Patient Specific. Protocol Identification Number (PID) Must be on each individual. MRI Image

Transcription

1 MRI PROCEDURE GUIDELINES Patient Specific Protocol Identification Number (PID) Must be on each individual MRI Image [Protocol 11/04/13, Version 1.4] (Revised 09/03/2014) Page 1 of 72

2 Abbreviations: BH: Breath hold CMRI: Cardiovascular magnetic resonance imaging ECG: Electrocardiography GRE: Gradient recalled echo LAO: Left anterior oblique IR: Inversion recovery NBH: Non breath hold PSIR: Phase sensitive inversion recovery SSFP: Steady state free precession TSE: Turbo spin echo VLA: Ventricular long axis HLA: Horizontal long axis Revision history: 1.0 Original document 1.1 Added fast cine SAX, T2 maps 1.2 Added T1 and T2 mapping instructions for Philips scanners 1.3 Added additional scanning details 1.4 Updated imaging parameters and sequence descriptions Page 2 of 72

3 Change log for Protocol Version 1.4 Please take a moment to note the following changes in this protocol version. For imaging parameter changes, we advise that your protocol card / scanner protocol be revised and resaved so images are correctly acquired with your next study participant. A. Study Image and Transfer Moved information regarding study image and transfer to Page 4; Clarifications noted on where to enter study ID number (PID) and Acrostic into patient registration page for MRI B. Ref D DB_HEART_FAT On Page 14, the slice gap was changed from 10mm to 3 mm. Please verify this imaging parameter is corrected in your protocols. The slice thickness (7mm) + slice gap (3mm) should equal 10mm between slices. C. Ref L SAX_5SL_REF In the notes for prescription on Page 25, the details have been revised so consistent throughout protocol. Please prescribe Ref L using the HLA_CINE at end-systole. D. Ref U SAX_CINE_STACK_(LV_and_LA) In the notes for prescription on Page 46, detail has been added as to when the BP and HR should be acquired. Please measure the BP and HR when at a slice near the mid-cavity of the left ventricle. In the imaging parameters on Page 47, the slice thickness was incorrect. Please revise protocol to have slice thickness = 8mm, slice gap = 2 mm for a total of 10mm between slices. E. Ref Z AX_*_AORTA_2D_PhCon On Page 64, the GE imaging parameter of views per segment (VPS) has been revised from 6 to 2. Please ensure your protocol settings now have VPS = 2 if using GE scanner. Page 3 of 72

4 Study image and completion form transfer note to MRI Technologist: CCCWFU CCOP Research Base # Immediately upon completion of the study, technologists should submit images to the MRI Reading Center at Wake Forest via the CTP PREVENT node on the scanner. In essence, you will transfer images to the PC that has been sited at you location for the purpose of this study. From that PC, participants images will be automatically encrypted and transmitted to the MRI core lab for further analysis. The encryption schema used is https, the standard for secure website transactions, used by banks and e-commerce worldwide. Additionally, technologists should burn a CD to give to the PREVENT CCOP Study Coordinator. Data should also be stored on the local PACS system. MRI technologists should fill-out the MRI completion form and give to the PREVENT Study Coordinator for transmission to the MRI Reading Center. For sites that did not receive a computer for image transfer: Please burn an extra CD* and give to the CCOP Coordinator to mail to Wake Forest MRI Reading Center: Dr. Greg Hundley Wake Forest Health Sciences Medical Center Blvd. Winston Salem, NC *Please place the following information in the Patient Registration Window before the exam begins: - Place with the study ID number (PID) in the Referring Physician Field - Place the acrostic in the Requesting Physician Field. - These should be given to you by the Study Coordinator. Page 4 of 72

5 Please Name the Sequences According to the Guidelines Below: CCCWFU CCOP Research Base # Please name the sequences on the scanner according to the left column. The right column is for your information. NAME _3_PLANE_SCOUT ABD_LOC DB HEART FAT VLA_SCOUT HLA_SCOUT SAX_SCOUT LAO_SCOUT_BH LAO_SCOUT_FB VLA_CINE HLA_CINE SAX_5SL_REF GRID_TAG_SAX_* TAG_SAX_MID_90_DEG TAG_SAX_MID_0_DEG *_SAX_T1_MAP_PRE *_SAX_DB_T2W *_SAX_T2_MAP DEFINITION (three plane scout) (Abdominal localizer) (axial stack of heart using HASTE / SS-FSE/ SS-TSE) (white-blood vertical or pseudovertical long axis scout, 2 chamber) (white-blood horizontal long axis scout, 4 chamber) (white-blood short axis scout) (left anterior oblique scout aka aorta candy cane shot, breath-held) (left anterior oblique scout aka aorta candy cane shot, free-breathing) (white-blood vertical long axis cine, 2 chamber) (White-blood horizontal long axis cine, 4 chamber) (short axis 5 slice reference planned at end-systole on HLA_CINE) (SAX grid tags at *[BASE, MID, APEX]) (horizontal line tags at MID SAX) (vertical line tags at MID SAX) (pre-contrast T1 map at *[BASE, MID, APEX]) (pre- contrast T2-weighted image at *[BASE, MID, APEX]) (pre-contrast T2 map at *[BASE, MID, APEX]) DB_T2_AX_THORACIC_AO_Wall_Thk (T2-weighted scan of aortic wall thickness in the ascending and descending aorta, planned from LAO_SCOUT_BH) DB_T2_AX_DIAPHR_AO_Wall_Thk (T2-weighted scan of aortic wall thickness at the level of the diaphragm, planned from LAO_SCOUT_BH) Page 5 of 72

6 DB_T2_AX_BIFUR_AO_Wall_Thk (T2-weighted scan of aortic wall thickness at 2 cm above the bifurcation, planned from ABD_LOC) SAX_CINE_STACK_REAL_TIME_TRIGGERED (Realtime, free-breathing cine stack in SAX planes covering LA to LV) SAX_CINE_STACK_(LV_and_LA) *_SAX_T1_MAP_12MIN (short axis cine using SSFP sequence) (post-contrast T1 map at 12 minutes post Gd at *[BASE, MID, APEX]) POST_TI_SCOUT_SAX_MID (TI scout on Siemens at MID SAX) SS_DE_Entire_LV_(NBH) (delayed enhancement short axis single shot SSFP, free-breathing) PSIR_DE_4CH (delayed enhancement horizontal long axis gradient echo) PSIR_DE_3CH PSIR_DE_2CH AX_THORACIC_AORTA_2D_PhCon (delayed enhancement 3 chamber gradient echo) (delayed enhancement 2chamber gradient echo) (Phase contrast of thoracic aorta through ascending and descending aorta, planned from LAO_SCOUT_FB) AX_DIAPHR_AORTA_2D_PhCon (Phase contrast of thoracic aorta through aorta at diaphragm, planned from LAO_SCOUT_FB) AX_BIFUR_AORTA_2D_PhCon (Phase contrast of thoracic aorta through aorta at 2 cm above the bifurcation, planned from ABD_LOC) *_SAX_T1_MAP_25MIN (post-contrast T1 map at 25 minutes post Gd at *[BASE, MID, APEX]) T1_AX_ABDOMEN_FAT (T1-weighted turbo spin echo in axial planes at L2, L3, L4) Page 6 of 72

