Good afternoon to all… Thank you for the nice introduction.

First, I want to thank the opportunity to being here to present this webinar, namely
to Graciano Paulo for the nice invitation.

SLIDE 2

This is my outline of this presentation. We will start with the anatomy of the heart
distinguishing the body planes and the cardiac or heart planes.

Then we will pass to all views of a heart MRI.

So, the two main coordinate systems used for cardiac MRI include the body
(scanner) planes and the cardiac planes.

SLIDE 3

Starting with body planes, we know that they are oriented orthogonal to the long axis
of the body and consist of axial, sagittal, and coronal planes, as we can see in the
figure.

These planes are used to derive the scout images and provide a qualitative overview
of cardic morphology. However, the obliquity (≈ 45°) of these planes to the walls of
the heart precludes accurate anatomic and functional characterization. Rather, such
information should be obtained from the specialized cardiac planes.

SLIDE 4

The standard cardiac planes are established using the scout images and include
short axis, horizontal long axis (four-chamber view), and vertical long axis (two-
chamber view).

More ahead we will study the anatomy in MRI of each view.

SLIDE 5

The anatomical axis of the heart or long-axis (base-apex) is usually directed

anteriorly, inferiorly, and to the left. Consequently, the atria are situated posteriorly
and superiorly, and the ventricles are situated anteriorly and inferiorly.

APONTAR PARA A IMAGEM

SLIDE 6

Before we move on to the different planes I will describe the 4 chamber of the heart
and what can we see in MRI.
So, the first chamber that I will talk about is the right atrium.

The right atrium forms the right border of the heart and it receives deoxygenated
blood from superior and inferior venae cava and coronary sinus.

It has as the shape of an irregular ellipsoid, except for the right atrial appendage,
which arises anteriorly. The right atrial appendage overlies the aortic root. This
appendage has a triangular appearance and is best appreciated ventral to the
junction of the superior vena cava (SVC) and right atrium.
The right atrium is separated from the left atrium by the interatrial septum.
One of the main anatomic landmarks of this chamber is the crista terminalis, that is
a muscular ridge on the anterior aspect of the chamber. The atrium is lined by
pectinate muscles to the left of this crest, and these extend into the right atrial
appendage.
A curiosity: The atrial lead of an external pacemaker is frequently located in these
muscles. To the right of the crista terminalis, the atrial lining is smooth and this
represents the right horn of the sinus venosus.

SLIDE 7

The left atrium receives oxygenated blood from the pulmonary circulation that is then
delivered to the left ventricle and then into the systemic circulation.
It is grossly cuboidal.

The left atrium is separated from the right atrium by the intertribal (interatrial) septum,
with the small depression, the fossa ovale, at the site of the closed foramen ovale. It
is smaller by volume than the right atrium but with thicker walls.
The left atrial appendage is long and narrow, curving anteriorly from the left around
the pulmonary trunk.

SLIDE 8

LER O SLIDE

SLIDE 9

The right ventricle is separated by the right atrium by the tricuspid valve and it lies
on the diaphragm, and it is the largest portion of the anterior surface of the heart.
The interior ventricular surface has irregular muscular ridges known as trabeculae
carnae.
Arising from the apical aspect of the IV septum, the septomarginal
trabecula (or moderator band) extends to the anterior papillary muscle
Superiorly the chamber tapers as the funnel-shaped outflow tract, known as
the conus arteriosus (orinfundibulum), which lack trabeculae and continues
beyond the pulmonary valve as the pulmonary trunk.

