CMR Fingerprinting for Myocardial T1, T2, and ECV Quantification in Patients With Nonischemic Cardiomyopathy

The future of cardiovascular magnetic resonance: All-in-one vs. real-time (Part 1)

Cardiovascular magnetic resonance (CMR) protocols can be lengthy and complex, which has driven the research community to develop new technologies to make these protocols more efficient and patient-friendly. Two different approaches to improving CMR have been proposed, specifically "all-in-one" CMR, where several contrasts and/or motion states are acquired simultaneously, and "real-time" CMR, in which the examination is accelerated to avoid the need for breathholding and/or cardiac gating. The goal of this two-part manuscript is to describe these two different types of emerging rapid CMR. To this end, the vision of each is described, along with techniques which have been devised and tested along the pathway of clinical implementation. The pros and cons of the different methods are presented, and the remaining open needs of each are detailed. Part 1 will tackle the "all-in-one" approaches, and Part 2 the "real-time" approaches along with an overall summary of these emerging methods.

Cardiac MR Fingerprinting: Overview, Technical Developments, and Applications

Cardiovascular magnetic resonance (CMR) is an established imaging modality with proven utility in assessing cardiovascular diseases. The ability of CMR to characterize myocardial tissue using T1 - and T2 -weighted imaging, parametric mapping, and late gadolinium enhancement has allowed for the non-invasive identification of specific pathologies not previously possible with modalities like echocardiography. However, CMR examinations are lengthy and technically complex, requiring multiple pulse sequences and different anatomical planes to comprehensively assess myocardial structure, function, and tissue composition. To increase the overall impact of this modality, there is a need to simplify and shorten CMR exams to improve access and efficiency, while also providing reproducible quantitative measurements. Multiparametric MRI techniques that measure multiple tissue properties offer one potential solution to this problem. This review provides an in-depth look at one such multiparametric approach, cardiac magnetic resonance fingerprinting (MRF). The article is structured as follows. First, a brief review of single-parametric and (non-Fingerprinting) multiparametric CMR mapping techniques is presented. Second, a general overview of cardiac MRF is provided covering pulse sequence implementation, dictionary generation, fast k-space sampling methods, and pattern recognition. Third, recent technical advances in cardiac MRF are covered spanning a variety of topics, including simultaneous multislice and 3D sampling, motion correction algorithms, cine MRF, synthetic multicontrast imaging, extensions to measure additional clinically important tissue properties (proton density fat fraction, T2 *, and T1ρ ), and deep learning methods for image reconstruction and parameter estimation. The last section will discuss potential clinical applications, concluding with a perspective on how multiparametric techniques like MRF may enable streamlined CMR protocols. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 1.

Quantitative MRI in cardiometabolic disease: From conventional cardiac and liver tissue mapping techniques to multi-parametric approaches

Cardiometabolic disease refers to the spectrum of chronic conditions that include diabetes, hypertension, atheromatosis, non-alcoholic fatty liver disease, and their long-term impact on cardiovascular health. Histological studies have confirmed several modifications at the tissue level in cardiometabolic disease. Recently, quantitative MR methods have enabled non-invasive myocardial and liver tissue characterization. MR relaxation mapping techniques such as T₁, T_1ρ, T₂ and T₂* provide a pixel-by-pixel representation of the corresponding tissue specific relaxation times, which have been shown to correlate with fibrosis, altered tissue perfusion, oedema and iron levels. Proton density fat fraction mapping approaches allow measurement of lipid tissue in the organ of interest. Several studies have demonstrated their utility as early diagnostic biomarkers and their potential to bear prognostic implications. Conventionally, the quantification of these parameters by MRI relies on the acquisition of sequential scans, encoding and mapping only one parameter per scan. However, this methodology is time inefficient and suffers from the confounding effects of the relaxation parameters in each single map, limiting wider clinical and research applications. To address these limitations, several novel approaches have been proposed that encode multiple tissue parameters simultaneously, providing co-registered multiparametric information of the tissues of interest. This review aims to describe the multi-faceted myocardial and hepatic tissue alterations in cardiometabolic disease and to motivate the application of relaxometry and proton-density cardiac and liver tissue mapping techniques. Current approaches in myocardial and liver tissue characterization as well as latest technical developments in multiparametric quantitative MRI are included. Limitations and challenges of these novel approaches, and recommendations to facilitate clinical validation are also discussed.

