JETStream Workspace Release 3.0 Cardiac Applications

Transcription

1 JETStream Workspace Release 3.0 Cardiac Applications INSTRUCTIONS FOR USE D-ENG, REV A

2 Copyright Statement Philips Medical Systems has taken care to ensure the accuracy of this document. However, Philips Medical Systems assumes no liability for errors or omissions and reserves the right to make changes without further notice to any products herein to improve reliability, function, or design. Philips Medical Systems provides this guide without warranty of any kind, either implied or expressed, including, but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Philips Medical Systems may make improvements or changes in the product(s) and/or program(s) described in this manual at any time. This document contains proprietary information which is protected by copyright. All rights are reserved. No part of this manual may be photocopied, reproduced, or translated to another language without written permission from Philips Medical Systems. Philips Medical Systems reserves the right to revise this publication and to make changes in content from time to time without obligation on the part of Philips Medical Systems to provide notification of such revision or change. Trademarks ADAC, CPET Imaging System, CPET Plus Imaging System, FORTE TM, Cardio TM, CardioMD, CardioTrac TM, Cardio TM 60, GlobalQ, Solus TM, Vertex TM, Vertex TM Plus, Vertex TM 60, EPIC TM, Pegasys TM, Pegasys TM X, Pegasys TM MD, Pegasys TM MD+, Pegasys TM Ultra, Atlas TM, AutoQUANT, ARGUS, GENESYS, AutoSPECT, AutoSPECT Plus, CardiaQ, PINNACLE, SMARTSIM, P3IMRT, InStill, P 3 MD, PIXELAR, ALLEGRO, JETStream, SKYLight, Transcam TM, SKYTable TM, Midas TM, MOSAIC TM, Shadow TM, Vantage TM, ExSPECT TM, ACCESS TM, X-ACT TM, FlexLOGIC TM, TeleLOGIC TM, InteLOGIC TM, SENTRY TM, VersaTable TM, ColliMATE TM, EZX TM, CCT TM, WebView TM, MCD/AC TM and GEMINI TM are trademarks or registered trademarks of Philips Medical Systems. Adobe, the Adobe logo, Acrobat, the Acrobat logo, and PostScript are trademarks of Adobe Systems Incorporated or its subsidiaries and may be registered in certain jurisdictions. Sun, SunView, NFS, OpenWindows, Solaris, and SPARCstation are trademarks of Sun Microsystems, Inc. SPARC is a registered trademark of SPARC International, Inc. SPARCstation is a trademark of SPARC International, Inc. licensed exclusively to Sun Microsystems, Inc. UNIX and OPEN LOOK are registered trademarks of UNIX System Laboratories, Inc. X Window System is a trademark of the Massachusetts Institute of Technology. Microsoft and Windows are either registered trademarks or trademarks of Microsoft Corporation in the United States and/or other countries. Symantec and Symantec pcanywhere are U.S. registered trademarks of Symantec Corporation. Symantec AntiVirus and Symantec WinFax PRO are trademarks of Symantec Corporation. Other brand or product names are trademarks or registered trademarks of their respective holders. Prescription Device Statement Caution: Federal law restricts this device to sale by or on the order of a physician (or properly licensed practitioner). Copyright 2007, Koninklijke Philips Electronics N.V. 540 Alder Drive, Milpitas, CA, 95035, USA D-ENG, REV A PROPERTY OF KONINKLIJKE PHILIPS ELECTRONICS N.V.

3 Disclaimer Neither Philips Medical Systems or any of its worldwide affiliates shall be liable or obligated in any manner in respect of bodily injury and/or property damage from the use of the software if such is not in strict compliance with instructions and safety precautions contained in the relevant operating manuals and in all supplements thereto, in all product labels, and according to all terms of warranty and sale of the system, or if any change not authorized by Philips Medical Systems is made to the software operating the system. CE Marking JETStream Workspace Cardiac Applications Cardiology Module is CE Marked to the Medical Device Directive 93/42/EEC. Manufacturer: ADAC Laboratories 540 Alder Drive Milpitas, CA European Authorized Representative for ADAC Laboratories: Philips Medical Systems Nederland B.V. PMS Quality & Regulatory Affairs Veenpluis PC Best The Netherlands

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5 Contents 1 Introduction 1 Intended Use 1 Organization of This Manual 1 Conventions Used in This Manual 2 Overview 3 General Information 5 Loading Studies 5 Object Associations 5 Common Controls 5 Cardiac Layout Information 6 Viewing Snapshots and Pages 7 Snapshot Layout 8 Page Layout 9 Warnings and Precautions 9 Quality Assurance 9 2 Layout Tools and Graphic Controls 11 What this Chapter Contains 11 Introduction 11 Tools and Controls 12 Image Action 12 Fit Curve 12 Validate Window 13 Image Synchronization 13 Synchronize Cines 13 Synchronized Display 14 Synchronized Triangulation 14 Layout Display 15 Axis 15 Normalization 15 Mask Volume 17 JETStream Workspace Cardiac Applications Contents v

6 ROI Definition 18 Cardiac ROI 18 Cardiac ROI Redraw 19 Return 19 3 MUGA Analysis 21 What This Chapter Contains 21 Introduction 21 Performing MUGA Analysis 22 Defining ROIs 22 Reviewing Results 31 Phase Analysis Layout 32 Series Layout 35 Defining Defaults Files 37 Algorithms Used in MUGA Analysis 41 Prerequisites 41 Preprocessing 41 Geometric 41 Tail-drop correction 42 Finding the edge of the LV 43 Is the second derivative the best choice? 43 The use of the Gradient 44 General location of the ventricles 44 Finding the septum 45 Finding the center of the LV 45 Performing the radial search 45 Finding the edge of the LV at ES 46 Finding the edge of the RV 46 Computing the ejection fraction 46 Computing the EF 47 Creating a high temporal resolution LV volume curve 47 Computing the LV diastolic volume 48 References 48 vi Contents JETStream Workspace Cardiac Applications

7 4 MUGA Display 49 What This Chapter Contains 49 Introduction 49 Multi-Cines Layout 50 5 Cardiac SPECT Display 53 What This Chapter Contains 53 Introduction 53 Mask Layout 54 Three View Layout 57 Three View No Gate Layout 60 One View Layout 62 Tomo View Layout 66 Composite Layout 68 Saving Data 70 6 Cardiac Vantage SPECT Display 73 What This Chapter Contains 73 Introduction 73 Mask Layout 74 Three View Layout 77 One View Layout 79 Tomo Layout 82 Volume TR Layout 84 Frame Layout 86 Vantage QC Layout 88 Saving Data 90 7 First Pass and Shunt Analysis 93 What This Chapter Contains 93 Introduction 93 Performing First Pass Analysis 94 Setting Initial Timing Regions of Interest 95 Reviewing for Quality Control 99 Drawing ROIs and Selecting Ventricular Cycles JETStream Workspace Cardiac Applications Contents vii

8 for Analysis 101 LVEF Report Layout 101 RVEF Report Layout 108 Reviewing Results 115 Wallmotion Report Layout 115 Functional Report Layout 117 Performing Left-to-Right Shunt Analysis 119 Setting Initial Timing Regions of Interest 119 Reviewing for Quality Control 121 Determining the Qp/Qs Ratio 122 Index 127 viii Contents JETStream Workspace Cardiac Applications

9 1 Introduction Intended Use JETStream Workspace Cardiology Module is a suite of cardiac applications that run on JETStream Workspace. JETStream Workspace is a nuclear medicine image display and processing workstation that provides software applications used to process, analyze, and display medical images/data. The results obtained may be used as a tool, by a nuclear physician, in determining the diagnosis of patient disease conditions in various organs, tissues, and other anatomical structures. The data processed may be derived from any nuclear medicine gamma camera. The JETStream Workspace system should only be operated by qualified healthcare professionals trained in the use of nuclear medicine equipment. JETStream Workspace is a nuclear medicine workstation that is operated in a hospital, clinic, or doctor s office. Patient data may be transferred via DICOM over Local Area Networks (LAN), or Wide Area Networks (WAN). The primary users of this product include nuclear medicine technologists who process the data and physicians who display, review, and interpret the processed image data. Organization of This Manual This manual contains the following chapters: JETStream Workspace Cardiac Applications 1: Introduction 1

10 Conventions Used in This Manual Chapter 1, Introduction, contains conventions used in this manual, and an overview of the applications. Chapter 2, Layout Tools and Graphic Controls, contains descriptions of the various layout tools and graphic controls that appear in applications described in this manual. Chapters 3 through 7 describe how to use the individual JETStream Workspace cardiac applications, including descriptions of their screens and controls. Conventions Used in This Manual This manual uses the following conventions: WARNING: Messages that alert you to conditions that may result in death or serious injury. CAUTION: Messages that alert you to conditions that may result in one or more of the following: - Minor or moderate injury to you or the patient - Damage to the equipment or other property - Data loss IMPORTANT: Vital information that describes how to properly install, configure, or use the system. Note: Additional information that may help explain an action or procedure. <Enter> Press the Enter key on the PC keyboard. Computer messages displayed on the screen are represented using the Courier font. For example, Reboot After Installation. 2 1: Introduction JETStream Workspace Cardiac Applications

11 Overview Keyboard entries that you type as they appear are represented by a boldface Courier font. For example, In the top field, type PDT. Prompts and keyboard entries that are system configuration dependent are represented using italic Courier font. For example, Enter IP address: All host names, IP addresses, and Ethernet addresses displayed in these procedures are examples only. Before entering host names, IP addresses, or Ethernet addresses, check the existing network configuration to make sure that you do not duplicate any existing entries. All warnings and cautions are noted in the appropriate section of the manual, where procedures that warrant them are described. Overview There are 5 standard applications in the JETStream Workspace Cardiology Module: MUGA Analysis The MUGA (Multiplanar Gated Acquisition) Analysis application allows you to automatically segment and quantify gated blood pool datasets. Refer to Chapter 3, which starts on page 21, for details. MUGA Display The MUGA (Multiplanar Gated Acquisition) Display application provides a way to review gated cines of cardiac patients. JETStream Workspace Cardiac Applications 1: Introduction 3

12 Overview Refer to Chapter 4, which starts on page 49, for details. Cardiac SPECT Display The Cardiac SPECT Display application provides a way to review myocardial slice images of cardiac patients. Images can be Stress and Rest Gated SAX images, and Stress and Rest SAX images. It displays up to 4 datasets. Gated objects appear in static (splash) and cine format. Refer to Chapter 5, which starts on page 53, for details. Cardiac Vantage SPECT Display The Cardiac Vantage SPECT application provides a way to review Vantage myocardial slice images of cardiac patients. It displays Stress and Rest SAX, Stress and Rest Corrected SAX, and Gated SAX images. Gated objects appear as cines. The application also allows you to display the transmission projection data and reference images along with the comparative stress/rest/corrected images. Refer to Chapter 6, which starts on page 73, for details. First Pass and Shunt Analysis Using the First Pass and Shunt Analysis application, you can perform both first pass analysis and left-to-right shunt analysis on dynamic, non-gated cardiac data. Refer to Chapter 7, which starts on page 93, for details 4 1: Introduction JETStream Workspace Cardiac Applications