7 General Overview This is a 60 minute cardiovascular MR exam that also acquires some information related to body habitus. Items below in bold black text are required from all sites. Items with underlined bold black text are required from all sites when participants are eligible and consent to receive contrast. Items in bold black text in parenthesis with an asterisk (*) require special software from respective imaging vendors and may not be acquired at all study sites. Different sections of this protocol are as follows: Localizer images (scout images) 1) Chest 3 plane localizer with breath-hold 2) Abdominal localizer 3 plane with breath-hold 3) LV 2 & 4 chamber localizer 4) LV Short axis localizer 5) LAO or parasagittal candy cane view of the aorta with and without breath-holding SAX 5-slice reference prescribes 5 slices from mitral valve to tip of heart with the 2 nd, 3 rd, and 4 th slices used as the basal, mid, and apical SAX prescriptions. (*Tagging) imaging of the left ventricle with grid tags in basal, mid, and apical SAX views. These series of images will be used to assess myocardial strain. The middle short axis view will be repeated with single plane grid tags to assess LV diastolic function. Thus the middle short axis view with be acquired 3 times with tissue tagging: once with grid tags and then twice with longitudinal tags at 90 orientation to one another. Pre-contrast T2-weighted axial scan with fat saturation will be used to measure aortic wall thickness in 3 locations: Axially at the level of the pulmonary artery to assess the proximal ascending and descending thoracic aorta At the level of the diaphragm 2 cm above the bifurcation of iliac arteries to assess the abdominal aorta (*Pre-contrast T1 map) imaging in basal, mid, and apical SAX views (same as tagging) to assess the pre-contrast T1 values of the LV myocardium. (*Pre-Contrast T2 map) imaging in basal, mid, and apical SAX views (same as tagging) to assess the pre-contrast T2 values of the LV myocardium. Pre-Contrast T2 Weighted Imaging in basal, mid, apical SAX views (same as tagging) to access the pre-contrast T2 values of the LV myocardium. Gadolinium injection: Relevant only to participants who are eligible for the delayed contrast enhancement portion of the study. In the current protocol gadolinium-based contrast agent (0.15 mmol/kg body weight, total dose, use ProHance ONLY) is administered prior to short axis cine imaging. Page 7 of 72

8 Cine images acquired in the short-axis plane from the base of the left atrium to the apex of the left ventricle, using the Steady State Free Precession (SSFP) technique. Two higher temporal resolution Long-axis SSFP cine series will also be acquired in the four-chamber view and two-chamber view. In addition for those with capability, a real-time short-axis stack of cine images will be acquired. (*Post-contrast T1 map) imaging of the left ventricle at exactly 12 minutes post Gd (in the same locations as the Pre-contrast T1 maps) to assess the post-contrast T1 values. TI time determination: A TI (inversion time) scout (Siemens) will be performed on Siemens scanners to help select the optimal TI for viability imaging. For the GE scanners, test TI sequences at TI 175, 200, and 225 msec will be performed. (*Single-shot delayed enhancement) (Siemens and Phillips MRI scanners only). The same slice position as multiple shot, however all slices will be acquired in one breath-hold with SSFP sequence. Fast gradient echo (multiple-shot) delayed enhancement images must be acquired at 15 minutes after the contrast agent injection, in the 2, 3, and 4 chamber long-axis planes (note: the 2 and 4 chamber will occur in the same planes as the high temporal resolution the cine series), and the 3 short axis planes imaging in basal, mid, and apical SAX views (same as tagging) to assess the pre-contrast T1 values of the LV myocardium. A segmented inversion recovery (IR) spoiled gradient recalled echo (GRE) sequence is to be used. A phase sensitive acquisition sequence will be used on Siemens scanners. A standard sequence will be used on the GE scanner. (*Post-contrast T1 map) imaging at exactly 25 minutes post Gd (in same locations as the Pre-contrast T1 maps) to assess the post-contrast T1 values. Phase-contrast of the thoracic and abdominal aorta will be used to measure aortic pulse wave velocity. These slices will be acquired in the same three slice positions used to assess aortic wall thickness: one in the proximal aorta, the second at the level of the diaphragm, and the final one 2 cm above the bifurcation of the iliac arteries from the descending abdominal aorta. T1 Turbo spin-echo images axially placed at the level of L2 & L4 vertebrae to assess visceral fat. Technologists will need to include the Participant Study ID Number in the Referring Physician Field when entering the MRN and patient name in the scanner. Technologists are required to complete an MRI Encounter Form for each participant at the end of each MRI scan. Steps for Image Acquisition and the MR sequence parameters for the protocol are given below. Vendor-specific implementations of the protocol are also provided. Page 8 of 72

9 Participant Preparation 1. Complete the MRI safety screening form required at your institution. All PREVENT participants must be screened for MRI safety/compatibility. 2. Request participant use the rest room before the study. 3. Breath-holding is done at resting lung volume for the entire PREVENT protocol. a. Test breath-holding. The participant is required to be able to hold their breath for 15 seconds at resting lung volume twice in order to participate in the protocol. b. Inform and train participant on breath-holding, example: Breath in Let your air out until you are comfortable, and stop breathing. 4. Make sure that the connectors for cardiac coils and ECG are in place. 5. Remember to place nonferromagnetic brachial blood pressure cuff on participant s arm prior to beginning the MRI scans. This is needed to record blood pressures during certain sequences as marked on the encounter form. 6. Thoroughly clean the ECG contact area with alcohol swabs. With participant supine on the table, attach ECG electrodes to his/her chest according to your MRI manufacturer suggestions. 7. If selected and consented for gadolinium (circled yes on MRI completion form), place a 22 G cannula in the right antecubital vein. Alternatively, gadolinium may be administered by butterfly needle under direct observation. Note that lack of venous access is not a protocol contraindication to MRI scanning. 8. If selected and consented for gadolinium, prepare a dose of gadolinium-based contrast agent (0.15 mmol/kg, Prohance) with 20 ml saline flush. Page 9 of 72

10 Image Acquisition A. MRI completion form Complete the PREVENT MRI completion form AT THE END OF THE SCAN for each required component. It is recommended that this form is completed in real-time during the study to ensure no sequences are skipped and the blood pressures, heart rates, and counter times are recorded as necessary. Page 10 of 72

11 REF B: Series Description: Notes: _3_PLANE_SCOUT 3 Plane Localizer Steady-state free precession scout images Series Prescription Details Series Rx Notes Prescribe series from: Orientation: Number of Slices Localize the heart at the isocenter. three orthogonal planes (axial, coronal and sagittal) At least three slices per plane (at least 9 image Breath-holding: Yes, resting lung volume Sample Images Page 11 of 72

12 REF C: ABD_LOC Series Description: Abdominal Localizer Notes: Perform multi-plane abdominal localizer (coronal and sagittal); Siemens sequence name = tfi2d1_84. A coronal plane that appreciates the aorta bifurcation will be used in planning future series. A sagittal plan that appreciates L2-L4 will be used in planning future series. Series Prescription Details Series Rx Notes Prescribe series from: _3_PLANE_SCOUT (Ref B) Orientation: Number of Slices Breath-holding: Coronal and Sagittal 3-5 sagittal slices; 8-10 coronal slices Yes Image Parameters Image Parameter Slice Thickness Slice Gap Value 5mm 5 mm TR 260 TE 1.08 Number of Phase Encodings 143 Percent Sampling 75 % Percent Phase FOV 100% Pixel Bandwidth 1132 Matrix 192 x 144 Flip Angle 65 degrees Page 12 of 72