SLIDE 10
Separating the left atrium and left ventricle, we have the mitral valve. The left
ventricle is conical in shape with an anteroinferiorly projecting apex and is longer
with thicker walls than the right ventricle. It is separated from the right ventricle by
the interventricular septum,
In normal anatomy, the left ventricle is positioned posteriorly and to the left. The
septum is smooth with no trabeculae and the left ventricular outflow tract lacks a
muscular part. The interventricular septum consists of a muscular and a
membranous part.
It hasTwo papillary muscles attached to MV by chordae tendineae:
ü Anterolateral and Posteromedial

SLIDE 11

Ler slide

SLIDE 12

Now we will study the anatomical stacks, with strict slabs without angulation.
The axial plane can depict the four chambers of the heart and the pericardium
simultaneously.
This stric plane is especially useful for the evaluation of thoracic vascular structures
as the ascending and descending thoracic aorta, the superior and inferior vena cava,
the pulmonary trunk and right and left pulmonary artery. The right and left pulmonary
veins entering the left atrium are also well depicted. Images in transverse orientation
through the heart allow the evaluation of morphology of the ventricles and atria. Also
the right ventricular free wall, the right ventricular outflow tract, the pericardium and
mediastinum are well depicted. It has been suggested that right ventricular volume
and function quantification by planimetry can be performed more accurately on
transversely oriented images instead of short axis images

SLIDE 13

At the third thoracic vertebrae, we can see the three main vessels that arise from
aortic arch. This is a T2 HASTE dark blood sequence, that we see the vessels with
low signal. From the midplane to the left side, we can distinguish the brachiocephalic
artery, the left common carotid artery and the left subclavian artery from anterior to
posterior, right to left. We can also see the right and let brachiocephalic veins, which
are more proeminent and larger than the arteries.
In a midplane of the image we can see anteriorly the trachea and the esophagus
posteriorly.

SLIDE 14

In this slide, we can see the same anatomical structures but in a T1 vibe sequence
with gadolinium, demonstrating a high signal of the vessels.
SLIDE 15

Lowering a thoracic level, to T4 level, we can see the aortic arch. Its course is an
arch from right to left and front to back; lies anterior and to the left of the trachea.
Depending on the patient’s anatomy, at this level we can se the junction of the two
brachiocephalic veins or the superior vein cava (right part of the image).

SLIDE 16
These are the same structures described previously, but in a bright blood sequence,
as TRUFFI. We can see the high signal intensity in vessels.

SLIDE 17

At the T4-T5 level, it is known as the carina level, where trachea bifurcates in the
two-main bronchus (right and left).
At this level, we can see the azygos veins positioned in the right and anterior part in
relation with the vertebrae column with its junction to superior vein cava, that is
positioned more anteriorly and in a right position. Adjacent at the left side of the
superior vein cava we can see a round structure that is the ascending aorta, that
arised from the left ventricle, situated inferiorly. In a posterior and left sided we can
see the descending part of aorta adjacent to the vertebrae. In an intermediate position
between the “two aortas”, we begin to see the pulmonary trunk or artery that ascends
from the right ventricle.

SLIDE 18

At the T5-T6 level, we can see at the anterior part of the image, from right to left, the
superior vein cava, the ascending aorta and the main pulmonary artery, respectively.
The latter structure bifurcates into the right pulmonary artery and the left pulmonary
artery, that will enter at the pulmonary hilum.
Posteriorly to the pulmonary arteries, we can distinguish the two main bronchus.
At the most posterior part of the image, we can see from right to the left side: the
azygos vein, esophagus and descending aorta, respectively.

SLIDE 19

In this slide, we can see the same structures described on the previous slide, but in
T1 vibe sequence with gadolinium. We can see very well the bifurcation of the
pulmonary artery trunk. This image can be a very helpful to to prescribe the right
ventricle outflow tract.
The pulmonary trunk lies entirely within the pericardial sac. It arises from the right
ventricle and ascends in front of the ascending artery, situating in a left position to
the latter. Then it courses posteriorly and to the left, where it bifurcates into the left
and the right pulmonary arteries, that have deoxygenated blood.

SLIDE 20

At T6 level, we can start to see the heart chambers. This plane passes through
through the most superior region of the heart where, normally, only the superior
portion of the atria are present. The left atrium forms the posterior surface of the
heart and will expand more inferiorly.
Please note the pericardium encircling the heart and adjacent blood vessels.
the right atrium and superior vein cava are at a right position when compared to
ascending aorta, that is in an intermediate position between the right atrium and SVC
and the pulmonary main artery or pulmonary trunk.
On the most posterior part of the cardiovascular structures we have the descending
aorta.