13 General Information General Information Loading Studies There are three ways to load a study into an application. See the section on Loading a Study in the JETStream Workspace Instructions for Use for details. To run an application directly, click its button on the application toolbar. Object Associations Each application is configured to open studies with specific object names (a field in the study s header). To change the object names an application accepts, see Matching Datasets to Dataset Drop Boxes in the Configuring JETStream Workspace Instructions for Use. If you try to use an application to open a study with incompatible object names, a message appears stating that auto-matching failed, and asking if you want to open it manually. Common Controls The controls in the top toolbar are common to all applications: exiting, saving, printing, annotating, etc.: Figure 1 Common controls For information on these, see the section on Common Tasks in the JETStream Workspace Instructions for Use. JETStream Workspace Cardiac Applications 1: Introduction 5

14 General Information Cardiac Layout Information If you click on a cardiac study in the Patient Folder List, when its application comes up you see an arbitrary number of views, depending on what datasets are in the study. If you load datasets manually, you can use a layout to its fullest capabilities. (For more on manual loading, see Loading a Study in an Arbitrary Application in the JETStream Workspace Instructions for Use). Generally, JETStream Workspace displays a maximum of 10 images for each view. It can use a combination of these objects: Stress short axis Rest short axis Gated stress short axis Gated rest short axis This means you can potentially have up to 12 views: Stress short axis slices Rest short axis slices Gated stress short axis Gated rest short axis Stress horizontal long axis Rest horizontal long axis Gated stress horizontal long axis Gated rest horizontal long axis Stress vertical long axis Rest vertical long axis Gated stress vertical long axis Gated rest vertical long axis 6 1: Introduction JETStream Workspace Cardiac Applications

15 General Information Note JETStream Workspace creates horizontal and vertical long axis images from the short axis images. If you include the HLA and VLA images in a study, the datasets do not load properly. The solution is either to send only the SAX images to the JETStream Workspace system, or to delete the HLA and VLA images after they arrive (before you display the images). For details on deleting an object, see Deleting Studies and Datasets in the JETStream Workspace Instructions for Use. Viewing Snapshots and Pages Most of the JETStream Workspace applications include layouts for viewing the following types of screenshot images: Snapshots Snapshots are screenshots saved from systems other than JETStream Workspace (e.g., secondary captures; or snapshots from a Pegasys, whose snapshot filenames contain the suffix _SS). Pages Pages are screenshots saved from a JETStream Workspace application. You can load multiple snapshots and pages into an application, although you can view only one snapshot or page at a time. If you have loaded more than one snapshot or page, a screenshot button appears on the layout toolbar in the appropriate layout for each snapshot or page you have loaded. The tooltip for each button is the filename of the corresponding image; click a button to view that image. JETStream Workspace Cardiac Applications 1: Introduction 7

16 General Information Figure 2 Screenshot button You can also use the Previous Object and Next Object buttons to browse through multiple snapshot and page images. Previous Object Next Object Figure 3 Previous Object and Next Object buttons Note Many of the JETStream Workspace applications allow you to load and view only a snapshot or a page (without other datasets). For some applications, however, you must load the application s minimum dataset requirement with any snapshots or pages you want to view. For each of these applications, this restriction is indicated in its corresponding chapter. Snapshot Layout The Snapshot layout displays a single snapshot image in a 1-zone display. For snapshots, the only image control you have is colormap choice. For more on this, see Controlling Image Colors in the JETStream Workspace Instructions for Use. Note Although multiple images may appear in a snapshot, they cannot be selected individually, since they are displayed only as part of the snapshot. 8 1: Introduction JETStream Workspace Cardiac Applications

17 Warnings and Precautions Page Layout The Page layout displays a single page image in a 1-zone display. Unlike the Snapshot layout, the Page layout is interactive: With the exception of layout toolbar buttons, the same basic JETStream Workspace controls that were available in the layout from which a page was saved are available in the Page layout display of that page. Warnings and Precautions Caution Caution Caution It is important to note that when you use Load during a manual load, JETStream Workspace may not load the objects in the proper thumbnail squares. This means that some objects may be mislabeled in the application. Do not use captured images or saved screens for diagnostic use. They may not include all the information necessary for a diagnosis. For this reason, they are only for reference, or inclusion in documents such as reports and presentations. Ensure that any hardcopy output that is to be used for interpretation is of diagnostic quality (printed on Codonics printers, for example). Non-diagnostic output may lead to misinterpretation. Quality Assurance This application module requires no diagnostics, calibration, or testing. JETStream Workspace Cardiac Applications 1: Introduction 9

18 Quality Assurance 10 1: Introduction JETStream Workspace Cardiac Applications

19 2 Layout Tools and Graphic Controls What this Chapter Contains This chapter contains the following sections: Introduction (page 11) Tools and Controls (page 12) Introduction The applications described in this book contain various layout tools and graphic controls that appear either as buttons in the layout toolbar or in various forms (e.g., sliders) next to viewports in which you use them. These tools can be divided into four basic categories: Image Action Buttons you use to perform actions or calculations. Image Synchronization Buttons you use to perform the same action or calculations simultaneously on a group of images. Layout Display Buttons you use to change what images and data are displayed in a layout. JETStream Workspace Cardiac Applications 2: Layout Tools and Graphic Controls 11

20 Tools and Controls ROI Definition Buttons you use when defining regions of interest. This chapter contains descriptions of those tools and controls that appear in applications in the JETStream Workspace Cardiology Module. Note The tools and controls do not appear in all applications or layouts; depending on the loaded datasets, all layouts may not be available in an application. Tools and Controls Image Action Fit Curve The Fit Curve buttons appear in the First Pass and Shunt Analysis application. There are two Fit Curve buttons. Fit primary (Qp) Fit secondary (Qs) Figure 4 Fit Curve button When you click one of the Fit Curve buttons, the application adjusts the corresponding fit curve in the appropriate graph based on the current timing marker positions in that graph. 12 2: Layout Tools and Graphic Controls JETStream Workspace Cardiac Applications

21 Tools and Controls Validate Window The Validate Window button appears in the First Pass and Shunt Analysis application. Figure 5 Validate Window button If you redefine the time window used by the application in selecting cardiac cycles, clicking the Validate Window button directs the application to reselect the ED and ES peaks. Image Synchronization Synchronize Cines The Synchronize Cines button appears in the following applications: MUGA Analysis MUGA Display Figure 6 Synchronize Cines button This button allows you to sync multiple cardiac cines. Clicking this button syncs all the cines to the LAO cine (upper left). It also adjusts the cine rates to match that of the LAO cine. This means that you can adjust all the cine rates at once by adjusting the LAO rate, and then clicking Synchronize Cines button. JETStream Workspace Cardiac Applications 2: Layout Tools and Graphic Controls 13

22 Tools and Controls Synchronized Display The Synchronized Display button appears in the following applications: Cardiac SPECT Display Cardiac Vantage SPECT Display Figure 7 Synchronized Display button When the Synchronized Display button is active (highlighted), you can perform the same actions simultaneously on all images displayed. The specific actions synchronized vary, depending on the layout in which this button appears. Synchronized Triangulation The Synchronized Triangulation button appears in the following applications: Cardiac SPECT Display Cardiac Vantage SPECT Display Figure 8 Synchronized Triangulation button With the Synchronized Triangulation button active (highlighted), you can triangulate among all images in a dataset at the same time. 14 2: Layout Tools and Graphic Controls JETStream Workspace Cardiac Applications

23 Tools and Controls Layout Display Axis The Axis buttons appear in the following applications: Cardiac SPECT Display Cardiac Vantage SPECT Display There are three Axis buttons. Short Axis view Horizontal Long Axis view Vertical Long Axis view Figure 9 Axis buttons Using the Axis buttons, you can change the axis of the images displayed in layouts that display only one axis at a time. Normalization Normalization buttons appear in the following applications: Cardiac SPECT Display Cardiac Vantage SPECT Display There are three Normalization buttons. JETStream Workspace Cardiac Applications 2: Layout Tools and Graphic Controls 15

24 Tools and Controls Normalize to series Normalize to each frame Normalize to myocardium Figure 10 Normalization buttons Depending on the layout and the datasets you have loaded: All Normalization buttons may not be available. Multiple sets of Normalization buttons may be available. Each tooltip indicates which images the button affects (series, frame, or myocardium). Clicking the Normalize to the series button performs the usual normalization using the hottest pixel in the entire slice volume (for volume datasets) or series (for dynamic datasets). This button appears in both cardiac and noncardiac applications. Clicking the Normalize to each Frame button normalizes to the maximum pixel value in the superior half of the pixel data space in each frame. This button appears only in non-cardiac applications. Clicking the Normalize to myocardium button normalizes each cardiac slice individually to the maximum pixel value in the myocardium. This button appears only in cardiac applications. For more on normalization, see Adjusting an Image s Dynamic Range in the JETStream Workspace Instructions for Use. 16 2: Layout Tools and Graphic Controls JETStream Workspace Cardiac Applications

25 Tools and Controls Mask Volume The Mask Volume button appears in the following applications: Cardiac SPECT Display Cardiac Vantage SPECT Display Figure 11 Mask Volume button The Mask Volume button allows you to mask out or black out a portion of the image for all slices in the selected dataset. While the button is active, drag upward in one of the SAX or VLA images in the dataset you want to affect; this pulls up a mask across all slices in that dataset. Similarly, drag downward to unmask the slices. When images are partially or totally masked: The masked area of each slice image is blank. The pixel value in the masked portion of each slice image is zero. Note Note Although you can pull up a mask using only an SAX or VLA image, the application applies the mask to all images SAX, VLA, and HLA in the dataset. The mask remains in place until you pull it back down. JETStream Workspace Cardiac Applications 2: Layout Tools and Graphic Controls 17

26 Tools and Controls ROI Definition Cardiac ROI The Cardiac ROI buttons appear in the First Pass and Shunt Analysis application (for ED, ES, and BKG ROIs), and in the MUGA Analysis application (for RV and BKG ROIs). There are four Cardiac ROI buttons. Draw ED ROI Draw ES ROI Draw RV ROI Draw BKG ROI Figure 12 Cardiac ROI buttons Using these buttons, you can define cardiac ROIs on either the left or the right ventricle, depending on the layout in which the buttons appear. When you click one of these buttons, the cursor becomes a crosshair. Use the crosshair to position the cursor precisely, and click to create a starting point. Whenever you click, a line is drawn to the new point. Keep drawing lines until you get back to where you started. To close the ROI, double-click on or near the first point you created. Note Drawing an ROI using one of the Cardiac ROI buttons works the same way as creating a polygonal ROI using the Create Hand-drawn ROI control from the pop-up menu that appears when you right-click in a viewport. A 18 2: Layout Tools and Graphic Controls JETStream Workspace Cardiac Applications