13 REF C (Continued): ABD_LOC Series Description: Abdominal Localizer Sample Images Page 13 of 72

14 REF D: DB_HEART_FAT Series Description: Axial HASTE/SS-FSE heart stack Notes: This is a Spin Echo Dark blood sequence (Siemens = HASTE [h2d1_133], GE = SS-FSE, Philips = SS-TSE). Slices will be acquired in an axial stack covering the diaphragm to superior level of the aortic arch. Make sure fat saturation is NOT used. Series Prescription Details Series Rx Notes Sample Series Rx Prescribe series from: _3_PLANE_SCOUT (Ref B) Orientation: Axial Number of Slices Variable; At least 10 Breath-holding: Yes, resting lung volume Image Parameters Image Parameter Slice thickness Slice gap Value 7 mm 3 mm TR 700 TE 19 Number of phase encodes 72 Percent Sampling 80 Percent Phase FOV 96.45% Pixel Bandwidth 766 Page 14 of 72

15 REF D (Continued): DB_HEART_FAT Series Description: Axial HASTE/SS-FSE heart stack Sample Images Page 15 of 72

16 REF E: VLA_SCOUT Series Description: White-blood 2 Chamber localizer; Pseudovertical long-axis localizer Notes: This is a bright-blood steady-state free precession, one slice (non-cine) image. Series Prescription Details Series Rx Notes Sample Series Rx Prescribe series from: Plan this on the axial scout view (_3_PLANE_SCOUT, Ref B) with the largest volume of heart, from the base (middle of the mitral valve) to apex of the LV, on the axial scouts. Orientation: Oblique Number of Slices 1 Breath-holding: Yes, resting lung volume Sample Image Page 16 of 72

17 REF F: HLA_SCOUT Series Description: White-blood 4 Chamber localizer; horizontal long-axis localizer Notes: This is a bright-blood steady-state free precession, one slice (non-cine) image. Series Prescription Details Series Rx Notes Sample Series Rx Prescribe series from: Plan this on the axial scout view (_3_PLANE_SCOUT, Ref B) with the largest volume of heart, from the base (middle of the mitral valve) to apex of the LV, on the axial scouts. Cross-reference with VLA_Scout (Ref E) Orientation: Oblique Number of Slices 1 Breath-holding: Yes, resting lung volume Sample Image Page 17 of 72

18 REF G: SAX_SCOUT Series Description: White-blood short-axis localizers Notes: These are a bright-blood steady-state free precession, non-cine images covering the whole heart from great arteries to the apex. Data acquisition at the diastolic phase. Series Prescription Details Series Rx Notes Sample Series Rx Prescribe series from: VLA_SCOUT (Ref E) crossreferenced with HLA_SCOUT (Ref F) Orientation: Oblique 12 Number of Slices 12 Breath-holding: Yes, resting lung volume Sample Images Page 18 of 72

19 REF H: LAO_SCOUT_BH Series Description: Aorta candy cane localizer, breath-held Notes: This localizer is a left anterior oblique in the candy cane plane of the thoracic aorta. This multi-slice localizer will be used for planning the DB Aorta Wall Thickness T2w images (Ref R). Series Prescription Details Prescribe series from: Orientation: Series Rx Notes _3_PLANE_SCOUT (Ref B) axial image with ascending and descending aorta Left anterior oblique; plane center slice through ascending and descending aorta Sample Series Rx Number of Slices 6 Breath-holding: Yes, resting lung volume Sample Image(s) Page 19 of 72

20 REF I: LAO_SCOUT_FB Series Description: Aorta candy cane localizer, free-breathing Notes: This localizer is a left anterior oblique in the candy cane plane of the thoracic aorta. This multi-slice localizer will be used for planning the aorta phase contrast images (Ref Y). Slices may be in a different location than the breath-held LAO localizers from Ref H. Series Prescription Details Prescribe series from: Orientation: Series Rx Notes _3_PLANE_SCOUT (Ref B) axial image with ascending and descending aorta Left anterior oblique; plane center slice through ascending and descending aorta Sample Series Rx Number of Slices 6-8 Breath-holding: No Sample Image(s) Page 20 of 72

21 REF J: VLA_CINE Series Description: 2 Ch CINE White-blood 16 ms Notes: This is a high resolution (16ms) 2 chamber vertical long-axis white-blood steady state free precession cine with 40 phases acquired in one breathhold. Cines should begin at end-diastole. Series Prescription Details Series Rx Notes Sample Series Rx Prescribe series from: Orientation: Copy slice positioning of VLA_SCOUT (Ref E) Oblique Number of Slices 1 Breath-holding: Yes VLA_SCOUT (Ref E) Image Parameters Image Parameter Siemens GE Philips Dicom Tag Sequence Type True FISP FIESTA b-fff Repetition Time (TR; ms) Min; 16 ms Min Min, 2.8 Echo Time (TE; ms) Minimized Min Full Minimized Flip Angle (degrees) Maximum 70 Maximum 45 Maximum 60 Field of View (mm) 360* * *360 Spatial Resolution (mm) 1.4*1.9*6 1.4*1.9*6 1.4*1.9*6 Image Matrix 256* * *192 Slice Thickness (mm) Page 21 of 72

22 REF J (Continued): VLA_CINE Series Description: 2 Ch CINE White-blood 16 ms Image Parameters (Continued) Image Parameter Siemens GE Philips Dicom Tag Number of phases Bandwidth (Hz/pixel) 1221 Parallel Imaging GRAPPA: kHz, 977 Hz/pixel ASSET Partial Fourier (if any) Off No No 1200 SENSE=2 Gating ECG/Retro ECG/Retro ECG/Retro Number of segments Temporal Resolution (ms) ~16 ms Breath-hold time(s) Sample Image Page 22 of 72

23 REF K: HLA_CINE Series Description: 4 Ch CINE White-blood 20 ms Notes: This is a high resolution (20ms) 4 chamber vertical long-axis white-blood steady state free precession cine with 40 phases acquired in one breathhold. Cines should begin at end-diastole. Series Prescription Details Prescribe series from: Orientation: Series Rx Notes Copy slice positioning of HLA_SCOUT (Ref F) or Rx from SAX_SCOUT (Ref G) Oblique Sample Series Rx Number of Slices 1 Breath-holding: Yes HLA_SCOUT (Ref F) Image Parameters Image Parameter Siemens GE Philips Sequence Type True FISP FIESTA b-fff Repetition Time (TR; ms) Min; 16 ms Min Min, 2.8 Echo Time (TE; ms) Minimized Min Full Minimized Flip Angle (degrees) Maximum 70 Maximum 45 Maximum 60 Field of View (mm) 360* * *360 Spatial Resolution (mm) 1.4*1.9*6 1.4*1.9*6 1.4*1.9*6 Image Matrix 256* * *192 Slice Thickness (mm) Page 23 of 72

24 REF K (Continued): HLA_CINE Series Description: 4 Ch CINE White-blood 20 ms Image Parameters (Continued) Image Parameter Siemens GE Philips Dicom Tag Number of phases Bandwidth (Hz/pixel) 1221 Parallel Imaging GRAPPA: kHz, 977 Hz/pixel ASSET Partial Fourier (if any) Off No No 1200 SENSE=2 Gating ECG/Retro ECG/Retro ECG/Retro Number of segments Temporal Resolution (ms) ~16 ms Breath-hold time(s) Sample Image Page 24 of 72

25 REF L: SAX_5SL_REF Series Description: SAX 5 slice reference plotted at end-systole on HLA_CINE Notes: Plot 5 SAX planes on the HLA _CINE series with the first slice at the mitral valve plane and the fifth slice at the tip of the heart. The images will be acquired at end-systole. Slices 2, 3, and 4 will be used for base, mid, and apical SAX prescriptions in subsequent scans. Series Prescription Details Series Rx Notes Sample Series Rx Prescribe series from: HLA_CINE (Ref K) prescribe from endsystole phase of cine Orientation: Oblique Number of Slices 5 Breathholding: Yes Slice 2 will be used as the Basal SAX Slice 3 will be used as the Mid-Cavity SAX Slice 4 will be used as the Apex SAX In following 3 SAX image acquisitions. Page 25 of 72