Dynamic Cardiac Magnetic Resonance Fingerprinting During Vasoactive Breathing Maneuvers: First Results

BACKGROUND

Cardiac magnetic resonance fingerprinting (cMRF) enables simultaneous mapping of myocardial T1 and T2 with very short acquisition times. Breathing maneuvers have been utilized as a vasoactive stress test to dynamically characterize myocardial tissue in vivo. We tested the feasibility of sequential, rapid cMRF acquisitions during breathing maneuvers to quantify myocardial T1 and T2 changes.

METHODS

We measured T1 and T2 values using conventional T1 and T2-mapping techniques (modified look locker inversion [MOLLI] and T2-prepared balanced-steady state free precession), and a 15 heartbeat (15-hb) and rapid 5-hb cMRF sequence in a phantom and in 9 healthy volunteers. The cMRF_5-hb sequence was also used to dynamically assess T1 and T2 changes over the course of a vasoactive combined breathing maneuver.

RESULTS

In healthy volunteers, the mean myocardial T1 of the different mapping methodologies were: MOLLI 1,224 ± 81 ms, cMRF_15-hb 1,359 ± 97 ms, and cMRF_5-hb 1,357 ± 76 ms. The mean myocardial T2 measured with the conventional mapping technique was 41.7 ± 6.7 ms, while for cMRF_15-hb 29.6 ± 5.8 ms and cMRF_5-hb 30.5 ± 5.8 ms. T2 was reduced with vasoconstriction (post-hyperventilation compared to a baseline resting state) (30.15 ± 1.53 ms vs. 27.99 ± 2.07 ms, p = 0.02), while T1 did not change with hyperventilation. During the vasodilatory breath-hold, no significant change of myocardial T1 and T2 was observed.

CONCLUSIONS

cMRF_5-hb enables simultaneous mapping of myocardial T1 and T2, and may be used to track dynamic changes of myocardial T1 and T2 during vasoactive combined breathing maneuvers.

State of the Art: Quantitative Cardiac MRI in Cardiac Amyloidosis

Cardiac amyloidosis (CA) is characterized by amyloid infiltration in the myocardial extracellular space, causing heart failure. Patients with CA are currently underdiagnosed. Cardiac involvement is significantly associated with the prognosis and treatment decision-making for CA. Early identification and accurate stratification are the crucial first step in patient management. Comprehensive cardiac MRI-based evaluation of the cardiac structure, function, and myocardial tissue characterization assesses cardiac involvement by tracing disease processes. Emerging quantitative tissue characterization techniques have introduced new measures that can identify early staged CA and monitor disease progression or response after treatment. Quantitative cardiac MRI is becoming an instrumental tool in understanding CA, which leads to changes in individualized patient care. This review aimed to discuss the quantitative cardiac MRI-based assessment of CA using established and emerging techniques. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 3.

Clinical evaluation of the Multimapping technique for simultaneous myocardial T1 and T2 mapping