27 Tools and Controls description of this control can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Cardiac ROI Redraw The Cardiac ROI Redraw buttons appear in the MUGA Analysis application. There are two Cardiac ROI Redraw buttons. Redraw ED region (LV) Redraw ES region (LV) Figure 13 Cardiac ROI Redraw buttons When you click one of these buttons, a redraw layout appears in which you can manually draw or redraw the corresponding ROI. After you have completed the ROI, you can return to the main layout using the Return button. Return The Return button appears in the MUGA Analysis application. Figure 14 Return button The Return button takes you from an interim layout back to the associated main layout. JETStream Workspace Cardiac Applications 2: Layout Tools and Graphic Controls 19

28 Tools and Controls Note This button is not the same as the Previous Layout button on the application toolbar. The Return button is available only in layouts that are part of a main layout (e.g., redraw layouts). 20 2: Layout Tools and Graphic Controls JETStream Workspace Cardiac Applications

29 3 MUGA Analysis What This Chapter Contains This chapter contains the following sections: Introduction (page 21) Performing MUGA Analysis (page 22) Defining Defaults Files (page 37) References (page 48) Introduction The MUGA (Multiplanar Gated Acquisition) Analysis application allows you to automatically segment and quantify gated blood pool datasets. Figure 15 MUGA application icon The minimum dataset requirements for loading a study in this application are: 1 gated dataset, LAO view Note Do not load more than 96 frames (for all datasets combined). If you do, the application will terminate. JETStream Workspace Cardiac Applications 3: MUGA Analysis 21

30 Performing MUGA Analysis Caution Note It is important to note that when you use Load during a manual load, JETStream Workspace may not load the objects in the proper thumbnail squares. This means that some objects may be mislabeled in the application. To display snapshots or pages in this application, you must also meet this application s minimum dataset loading requirement. Performing MUGA Analysis Defining ROIs The application opens in the LV Ejection Fraction layout: 22 3: MUGA Analysis JETStream Workspace Cardiac Applications

31 Performing MUGA Analysis Save Defaults button Retrieve ROIs button Restart button Figure 16 LV Ejection Fraction layout Note The application re-centers and zooms the input datasets as needed to accurately determine the heart boundaries. This layout displays the following: a cine of the entire dynamic sequence in the LAO view an amplitude image a phase image JETStream Workspace Cardiac Applications 3: MUGA Analysis 23

32 Performing MUGA Analysis a phase histogram a regional ejection fraction image 1 ED frame 1 ES frame a graph showing the LV time-activity curve and corresponding derivative curve Note The true left-ventricular time-activity curve can be considered to be a linear interpolation between the curve created by the ED ROI and the curve created by the ES ROI. It has been demonstrated that the LV curve can be obtained by subtracting a factor α and multiplying by another factor 1/λ inferior to 1 from the ED curve (obtained with the ED ROI): α = max 100 (max-min) / EF (EF in %) and 1/λ = LVSV / (max-min) You can recalculate the EF by changing the ED and ES frames. To change the ED or ES frame: 1 Click Select ED Frame or Select ES Frame. Select ED Frame Select ES Frame Figure 17 Frame select buttons A dialog appears: 24 3: MUGA Analysis JETStream Workspace Cardiac Applications

33 Performing MUGA Analysis Figure 18 ED frame number dialog 2 Type the frame number and click OK. Note The appropriate viewport and the values reported on the layout will reflect the new frame. This layout also displays the following data: HR (heart rate) LV Ejection Fraction LV ED Volume LV ES Volume Peak Ejection Rate Peak Filling Rate Time to percent filled at 50%, 33%, and 25% Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: Browse JETStream Workspace Cardiac Applications 3: MUGA Analysis 25

34 Performing MUGA Analysis Pan Zoom Background:Brightness Cine Modes More Info... Reset The application automatically defines and displays LV ES and LV ED ROIs, but you can redraw them as necessary using the Cardiac ROI Redraw buttons. If you have saved ROIs from a previous session, you can load them in. See page 31 for instructions. Otherwise, you can redraw the ROIs. Important If you draw ROIs and then change the frame number, the following message appears at the bottom of the screen: Manual processing or manual changes performed, and system-created ROIs replace the ones you have already drawn. To redraw ROIs: Depending on what you are doing, you may not need to perform all the steps in this procedure. 1 Adjust the display as necessary using the basic controls. 2 If you need to adjust the location or zoom of the image, click Reorient & Zoom. You might use this to center the image or pan it to remove an unwanted hot spot. A layout appears in which you can use the right-click controls to adjust the image s pan and zoom. 26 3: MUGA Analysis JETStream Workspace Cardiac Applications

35 Performing MUGA Analysis Return button Figure 19 Example of a reorient layout When you are satisfied with the reoriented image, click the Return button. 3 Review the LV ED and LV ES ROIs. If the ED ROI is too wide, you can trim it based on contours in the Amplitude image using Erode Using Amplitude Image. JETStream Workspace Cardiac Applications 3: MUGA Analysis 27

36 Performing MUGA Analysis 4 Review the Amplitude image and if necessary, click Erode Using Amplitude Image to adjust the ED ROI. 5 If necessary, select the LV ED or LV ES ROI to redraw by clicking the appropriate Cardiac ROI Redraw button: Redraw ED Region Redraw ES Region A redraw layout appears in which you can manipulate the selected ROI. Figure 20 Example of a redraw layout 28 3: MUGA Analysis JETStream Workspace Cardiac Applications

37 Performing MUGA Analysis 6 Use the basic ROI controls to manipulate the ROI. 7 When you are satisfied with the redrawn ROI, click the Return button. 8 Click the Draw RV ROI button to add an RV ROI. A redraw layout appears with an automatically generated RV ROI. 9 Use the basic ROI controls to manipulate the ROI. 10 When you are satisfied with the redrawn ROI, click the Return button. The RV ROI now appears on the images. 11 If necessary, click Draw Bkg ROI to create a background ROI. Note The small yellow crosshair on the default screen identifies the single pixel that is used as the minimum for the ROI created when you click Draw Bkg ROI. JETStream Workspace Cardiac Applications 3: MUGA Analysis 29

38 Performing MUGA Analysis Figure 21 Example of a background ROI layout 12 Review the automatically-drawn background ROI. Modify or redraw it if necessary, and click Return. Note After calculating or redrawing the background ROI, the quantitative results reported in the layout are updated. 30 3: MUGA Analysis JETStream Workspace Cardiac Applications

39 Performing MUGA Analysis Note If you redraw ROIs and then you would like to discard your edits and return to the original automaticallygenerated version of the ROIs, click Restart (see Figure 16). You can save the ROIs you have drawn and reuse them whenever you open the study. To save ROIs: 1 Click Save screen to local DB. A Save dialog appears. 2 Type a name for the file. To reuse saved ROIs: 1 When you load the study, be sure to select the page you saved above. 2 In the application, display the page by clicking on the Page layout button. 3 Click Retrieve Rois (see Figure 16). This returns you to the EF layout, which now has the ROIs loaded in the EF data. Reviewing Results You can review results in two layouts: Phase Analysis Series JETStream Workspace Cardiac Applications 3: MUGA Analysis 31

40 Performing MUGA Analysis Note Note Phase and amplitude images in the layouts are standard Nuclear Medicine images. The definition and usage of these images are not unique to the JETStream Workspace system. The phase image represents volumetric changes in each pixel, demonstrating which areas of the heart beat in phase with the atria and ventricles, and which areas beat out of phase, such as with arrhythmias. The amplitude image displays the values of maximum count changes with no regard to phase, in effect describing the magnitude of cardiac contraction. You cannot zoom or pan phase and amplitude images. Phase Analysis Layout Click the Phase Analysis button to display multiharmonic phase analysis results. This layout displays the following LV data: a phase image a histogram values based on the ROIs defined in the LV Ejection Fraction layout for the following: - LV Ejection Fraction - LV ED Volume - LV Mode - LV Avg - Std Dev This layout also displays the following RV data: a phase image a histogram 32 3: MUGA Analysis JETStream Workspace Cardiac Applications

41 Performing MUGA Analysis values based on the ROI defined in the LV Ejection Fraction layout for the following: - RV Ejection Fraction - Stroke Volume Ratio - RV Mode - RV Avg - Std Dev Note EF calculation for the left ventricle is based on the use of two regions of interest. Due to morphology, however, the right ventricle EF is calculated in a different way. It is too difficult to delineate the true contour of the RV at end systole, and therefore only the RV ED ROI can be used. This means that one cannot calculate the RV EF first and then use it to adjust the RV curve, because calculating the EF this way requires using two ROIs (as with the LV). Instead, an initial RV curve must be obtained from the RV ED ROI alone. This initial curve must then be adjusted using factors derived from those computed on the LV, after which the RV ED, RV SV and RV EF can be computed from the adjusted RV curve. Assuming that the RV background is higher than the LV background, the value 1.1 α is subtracted from the RV curve. Then, assuming that the RV ED ROI cannot encompass the whole RV because of its convoluted shape, the subtracted curve is multiplied by 1.2/λ α and 1/λ; these are the adjustment factors used on the LV curve. Those two RV factors must be adjusted during the clinical validation to yield an average stroke volume ratio of unity and an average end-diastolic volume ratio compatible with statistics. JETStream Workspace Cardiac Applications 3: MUGA Analysis 33

42 Performing MUGA Analysis Once the RV curve has been corrected, RVED, RVSV, and RVEF are measured directly from it: max, max-min and (max-min)/max, respectively. Then, the Stroke Volume Ratio (SVR) is calculated as LVSV/RVSV; LVSV is either as measured on the LV curve or remembered from the LVEF computation. Before displaying these results, LVED, as measured on the LV curve, and RVED are normalized by a common factor (= 100/LVED) such that LVED becomes 100, to emphasize the fact that all volume measurements are relative. Figure 22 Phase Analysis layout 34 3: MUGA Analysis JETStream Workspace Cardiac Applications

43 Performing MUGA Analysis In this layout, the only image control you have is colormap choice. For more on this, see Controlling Image Colors in the JETStream Workspace Instructions for Use. Series Layout Click the Series Layout button to display the Series layout. For each dataset you have loaded, this layout displays the following: a cine of the entire dynamic sequence multiple individual frames in the dynamic sequence an amplitude image a phase image JETStream Workspace Cardiac Applications 3: MUGA Analysis 35

44 Performing MUGA Analysis Figure 23 Series layout (four datasets loaded) Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: 36 3: MUGA Analysis JETStream Workspace Cardiac Applications