26 REF L (Continued): SAX_5SL_REF Series Description: SAX 5 slice reference plotted at end-systole on HLA_CINE Sample Images Slice 1 Slice 2 (BASE) Slice 3 (MID) Slice 4 (APEX) Slice 5 Page 26 of 72

27 REF M: GRID_TAG_SAX_BASE GRID_TAG_SAX_MID GRID_TAG_SAX_APEX Series Description: Specialized software at selected sites. For sites that are able, this is a SPAMM cine series. Notes: 3 slices bright blood (FGRE) grid tag images acquired with Prospective gating. Typically phases are achieved. Make sure that sharing view button is switched to ON on the Siemens scanner, to double the number of phases. (View sharing can be found on the Physio card, Cardiac tab) This is automatic on the GE scanner. Images are acquired at RESTING LUNG VOLUME. Ensure gating occurs at QRS so that the first image is enddiastolic. Series Prescription Details Prescribe series from: Orientation: Number of Slices Breath-holding: Series Rx Notes Copy slice positions from SAX_5SL_REF (Ref L) to prescribe slices: Slice 2 = BASE Slice 3 = MID Slice 4 = APEX Oblique, SAX 1 per acquisition (BASE, then MID, then APEX) Yes, resting lung volume Sample Series Rx Page 27 of 72

28 REF M (Continued): GRID_TAG_SAX_BASE GRID_TAG_SAX_MID GRID_TAG_SAX_APEX Series Description: Specialized software at selected sites. For sites that are able, this is a SPAMM cine series. Image Parameters Image Parameter General Siemens GE Philips Sequence Gradient Echo FLASH Fast GRE FFE Repetition Time (TR; ms) Minimize 6.35 Min 6.1 Echo Time (TE; ms) Minimize 2.5 Min full 3 Flip Angle (degrees) Views per segment/ segmentation factor 9 8 Single phase Field of View (mm) 360* * * *360 Spatial Resolution (mm) 1.4*2.8*10 1.4*2.8*10 1.4*2.8*10 Image Matrix 256* * *128 Slice Thickness (mm) Number of slices Bandwidth (Hz/pixel) Parallel Imaging No No No No Partial Fourier (if any) No None No No Gating Prospective Prospective Prospective Prospective Tag Spacing 7 mm 7 5 pixels (7mm) 7 mm Page 28 of 72

29 REF M (Continued): GRID_TAG_SAX_BASE GRID_TAG_SAX_MID GRID_TAG_SAX_APEX Series Description: Specialized software at selected sites. For sites that are able, this is a SPAMM cine series. Sample Image(s) Example of an End Diastolic grid tag image Page 29 of 72

30 REF N: TAG_SAX_MID_90_DEG TAG_SAX_MID_0_DEG Series Description: Specialized software at selected sites. For sites that are able, this is a SPAMM cine series. Notes: 1 slice position bright blood (FGRE) images in the middle short axis plane prescribed from Slice 3 of SAX_5SL_REF (Ref L). Use Prospective gating. Typically phases are achieved. Make sure that sharing view button is switched to ON on the Siemens scanner, to double the number of planes. This is automatic on the GE scanner. Images are acquired at RESTING LUNG VOLUME (*Copy the exact same slices and parameters from the horizontal prescription and convert it to vertical tags (see protocol details). Click on TAG SAX MID 90 DEGREES, right mouse click Append sequence, open sequence, under physio page cardiac change direction to 0 GE Scanners: from the user CV card choose the tagging angle and set it to 0 degrees for horizontal tag lines and 90 degrees for the vertical tag lines. From the same CV card choose the copy it and set it to 0. This is being done in order to prevent the scanner from increasing number of planes. * Make sure that the tag lines are perpendicular to the Frequency encoding direction (FED). Frequency direction is shown as a small arrow at the side of the image in the mini viewer. The tag line direction is correct if it goes in the direction of the phase wrap seen at the edges of the image. Siemens Scanners: Tag directions will automatically change when the user changes the phase encoding direction (note, this is already pre-built into the protocol that Hopkins will to you). Therefore, by changing the phase encoding direction, the direction of the tag lines will correctly change by themselves. Page 30 of 72

31 REF N (Continued): TAG_SAX_MID_90_DEG TAG_SAX_MID_0_DEG Series Description: Specialized software at selected sites. For sites that are able, this is a SPAMM cine series. Series Prescription Details Prescribe series from: Series Rx Notes Copy slice positions from SAX_5SL_REF (Ref L) to prescribe slices: Sample Series Rx Orientation: Slice 3 = MID Oblique, SAX Number of Slices 1 MID SAX at 90 Degrees 1 MID SAX at 0 Degrees Breath-holding: Yes, resting lung volume Sample Image(s) Page 31 of 72

32 REF O: BASE_SAX_T1_Map_PRE MID_SAX_T1_Map_PRE APEX_SAX_T1_Map_PRE Series Description: Specialized software at selected sites. For sites that are able, this is quantitative SAX T1 map acquired in three planes Notes: Pre-contrast T1 maps Series Prescription Details Prescribe series from: Orientation: Number of Slices Breath-holding: Series Rx Notes Copy slice positions from SAX_5SL_REF (Ref L) to prescribe slices: Slice 2 = BASE Slice 3 = MID Slice 4 = APEX Oblique, SAX 1 per acquisition (BASE, then MID, then APEX) Yes, resting lung volume Sample Series Rx Page 32 of 72

33 REF O (Continued): BASE_SAX_T1_Map_PRE MID_SAX_T1_Map_PRE APEX_SAX_T1_Map_PRE Series Description: Specialized software at selected sites. For sites that are able, this is quantitative SAX T1 map acquired in three planes. Several series will be produced. Image Parameters Image Parameter Siemens GE Philips Sequence WIP 488 Repetition Time (TR; ms) Echo Time (TE; ms) Single-shot BTFE 3.9ms 1.95ms Flip Angle (degrees) 70 degrees 50 degrees Field of View (mm) 360x360 mm 2 380x342 Image Matrix 192x x152 Slice Thickness (mm) 6 mm 8mm Number of slices 3 Vendor 3 Bandwidth (Hz/pixel) 930 matched Parallel Imaging GRAPPA=2 specifications SENSE=2 Partial Fourier (if any) Other Distortion Correction=On; Sequence Special: T1 Map, 3 Inversions, TI start 100, TI Increment 80, Delay 160, Motion Correction=On, Acq HB1=3, AcqHB2=3, AcqHB3=5, Rec HB1=3, RecHB2=3, RecHB3=0 partial Fourier acquisition TFE factor=49; 191ms acquisition window; Look Locker 1/2/3 = 100, 200, 350ms All other parameters should be the default settings. The image sequence is acquired with breath-holding. Several series will be produced. Images should be acquired in all participants whether or not gadolinium contrast is injected. Page 33 of 72

34 REF O (Continued): BASE_SAX_T1_Map_PRE MID_SAX_T1_Map_PRE APEX_SAX_T1_Map_PRE Series Description: Specialized software at selected sites. For sites that are able, this is quantitative SAX T1 map acquired in three planes. Several series will be produced. Sample Image Image will be in color Page 34 of 72