The Multimapping technique was recently proposed for simultaneous myocardial T₁ and T₂ mapping. In this study, we evaluate its correlation with clinical reference mapping techniques in patients with a range of cardiovascular diseases (CVDs) and compare image quality and inter- and intra-observer repeatability. Multimapping consists of an ECG-triggered, 2D single-shot bSSFP readout with inversion recovery and T₂ preparation modules, acquired across 10 cardiac cycles. The sequence was implemented at 1.5T and compared to clinical reference mapping techniques, modified Look-Locker inversion recovery (MOLLI) and T₂ prepared bSSFP with four echo times (T₂bSSFP), and compared in 47 patients with CVD (of which 44 were analyzed). In diseased myocardial segments (defined as the presence of late gadolinium enhancement), there was a high correlation between Multimapping and MOLLI for native myocardium T₁ (r² = 0.73), ECV (r² = 0.91), and blood T₁ (r² = 0.88), and Multimapping and T₂bSSFP for native myocardial T₂ (r² = 0.80). In healthy myocardial segments, a bias for native T₁ (Multimapping = 1,116 ± 21 ms, MOLLI = 1,002 ± 21, P < 0.001), post-contrast T₁ (Multimapping = 479 ± 31 ms, MOLLI = 426 ± 27 ms, 0.001), ECV (Multimapping = 21.5 ± 1.9%, MOLLI = 23.7 ± 2.3%, P = 0.001), and native T₂ (Multimapping = 48.0 ± 3.0 ms, T₂bSSFP = 53.9 ± 3.5 ms, P < 0.001) was observed. The image quality for Multimapping was scored as higher for all mapping techniques (native T₁, post-contrast T₁, ECV, and T₂bSSFP) compared to the clinical reference techniques. The inter- and intra-observer agreements were excellent (intraclass correlation coefficient, ICC > 0.9) for most measurements, except for inter-observer repeatability of Multimapping native T₁ (ICC = 0.87), post-contrast T₁ (ICC = 0.73), and T₂bSSFP native T₂ (ICC = 0.88). Multimapping shows high correlations with clinical reference mapping techniques for T₁, T₂, and ECV in a diverse cohort of patients with different cardiovascular diseases. Multimapping enables simultaneous T₁ and T₂ mapping and can be performed in a short breath-hold, with image quality superior to that of the clinical reference techniques.

A Self-Supervised Deep Learning Reconstruction for Shortening the Breathhold and Acquisition Window in Cardiac Magnetic Resonance Fingerprinting

The aim of this study is to shorten the breathhold and diastolic acquisition window in cardiac magnetic resonance fingerprinting (MRF) for simultaneous T1, T2, and proton spin density (M0) mapping to improve scan efficiency and reduce motion artifacts. To this end, a novel reconstruction was developed that combines low-rank subspace modeling with a deep image prior, termed DIP-MRF. A system of neural networks is used to generate spatial basis images and quantitative tissue property maps, with training performed using only the undersampled k-space measurements from the current scan. This approach avoids difficulties with obtaining in vivo MRF training data, as training is performed de novo for each acquisition. Calculation of the forward model during training is accelerated by using GRAPPA operator gridding to shift spiral k-space data to Cartesian grid points, and by using a neural network to rapidly generate fingerprints in place of a Bloch equation simulation. DIP-MRF was evaluated in simulations and at 1.5 T in a standardized phantom, 18 healthy subjects, and 10 patients with suspected cardiomyopathy. In addition to conventional mapping, two cardiac MRF sequences were acquired, one with a 15-heartbeat(HB) breathhold and 254 ms acquisition window, and one with a 5HB breathhold and 150 ms acquisition window. In simulations, DIP-MRF yielded decreased nRMSE compared to dictionary matching and a sparse and locally low rank (SLLR-MRF) reconstruction. Strong correlation (R2 &gt; 0.999) with T1 and T2 reference values was observed in the phantom using the 5HB/150 ms scan with DIP-MRF. DIP-MRF provided better suppression of noise and aliasing artifacts in vivo, especially for the 5HB/150 ms scan, and lower intersubject and intrasubject variability compared to dictionary matching and SLLR-MRF. Furthermore, it yielded a better agreement between myocardial T1 and T2 from 15HB/254 ms and 5HB/150 ms MRF scans, with a bias of −9 ms for T1 and 2 ms for T2. In summary, this study introduces an extension of the deep image prior framework for cardiac MRF tissue property mapping, which does not require pre-training with in vivo scans, and has the potential to reduce motion artifacts by enabling a shortened breathhold and acquisition window.

The role of artificial intelligence in paediatric cardiovascular magnetic resonance imaging

Artificial intelligence (AI) offers the potential to change many aspects of paediatric cardiac imaging. At present, there are only a few clinically validated examples of AI applications in this field. This review focuses on the use of AI in paediatric cardiovascular MRI, using examples from paediatric cardiovascular MRI, adult cardiovascular MRI and other radiologic experience.