45 Defining Defaults Files Browse Pan Zoom Cine Modes More Info... Reset If you stop and start a cine, it may be out of sync with other cines. To sync them up again, use the Synchronize Cines button. Note The Synchronize Cines button syncs all the cines to the cine in the upper left. It also adjusts the cine rates to match that of the LAO cine. Defining Defaults Files Using the Save Defaults dialog, you can define your own default parameter sets by modifying the settings in the currently applied Philips Defaults file and saving the changed defaults file as a User Defaults file. You can also delete User Defaults files. Important You cannot delete a Philips Defaults file or replace it with a changed defaults file. JETStream Workspace Cardiac Applications 3: MUGA Analysis 37

46 Defining Defaults Files Figure 24 MUGA Defaults Selection dialog The LV Ejection Fraction: slope and intercept values are values you must calculate based on analyzing patient studies. To calculate slope and intercept: 1 Process enough ejection fraction studies on your acquisition system to result in a total of at least 24 studies (60 studies is optimal) with the following characteristics: 1/3 of the studies should have EF < 40% 1/3 of the studies should have 40% < EF < 60% 1/3 of the studies should have EF > 60% 2 Process the same studies on JETStream Workspace in this application using a slope value of 1.0 and intercept of : MUGA Analysis JETStream Workspace Cardiac Applications

47 Defining Defaults Files Important Note Be sure to use 1.0 and 0 as the slope and intercept values for this step. If you do not, you cannot establish a baseline for comparison with your acquisition system. 3 Create a graph that plots the JETStream Workspace results on the x axis and your acquisition system s results on the y axis. 4 Perform a linear regression on the plots. 5 Use the slope and intercept values of the resulting line (y = mx + b) as the values in the defaults dialog. You can perform this procedure for as many acquisition systems as you have and create a defaults file for each one. To define your own defaults file: 1 Click the Save Defaults button. Figure 25 Save Defaults button The Defaults Dialog for the current application appears. 2 Make changes to the fields as desired. 3 Enter a File Name for your new defaults file, if you do not want to use the default provided. 4 When you are finished, do one of the following: Click Save to save the new defaults file. Note Saved user-defined defaults files appear in the User Defaults section of the Defaults Dialog the next time you open it, either by launching the application or clicking the Load Defaults button from inside the application. JETStream Workspace Cardiac Applications 3: MUGA Analysis 39

48 Defining Defaults Files Note Note In most applications that use defaults files, if you click Save instead of Save and Apply, you can still apply the new defaults file to the currently loaded datasets at a later time in the same session by clicking the Load Defaults button and selecting the new defaults file from the list of User Defaults. Click Save and Apply to save your changes and apply them to the datasets currently loaded. Click Update Site Level to save the new defaults file to the Default folder (site level settings). This choice is available only to users with administrator privileges. Click Delete to permanently erase the file that appears in the File Name field. Click Cancel to return to the current layout without saving any changes you have made. To delete a defaults file: 1 Load the defaults file you want to delete using one of the following methods: When you open the application, select that defaults file from the list in the initial Defaults Dialog that appears. In the application, click the Load Defaults button and select that file from the list in the Defaults Dialog. Important You can delete only User Defaults files; you cannot delete a Philips Defaults file or replace it with a changed defaults file. 2 Click the Save Defaults button. The Defaults Dialog for the current application appears. 40 3: MUGA Analysis JETStream Workspace Cardiac Applications

49 Algorithms Used in MUGA Analysis 3 Click Delete to delete the current defaults file. 4 Click OK in the confirmation dialog. 5 Click Cancel to close the Defaults Dialog and return to the current layout. The deleted defaults file no longer appears in the list of User Defaults. Algorithms Used in MUGA Analysis Prerequisites The ventricles should be reasonably centered in the frame and the septum should appear vertical, as the edgedetection algorithms will make such assumptions. There should be enough counts to support the various operations required by the processing - of the order of one million counts total inside the ventricles, all frames combined. In case the acquisition was too short or the isotope dose too weak, a preference attribute is provided that will trigger the use of extra-smoothing where appropriate. Preprocessing Geometric The images are converted to matrices, regardless of their original format; if the pixel size is larger than 0.35 cm, the sequence of frames is re-centered, using the center of gravity of the amplitude image as new center, and a zoom is applied such that the new pixel size is 0.3 cm. JETStream Workspace Cardiac Applications 3: MUGA Analysis 41

50 Algorithms Used in MUGA Analysis Tail-drop correction Some datasets will originate from acquisition systems that do not provide for tail-drop correction. Tail-drop is due to the fact that the duration of the heart cycle varies by as much as 20% even in healthy individuals. Thus, if the time per frame is adjusted to accommodate the longest heart cycle, any shorter cycle will terminate before the end of the last frame, thereby leaving that last frame or (or the last 2 or more frames) with fewer counts than expected. To decide whether a correction is required, we compare the total counts in the second, the penultimate and the last frame: if the last frame has at least as many counts as the previous one, within 2 standard deviations, and at least 95% of the counts in the second frame, then there is no need for correction. If a correction is required, we start by discarding any frame at the end that would have less than half the activity of the second one, on the grounds that they do not really belong in the average heart cycle - they are superfluous. A frame is then created by summing together all frames in the sequence; this frame is used to generate a region of interest from the 50% isocontour and the ROI, in turn, is applied to the sequence to mask off the heart - and thus eliminate any count variation due to the emptying and filling of the cardiac chambers. A total activity curve is derived from the masked sequence and normalized so that the second point has a value of one (the first frame usually lasts a little less than the others, due to the random time of appearance of the R-wave;) the original sequence is then divided by this curve. Fourier analysis: first, the average frame is generated from the sequence and median filtered (if the extrasmoothing, mentioned at the end of the first paragraph, is 42 3: MUGA Analysis JETStream Workspace Cardiac Applications

51 Algorithms Used in MUGA Analysis enabled, a 10% background is subtracted from that frame - and, therefore, from every frame of the reconstructed sequence; see below.) Then the first 4 sine and cosine images are calculated and filtered. The first sine and cosine are used to create the Amplitude and Phase images. A phase histogram is also generated Then, the average frame and the 4 harmonic pairs of sine and cosine are used to regenerate a time-filtered sequence; this new sequence will be used for the rest of the processing. Finding the edge of the LV The edges of organs in nuclear medicine planar images are generally estimated to lie at the points where the rate of decrease in activity starts slowing down: these correspond to a maximum in the second derivative of the activity profile. The edge finding algorithm consists, therefore, in deciding on a good estimate of the center of the organ and finding maxima of the second derivative of activity profiles along radii issued from that center. To estimate the location of the LV center, we calculate the center of gravity of the amplitude image, and then eliminate all pixels to the anatomical right of that point and recalculate the center of gravity. Is the second derivative the best choice? The point of maximum slope would be just as valid a criterion for the edge, albeit one that would delineate a tighter edge. The advantage of the second derivative is that it reaches a maximum at the watershed lines, such as the septum between right and left ventricles. JETStream Workspace Cardiac Applications 3: MUGA Analysis 43

52 Algorithms Used in MUGA Analysis The use of the Gradient The gradient is a measure of the variation of activity around each point of the image; it is defined by: A x A y 2 Adding its gradient to an image will emphasize the areas of maximum slope, which can make the image easier to interpret. General location of the ventricles In order to get some idea of where the LV lies, we will first find a group of pixels that most likely belong to either ventricle and to nothing else. We can obtain such a cluster of pixels by generating an amplitude image, reduced to areas that move in phase with the ventricles (thus rejecting the atria.) We call this image pseudo-amplitude and we obtain it as the sum of -sin1 + +cos1, i.e. we eliminate all positive values of the first harmonic sine image and all negative values of the cosine image and create the pseudoamplitude as cos1-sin1, with some fairly heavy smoothing. Select ED frame and generate 2nd derivative images: a rough contour of both ventricles together is obtained from the pseudo-amplitude image and used to generate a timeactivity curve from the gated sequence; the point of maximum activity on that curve determines the index of the ED frame in the sequence. That frame is then enhanced by adding its gradient to it. Then, 2nd derivative images of the ED frame are generated, along X, Y and both diagonals, and they are summed together to form what we call the pseudo-laplacian image. 44 3: MUGA Analysis JETStream Workspace Cardiac Applications

53 Algorithms Used in MUGA Analysis Finding the septum A first approximation of the septum is obtained by looking for the bottom of the valley between RV and LV. This approximation is used to generate a mask that will eliminate the RV and all points to the (anatomical) right (left, on the screen) of the LV. Eliminating pixels above the ventricles: in a similar manner, we want to eliminate al the points above the ventricles; this is done by using a mask containing all points under the upper limit of the pseudo-amplitude image. This mask will be used to eliminate all points situated above the ventricles, we call it bi-ventricular mask. Finding the center of the LV Masking the pseudo-amplitude image with the septum mask, we obtain a reasonable approximation of the LV; then, the center of gravity of that image gives us a very good estimate of the position of the center of the LV. Creating an edge-enhanced LV frame: starting from the enhanced ED frame (ED frame plus gradient), we apply the septum mask and the bi-ventricular mask and subtract the sum of 2nd derivatives, thus obtaining an LV image with accentuated edges, with pixel values along the edge often going down to 0. This image is further masked by the 20% isocontour of the original ED frame, to make sure we do not include any non-cardiac areas. Performing the radial search Using the coordinates of the LV center, and the edgeenhanced ED frame, we perform a radial search for the first local minimum along each radius. If there is no local minimum, we stop at the first zero. This operation yields a closed contour, which we smooth with a median filter. JETStream Workspace Cardiac Applications 3: MUGA Analysis 45

54 Algorithms Used in MUGA Analysis Having obtained a good estimate of the full contour of the LV, we use the geometric center of that closed curve as a better estimate of the location of the center of the LV and repeat the radial search one more time. This final contour is then used to create the LVED ROI Finding the edge of the LV at ES The search for the LVES ROI is much simpler, as we already know where the LV is and where its center lies. We obtain an enhanced ES frame just as we did for the ED, and perform the radial search on it as for the ED. Finding the edge of the RV We only determine one automatic ROI for the RV; it is obtained as the exclusion of the pseudo-amplitude biventricular contour and the LVED contour. Computing the ejection fraction Measuring ED and ES counts and background: using the LVED ROI, we create an accurate raw LV volume curve, from which we determine the index of the real ED and ES frames. Applying the ED ROI to the ED frame and the ES ROI to the ES frame, we obtain edcounts and escounts. Background is normally estimated as 95% of the smallest pixel value encountered in the ED frame within the ED ROI, which is indicated by the single yellow pixel on the edge of the ED ROI on the LV Ejection Fraction page. The reasoning is that, if there were no background, at least one pixel (more likely a whole series of pixels) at the very edge of the ventricle would be very close to zero, for 46 3: MUGA Analysis JETStream Workspace Cardiac Applications