35 REF P: BASE_SAX_DB_T2W MID_SAX_DB_T2W APEX_SAX_DB_T2W Series Description: Dark blood STIR SAX images. Notes: The image sequence is acquired with breath-holding. T2 weighted images should be acquired in all participants whether or not gadolinium contrast is injected. These are dark blood images with Fat Saturation turned on. Series Prescription Details Prescribe series from: Orientation: Number of Slices Breath-holding: Series Rx Notes Copy slice positions from SAX_5SL_REF (Ref L) to prescribe slices: Slice 2 = BASE Slice 3 = MID Slice 4 = APEX Oblique, SAX 1 per acquisition (BASE, then MID, then APEX) Yes, resting lung volume Sample Series Rx Page 35 of 72

36 REF P (Continued): BASE_SAX_DB_T2W MID_SAX_DB_T2W APEX_SAX_DB_T2W Series Description: Dark blood STIR SAX images. Image Parameters SIEMENS: STIR imaging with the following parameters: Routine: FOV = 360x300 mm 2 ; Contrast: Slice-sel IR, 170ms TI; Matrix: 256x256; Normalize: On; Physio: Trigger pulse 2, Dark blood on, 200% thickness, 200 flip angle; Bandwidth 781 Hz/Px; Turbo Factor 25. RF Pulse: fast, Gradient mode: fast. Turn Fat Sat on. All other parameters should be the default settings. PHILIPS and GE: Vendor matched specifications Sample Image(s) Page 36 of 72

37 REF Q: BASE_SAX_T2_MAP MID_SAX_T2_MAP APEX_SAX_T2_MAP Series Description: Specialized software at selected sites. For sites that are able, this is quantitative SAX T2 map acquired in three planes. Notes: The image sequence is acquired with breath-holding. Several series will be produced. T2 map images should be acquired in all participants whether or not gadolinium contrast is injected. Series Prescription Details Prescribe series from: Orientation: Number of Slices Breath-holding: Series Rx Notes Copy slice positions from SAX_5SL_REF (Ref L) to prescribe slices: Slice 2 = BASE Slice 3 = MID Slice 4 = APEX Oblique, SAX 1 per acquisition (BASE, then MID, then APEX) Yes, resting lung volume Sample Series Rx Page 37 of 72

38 REF Q (Continued): BASE_SAX_T2_MAP MID_SAX_T2_MAP APEX_SAX_T2_MAP Series Description: Specialized software at selected sites. For sites that are able, this is quantitative SAX T2 map acquired in three planes. Image Parameters Image Parameter Siemens GE Philips Sequence TR WIP448 T2 Mapping T2SSFP, single shot 3xRR TE Echo spacing [0, 24, 55ms] 2.6ms echo spacing Flip angle 70 degrees 40 degrees FOV 360x360 mm 2 Vendor Matrix 192x160 matched specifications 160x96 Slice thickness 6 mm Bandwidth 930 Hz/pixel 1488 Hz/pixel bandwidth Parallel imaging Other Sequence special card Sample Image GRAPPA=2 Vendor matched specifications Distortion Correction=On; T2 Map, T2 Preps=3 (0,24,55ms), Motion Correction=On GRAPPA 2 All other parameters should be the default settings. Image will be in color Page 38 of 72

39 REF R: DB_T2_AX_THORACIC_AO_Wall_Thk DB_T2_AX_DIAPHR_AO_Wall_Thk DB_T2_AX_BIFUR_AO_Wall_Thk Series Description: Dark blood T2-weighted images with Fat Saturation in order to appreciate the aortic wall thickness. Notes: DB_T2_AX_THORACIC_AO_Wall_Thk and DB_T2_AX_DIAPHR_AO_Wall_Thk are planned from LAO_SCOUT_BH localizer (Ref H). DB_T2_AX_BIFUR_AO_Wall_Thk is planned from ABD_LOC (Ref C). Importantly, this set of images will be performed with fat saturation in order to obtain a round, clearly delineated circular lumen of the thoracic aorta. Series Prescription Details - DB_T2_AX_THORACIC_AO_Wall_Thk Prescribe series from: Orientation: Series Rx Notes Prescribe off of the LAO_SCOUT_BH (Ref H) images and select the slice with the best view of the aorta candy cane. Prescribe an oblique plane running perpendicular through the ascending and descending aorta as shown on the right. Axial; oblique Sample Series Rx Number of Slices 1 Breath-holding: yes Page 39 of 72

40 REF R (Continued): DB_T2_AX_THORACIC_AO_Wall_Thk DB_T2_AX_DIAPHR_AO_Wall_Thk DB_T2_AX_BIFUR_AO_Wall_Thk Series Description: Dark blood T2-weighted images with Fat Saturation in order to appreciate the aortic wall thickness. Series Prescription Details - DB_T2_AX_DIAPHR_AO_Wall_Thk Prescribe series from: Orientation: Series Rx Notes Prescribe off of the LAO_SCOUT_BH (Ref H) images and select the slice with the best view of the aorta candy cane. Prescribe an oblique plane running perpendicular through the aorta at the level of the diaphragm as shown on the right. Axial; oblique Sample Series Rx Number of Slices 1 Breath-holding: yes Page 40 of 72

41 REF R (Continued): DB_T2_AX_THORACIC_AO_Wall_Thk DB_T2_AX_DIAPHR_AO_Wall_Thk DB_T2_AX_BIFUR_AO_Wall_Thk Series Description: Dark blood T2-weighted images with Fat Saturation in order to appreciate the aortic wall thickness. Series Prescription Details - DB_T2_AX_BIFUR_AO_Wall_Thk Prescribe series from: Orientation: Series Rx Notes Prescribe off of the ABD_LOC (Ref C) images and select the slice with the best view of the aortic bifurcation. Prescribe a plane running perpendicular through the aorta at the level 2 cm superior to the bifurcation as shown on the right. Axial Sample Series Rx Number of Slices 1 Breath-holding: yes Page 41 of 72

42 REF R (Continued): DB_T2_AX_THORACIC_AO_Wall_Thk DB_T2_AX_DIAPHR_AO_Wall_Thk DB_T2_AX_BIFUR_AO_Wall_Thk Series Description: Dark blood T2-weighted images with Fat Saturation in order to appreciate the aortic wall thickness. Image Parameters Image Parameter Siemens GE Philips Coil Body Matrix Gore Cardiac Cardiac Plane Axial Axial Axial Field of View Slice thickness Spacing Averages Matrix 256 x x x256 Phase FOV 100% % Bandwidth TR 658 Auto 1000 TE Gating Ecg Cardiac prospective Trigger Sequence variant Tsc NEX PSD Options FSE XL Gat, Seq, Fast, VBw, Bsp Flow Comp No Yes Sequential Off Gap 0 1 Inversion Time 650 ETL Frequency Unswap Page 42 of 72

43 REF R (Continued): DB_T2_AX_THORACIC_AO_Wall_Thk DB_T2_AX_DIAPHR_AO_Wall_Thk DB_T2_AX_BIFUR_AO_Wall_Thk Series Description: Dark blood T2-weighted images with Fat Saturation in order to appreciate the aortic wall thickness. Sample Image(s) Localizing Image Resulting Image Page 43 of 72

44 REF S: SAX_CINE_STACK_REAL_TIME_TRIGGERED Series Description: Specialized software at selected sites. For sites that are able, this is realtime, cardiac triggered, free-breathing cine stack acquired in the SAX plane. Notes: Begin scanning 1 cm above the mitral valve plane. Slices should be set in descending order from base to apex. The last apical slice should locate within the myocardium such that the slices could cover left atrium as much as possible Minimum of 40 phases covering LV from atria to apex. Series Prescription Details Series Rx Notes Sample Series Rx Prescribe series from: HLA_SCOUT (Ref F). Orientation: SAX Oblique Number of Slices Minimum of 12 slices Breath-holding: No Page 44 of 72

