Myocardial tagging by Cardiovascular Magnetic Resonance: evolution of techniques--pulse sequences, analysis algorithms, and applications

Cardiovascular magnetic resonance (CMR) tagging has been established as an essential technique for measuring regional myocardial function. It allows quantification of local intramyocardial motion measures, e.g. strain and strain rate. The invention of CMR tagging came in the late eighties, where the technique allowed for the first time for visualizing transmural myocardial movement without having to implant physical markers. This new idea opened the door for a series of developments and improvements that continue up to the present time. Different tagging techniques are currently available that are more extensive, improved, and sophisticated than they were twenty years ago. Each of these techniques has different versions for improved resolution, signal-to-noise ratio (SNR), scan time, anatomical coverage, three-dimensional capability, and image quality. The tagging techniques covered in this article can be broadly divided into two main categories: 1) Basic techniques, which include magnetization saturation, spatial modulation of magnetization (SPAMM), delay alternating with nutations for tailored excitation (DANTE), and complementary SPAMM (CSPAMM); and 2) Advanced techniques, which include harmonic phase (HARP), displacement encoding with stimulated echoes (DENSE), and strain encoding (SENC). Although most of these techniques were developed by separate groups and evolved from different backgrounds, they are in fact closely related to each other, and they can be interpreted from more than one perspective. Some of these techniques even followed parallel paths of developments, as illustrated in the article. As each technique has its own advantages, some efforts have been made to combine different techniques together for improved image quality or composite information acquisition. In this review, different developments in pulse sequences and related image processing techniques are described along with the necessities that led to their invention, which makes this article easy to read and the covered techniques easy to follow. Major studies that applied CMR tagging for studying myocardial mechanics are also summarized. Finally, the current article includes a plethora of ideas and techniques with over 300 references that motivate the reader to think about the future of CMR tagging

Automatic segmentation in CMR - Development and validation of algorithms for left ventricular function, myocardium at risk and myocardial infarction

In this thesis four new algorithms are presented for automatic segmentation in cardiovascular magnetic resonance (CMR); automatic segmentation of the left ventricle, myocardial infarction, and myocardium at risk in two different image types. All four algorithms were implemented in freely available software for image analysis and were validated against reference delineations with a low bias and high regional agreement. CMR is the most accurate and reproducible method for assessment of left ventricular mass and volumes and reference standard for assessment of myocardial infarction. CMR is also validated against single photon emission computed tomography (SPECT) for assessment of myocardium at risk up to one week after acute myocardial infarction. However, the clinical standard for quantification of left ventricular mass and volumes is manual delineation which has been shown to have a large bias between observers from different sites and for myocardium at risk and myocardial infarction there is no clinical standard due to varying results shown for the previously suggested threshold methods. The new automatic algorithms were all based on intensity classification by Expectation Maximization (EM) and incorporation of a priori information specific for each application. Validation was performed in large cohorts of patients with regards to bias in clinical parameters and regional agreement as Dice Similarity Coefficient (DSC). Further, images with reference delineation of the left ventricle were made available for future benchmarking of left ventricular segmentation, and the new automatic algorithms for segmentation of myocardium at risk and myocardial infarction were directly compared to the previously suggested intensity threshold methods. Combining intensity classification by EM with a priori information as in the new automatic algorithms was shown superior to previous methods and specifically to the previously suggested threshold methods for myocardium at risk and myocardial infarction. Added value of using a priori information and intensity correction was shown significant measured by DSC even though not significant for bias. For the previously suggested methods of infarct quantification a poorer result was found in the new multi-center, multi-vendor patient data than in the original validation in animal studies or single center patient studies. Thus, the results in this thesis also show the importance ofusing both bias and DSC for validation and performing validation in images of representative quality as in multi-center, multi-vendor patient studies