55 Algorithms Used in MUGA Analysis reasons of continuity. However, for users who prefer the more classical method of using a separate ROI for background, this option is selectable in the preferences Computing the EF The ventricular counts are corrected for background, more background being subtracted form the ES counts, on the assumption that background is higher near the base of the ventricle. The computation sequence is: edcounts = edcounts -.97 bkg edpixels; escounts = escounts bkg espixels; lvstroke = edcounts - escounts; LVEF = 100 lvstroke / edcounts; For esthetic reasons, the curve is adjusted (by scaling and thresholding) so that it reflects the same EF and stroke volume as the ones just calculated. Creating a high temporal resolution LV volume curve Gated sequences are usually acquired with a frame duration of the order of 40 ms, yielding a volume curve with approximately 20 points. This is not really sufficient to calculate accurately parameters such as the time of maximum filling rate; in order to obtain better precision, we resample the curve using its Fourier transform, limited to 4 harmonics, and inverse-transformed into N points, such that each point represents exactly 10 ms, regardless of the original time per frame. This new curve is used to compute the fast emptying and fast filling rates, their time of occurrence, and the time of 25%, 33% and 50% filling. JETStream Workspace Cardiac Applications 3: MUGA Analysis 47

56 References Computing the LV diastolic volume Using the Massardo method, the volume is computed as: LVED volume 1.38 (pixelsize) 3 edcounts = maxvalue References Improved Detection of anterior Left Ventricular Aneurysm with Multiharmonic fourier Analysis Heric B. Valette, Michel H. Borguignon, et al. J Nucl Med 1990; 31: Filters and Fourier Analysis of Gated Blood Pool Studies: A Search for the Optimal Combination H. Valette, M H Bourguignon, et al. Phys Med Biol 1990; 35(1):1-11 A fully automated determination of the left ventricular region of interest in nuclear angiocardiography ML Goris, JH McKillop, PA Briandet Cardiovasc Intervent Radilo 1981;4(2): : MUGA Analysis JETStream Workspace Cardiac Applications

57 4 MUGA Display What This Chapter Contains This chapter contains the following sections: Introduction (page 49) Multi-Cines Layout (page 50) Introduction The MUGA (Multiplanar Gated Acquisition) Display application provides a way to review gated cines of cardiac patients. Figure 26 MUGA Display application icon The minimum dataset requirements for loading a study in this application are: 1 gated dataset in any of four views (LAO, RAO, Anterior, Lateral) Caution It is important to note that when you use Load during a manual load, JETStream Workspace may not load the objects in the proper thumbnail squares. This means that some objects may be mislabeled in the application. JETStream Workspace Cardiac Applications 4: MUGA Display 49

58 Multi-Cines Layout Multi-Cines Layout This layout displays up to four cines of the following images, depending on the selected study: LAO ANT LAT RAO Supported image resolutions are: 64 x x : MUGA Display JETStream Workspace Cardiac Applications

59 Multi-Cines Layout Figure 27 Multi-Cines layout Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: JETStream Workspace Cardiac Applications 4: MUGA Display 51

60 Multi-Cines Layout Browse Pan Zoom Background:Brightness Cine Modes More Info... Reset If you stop and start a cine, it may be out of sync with other cines. To sync them up again, use the Synchronize Cines button. Note The Synchronize Cines button syncs all the cines to the cine in the upper left. It also adjusts the cine rates to match that of the LAO cine. 52 4: MUGA Display JETStream Workspace Cardiac Applications

61 5 Cardiac SPECT Display What This Chapter Contains This chapter contains the following sections: Introduction (page 53) Mask Layout (page 54) Three View Layout (page 57) Three View No Gate Layout (page 60) One View Layout (page 62) Tomo View Layout (page 66) Composite Layout (page 68) Saving Data (page 70) Introduction The Cardiac SPECT Display application provides a way to review myocardial slice images of cardiac patients. Images can be Stress and Rest Gated SAX images, and Stress and Rest SAX images. It displays up to 4 datasets. Gated objects appear in static (splash) and cine format. Figure 28 Cardiac SPECT Display application icon JETStream Workspace Cardiac Applications 5: Cardiac SPECT Display 53

62 Mask Layout The minimum dataset requirements for loading a study in this application are: 1 SPECT volume dataset (Stress or Rest SAX) or 1 gated volume dataset (Stress or Rest Gated SAX) or 1 tomo (Stress or Rest) or 1 gated tomo (Stress or Rest) Caution It is important to note that when you use Load during a manual load, JETStream Workspace may not load the objects in the proper thumbnail squares. This means that some objects may be mislabeled in the application. Mask Layout This layout displays multiple images for each of these views, depending on the selected study: Stress and Rest gated SAX Stress SAX Rest SAX It creates three views from the datasets: SAX stress and rest slice and cine VLA stress and rest slice and cine HLA stress and rest slice and cine 54 5: Cardiac SPECT Display JETStream Workspace Cardiac Applications

63 Mask Layout Note The dataset consists only of short axis information; the vertical and horizontal datasets are generated automatically. Supported image resolutions are: 64 x x x 256 In this layout, you can define a closed region mask in the dataset that sets the pixel values of data inside or outside the mask to 0. The ROI for the mask appears on the SAX image, even if you bring up the menu on an HLA or VLA image. However, any masked images are preserved in viewports in other layouts. To create a mask: 1 Create an ROI on an image. Note Note If you create more than one ROI, the first one created will be used as the mask. Other ROIs are ignored. 2 Right-click on the ROI. 3 Select ROIs->Mask In to set the pixels inside the ROI to 0; select ROIs->Mask Out to set the pixels outside the ROI to 0. The window/level and normalizations are calculated and rendered based on the unmasked pixel values. JETStream Workspace Cardiac Applications 5: Cardiac SPECT Display 55

64 Mask Layout Figure 29 Mask layout Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: 56 5: Cardiac SPECT Display JETStream Workspace Cardiac Applications

65 Three View Layout Browse Zoom Cine Modes More Info... ROIs Reset To normalize the images, click either the Normalize to the series or the Normalize to myocardium button. You can saved masked datasets so that you can load and review them in a later session. For more on this see Saving Data on page 70. Three View Layout This layout displays multiple images for each of these views, depending on the selected study: Stress and Rest gated SAX Stress SAX Rest SAX It creates three views from the datasets: SAX slices VLA slices HLA slices Note The dataset consists only of short axis information; the vertical and horizontal datasets are generated automatically. JETStream Workspace Cardiac Applications 5: Cardiac SPECT Display 57

66 Three View Layout Supported image resolutions are: 64 x x x 256 Figure 30 Three View layout with Stress SAX, Rest SAX, Stress gated SAX, and Rest gated SAX 58 5: Cardiac SPECT Display JETStream Workspace Cardiac Applications

67 Three View Layout Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: Triangulate Zoom Background:Brightness Cine Modes More Info... Reset To normalize the images, click either the Normalize to the series or the Normalize to myocardium button. Use the Synchronized Triangulation button to coordinate triangulation among all images displayed. Use the Mask Volume button to mask the slices in one or more datasets. Note Note You can save masked datasets; see Saving Data on page 70. You can then load them into the application in a later session to review them. If you want to view slices for alignment, you can either use the triangulation feature (click and drag inside an image) or you can click on an image and press the left and right arrow keys on the keyboard. JETStream Workspace Cardiac Applications 5: Cardiac SPECT Display 59

68 Three View No Gate Layout Three View No Gate Layout This layout displays multiple images for each of these views, depending on the selected study: Stress SAX Rest SAX It creates three views from the datasets: SAX slices HLA slices VLA slices Note The dataset consists only of short axis information; the vertical and horizontal datasets are generated automatically. Supported image resolutions are: 64 x x x : Cardiac SPECT Display JETStream Workspace Cardiac Applications

69 Three View No Gate Layout Figure 31 Three View No Gate layout Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: JETStream Workspace Cardiac Applications 5: Cardiac SPECT Display 61

70 One View Layout Triangulate Zoom Background:Brightness More Info... Reset To normalize the images, click either the Normalize to the series or the Normalize to myocardium button. Use the Synchronized Triangulation button to coordinate triangulation among all images displayed. Use the Mask Volume button to mask the slices in one or more datasets. Note Note You can save masked datasets; see Saving Data on page 70. You can then load them into the application in a later session to review them. If you want to view slices for alignment, you can either use the triangulation feature (click and drag inside an image) or you can click on an image and press the left and right arrow keys on the keyboard. To normalize the images, click either the Normalize to the series or the Normalize to myocardium button. One View Layout Depending on the selected study, this layout displays multiple images for each of the following: 62 5: Cardiac SPECT Display JETStream Workspace Cardiac Applications

71 One View Layout Summed stress SAX Summed rest SAX Gated stress and rest SAX Images in only one axis appear in the layout, but you can switch among them using the Axis buttons. The application creates images in three axes from the datasets: SAX slices VLA slices HLA slices Note The datasets consist only of short axis information; the vertical and horizontal datasets are generated automatically. Images can be summed or gated. Supported image resolutions are: 64 x x x 256 JETStream Workspace Cardiac Applications 5: Cardiac SPECT Display 63

72 One View Layout Figure 32 One View layout with gated Stress and Rest SAX Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: 64 5: Cardiac SPECT Display JETStream Workspace Cardiac Applications

73 One View Layout Browse Pan Zoom Background:Brightness Cine Modes More Info... Reset To normalize the images, click either the Normalize to the series or the Normalize to myocardium button. Use the Synchronized Display button to synchronize the following actions among all images displayed: Browse Pan Zoom Background:Brightness Use the Mask Volume button to mask the slices in one or more datasets. Note Note You can save masked datasets; see Saving Data on page 70. You can then load them into the application in a later session to review them. If you want to view slices for alignment, you can either use the triangulation feature (click and drag inside an image) or you can click on an image and press the left and right arrow keys on the keyboard. JETStream Workspace Cardiac Applications 5: Cardiac SPECT Display 65

74 Tomo View Layout Tomo View Layout This layout displays up to four of the following cines, depending on the selected study: Gated rest tomo Gated stress tomo Stress tomo Rest tomo It can use the following datasets: Gated stress tomo Gated rest tomo Stress tomo Rest tomo Any other raw data tomo 66 5: Cardiac SPECT Display JETStream Workspace Cardiac Applications

75 Tomo View Layout Figure 33 Tomo View layout Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: JETStream Workspace Cardiac Applications 5: Cardiac SPECT Display 67

76 Composite Layout Browse Pan Zoom Background:Brightness Cine Modes More Info... Reset Composite Layout This layout displays multiple images and cines for each of these views, depending on the selected study: Summed stress and rest tomos Stress SAX Rest SAX It creates three views from the datasets: SAX slices VLA slices HLA slices Note The dataset consists only of short axis information; the vertical and horizontal datasets are generated automatically. 68 5: Cardiac SPECT Display JETStream Workspace Cardiac Applications

77 Composite Layout Figure 34 Composite layout Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: JETStream Workspace Cardiac Applications 5: Cardiac SPECT Display 69