45 REF T: CONTRAST INJECTION The gadolinium dose is 0.15 mmol/kg, using ProHance only. This is infused at 1 ml/sec, followed by saline flush of 20 ml. If the IV gauge is small, the infusion rate may be decreased and is not critical (perfusion images are not obtained). A butterfly needle is acceptable if veins are small. Delayed enhancement images must be acquired starting at 15 minutes after gadolinium injection. Gadolinium should not be injected in participants who are excluded from the viability (contrast enhanced) section of the exam, for any reason. Please check the MRI completion form to verify if the participant should/should not receive gadolinium. If participant is eligible for gadolinium, record volume and time of each injection on the MRI completion form. The time of injection should be recorded from the clock time displayed on the scanner. Use the timer provided by the MRI Reading center for the precise timing of T1 mapping and SA gradient echo delayed enhancement imaging. Page 45 of 72

46 REF U: SAX_CINE_STACK_(LV_and_LA) Series Description: Short axis cine stack encompassing LV and LA. Notes: ** Record BP and HR during concatenated acquisition when at slice near the mid-cavity of the left ventricle** Cine short axis images should be obtained while waiting for gadolinium to wash-out from the myocardium. Bright blood (SSFP) sequence, breath-hold (resting lung volume), minimum of 12 slices, 40 phases, covering the whole heart from the atria to apex. Cines should begin at end-diastole. Parallel imaging (e.g. ASSET, SENSE, or GRAPPA) with an acceleration factor of 2 to reduce acquisition time (optional). Begin scanning 1 cm above the mitral valve plane. Slices should be set in descending order from base to apex. The last apical slice should locate within the myocardium such that the slices could cover left atrium as much as possible Minimum of 40 phases covering LV from atria to apex. Flip angle should be set at the largest possible (usually 45-70º). Series Prescription Details Prescribe series from: Series Rx Notes HLA_SCOUT (Ref F). If SAX_CINE_STACK_REAL_ TIME_TRIGGERED (Ref S) was performed, the slice positioning should be copied. Sample Series Rx Orientation: SAX Oblique Number of Slices Minimum of 12 slices Breath-holding: Yes, do concatenations / multiple acquisitions with BH for each slice Page 46 of 72

47 REF U (Continued): SAX_CINE_STACK_(LV_and_LA) Series Description: Short axis cine stack encompassing LV and LA. Image Parameters Image Parameter Siemens GE Philips Sequence Type True FISP FIESTA b-fff Repetition Time (TR; ms) Min; 16 ms Min Min, 2.8 Echo Time (TE; ms) Minimized Min Full Minimized Flip Angle (degrees) Maximum 70 Maximum 45 Maximum 60 Field of View (mm) 360* * *360 Spatial Resolution (mm) 1.4*1.9*6 1.4*1.9*6 1.4*1.9*6 Image Matrix 256* * *192 Slice Thickness (mm) Slice Gap (mm) Number of phases Bandwidth (Hz/pixel) kHz, 977 Hz/pixel 1200 Parallel Imaging GRAPPA: 2-3 ASSET SENSE=2 Partial Fourier (if any) Off No No Gating ECG/Retro ECG/Retro ECG/Retro Number of segments Temporal Resolution (ms) ~16 ms Breath-hold time(s) Page 47 of 72

48 REF U (Continued): SAX_CINE_STACK_(LV_and_LA) Series Description: Short axis cine stack encompassing LV and LA. Sample Image(s) Page 48 of 72

49 REF V: BASE_SAX_T1_MAP_12MIN MID_SAX_T1_MAP_12MIN APEX_SAX_T1_MAP_12MIN Series Description: Specialized software at selected sites. For sites that are able, this is quantitative SAX T1 map acquired in three planes. Several series will be produced. Notes: 12 minute post-contrast T1 maps. Record counter time on MRI completion/encounter form. Series Prescription Details Prescribe series from: Orientation: Number of Slices Breath-holding: Series Rx Notes Copy slice positions from SAX_5SL_REF (Ref L) to prescribe slices: Slice 2 = BASE Slice 3 = MID Slice 4 = APEX Oblique, SAX 1 per acquisition (BASE, then MID, then APEX) Yes, resting lung volume Sample Series Rx Page 49 of 72

50 REF V (Continued): BASE_SAX_T1_Map_12MIN MID_SAX_T1_Map_12MIN APEX_SAX_T1_Map_12MIN Series Description: Specialized software at selected sites. For sites that are able, this is quantitative SAX T1 map acquired in three planes. Several series will be produced. Image Parameters Image Parameter Siemens GE Philips Sequence WIP 488 Repetition Time (TR; ms) Echo Time (TE; ms) Single-shot BTFE 3.9ms 1.95ms Flip Angle (degrees) 70 degrees 50 degrees Field of View (mm) 360x360 mm 2 380x342 Image Matrix 192x x152 Slice Thickness (mm) 6 mm 8mm Number of slices 3 Vendor 3 Bandwidth (Hz/pixel) 930 matched Parallel Imaging GRAPPA=2 specifications SENSE=2 Partial Fourier (if any) Other Distortion Correction=On; Sequence Special: T1 Map, 3 Inversions, TI start 100, TI Increment 80, Delay 160, Motion Correction=On, Acq HB1=3, AcqHB2=3, AcqHB3=5, Rec HB1=3, RecHB2=3, RecHB3=0 All other parameters should be the default settings. partial Fourier acquisition TFE factor=49; 191ms acquisition window; Look Locker 1/2/3 = 100, 200, 350ms Page 50 of 72

51 REF V (Continued): BASE_SAX_T1_Map_12MIN MID_SAX_T1_Map_12MIN APEX_SAX_T1_Map_12MIN Series Description: Specialized software at selected sites. For sites that are able, this is quantitative SAX T1 map acquired in three planes. Several series will be produced. Sample Image Image will be in color Page 51 of 72

52 REF W: POST_TI_SCOUT_SAX_Mid Series Description: T1-weighted sequence with multiple inversion times acquired in MID SAX plane. Notes: The purpose of these sets of images is to find the best inversion time so that the myocardium appears dark. This is a bright blood (SSFP), BH sequence; If myocardium is not nulled, increase TI by 25 ms increments and check resulting images. Record selected inversion time that nulls the myocardium at the baseline MRI scan on the top of the MRI completion/encounter form. Use TI from baseline scan at subsequent follow-up scans. For GE images, use test TI times of 175, 200, 225 msec. Use the optimum TI where normal myocardium is nulled (darkest). In the example to the right, TI 300 is optimal. YOU ARE ALLOWED TO INCREASE THE TI DURING THE ACQUISITION. Series Prescription Details Prescribe series from: Orientation: Number of Slices Breath-holding: Series Rx Notes Copy slice positions from SAX_5SL_REF (Ref L) to prescribe slices: Slice 3 = MID Oblique, SAX 1 per acquisition (BASE, then MID, then APEX) Yes, resting lung volume Sample Series Rx Page 52 of 72

53 REF W (Continued): POST_TI_SCOUT_SAX_Mid Series Description: T1-weighted sequence with multiple inversion times acquired in MID SAX plane. Sample Image(s) Page 53 of 72

54 REF X: SS_DE_Entire_LV_(NBH) Series Description: Free breathing delayed enhancement sequence acquired in a SAX stack (no gap) covering the LV. Notes: Use TI determined at baseline scan (Ref W). Siemens and Philips only. Single-shot inversion recovery (IR) steady state free precession (SSFP) sequence, use PSIR on Siemens scanners. Use parallel imaging (e.g. ASSET, SENSE, or GRAPPA) with an acceleration factor of 2. Acquire in same short axis and long axis planes as cine images. Slice thickness: 10 mm; Gap: none (contiguous slices). These images are to be acquired 15 minutes after contrast injection (Ref T). Series Prescription Details Series Rx Notes Sample Series Rx Prescribe series from: HLA_SCOUT (Ref F) Orientation: SAX, Oblique Number of Slices Variable, at least 10 Breath-holding: No Page 54 of 72

