How-I-do-it

Cardiac Dot Engine:

Significant Time Reduction at
Cardiac Magnetic Resonance Imaging
Jesús Ciro Pueyo, M.D., Ph.D.1; Paula García-Barquín, M.D.1; Laura Romina Zalazar, M.D.1;
José Miguel Madrid, M.D.1; Jon Etxano, M.D.1; Efrén Ojeda, M.Sc.2; Óscar Fernández3

1
Department of Radiology, Clínica Universidad de Navarra, Pamplona, Spain
2
Siemens Healthcare, Erlangen, Germany
3
Siemens Healthcare Getafe (Madrid), Spain

Introduction However, CMR is not without certain The system guides you through
limitations. Firstly, it requires skilled a series of graphical illustrations
Cardiac Magnetic Resonance (CMR)
personnel with a good knowledge of selecting some anatomical reference
has rapidly developed and is now
cardiac anatomy and cardiac planes. points on the heart. The software
the technique of choice in the study
Secondly, the scan times for CMR then performs an automatic planning
of multiple heart diseases and an
studies are substantially longer than of the different cardiac planes with-
important tool for planning revascu-
for other types of study (with up to out the need for user intervention.
larization strategies in patients with
more than an hour on stress heart It also allows you to obtain super-
coronary artery disease [1]. It allows
exams) and remain a limiting factor imposable slices in all sequences of
the assessment of cardiac morphol-
in the recruitment of patients suffer- the study, increasing confidence in
ogy and function. Therefore, it pro-
ing from claustrophobia. our diagnoses [3].
vides important information about
tissue characterization by detecting In order to reduce CMR scan times,
the first steps of the ischemic cas- the Cardiac Dot Engine has been Clinical experience
cade through perfusion sequences. developed. It is a new software Our experience with the Dot software
An appropriate assessment of myo- technology from Siemens Healthcare, began in June 2013. To date, we have
cardial viability can be performed which offers a review of CMR fully performed in our center over 272 CMR
with delayed enhancement guided and suited to the needs of studies of which 60% are stress studies
sequences [2]. the patient. after administration of adenosine. All

1A 1B

1 Automatic planning of the different cardiac axis with Cardiac Dot Engine.

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studies have been performed under Table 1

medical supervision and have been
reproducible and high-quality diagnos- Conventional CMR Stress CMR
tic scans. During this time, we have
observed a significant reduction of Localizer Localizer

the average scan time. HASTE HASTE

We therefore proposed the following AAHeart-Scout AAHeart-Scout

study to assess the time saved by using Function 4-chamber Function 4-chamber
the Cardiac Dot Engine in both conven-
Dynamic rest Dynamic stress adenosine
tional and stress studies, compared to (Gadovist® 0.1 mmol/kg, 4 ml/s) (Gadovist® 0.1 mmol/kg, 4 ml/s)
standard cardiac scans.
Function 2 + 3-chamber Function 2 + 3-chamber

Materials and methods Function short-axis Function short-axis

Study design and patients Delayed enhancement Delayed enhancement

We have retrospectively reviewed Dynamic rest

a total of 194 patients consecutively (Gadovist® 0.1 mmol/kg, 4 ml/s)
between October 2012 and March
2014 with CMR studies performed Specifications of both study protocols (stress and conventional CMR) performed at our
at our Siemens 1.5T system Siemens 1.5T MAGNETOM Aera XQ.
(MAGNETOM Aera XQ) with an
18-channel body matrix coil.
2A 2B
For the correct categorization of
the study we took into account some
variables:
• First, the type of study of stress or
conventional CMR. The technical
specifications of both protocol
studies are summarized in Table 1.
• Second, the use of Short Tau
Inversion Recovery (STIR) sequences.
We usually use this sequence for
patients with suspected acute
MR images show positive findings on stress study in a 53-year-old man with
disease or suspicion of infiltrative 2
chest pain. The inferolateral wall stress-induced perfusion shows a defect (2A)
heart disease.
that corresponds with a stenosis involving the left circumflex artery (LCX),
• Third, the use of the Cardiac Dot disappearing in the dynamic perfusion study (2B).These findings were
confirmed on subsequent invasive angiography with successful coronary
Engine or conventional software.
stenting of the stenosis.
Depending on the different variables,
we obtained eight groups comparing
the average scan time with the Results significant decrease of the examina-
Cardiac Dot Engine and without it tion time has been observed
(conventional software). The image quality of all studies with a reduction of 19.7 minutes
obtained a result between 9 and 10. (t = 45.11 min +/- 14.7) using the
The total examination time comprises
the time from the beginning until the For conventional CMR studies Cardiac Dot Engine compared to
end of each scan. with STIR sequences (58 patients) (t = 64.9 min +/- 7.8) examination
statistically significant differences times using conventional software
The image quality of the studies in the average examination time (P = .001).
has been assessed by a radiologist using the Cardiac Dot Engine
with over 20 years of experience Furthermore, for CMR studies
(t = 39.1 min +/- 12.1) have been without STIR sequences (31 patients)
on a 10-point scale (1 = poor to observed, reducing the average
10 = excellent). a significant mean reduction of the
examination time by 26.5 minutes examination time of 15.5 minutes
The statistical analysis has been compared to examination times has been found, which has been
performed using a Student’s T-test using conventional software also statistically significant
for independent samples to compare (t = 65.6 min +/- 14.1) (P = .003). (t = 57.7 min +/- 14.7) compared to
means. SPSS Statistics software 20.0 For stress CMR studies with STIR (t = 42.2 min +/- 16.1) (P= .001).
(IBM corporation, Armonk, NY, USA) sequences (27 patients) a statistically
has been used.