78 Saving Data Triangulate Browse Pan Zoom Background:Brightness Cine Modes More Info... Reset To normalize the images, click either the Normalize to the series or the Normalize to myocardium button. Use the Synchronized Triangulation button to coordinate triangulation among all images displayed. Use the Mask Volume button to mask the slices in one or more datasets. Note Note You can save masked datasets; see Saving Data on page 70. You can then load them into the application in a later session to review them. If you want to view slices for alignment, you can either use the triangulation feature (click and drag inside an image) or you can click on an image and press the left and right arrow keys on the keyboard. Saving Data You can saved masked datasets so that you can load and review them in a later session. 70 5: Cardiac SPECT Display JETStream Workspace Cardiac Applications

79 Saving Data To save masked datasets: 1 Click the Save Data button. Figure 35 Save Data button The Save Data... dialog appears. 2 Select the datasets you want to save by checking the corresponding boxes. Note Note Unchecked datasets are not saved. 3 Enter a new name for each selected dataset. The name appears as the Object Name in the patient browser. Use a meaningful naming convention, such as appending _mask to the default dataset name, so you can easily identify this type of dataset in future sessions. 4 Click Save. The selected masked datasets are saved in the same exam as the original datasets. The pixel value of the masked portions of the images is zero. Clicking Cancel returns you to the current layout without saving. JETStream Workspace Cardiac Applications 5: Cardiac SPECT Display 71

80 Saving Data 72 5: Cardiac SPECT Display JETStream Workspace Cardiac Applications

81 6 Cardiac Vantage SPECT Display What This Chapter Contains This chapter contains the following sections: Introduction (page 73) Mask Layout (page 74) Three View Layout (page 77) One View Layout (page 79) Tomo Layout (page 82) Volume TR Layout (page 84) Vantage QC Layout (page 88) Saving Data (page 90) Introduction The Cardiac Vantage SPECT application provides a way to review Vantage myocardial slice images of cardiac patients. It displays Stress and Rest SAX, Stress and Rest Corrected SAX, and Gated SAX images. Gated objects appear as cines. The application also allows you to display the transmission projection data and reference images along with the comparative stress/rest/corrected images. JETStream Workspace Cardiac Applications 6: Cardiac Vantage SPECT Display 73

82 Mask Layout Figure 36 Cardiac Vantage Display application icon The minimum dataset requirements for loading a study in this application are: 1 SPECT volume dataset (Stress or Rest SAX) or 1 gated volume dataset (Stress or Rest Gated SAX) or 1 tomo (Stress or Rest) or 1 gated tomo (Stress or Rest) or 1 reference image (static) Caution It is important to note that when you use Load during a manual load, JETStream Workspace may not load the objects in the proper thumbnail squares. This means that some objects may be mislabeled in the application. Mask Layout This layout displays multiple images for each of these views, depending on the selected study: Stress and Rest gated SAX Stress SAX Rest SAX 74 6: Cardiac Vantage SPECT Display JETStream Workspace Cardiac Applications

83 Mask Layout It creates three views from the datasets: SAX stress and rest slice and cine VLA stress and rest slice and cine HLA stress and rest slice and cine Note The dataset consists only of short axis information; the vertical and horizontal datasets are generated automatically. Supported image resolutions are: 64 x x x 256 In this layout, you can define a closed region mask in the dataset that sets the pixel values of data inside or outside the mask to 0. The ROI for the mask appears on the SAX image, even if you bring up the menu on an HLA or VLA image. However, any masked images are preserved in viewports in other layouts. To create a mask: 1 Create an ROI on an image. Note If you create more than one ROI, the first one created will be used as the mask. Other ROIs are ignored. 2 Right-click on the ROI. 3 Select ROIs->Mask In to set the pixels inside the ROI to 0; select ROIs->Mask Out to set the pixels outside the ROI to 0. JETStream Workspace Cardiac Applications 6: Cardiac Vantage SPECT Display 75

84 Mask Layout Note The window/level and normalizations are calculated and rendered based on the unmasked pixel values. Figure 37 Mask layout Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: 76 6: Cardiac Vantage SPECT Display JETStream Workspace Cardiac Applications

85 Three View Layout Browse Zoom More Info... Cine Modes ROIs Reset To normalize the images, click either the Normalize to the series or the Normalize to myocardium button. You can saved masked datasets so that you can load and review them in a later session. For details, see Saving Data on page 90. Three View Layout This layout displays gated cines for each of these views, depending on the selected study: Stress SAX Rest SAX Stress HLA Rest HLA Stress VLA Rest VLA It can use these datasets: Stress SAX Stress corrected SAX Rest SAX JETStream Workspace Cardiac Applications 6: Cardiac Vantage SPECT Display 77

86 Three View Layout Rest corrected SAX Gated SAX Note The dataset consists only of short axis information; the vertical and horizontal datasets are generated automatically. Supported image resolutions are: 64 x x 128 Figure 38 Three View layout 78 6: Cardiac Vantage SPECT Display JETStream Workspace Cardiac Applications

87 One View Layout Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: Triangulate Background:Brightness Zoom More Info... Cine Modes Reset To normalize the images, click either the Normalize to the series or the Normalize to myocardium button. You can browse the image slices by placing the cursor over an image and using the left and right arrow buttons on the keyboard. Note You can save masked datasets; see Saving Data on page 90. You can then load them into the application in a later session to review them. One View Layout This layout displays multiple images for each of these views, depending on the selected study: Stress Stress AC JETStream Workspace Cardiac Applications 6: Cardiac Vantage SPECT Display 79

88 One View Layout Rest Rest AC Images in only one axis appear in the layout, but you can switch among them using the Axis buttons. It can use these datasets: Stress SAX Stress corrected SAX Rest SAX Rest corrected SAX Gated SAX Note The datasets consist only of short axis information; the vertical and horizontal datasets are generated automatically. Supported image resolutions are: 64 x x : Cardiac Vantage SPECT Display JETStream Workspace Cardiac Applications

89 One View Layout Figure 39 One View layout Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: JETStream Workspace Cardiac Applications 6: Cardiac Vantage SPECT Display 81

90 Tomo Layout Browse Pan Zoom Background:Brightness More Info... Reset To normalize the images, click either the Normalize to the series or the Normalize to myocardium button. Use the Synchronized Display button to synchronize the following actions among all images displayed: Browse Pan Zoom Background:Brightness Use the Mask Volume button to mask the slices in one or more datasets. Note You can save masked datasets; see Saving Data on page 90. You can then load them into the application in a later session to review them. Use the Mask Volume button to mask the slices in one or more datasets. Tomo Layout This layout displays multiple images of each of the following views, depending on the selected study: 82 6: Cardiac Vantage SPECT Display JETStream Workspace Cardiac Applications

91 Tomo Layout Stress tomo emission Stress tomo transmission Rest tomo emission Rest tomo transmission Supported image resolutions are: 64 x x 128 Figure 40 Tomo layout JETStream Workspace Cardiac Applications 6: Cardiac Vantage SPECT Display 83

92 Volume TR Layout Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: Browse Pan Zoom Background:Brightness Cine Modes More Info... Reset Volume TR Layout This layout displays multiple volume transmission images, depending on the selected studies. It can use these datasets: Stress Transverse Transmission Rest Transverse Transmission 84 6: Cardiac Vantage SPECT Display JETStream Workspace Cardiac Applications

93 Volume TR Layout Figure 41 Volume TR layout Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: JETStream Workspace Cardiac Applications 6: Cardiac Vantage SPECT Display 85

94 Frame Layout Browse Pan Zoom Background:Brightness Image Manipulation More Info... Reset Frame Layout This layout is available only if you have loaded reference images. 86 6: Cardiac Vantage SPECT Display JETStream Workspace Cardiac Applications

95 Frame Layout Figure 42 Frame layout Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: JETStream Workspace Cardiac Applications 6: Cardiac Vantage SPECT Display 87

96 Vantage QC Layout Pan Zoom Background:Brightness More Info... Image Manipulation ROIs Reset Vantage QC Layout This layout displays multiple images of each of the following, depending on the selected study: Stress attenuation map slices Rest attenuation map slices Additionally, it displays: Stress emission cine Rest emission cine Transmission/emission QC information (if present) Note This layout displays the Vantage post-acquisition QC (Truncation and Count) values on the transmission map page provided the information is available in the image header. Supported image resolutions are: 64 x x : Cardiac Vantage SPECT Display JETStream Workspace Cardiac Applications

97 Vantage QC Layout Figure 43 Vantage QC layout Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: JETStream Workspace Cardiac Applications 6: Cardiac Vantage SPECT Display 89

98 Saving Data Browse Pan Zoom Background:Brightness More Info Cine Modes Reset Saving Data You can saved masked datasets so that you can load and review them in a later session. To save masked datasets: 1 Click the Save Data button. Figure 44 Save Data button The Save Data... dialog appears. 2 Select the datasets you want to save by checking the corresponding boxes. Note Unchecked datasets are not saved. 3 Enter a new name for each selected dataset. The name appears as the Object Name in the patient browser. Use a meaningful naming convention, such as appending _mask to the default dataset name, so you can easily identify this type of dataset in future sessions. 90 6: Cardiac Vantage SPECT Display JETStream Workspace Cardiac Applications

99 Saving Data 4 Click Save. The selected masked datasets are saved in the same exam as the original datasets. The pixel value of the masked portions of the images is zero. Note Clicking Cancel returns you to the current layout without saving. JETStream Workspace Cardiac Applications 6: Cardiac Vantage SPECT Display 91

100 Saving Data 92 6: Cardiac Vantage SPECT Display JETStream Workspace Cardiac Applications

101 7 First Pass and Shunt Analysis What This Chapter Contains This chapter contains the following sections: Introduction (page 93) Performing First Pass Analysis (page 94) Performing Left-to-Right Shunt Analysis (page 119) Introduction Using the First Pass and Shunt Analysis application, you can perform both first pass analysis and left-to-right shunt analysis on dynamic, non-gated cardiac data. Figure 45 First-Pass application icon The minimum dataset requirements for loading a study in this application are: 1 dynamic dataset Note To display snapshots or pages in this application, you must also meet this application s minimum dataset loading requirement. For dynamic first pass acquisitions, the following parameters are recommended: JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 93

102 Performing First Pass Analysis time per frame: 40 msec acquisition time: sec image resolution: 64 x 64 Important Note Longer acquisitions or higher image resolutions may result in poor system performance due to the resulting high volume of data. Also, the application is limited to datasets of no more than 900 frames. The first pass analysis portion of this application includes the following: Quantitative left and right ventricular analysis - volumes - ejection fraction - cardiac output Qualitative left ventricular and right ventricular analysis - wall motion - functional imaging analysis The left-to-right shunt analysis portion of this application allows you to calculate a Qp/Qs ratio using the gammavariate fit method. If you want to perform only left-to-right shunt analysis, go directly to the section Performing Left-to-Right Shunt Analysis, which starts on page 119. Performing First Pass Analysis First pass ventricular analysis consists of the following basic steps: 94 7: First Pass and Shunt Analysis JETStream Workspace Cardiac Applications