55 REF X (Continued): SS_DE_Entire_LV_(NBH) Series Description: Free breathing delayed enhancement sequence acquired in a SAX stack (no gap) covering the LV. Image Parameters Image Parameter General Siemens Philips Sequence Repetition Time (TR; ms) Single-shot Inversion Recovery SSFP True FISP IR Single- Shot Minimize Single-shot IR Echo Time (TE; ms) Minimize Minimize Minimize Flip Angle (degrees) Maximize Field of View (mm) Spatial Resolution (mm) frequency * phase (depending on participant size) Better than 3.0 * 3.0 * * *300 Better than 3.0 * 3.0 * 10.0 Image Matrix At least 108 * * *130 Slice Thickness (mm) Slice Gap (mm) Number of slices Magnetization Preparation Inversion time (TI; ms) None (contiguous slices) (Same as for Cines) short-axis slices to cover heart from valve plane to apex Inversion Recovery (IR) Optimize, using TI scout 0 0 ~12 SA ~12 SA Non-sel. IR Start with 300 if uncertain Better than 3.0 * 3.0 * 10.0 Non-sel. IR Bandwidth (Hz/pixel) Parallel Imaging Acceleration factor:2 GRAPPA:2 2 Partial Fourier (if any) None Off Trigger Every heart beat 1 trigger pulses 1 Number of segments Breath-hold time(s) (BH optional) 13 Page 55 of 72

56 REF X (Continued): SS_DE_Entire_LV_(NBH) Series Description: Free breathing delayed enhancement sequence acquired in a SAX stack (no gap) covering the LV. Sample Image(s) Magnitude Phase Sensitive Inversion Recovery Page 56 of 72

57 REF Y: PSIR_DE_4CH PSIR_DE_3CH PSIR_DE_2CH Series Description: Phase Sensitive Inversion Recovery delayed enhancement acquired in 4 Chamber, 3 Chamber, and 2 Chamber views Notes: Use TI determined at baseline scan (Ref W). Siemens and Philips only. Single-shot inversion recovery (IR) steady state free precession (SSFP) sequence, use PSIR on Siemens scanners. Use parallel imaging (e.g. ASSET, SENSE, or GRAPPA) with an acceleration factor of 2. Acquire in same short axis and long axis planes as cine images. Slice thickness: 8 mm; Gap: none (contiguous slices). Series Prescription Details Series Rx Notes Copy slice position from HLA_SCOUT (Ref F) for 4CH Prescribe series from: Prescribe oblique from HLA_SCOUT (Ref F) and VLA_SCOUT (Ref E) for 3CH Copy slice position from VLA_SCOUT (Ref E) for 2CH Orientation: Oblique Number of Slices 1 x 4CH, 1 x 3CH, 1 x 2CH Breath-holding: No Page 57 of 72

58 REF Y (Continued): PSIR_DE_4CH PSIR_DE_3CH PSIR_DE_2CH Series Description: Phase Sensitive Inversion Recovery delayed enhancement acquired in 4 Chamber, 3 Chamber, and 2 Chamber views Image Parameters Image Parameter General Siemens Philips Sequence Repetition Time (TR; ms) Single-shot Inversion Recovery SSFP True FISP IR Single- Shot Minimize Single-shot IR Echo Time (TE; ms) Minimize Minimize Minimize Flip Angle (degrees) Maximize Field of View (mm) Spatial Resolution (mm) frequency * phase (depending on participant size) Better than 3.0 * 3.0 * * *300 Better than 3.0 * 3.0 * 10.0 Image Matrix At least 108 * * *130 Slice Thickness (mm) Number of slices Magnetization Preparation Inversion time (TI; ms) 1 x 4CH, 1 x 3CH, 1 x 2CH Inversion Recovery (IR) Optimize, using TI scout 1 x 4CH, 1 x 3CH, 1 x 2CH Non-sel. IR Start with 300 if uncertain Better than 3.0 * 3.0 * x 4CH, 1 x 3CH, 1 x 2CH Non-sel. IR Bandwidth (Hz/pixel) Parallel Imaging Acceleration factor:2 GRAPPA:2 2 Partial Fourier (if any) None Off Trigger Every heart beat 1 trigger pulses 1 Number of segments Breath-hold time(s) (BH optional) 13 Page 58 of 72

59 REF Y (Continued): PSIR_DE_4CH PSIR_DE_3CH PSIR_DE_2CH Series Description: Phase Sensitive Inversion Recovery delayed enhancement acquired in 4 Chamber, 3 Chamber, and 2 Chamber views Sample Image(s) Phase Sensitive Inversion Recovery (4CH) Phase Sensitive Inversion Recovery (3CH) Phase Sensitive Inversion Recovery (2CH) Page 59 of 72

60 REF Z: AX_THORACIC_AORTA_2D_PhCon AX_DIAPHR_AORTA_2D_PhCon AX_BIFUR_AORTA_2D_PhCon Series Description: Free breathing, 2D Phase Contrast images of the aorta in 3 planes: the ascending-descending aorta at the level of the arch, at the level of the diaphragm, and at the level of 2 cm above the bifurcation. Notes: Phase-contrast gradient-echo images will be acquired in axial planes for determination of aortic stiffness. Measures of distensibility and pulse wave velocity will be performed on the phase-contrast images. Series Prescription Details - AX_THORACIC_AORTA_2D_PhCon Prescribe series from: Orientation: Series Rx Notes Prescribe off of the LAO_SCOUT_FB (Ref I) images and select the slice with the best view of the aorta candy cane. Prescribe an oblique plane running perpendicular through the ascending and descending aorta as shown on the right. Axial; oblique Sample Series Rx Number of Slices 1 Breath-holding: No Page 60 of 72

61 REF Z (Continued): AX_THORACIC_AORTA_2D_PhCon AX_DIAPHR_AORTA_2D_PhCon AX_BIFUR_AORTA_2D_PhCon Series Description: Free breathing, 2D Phase Contrast images of the aorta in 3 planes: the ascending-descending aorta at the level of the arch, at the level of the diaphragm, and at the level of 2 cm above the bifurcation. Series Prescription Details - AX_DIAPHR_AORTA_2D_PhCon Prescribe series from: Orientation: Series Rx Notes Prescribe off of the LAO_SCOUT_FB (Ref I) images and select the slice with the best view of the aorta candy cane. Prescribe an oblique plane running perpendicular through the aorta at the level of the diaphragm as shown on the right. Axial; oblique Sample Series Rx Number of Slices 1 Breath-holding: No Page 61 of 72

62 REF Z (Continued): AX_THORACIC_AORTA_2D_PhCon AX_DIAPHR_AORTA_2D_PhCon AX_BIFUR_AORTA_2D_PhCon Series Description: Free breathing, 2D Phase Contrast images of the aorta in 3 planes: the ascending-descending aorta at the level of the arch, at the level of the diaphragm, and at the level of 2 cm above the bifurcation. Series Prescription Details - AX_BIFUR_AORTA_2D_PhCon Prescribe series from: Orientation: Series Rx Notes Prescribe off of the ABD_LOC (Ref C) images and select the slice with the best view of the aortic bifurcation. Prescribe a plane running perpendicular through the aorta at the level 2 cm superior to the bifurcation as shown on the right. Axial Sample Series Rx Number of Slices 1 Breath-holding: No Page 62 of 72