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Stress CMR studies without STIR

sequences (78 patients) have also Table 2
shown mean examination times of
(t = 44.6 min +/- 16.8) using the
Time reduction in cardiac magnetic resonance
Cardiac Dot Engine compared to
(t = 65.1 min +/- 22.3) using the con- Dot
ventional software, which means a Non-Dot
time reduction of 20.4 min (P = .002) 70
(Table 2).
60
Discussion and limitations
Our study is not without limitations. 50

First of all, it is a retrospective study,

which has inherent disadvantages. 40

There are also independent variables

that may alter the average examina- 30
tion time. For example, at the time
Exam time (minutes)

of infusion of adenosine, as a rule,

there is a cardiologist present. The 20

mean arrival time of the cardiologist

is (t = 4.8 min +/- 7.1), which intro- 10
duces a considerable delay.
There may also be glitches that 0
force the study to be repeated, CMR STIR CMR-S STIR CMR non-STIR CMR-S non-STIR
although this is very rare. This
process, however, rarely extends CMR
beyond 5 minutes.
Another factor that may have 3A 3B
extended the examination times
at the beginning of this study is
the universal training of all MRI
personnel. It has been observed
that during the initial learning
phase, after the introduction of
the Cardiac Dot Engine, the average
examination times have been longer
than afterwards. However, once
the basic handling of the Dot Engine
has been learned, the Cardiac Dot 3C 3D
Engine has a fast learning curve
without requirement of highly
specialized technologists.

Conclusion
The Cardiac Dot Engine introduces
patient benefit by providing
systematically reproducible and
efficient studies that consistently
reduce examination time, resulting
in increased efficiency, reduced costs
and improved patient satisfaction
without ever sacrificing high-quality 3 Short axis (3A, B) and four-chamber-view (3C, D) demonstrates hypertrophic
changes as well as delayed contrast enhancement in the apex in a 43-year-old
diagnostic images.
man with hypertrophic cardiomyopathy.

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4A 4B Acknowledgements
The authors would like to thank
all the members of the Cardiac MRI
team from the Clínica Universidad
de Navarra (CUN) and the MRI nurses
for their valuable participation,
helpfulness and support during the
study, and also a very important
acknowledgment to our colleagues
from Siemens Healthcare, especially
Efrén Ojeda, for his continuous
support and contribution.
4C 4D

References
1 McMurray JJ, Adamopoulos S, Anker SD,
Auricchio A, Böhm M, Dickstein K et al.
ESC guidelines for the diagnosis and
treatment of acute and chronic heart
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Aug;14(8):803-69.
2 Montalescot G, Sechtem U, Achenbach
S, Andreotti F, Arden C, Budaj A et al.
2013 ESC guidelines on the
management of stable coronary artery
Delayed enhancement in the short axis (4A, B) and four-chamber-view (4C, D) disease: the Task Force on the
4
reveals the presence of a diffuse patchy enhancement pattern, very suggestive management of stable coronary artery
of cardiac amyloidosis in a patient with congestive heart failure. A cardiac disease of the European Society of
biopsy confirmed the diagnosis. Cardiology. Eur Heart J. 2013
Oct;34(38):2949-3003.
3 Moenninghoff C, Umutlu L, Kloeters C,
5A 5B Ringelstein A, Ladd ME, Sombetzki A
et al. Workflow efficiency of two
1.5 T MR scanners with and without
an automated user interface for head
examinations. Acad Radiol. 2013
Jun;20(6):721-30.

5C 5D

Contact
Jesús Ciro Pueyo, M.D., Ph.D.
Department of Radiology
Clínica Universidad de Navarra
Av. Pio XII, 36
5 (5A, B) Short axis and (5C, D) two-chamber-view of delayed enhancement
sequences. Arrows point to the septal wall of this patient, showing a severe
31008 Pamplona
subendocardial hyperenhancement that represents the region of myocardial Spain
infarction in the territory of left anterior descending (LAD) and the left Phone: +34 948255400
circumflex artery (LCX). Fax: +34 948296500
[email protected]

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