Feasibility of MR fingerprinting using a high-performance 0.55 T MRI system

BACKGROUND

MR fingerprinting (MRF) is a versatile method for rapid multi-parametric quantification. The application of MRF for lower MRI field could enable multi-contrast imaging and improve exam efficiency on these systems. The purpose of this work is to demonstrate the feasibility of 3D whole-brain T1 and T2 mapping using MR fingerprinting on a contemporary 0.55 T MRI system.

MATERIALS AND METHODS

A 3D whole brain stack-of-spirals FISP MRF sequence was implemented for 0.55 T. Quantification was validated using the NIST/ISMRM Quantitative MRI phantom, and T1 and T2 values of white matter, gray matter, and cerebrospinal fluid were measured in 19 healthy subjects. To assess MRF performance in the lower SNR regime of 0.55 T, measurement precision was calculated from 100 simulated pseudo-replicas of in vivo data and within-session measurement repeatability was evaluated.

RESULTS

T1 and T2 values calculated by MRF were strongly correlated to standard measurements in the ISMRM/NIST MRI system phantom (R² > 0.99), with a small constant bias of approximately 5 ms in T2 values. 3D stack-of-spirals MRF was successfully applied for whole brain quantitative T1 and T2 at 0.55 T, with spatial resolution of 1.2 mm × 1.2 mm × 5 mm, and acquisition time of 8.5 min. Moreover, the T1 and T2 quantifications had precision <5%, despite the lower SNR of 0.55 T.

CONCLUSION

A 3D whole-brain stack-of-spirals FISP MRF sequence is feasible for T1 and T2 mapping at 0.55 T.

Cardiac magnetic resonance fingerprinting: Trends in technical development and potential clinical applications

Quantitative cardiac magnetic resonance has emerged in recent years as an approach for evaluating a range of cardiovascular conditions, with T1 and T2 mapping at the forefront of these developments. Cardiac Magnetic Resonance Fingerprinting (cMRF) provides a rapid and robust framework for simultaneous quantification of myocardial T1 and T2 in addition to other tissue properties. Since the advent of cMRF, a number of technical developments and clinical validation studies have been reported. This review provides an overview of cMRF, recent technical developments, healthy subject and patient studies, anticipated technical improvements, and potential clinical applications. Recent technical developments include slice profile and pulse efficiency corrections, improvements in image reconstruction, simultaneous multislice imaging, 3D whole-ventricle imaging, motion-resolved imaging, fat-water separation, and machine learning for rapid dictionary generation. Future technical developments in cMRF, such as B0 and B1 field mapping, acceleration of acquisition and reconstruction, imaging of patients with implanted devices, and quantification of additional tissue properties are also described. Potential clinical applications include characterization of infiltrative, inflammatory, and ischemic cardiomyopathies, tissue characterization in the left atrium and right ventricle, post-cardiac transplantation assessment, reduction of contrast material, pre-procedural planning for electrophysiology interventions, and imaging of patients with implanted devices.

Technical feasibility of magnetic resonance fingerprinting on a 1.5T MRI-linac

Hybrid MRI-linac (MRL) systems enable daily multiparametric quantitative MRI to assess tumor response to radiotherapy. Magnetic resonance fingerprinting (MRF) may provide time efficient means of rapid multiparametric quantitative MRI. The accuracy of MRF, however, relies on adequate control over system imperfections, such as eddy currents and [Formula: see text], which are different and not as well established on MRL systems compared to diagnostic systems. In this study we investigate the technical feasibility of gradient spoiled 2D MRF on a 1.5T MRL. We show with phantom experiments that the MRL generates reliable MRF signals that are temporally stable during the day and have good agreement with spin-echo reference measurements. Subsequent in-vivo MRF scans in healthy volunteers and a patient with a colorectal liver metastasis showed good image quality, where the quantitative values of selected organs corresponded with the values reported in literature. Therefore we conclude that gradient spoiled 2D MRF is feasible on a 1.5T MRL with similar performance as on a diagnostic system. The precision and accuracy of the parametric maps are sufficient for further investigation of the clinical utility of MRF for online quantitatively MRI-guided radiotherapy.