103 Performing First Pass Analysis Setting initial timing regions of interest Reviewing for quality control Drawing ROIs and selecting ventricular cycles for analysis Reviewing results Important Note Timing marker placement and regions of interest cannot be saved for future use. It is sensible, therefore, to plan on performing the entire analysis in a single session. Although the timing lines and ROIs cannot be saved for future processing, you may find it useful to save the screen on which the timing lines and ROIs are set for review by the physician. Setting Initial Timing Regions of Interest The application opens in the TAC Generation layout. This layout displays four rows of data from the following areas, in order: SVC Superior Vena Cava RV Right Ventricle Lung Periphery LV Left Ventricle The images in the first column are composite images created from the frames contained within the 2 white timing markers in the corresponding graphs. Each image contains a rectangular region of interest (ROI). The images in the second column represent raw data time activity curves; the white lines are the timing markers. JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 95

104 Performing First Pass Analysis Figure 46 TAC Generation layout Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: 96 7: First Pass and Shunt Analysis JETStream Workspace Cardiac Applications

105 Performing First Pass Analysis Background:Brightness Browse Pan ROIs To set the initial timing regions of interest: 1 For each region (SVC, RV, lung, LV), drag in the graph to adjust the position and spacing of the timing markers to best visualize the corresponding organ. To move a single timing marker, drag outside the line. To move both timing markers simultaneously, drag between the lines. 2 To move the timing markers in finer increments, position the cursor in an image viewport and use the keyboard arrow keys to move the corresponding timing markers in the graph: Use the left and right arrow keys to move both lines together. Use the up and down arrow keys to change the spacing of the lines. 3 In the corresponding image, drag to place the ROI over the relevant portion of each individual organ. Important These ROIs are for timing purposes only, not for calculating ejection fraction. 4 Reposition timing markers and resize each ROI, as necessary. 5 When you are satisfied with the placement of all ROIs and timing markers, click the Quality Control layout button. JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 97

106 Performing First Pass Analysis Here is an example of correctly positioned ROIs and timing markers: Figure 47 Example of initial ROI and timing marker positions 98 7: First Pass and Shunt Analysis JETStream Workspace Cardiac Applications

107 Performing First Pass Analysis Reviewing for Quality Control Using the Quality Control layout, you can review the generated timing curves for quality control. This layout displays 1 large graph showing 4 time-activity curves representing the total counts over the regions of interest you defined in the TAC Generation layout. Calculated values for SVC MTT (superior vena cava maximum transit time) and Lung TT (lung transit time). Note This is a view-only layout; there are no controls available. JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 99

108 Performing First Pass Analysis Figure 48 Quality control layout To review for quality control (QC): 1 Examine the curves for data integrity and appropriateness. Important Pay careful attention to the quality control results. 2 If necessary, return to the TAC Generation layout to refine your selected timing regions of interest : First Pass and Shunt Analysis JETStream Workspace Cardiac Applications

109 Performing First Pass Analysis 3 Optionally, save this screen to your local database to include these curves as part of the patient record. 4 When you are satisfied with the timing ROIs, click the LVEF Report layout button to continue. Drawing ROIs and Selecting Ventricular Cycles for Analysis This application provides two layouts for drawing ROIs and selecting ventricular cycles for analysis: LVEF Report RVEF Report Note Both the LVEF and RVEF reports include Phase and Amplitude images. These are standard Nuclear Medicine images. The definition and usage of these images are not unique to the JETStream Workspace system. The phase image represents volumetric changes in each pixel, demonstrating which areas of the heart beat in phase with the atria and ventricles, and which areas beat out of phase, such as with arrhythmias. The amplitude image displays the values of maximum count changes with no regard to phase, in effect describing the magnitude of cardiac contraction. LVEF Report Layout When you enter this layout, the application automatically generates and selects LV cycles and displays the results. This layout displays the following for the left ventricle: 1 End Diastolic Frame 1 End Systolic Frame JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 101

110 Performing First Pass Analysis 1 Phase Frame 1 Amplitude Frame 1 LV time-activity curve (top graph) This graph includes 2 white timing markers that indicate the window of time on which calculations are based. 1 smoothed LV time-activity curve (bottom graph) This graph includes the smoothed time activity curve between the 2 white timing markers as set in the top graph, plus the scaled 2 nd derivative curve showing the available ventricular beats. Each cycle is indicated by a pair of lines: 1 white line at ED, and 1 blue line at ES. In this layout, you draw the LV ROIs that are used in subsequent calculations for the left ventricle such as ejection fraction (EF). You can also refine the LV cycle selection by adjusting the smoothing algorithm and derivation method used to generate the curves, changing the time window, and manually adding or removing cycles : First Pass and Shunt Analysis JETStream Workspace Cardiac Applications

111 Performing First Pass Analysis Figure 49 LVEF Report layout, initial appearance Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 103

112 Performing First Pass Analysis Pan Zoom Use Single ROI (ED) for EF Use Double ROI (ED_ES) for EF To draw ROIs for analysis: 1 Review the images and curves in the LV Report layout. 2 If necessary, use the Zoom control to enlarge the images and the Pan control to keep the zoomed images centered in the viewport. 3 Click the Draw ED ROI button. 4 Draw an ED ROI in the End Diastolic frame. The ROI appears in all viewports as you draw it. The application automatically generates and displays a background ROI in the End Diastolic frame in addition to the ED ROI you just drew. Note If you redraw the background ROI and then you would like to discard your edits and return to the original automatically-generated version of the ROI, click Restart. The application also displays the current EF calculation method, the background type (in this application, always Interpolative Background for LV), and the following calculated values: Avg EF (average ejection fraction) Heart Rate EF for each cycle (beat) 104 7: First Pass and Shunt Analysis JETStream Workspace Cardiac Applications

113 Performing First Pass Analysis Note To redraw an ROI, click the corresponding Draw ROI button and redraw that ROI. When you have completed the new ROI, the old ROI disappears. Figure 50 LVEF Report layout with data 5 If you want to use a double ROI method for calculating ejection fraction, click the Draw ES ROI button, and draw an ES ROI in the End Systolic frame. 6 If necessary, click the Draw Bkgd ROI button and redraw the background ROI. 7 You can switch between EF calculation methods by rightclicking in an image viewport and changing the selection: JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 105

114 Performing First Pass Analysis Use single ROI (ED) for EF (default when you have drawn only the ED ROI) Use double ROI (ED, ES) for EF (default when you have drawn both the ED and ES ROIs) As you complete a new or redrawn ROI, or change the EF calculation method, the application automatically updates the data displayed. To adjust the curves: 1 Change the smoothing algorithm by right-clicking in the top graph and changing the selection: Use normal smooth (default) Use high frequency smooth 2 Change the derivation method by right-clicking in the top graph and changing the selection: Use normal derivative (default) Use high frequency derivative Use low frequency derivative As you change the smoothing algorithm and derivation method selections, the application automatically updates the corresponding images and graphs to reflect the changes. You can keep changing the selections until you determine which combination produces the best results. To adjust the time window: 1 Place the cursor anywhere in the top graph. 2 Use the keyboard arrow keys to move the corresponding timing markers in the graph: 106 7: First Pass and Shunt Analysis JETStream Workspace Cardiac Applications

115 Performing First Pass Analysis Use the left and right arrow keys to move both lines together. Use the up and down arrow keys to change the spacing of the lines. 3 When you are finished moving the timing markers, click the Validate Window button. 4 The application reselects the ED and ES peaks based on the new time window, and updates the images. You can keep changing the window until you determine which placement produces the best results. Note If the time window set automatically by the application is acceptable, you do not need to click Validate Window. To manually add a cycle: 1 Right-click in the bottom graph. 2 In the pop-up menu, click Manually select cycle. A new pair of lines appears to the right of the existing cycles. Note The new ED line is white, the new ES line is temporarily gray, and all lines in existing cycles are temporarily blue until you validate the new cycle (see below). 3 With the cursor positioned in the graph: Use the left and right keyboard arrow keys to move the new lines to where you want them. Use the up and down keyboard arrow keys to change the spacing between the new lines. JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 107

116 Performing First Pass Analysis Note Note It is important that you do not use the mouse buttons to position the cursors. If you do so, the right-click menu will not include the Validate selected cycle feature. 4 When you are satisfied with the position of the new lines, right-click in the graph again. 5 In the pop-up menu, click Validate selected cycle. This menu item does not appear if you have left-clicked in the graph after selecting Manually select cycle. The application automatically updates all images and data. To manually remove a cycle: 1 Right-click in the bottom graph. 2 In the pop-up menu, Manually deselect cycle. 3 In the graph, click between a pair of lines to remove the corresponding cycle. The application automatically updates all images and data. When you are satisfied with all ROIs, curves, and cycles in this layout, click the RVEF Report layout button to continue. RVEF Report Layout When you enter this layout, the application automatically generates and selects RV cycles and displays the results. This layout displays the following for the right ventricle: 1 End Diastolic Frame 1 End Systolic Frame 1 Phase Frame 1 Amplitude Frame 108 7: First Pass and Shunt Analysis JETStream Workspace Cardiac Applications

117 Performing First Pass Analysis 1 RV time-activity curve (top graph) This graph includes 2 white timing markers. 1 smoothed RV time-activity curve (bottom graph) This graph includes the smoothed time activity curve between the 2 white timing markers as set in the top graph, plus the scaled 2 nd derivative curve showing the available ventricular beats. Each cycle is indicated by a pair of lines: 1 white line at ED, and 1 blue line at ES. In this layout, you draw the RV ROIs that are used in subsequent calculations for the left ventricle such as ejection fraction (EF). You can also refine the RV cycle selection by adjusting the smoothing algorithm and derivation method used to generate the curves, and manually adding or removing cycles. JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 109

118 Performing First Pass Analysis Figure 51 RVEF Report layout, initial appearance Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: 110 7: First Pass and Shunt Analysis JETStream Workspace Cardiac Applications

119 Performing First Pass Analysis Pan Zoom Use Single ROI (ED) for EF Use Double ROI (ED_ES) for EF To draw ROIs for analysis: 1 Review the images and curves in the RVEF Report layout. 2 If necessary, use the Zoom control to enlarge the images and the Pan control to keep the zoomed images centered in the viewport. 3 Click the Draw ED ROI button. 4 Draw an ED ROI in the End Diastolic frame. The ROI appears in all viewports as you draw it. The application also displays the current EF calculation method, the background type (in this application, always Flat Background for RV), and the following calculated values: Avg EF (average ejection fraction) Heart Rate EF for each cycle (beat) Note To redraw an ROI, click the corresponding Draw ROI button and redraw that ROI. When you have completed the new ROI, the old ROI disappears. JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 111