SLIDE 21

At T7 level, we can see the anterior or sternocostal surface that is formed by the
right ventricle and some portions of the right atrium.
The right side is the right atrium. The left side is the left ventricle and the posterior
surface of the heart is composed primarily by the left atrium, with some portions of
the left ventricle and the right atrium.
We can see on the bright blood sequence the septomarginal trabecula or moderator
band at the level of the right ventricle apex, that is continuous with the interventricular
septum.
We can see the thicker myocardium in the left ventricle comparing to the right
ventricle. The papillary muscles have low signal when compared to the chamber
(with blood).
Posteriorly to the heart we have again the descending artery.

SLIDE 22

At T8 level, we can see the lower portions of right atrium and ventricle and the lower
portion of left ventricle. Observe again the thicker myocardium at the left ventricle.
At this level we can observe the junction of the inferior vein cava inside the right
atrium and the junction of this chamber to the coronary sinus.

SLIDE 23

The pericardium is a conical, flask-like, fibroserous sac which contains

the heart and the roots of the great vessels and defines the middle mediastinum.
T1 and T2: appears as a low signal rim between the higher-signal mediastinal and
epicardial fat
The pericardial sac encloses the heart and the roots of the great vessels. The
pericardial cavity is outlined by the parietal and visceral layer of the inner
pericardium. Normal pericardium has a longer T1 than fat tissue, and therefore
presents with low signal intensity on T1-weighted MR images, and can be well
visualised due to the surrounding epicardial and pericardial fat. Normally, the
thickness of the pericardium measures less than 4 mm on CMR images.

SLIDE 24

The coronal plane can be used to assess the left ventricular out- ow tract, the left
atrium, and the pulmonary veins. It is only performed in vascular malformations.

SLIDE 25

Please notice the tha pulmonary trunk arises from right ventricle in front of ascending
aorta and as a course to the left where it bifurcates in the two main arterires.

The ascending aorta arises from left ventricle and it forms the aortic arch, that has a
course front to back and right to left, superior to the pulmonary trunk.

The pulmonary veins are the most posterior blood vessels of the heart vessels and
enter in left atrium.

SLIDE 26

From anterior to posterior, we have three images with bright blood (TRUFFI). First
we observe the right ventricle and its outflow tract because this chamber forms the
esternocostal surface of the heart.

Going to posterior anatomy, we can observe the two ventricles separated by

interventricular septum with a lower signal intensity, and we start to see the right
atrium.

At this level, we can see very well the outflow tract of the left ventricle and the
ascending artery.

In a posterior stack, we see the superior vein cave entering the right atrium, seeing
this chamber in all its extension and the tricuspid valve.

We can see also, the aortic arch and inferiorly to this structure the main pulmonary
artery.

SLIDE 27

More posteriorly, we can observe the bifurcation of the pulmonary trunk.

We can see also the inferior junction of the inferior vein cava into the right atrium. At
this level, we can observe too the posterior surface of the heart eith the left atrium
and we start to look the pulmonary veins entering into this heart chamber.

SLIDE 28

The sagittal plane can show the great vessels arising in continuity from the
ventricles. It may be helpful and important to delineate outflow tracts.

SLIDE 29

From right to left position, we can start to see the right atrium with thinner walls. In
the second image, we can observe the right atrium with all its extension with the
superior and inferior vein cava entering at their sinuses. We start visualizing the right
ventricle. Note that right pulmonary artery is posterior to superior vein cava, and the
right pulmonary vein is situated inferiorly to the artery. Is is the way that they occupy
the pulmonary hilum.

Going to the left side, we start to see the right ventricle with more extension and its
papillary muscles (with lower intensity of signal). At this level we observe the aortic
valve and the ascending artery with a superior course.

SLIDE 30

The first image is an excellent example of the right outflow tract where we can see
the conus arteriosus or the infundibulum continuing to the main pulmonary artery. In
a superior portion of the image we can see the aortic arch with a posterior course to
originate the descending aorta.

Going to the left part of the stack, we can see the left surface of the heart formed by
the left ventricle, mainly.

SLIDE 31

Now we start with the cine images.

