RR-interval, field of view (varied from 228–330 in the x-direction and 260–330 in the y-direction) and matrix size (varied from 140–180 in the x-direction and 256 in the y-direction). For DHE-MRI analysis, a custom analysis package (VPT software, Siemens, Erlangen, Germany) was used to manually delineate endocardial and epicardial myocardial edges. Scar was defined (as % of myocardium in a 17-segment model on custom software, Siemens Research) on DHE-MR images, as intensity > 2 standard deviation above viable myocardium. Transmurality score was recorded in all segments as follows: 0 = no scar, 1 = 1–25% scar, 2 = 26–50%, 3 = 51– 75% and 4 = > 75%. Total scar score was calculated as transmurality score for all segments/17. LV volumes, EF, demographics, risk factors, need for cardiac transplantation (CTx) and all-cause mortality were recorded. Figure 1.