1% 22% 1% Lower Extremity 6% Prostate 14% Vascularmri/seminars/slides/Spring 2014/IU... · Handzettel 1 Restricted ... MAGNETOM Flash 2/2007 “MRI offers the most detailed anatomic

Handzettel 1

Answers for life. Restricted © Siemens AG 2014 All rights reserved.

March 22nd, 2014 Bruce Spottiswoode, Ph.D.

Advances in Cardiovascular MRI

Page 2

Restricted © Siemens AG 2014 All rights reserved.

Distribution of MR Studies?

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CMR: Gold Standard for a Niche Market

Brain

22%

Head/Neck

7%

Spine

25%

Prostate

1%

Vascular

6%

Upper Extremity

12%

Abdo/Pelvis

6%

Chest

3%Breast

3%

Lower Extremity

14%

Cardiac

1%

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CMR: Available on any scanner platform

*This feature is currently under development;

It is not for sale in the U.S. and all other countries. Its future availability cannot be guaranteed.

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Cardiac Dot Engine: AutoAlign Heart

• Guided Workflow

Consistent results

• Automated Workflow

Reduced exam time

• Personalization

Implement dedicated workflow

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CMR Reading and Reporting

dynamic

4D Ventricular Function

flow

wall motion

Handzettel 2

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Cardiac Flow

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Cardiac Perfusion*

• Visual Assessment of hypo enhanced regions

Motion Correction

Parameter maps

• Pixel wise analysis

• Guided workflow reduces evaluation time

*This feature is currently under development; it is not for sale in the U.S. and all other countries. Its future

availability cannot be guaranteed.

Page 9


Diagnostic Imaging and Therapy

*This feature is currently under development; it is not for sale in the U.S. and all other countries. Its future

availability cannot be guaranteed.

1Robert S. Oakes, Rob S. MacLeod et al. University of Utah; MAGNETOM Flash 2/2007

“MRI offers the most detailed anatomic and physiologic

information about normal and damaged myocardial tissue.” 1

Segmentation of left atrium,

based on MR angiography images

MR soft tissue

differentiation and catheter lab image guidance will be

delivered with

MAGNETOM Artis Combi Suite*

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Trends in Cardiovascular MR

T1/T2/T2*

QISS

Real Time Flow

Fat/Water

Self-gating

Long T1 Suppression

Non-CE MRA @ 3T

FIDDLE Edema Imaging

Motion Correction

Heart Deformation

4D Flow

Gated CE-MRA

Virtual Spectral Inversion

Inline DS

CMR

Quantify

Workflow

Outcome

Speed Robustness

Accuracy

Guidelines

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Quantitative Methods

• Motivation

• Potentially objective approach to diagnostic imaging

• Establishment of clinically relevant quantitative thresholds

• Potential Clinical Impact

• Imaging results independent from scanner, operator, vendor

• Easier assessment of non-focal cardiovascular diseases

• Reporting of quantitative results

• Challenges

• Accuracy and Precision

• Establishment of normal values difficult and expensive

• Clinical acceptance

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Variations in myocardial T1

Infarct

Amyloid

Myocarditis

Rheumatalogical

(water/protein) (metal/fat)

Iron

Gd

Fat (Fabry disease)

Pre-contrast: T1 is associated with edema or protein deposition.

T1 is associated with lipid or iron deposition.

Post-contrast: T1 corresponding to increased contrast agent concentration is associated with fibrotic

scar or diffuse fibrosis which has a greater extracellular volume than normal.

Handzettel 3

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Quantitative Methods: Mapping at SCMR 2014

T1 Mapping Working Group Anderson-Fabry Disease (P2)

Normal values (P3, P18, P23) Transplants (P100, P391, P394)

Amyloid (O4-5, P294, P322, P341) Cardioversion (P157)

HOCM (O61, P393) MI (P205, P211, P222)

Myocarditis (O6, O62-3, P287, 290) Regurgitation (P238)

Systemic Sclerosis (O64) Dilative Cardiomyopathy (P289)

Resistant Hypertension (O65) Cyanosis in CHD (P108)

Kidney Disease (O66) Muscular dystrophy (P296)

Intramyocardial Hemorrhage (O7) Iron (O86, O02, P309, P323)

Non-isch. Cardiomyopathy (O88) Diabetes (O144)

Edema (O16) Aortic Stenosis (M7)

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Quantitative Methods: T1 Mapping