The vertical long axis is for evaluating the anterior and inferior walls and apex of the
left ventricle. An axial image through the LV and LA is chosen from the transverse
images. It is prescribed so that bisects the mitral valve and intersects the LV apex.
Please notice to the mitral valve.

SLIDE 32
To have a good anatomy in this two chamber view or vertical long axis, we have to
see these structures:
ANT: anterior wall
AP: apex
INF: inferior wall
LA: left atrium
LAA: left atrial appendage
LV: left ventricle
MV: mitral valve

For a good execution we have to see:

ü Anterior and inferior wall motion;
ü Assessment of the left atrial appendage and mitral valve.

SLIDE 33

Then we have to prescribe a fake short axis for better anatomy delineation of the
four chamber view.
We prescribe this view with a stack perpendicular to the anterior and inferior wall of
the myocardium.
The result image is that we can see the two ventricles, with the papillary muscles.
Please observe the tricuspid and mitral valve.

SLIDE 34

To prescribe the four chamber view or horizontal axis we use the anatomy of the
face shor axis view and the two chamber view or vertical axis.
So, we use a mid-ventricular short axis slice as a guide. The 4-chamber view is
prescribed by placing a slice bisecting the highest curvature of the right ventricle
(outlined in white). Avoid the left ventricular out ow tract.
A perpendicular plane to the vertical long axis image is chosen which intersects the
lower third of the mitral valve and the LV apex.

SLIDE 35

Anatomically, we have to have an excellent delineation of:

DA: Descending aorta
LA: Left atrium
LV: Left ventricle
LAT: lateral wall
MV: mitral valve
RA: Right atrium
RV: Right ventricle
S: Septum wall
TV: Tricuspid valve

For a good execution, we have to respect and look at these items:

 ü Septal and lateral walls motion LV;
ü Apex of LV;
ü RV free wall;
ü Chamber sizes;
ü Mitral and tricuspid valves function.

SLIDE 36

The short axis view shows cross sections of the left and the right ventricle that are
useful for volumetric measurements using, normally, Simpson’s Rule. The short axis
view is chosen such that a series of slices are perpendicular to the long axis of the
left ventricle.

SLIDE 37

We should have slices from the base to the apex of the heart. The base is located
posterior and at the right and the apex anterior and at left.

SLIDE 38

Anatomically, we can see:

• ANT: Anterior myocardium wall
• INF: Inferior myocardium wall
• LAT: Lateral myocardium wall
• S: Septum myocardium wall
• APM: Anterior papillary muscle
• PPM: Posterior papillary muscle
• LV: Left Ventricle
• RV: Right Ventricle
We can perform this short axis view on cine images and in T2 dark blood images
(infiltration, myocarditis, for example).

SLIDE 39

If we have different slices in different positions, we have different anatomical

structures.
At apical regions, we can observe the apical regions of the two ventricles with their
papillary muscles.
At apical region, we can see the moderator band in the right ventricle.

SLIDE 40

At a midcavity level, we can look at left ventricle the two papillary muscles that are
inside of this chamber: anterior and posterior muscles.

SLIDE 41
At a basal level, we can start to visualize the outflow tracts of the ventricles and these
slabs may be helpful to delineate the outflow tracts of the ventricles to calculate the
flow and velocity of the flow of the blood at these levels.

SLIDE 42

This image shows the 17-Segment Model of American Heart Association where we
can perform the Left Ventricle Segmentation Procedure
The muscle and cavity of the left ventricle can be divided into a variable number of
segments. Based on autopsy data the AHA recommends a division into 17 segments
for the regional analysis of left ventricular function or myocardial perfusion:
§ The left ventricle is divided into equal thirds perpendicular to the long
axis of the heart. This generates three circular sections of the left ventricle
named basal, mid-cavity, and apical. Only slices containing myocardium in all
360° are included.
§ The basal part is divided into six segments of 60° each. The segment
nomenclature along the circumference is: basal anterior, basal
anteroseptal, basal inferoseptal, basal inferior, basal inferolateral, and basal
anterolateral. The attachment of the right ventricular wall to the left ventricle
can be used to identify the septum.
§ Similarly the mid-cavity part is divided into six 60° segments called mid
anterior, mid anteroseptal, mid inferoseptal, mid inferior, mid inferolateral,
and mid anterolateral.
§ Only four segments of 90° each are used for the apex because of the
myocardial tapering. The segment names are apical anterior, apical
septal, apical inferior, and apical lateral.
§ The apical cap represents the true muscle at the extreme tip of the
ventricle where there is no longer cavity present. This segment is called
the apex.