120 Performing First Pass Analysis Figure 52 RVEF Report layout with data 5 If you want to use a double ROI method for calculating EF, click the Draw ES ROI button, and draw an ES ROI in the End Systolic frame. 6 You can switch between EF calculation methods by rightclicking in an image viewport and changing the selection: Use single ROI (ED) for EF (default when you have drawn only the ED ROI) Use double ROI (ED, ES) for EF (default when you have drawn both the ED and ES ROIs) 112 7: First Pass and Shunt Analysis JETStream Workspace Cardiac Applications

121 Performing First Pass Analysis As you complete a new or redrawn ROI, or change the EF calculation method, the application automatically updates the data displayed. To adjust the curves: 1 Change the smoothing algorithm by right-clicking in the top graph and changing the selection: Use normal smooth (default) Use high frequency smooth 2 Change the derivation method by right-clicking in the top graph and changing the selection: Use normal derivative (default) Use high frequency derivative Use low frequency derivative As you change the smoothing algorithm and derivation method selections, the application automatically updates the corresponding images and graphs to reflect the changes. You can keep changing the selections until you determine which combination produces the best results. To adjust the time window: 1 Place the cursor anywhere in the top graph. 2 Use the keyboard arrow keys to move the corresponding timing markers in the graph: Use the left and right arrow keys to move both lines together. Use the up and down arrow keys to change the spacing of the lines. 3 When you are finished moving the timing markers, click the Validate Window button. JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 113

122 Performing First Pass Analysis 4 The application reselects the ED and ES peaks based on the new time window, and updates the images. You can keep changing the window until you determine which placement produces the best results. Note If the time window set automatically by the application is acceptable, you do not need to click Validate Window. To manually add a cycle: 1 Right-click in the bottom graph. 2 In the pop-up menu, click Manually select cycle. A new pair of lines appears to the right of the existing cycles. Note Note The new ED line is white, the new ES line is temporarily gray, and all lines in existing cycles are temporarily blue until you validate the new cycle (see below). 3 With the cursor positioned in the graph: Use the left and right keyboard arrow keys to move the new lines to where you want them. Use the up and down keyboard arrow keys to change the spacing between the new lines. It is important that you do not use the mouse buttons to position the cursors. If you do so, the right-click menu will not include the Validate selected cycle feature. 4 When you are satisfied with the position of the new lines, right-click in the graph again. 5 In the pop-up menu, click Validate selected cycle. The application automatically updates all images and data : First Pass and Shunt Analysis JETStream Workspace Cardiac Applications

123 Performing First Pass Analysis To manually remove a cycle: 1 Right-click in the bottom graph. 2 In the pop-up menu, click Manually deselect cycle. 3 In the graph, click between a pair of lines to remove the corresponding cycle. The application automatically updates all images and data. When you are satisfied with all ROIs, curves, and cycles in this layout, continue with the next section in this chapter, Reviewing Results. Reviewing Results This application provides two layouts for reviewing first pass results: Wallmotion Report Functional Report Wallmotion Report Layout Click the Wallmotion Report layout button to display the Wallmotion Report layout. This layout displays: 1 cine each of the LV and RV cycles with overlaid isocontours indicating wall motion a cine of only the isocontours indicating LV wall motion (isocontour = 35% by factory default) a cine of only the isocontours indicating RV wall motion (isocontour = 25% by factory default) JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 115

124 Performing First Pass Analysis Important Wall motion assessment is very dependent on where you place the LV and RV initial timing ROIs. If you do not see wall motion data for both ventricles in the Wall Motion Report layout, return to the TAC Generation layout and reposition the LV and RV ROIs until wall motion data for both ventricles are displayed. Figure 53 Wallmotion layout Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls : First Pass and Shunt Analysis JETStream Workspace Cardiac Applications

125 Performing First Pass Analysis Here are some of the controls that may appear when you right-click in a viewport in this layout: Pan Zoom Background:Brightness Cine Modes Functional Report Layout Click the Functional Report layout button to display the Functional Report layout. This layout displays: 1 Fourier phase image each for LV and RV 1 Fourier amplitude image each for LV and RV 1 regional ejection fraction image (REFI) each for LV and RV The application computes the single harmonic Fourier phase and amplitude images and the REFIs from their corresponding composite cycles (LV, RV). JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 117

126 Performing First Pass Analysis Figure 54 Functional Report layout Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: Pan Zoom Background:Brightness 118 7: First Pass and Shunt Analysis JETStream Workspace Cardiac Applications

127 Performing Left-to-Right Shunt Analysis More Info... Reset Performing Left-to-Right Shunt Analysis Left-to-Right Shunt analysis consists of the following basic steps: Setting initial timing regions of interest. Reviewing for quality control. Determining the Qp/Qs (quantitative primary/quantitative secondary) ratio using the gammavariate fit method. If you have performed first pass analysis and now want to perform left-to-right shunt analysis in the same session, you have already completed the first two basic steps. Click the LRShunt Report layout button and go directly to Determining the Qp/Qs Ratio, which starts on page 122. If you are performing only left-to-right shunt analysis at this time, start with the section below. Setting Initial Timing Regions of Interest The application opens in the TAC Generation layout (see Figure 46 on page 96.). This layout displays four rows of data from the following areas, in order: SVC Superior Vena Cava JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 119

128 Performing Left-to-Right Shunt Analysis RV Right Ventricle Lung Periphery LV Left Ventricle The images in the first column are composite images created from the frames contained within the 2 white timer markers in the corresponding graphs. Each image contains a rectangular region of interest (ROI). The images in the second column represent raw data time activity curves; the white lines are the timer markers. Basic JETStream Workspace controls, such as keyboard commands and right-mouse controls, are available in this layout. Descriptions of all basic controls can be found in the JETStream Workspace Instructions for Use under Basic Image Controls. Here are some of the controls that may appear when you right-click in a viewport in this layout: Background:Brightness Browse Pan ROIs To set the initial timing regions of interest: 1 For each region (SVC, RV, lung, LV), drag in the graph to adjust the position and spacing of the timing markers to best visualize the corresponding organ. To move a single timing marker, drag outside the line. To move both timing markers simultaneously, drag between the lines : First Pass and Shunt Analysis JETStream Workspace Cardiac Applications

129 Performing Left-to-Right Shunt Analysis 2 To move the timing markers in finer increments, position the cursor in an image viewport and use the keyboard arrow keys to move the corresponding timing markers in the graph: Use the left and right arrow keys to move both lines together. Use the up and down arrow keys to change the spacing of the lines. 3 In the corresponding image, drag to place the ROI over the relevant portion of each individual organ. Important These ROIs are for timing purposes only, not for calculating ejection fraction. 4 Reposition timing markers and resize each ROI, as necessary. 5 When you are satisfied with the placement of all ROIs and timing markers, click the Quality Control layout button. Reviewing for Quality Control Using the Quality Control layout (see Figure 48), you can review the generated timing curves for quality control. This layout displays 1 large graph showing 4 time-activity curves representing the total counts over the regions of interest you defined in the TAC Generation layout. Calculated values for SVC MTT (superior vena cava maximum transit time) and Lung TT (lung transit time). Note This is a view-only layout; there are no controls available. JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 121

130 Performing Left-to-Right Shunt Analysis To review for quality control (QC): 1 Examine the curves for data integrity and appropriateness. Important Pay careful attention to the quality control results. 2 If necessary, return to the TAC Generation layout to refine your selected timing regions of interest. 3 Optionally, save this screen to your local database to include these curves as part of the patient record. 4 When you are satisfied with the timing ROIs, click the LRShunt Report layout button. Determining the Qp/Qs Ratio The LR Shunt Report layout initially displays a single graph. The graph contains a raw time-activity curve (in red) generated from the pulmonary ROI you defined in the TAC Generation layout; the two timing markers (white lines) are arbitrarily placed, for now : First Pass and Shunt Analysis JETStream Workspace Cardiac Applications

131 Performing Left-to-Right Shunt Analysis Figure 55 LR Shunt Report layout, initial appearance To determine the Qp/Qs ratio: 1 Position the cursor in the graph. 2 Move the timing markers using the keyboard arrow keys: With the cursor in the curve field, use the right and left arrow keys to place the left timing marker at the beginning of the steep upslope to mark the start of the transit uptake peak. JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 123

132 Performing Left-to-Right Shunt Analysis Note Important If the peak has multiple spikes, choose the latest. The first (very small) peak of the curve can be ignored. Using the up and down arrow keys, place the right marker at the end of the steepest dropoff on the downslope to mark the first point after the transit uptake peak. 3 Click the Fit Primary (Qp) button. The application applies a gamma-variate fit to the raw data and displays the resulting primary fit curve (in yellow) on the graph with the raw curve. The application then subtracts that fitted curve from the raw curve to generate a difference curve; the difference curve is displayed (in blue) in a second graph below the first one. 4 Carefully assess the fit. The yellow fit curve must follow the red raw curve as closely as possible. 5 Adjust the raw data to produce the best fitted curve possible: Reposition the timing markers in the graph. If necessary, return to the TAC Generation layout to further refine your initial timing regions of interest. Click the Fit Primary (Qp) button to view and assess the fit curve. 6 Continue making adjustments, clicking the Fit Primary (Qp) button after each change, until you are satisfied with the fit. 7 Position the cursor in the second graph. 8 Move the timing markers in the second graph using the keyboard arrow keys: 124 7: First Pass and Shunt Analysis JETStream Workspace Cardiac Applications

133 Performing Left-to-Right Shunt Analysis Using the right and left arrow keys place the left timing marker at the beginning of the steep upslope to mark the start of the recirculation uptake peak. Note If the peak has multiple spikes, choose the latest. The first (very small) peak of the curve can be ignored. Using the up and down arrow keys, place the right marker at the end of the steepest dropoff on the downslope to mark the first point after the recirculation uptake peak. 9 Click the Fit Secondary (Qs) button. The application applies a gamma-variate fit to the subtracted data and displays the resulting secondary fit curve (in green) on the graph with the difference curve. The application calculates the Qp/Qs ratio and displays that value above a third graph that contains all 4 curves. The Qp/Qs ratio is calculated as A A2 A1 where A1 = the area under the primary fitted curve, and A2 = the area under the secondary (shunt) fitted curve. 10 Carefully assess the secondary fit. Important The fit curve must follow the difference curve as closely as possible. 11 As before, reposition the timing markers in the graph to produce the best fitted curve possible. 12 Continue making adjustments, clicking the Fit Secondary (Qs) button after each change, until you are satisfied with the secondary fit. JETStream Workspace Cardiac Applications 7: First Pass and Shunt Analysis 125

134 Performing Left-to-Right Shunt Analysis Figure 56 LR Shunt Report layout, example of fitted curves Typically, Qp/Qs values less then 1.33 are considered normal; values equal to or greater than 1.33 may indicate the presence of a shunt : First Pass and Shunt Analysis JETStream Workspace Cardiac Applications