63 REF Z (Continued): AX_THORACIC_AORTA_2D_PhCon AX_DIAPHR_AORTA_2D_PhCon AX_BIFUR_AORTA_2D_PhCon Series Description: Free breathing, 2D Phase Contrast images of the aorta in 3 planes: the ascending-descending aorta at the level of the arch, at the level of the diaphragm, and at the level of 2 cm above the bifurcation. Image Parameters Image Parameter Siemens GE Philips Coil Body Matrix Gore Full Cardiac Plane Oblique Oblique Axial Field of View Repetition Time (TR; ms) Echo Time (TE; ms) 3.14 Min 2.8 Flip Angle (degrees) Averages 1 1 BW NEX Gated Cardiac Cardiac (auto # phases, TrigWin 10) Retrospective Sequence type Phase-contrast GRE Phase-contrast GRE 2D FFE Velocity encoding direction (for axial) Velocity encoding direction (for parasagital) Through-plane Through-plane Through-plane Head-Foot or Superior-Inferior Head-Foot or Superior-Inferior Slice Thickness 6 mm 6 6 Head-Foot or Superior-Inferior Distance Factor 20% (1.2m) Segments 6 Matrix 128 x x x128 Page 63 of 72

64 REF Z (Continued): AX_THORACIC_AORTA_2D_PhCon AX_DIAPHR_AORTA_2D_PhCon AX_BIFUR_AORTA_2D_PhCon Series Description: Free breathing, 2D Phase Contrast images of the aorta in 3 planes: the ascending-descending aorta at the level of the arch, at the level of the diaphragm, and at the level of 2 cm above the bifurcation. Image Parameters (Continued) Image Parameter Siemens GE Philips Phase FOV 100% % Phase encode direction A-P A-P A-P Phases PSD Options Vasc PC (Fast 2D Phase Contrast Gat, Seq, Fast Flow Comp Off Yes Gap 0 0 VPS Frequency 2 (adjust per patient s heart rate for ~15 phases) Grad Mode Whole Default VENC Vascular Screen User CV Screen Start with 200, may increase if aliasing is present S/I Venc: 200, Collapse: off, Recon: Ph Diff, Flow Analysis: on, Flow Dir: Slice, Additional Images: Obl S/I All set to zero Page 64 of 72

65 REF Z (Continued): AX_THORACIC_AORTA_2D_PhCon AX_DIAPHR_AORTA_2D_PhCon AX_BIFUR_AORTA_2D_PhCon Series Description: Free breathing, 2D Phase Contrast images of the aorta in 3 planes: the ascending-descending aorta at the level of the arch, at the level of the diaphragm, and at the level of 2 cm above the bifurcation. Sample Image(s) Resulting magnitude (top row) and velocity maps (bottom row) images Page 65 of 72

66 REF AA: BASE_SAX_T1_MAP_25MIN MID_SAX_T1_MAP_25MIN APEX_SAX_T1_MAP_25MIN Series Description: Specialized software at selected sites. For sites that are able, this is quantitative SAX T1 map acquired in three planes. Several series will be produced. Notes: 25 minute post-contrast T1 maps. Record counter time on MRI completion/encounter form. Series Prescription Details Prescribe series from: Orientation: Number of Slices Breath-holding: Series Rx Notes Copy slice positions from SAX_5SL_REF (Ref L) to prescribe slices: Slice 2 = BASE Slice 3 = MID Slice 4 = APEX Oblique, SAX 1 per acquisition (BASE, then MID, then APEX) Yes, resting lung volume Sample Series Rx Page 66 of 72

67 REF AA (Continued): BASE_SAX_T1_Map_25MIN MID_SAX_T1_Map_25MIN APEX_SAX_T1_Map_25MIN Series Description: Specialized software at selected sites. For sites that are able, this is quantitative SAX T1 map acquired in three planes. Several series will be produced. Image Parameters Image Parameter Siemens GE Philips Sequence WIP 488 Repetition Time (TR; ms) Echo Time (TE; ms) Single-shot BTFE 3.9ms 1.95ms Flip Angle (degrees) 70 degrees 50 degrees Field of View (mm) 360x360 mm 2 380x342 Image Matrix 192x x152 Slice Thickness (mm) 6 mm 8mm Number of slices 3 Vendor 3 Bandwidth (Hz/pixel) 930 matched Parallel Imaging GRAPPA=2 specifications SENSE=2 Partial Fourier (if any) Other Distortion Correction=On; Sequence Special: T1 Map, 3 Inversions, TI start 100, TI Increment 80, Delay 160, Motion Correction=On, Acq HB1=3, AcqHB2=3, AcqHB3=5, Rec HB1=3, RecHB2=3, RecHB3=0 partial Fourier acquisition TFE factor=49; 191ms acquisition window; Look Locker 1/2/3 = 100, 200, 350ms All other parameters should be the default settings. The image sequence is acquired with breath-holding. Several series will be produced. Page 67 of 72

68 REF AA (Continued): BASE_SAX_T1_Map_25MIN MID_SAX_T1_Map_25MIN APEX_SAX_T1_Map_25MIN Series Description: Specialized software at selected sites. For sites that are able, this is quantitative SAX T1 map acquired in three planes. Several series will be produced. Sample Image Image will be in color Page 68 of 72

69 REF BB: T1_AX_ABDOMEN_FAT Series Description: T1 weighted turbo spin-echo sequence acquired with 3 evenly spaced axial slices with 1 st and 3 rd centered at L2 and L4. Notes: To assess visceral fat, a series of images will be acquired to assess visceral fat volume. Series Prescription Details Series Rx Notes Sample Series Rx Prescribe series from: Sagittal plane on ABD_LOC (Ref C) Orientation: Number of Slices Axial 3 - evenly spaced axial slices with 1 st and 3 rd centered at L2 and L4. Breath-holding: Yes Page 69 of 72

70 REF BB: T1_AX_ABDOMEN_FAT Series Description: T1 weighted turbo spin-echo sequence acquired with 3 evenly spaced axial slices with 1 st and 3 rd centered at L2 and L4. Image Parameters Image Parameter Value Dicom Tag FOV Slice thickness (mm) Slice gap (mm) TR TE 350 mm 5mm Variable change distance factor as necessary 800 ms 36 ms Flip angle (degrees) 180 Matrix 256 * 256 Acceleration factor 2 Bandwidth 305 Hz/Px Turbo factor 11 Echo trains per slice 13 Gating ECG triggering Sample Image(s) Page 70 of 72

71 REF CC: Screensaves To capture localizer plane screen saves, Load cross planes (Asc to Desc, Diaphr, and Bifurc), candy cane LAO localizer (FREE BREATHING), and ABD localizer into Viewer. Tab through candy cane and ABD localizers to find best shots of aorta. 1. Asc to Desc and Desc to Diaphr a. Highlight both the Asc to Desc plane and the Diaphr plane, and finally click on the candy cane LAO (make sure candy cane is last selected) b. On the patient tab, click on Position Display Selection 2. Diaphr to Bifur a. Highlight both the Diaphr plane and the Bifur plane, and finally click on the ABD localizer (make sure ABD localizer is last selected) b. On the patient tab, click on Position Display Selection Page 71 of 72

72 REF CC (Continued): Screensaves Load the 4 Ch cine image into the Viewer and tab through to find end-systole image from which planning was done. Also load the SAX 5 slice Reference (section K) into the Viewer. 3. LV Five slice reference a. Highlight the 5 short axis images and finally click on the 4Ch b. On the patient tab, click on Position Display Selection 4. T1 Scout Screensaves a. Save these for export if contrast administered Page 72 of 72