0

10

20

30

40

50

60

70

1997 1999 2001 2003 2005 2007 2009 2011 2013

Jo

urn

al public

atio

ns o

n T

1 m

appin

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Courtesy: Dr. James Moon

The Heart Hospital London, UK

Downloads: 01/2014: >3200

Journal Publications on T1/ECV

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• T1 Mapping in Amyloid

Imaging Biomarker

Predictor for cardiac events

• Planned Trial: UK Biobank*

100,000 healthy volunteers

Native T1

• Planned Trial: HCMR**

2,750 HCM Patients

Native T1 and ECV

T1 Mapping: Imaging Biomarker

Courtesy: Dr. James Moon

SCMR 2014, O005

The Heart Hospital London, UK

*http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3668194/

**http://clinicaltrials.gov/show/NCT01915615

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Speed

• Motivation

• Shorter breath holds, higher temporal-spatial resolution

• Reduction of motion artifacts


• Shorter scan times

• Enabler for non-cooperative patients

• Pediatrics

• Challenges

• Sophisticated reconstruction approaches

• Identification of specific artifacts

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Robustness

• Motivation

• Consistent image quality for every patient condition

• Independent of operator


• Benchmarked diagnostic image quality across hospital system

• Shorter scan times, higher throughput

• Less re-calls of patients

• Challenges

• Engineering of robust sequences and reconstruction methods

• Clinical adoption of novel approaches

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Motion Correction – Already Clinical Routine?

Inline Time

Course Analysis

Doesch et al.; Invest Radiol-48(9):678

Handzettel 4

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Image Registration

“Finding a spatial transformation that relates positions in one image, to corresponding positions in one or more other images.”

http://biocomp.cnb.csic.es/~iarganda/bUnwarpJ/

Non-rigid

http://www.mathworks.com/matlabcentral/fileexchange/19086-

automatic-2d-rigid-body-image-registration

Rigid

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Nonrigid image registration: An engineering challenge

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Robustness: Introduction

Circ Cardiovasc Imaging. 2013 May 1;6(3):423-32 Page 22

Restricted © Siemens AG 2014 All rights reserved. *This product is currently under development; is not for sale in the U.S and other countries.

It‘s future availability cannot be guaranteed.

Motion Correction in T1 Mapping*

• Registration of original IR prepared images

• Challenge: Contrast inversions, zero crossing

• Solution:

Phase sensitive approach using

synthetic image estimation

Original Direct Registration Registration Using

synthetic estimates

0 200 400 600 800 1000 1200 1400 1600 1800 2000 2200

T1 (ms)

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Workflow

• Motivation

• Efficiency and Reliability

• Consistent quality of care


• Higher throughput

• Standards across hospital system

• Challenges

• Clinical adoption of workflow

• Consensus of approaches in community

• Implementation of guidelines into dedicated workflow

Page 24


Dedicated Protocol Trees

*This product is currently under development; is not for sale in the U.S and other countries. It‘s future availability cannot be guaranteed.

Acute Infarct

Adenosine Stress

Aortic Disease

Arrhythmogenic RV Myopathy

Chronic Ischemia

Coronary MRA

Mass & Thrombus

Nonischemic Myopathy

Pericardial Disease

LA and Pulmonary Veins

Valve Disease

*

Handzettel 5

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Guidelines and Outcome

• Motivation

• Efficient delivery of healthcare with impact

• Cost pressure

• Changes in healthcare systems worldwide

• Challenges

• Demographic trends

• Insecurity of changes in healthcare systems

• Value proposition of medical imaging

Page 26


Socio-economical costs of chronic diseases

Cumulative Costs

between 2011-2025

for chronic diseases

33%

18%

35%

10%

4% Lost output 2011-2030

by disease type Diabetes

4%

Chronic respiratory

diseases

10%

Mental health

35%

Cardiovascular

Diseases

33%

Cancer

18%

Breakdown of chronic disease cost, based on EPIC model

Trillion US $ (average of nearly US $500 billion per year) 7

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CMR: Market Trends

„

„

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EuroCMR Registry

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Summary

• Cardiovascular MRI

• Comprehensive cardiac assessment

• Niche market in MR

• Emerging Technologies: “Free breathing exam”

• Fast Imaging

• Motion Correction

• Quantitative Approaches

• Growth Opportunities

• Demonstrate cost efficiency and value proposition of CMR

• Standardization of imaging and workflow solutions

• Impact guidelines, appropriateness criteria and reimbursement

Page 30


Contact page

Bruce Spottiswoode, Ph.D.

Staff Scientist, US MR Research and Development

Siemens Healthcare USA, Inc.

737 North Michigan Ave Suite 1600

Chicago, IL 60611

Phone: +1 (312) 337-9287

E-mail: [email protected]

Documents

1% 22% 1% Lower Extremity 6% Prostate 14% Vascularmri/seminars/slides/Spring 2014/IU... · Handzettel 1 Restricted ... MAGNETOM Flash 2/2007 “MRI offers the most detailed anatomic