SLIDE 43

Each of these segments are irrigated by different coronary arteries as it is shown in

this figure.

SLIDE 44

This figure shows the junction of two image modalities, called hybrid imaging, in this
case PET-MRI, with the late gadolinium enhancement and the FDG uptake,
demonstrating better the myocardial segments that have a lesion and what is the
coronary artery involved in the segment irrigation.

SLIDE 45
We have sequences that we can visualize the coronary arterires without
intravascular contrast injection.
a navigator guided high spatial resolution 3D gradient-echo acquisition of the
coronary arteries, where a portion of the data necessary for constructing the 3D
volume is acquired during each heartbeat at mid diastole, when coronary blood flow
velocity is maximized.
To maximize the contrast between the flowing blood and the surrounding, both
muscle suppression and fat suppression pulses are applied to suppress signal from
tissue surrounding the coronary arteries. And we can see anatomically the coronary
arteries, as we se on these figures.

SLIDE 46

So, the coronary arteries can be indirectly evaluated by assessing myocardial

function in the territory perfused by a given artery in conjunction with the 17 model
of segmentation of left ventricle.

SLIDE 47

Finally, we have the prescription of the outflow tracts. First, the left outflow tract
where we can use the basal slab of the short axis view.
We prescribe a cine slab parallel to ascending aorta walls intersecting the Valsalva
sinuses.
Anatomically we have to observe a three chamber view (left atrium, left ventricle and
right ventricle) the aortic valve, the aortic vestibule, the mitral valve and the
interventricular septum.

SLIDE 48

In this slide we have the correct anatomy that we can see on a three chamber view
of MRI of the heart as I say previously.

SLIDE 49

To prescribe the second view of the outflow tract of the aortic valve we use the three
chamber view and we trace a slab that is parallel to the ascending aorta walls,
passing again the cusps of the aortic valve.
Anatomically we see the left ventricle vestibule, the aortic valve opening and closing
and the ascending aorta.

SLIDE 50

These two latter views used together will be used to make the axial view of the aortic
valve and to calculate the velocity of the flow.
The slab is perpendicular to the ascending aorta wall crossing the aortic valve.
In the cine axial or transversal view of the aortic valve we can observe the three
cuspids of the valve: the right coronary, the left coronary and the non coronary cusp.

SLIDE 51

To perform the right ventricle outflow tract view, we can use the transversal strict
stacks as I said previously intersecting a slab parallel to the main pulmonary artery
walls.
Anatomically, we have to observe the conus arteriosus or infundibulum, the
pulmonary valve and the main pulmonary artery.

SLIDE 52

To prescribe a second right ventricle outflow tract we make a perpendicular slab of

the other view, parallel to the anterior and posterior wall of the main pulmonary artery
that arises from the right ventricle. Anatomically we see an extension of the
pulmonary main artery and a part of the outflow tract of the right ventricle separated
by the aortic valve.

SLIDE 53

We use the two images to have the pulmonary valve view, with a round configuration,
anteriorly.

SLIDE 54

We can have another views, for example, the aortic arch view, where we can observe
the aortic arch in all its extension, from its origin to its course, from front to back,
from inferior to superior and then going down by the descending aorta.
Anatomically, along its course, we see the three main arteries that arise from it:
brachiocephalic trunk, left common carotid artery and the left subclavian artery.

SLIDE 55

This is a summary of the different views of the heart in a cardiac MRI.

SLIDE 56

Concluding:
• Heart MRI is a very specific examination in MRI;
• Knowledge of heart anatomy is crucial to a better performance in cardiac MRI;
• Heart anatomy can vary in the variety of planes and views of cardiac MRI;
• Formation is crucial.