How to Scan a Cardiac MRI Viability/MI Protocol (Part 1)

Intro to Cardiac Viability MRIs

How to Perform a Cardiac Viability MRI:
Morphology & Function

This hardware setup is widely used in clinical practice. It balances acquisition time, image quality, and patient comfort.

5. Capture the Initial Localizer Images

Before we can perform any MRI protocol, we must always capture initial localizer images of the patient. These images act as a guide for planning the detailed scans we will perform next.

We should always capture localizers in three planes:

1. Axial
2. Sagittal
3. Coronal

Once acquired, upload the initial localizer images into the three viewports.

Then, scroll through each of the image stacks to locate a central slice that clearly shows the anatomy of the heart.

✅ Correct Setup of Localizer Images for Cardiac Viability MRI:

Part 2: Plan and Acquire the Protocol Sequences

When all preparations are ready, we can start planning and acquiring the protocol sequences.

Let's go through the pulse sequences a standard cardiac viability MRI protocol includes, why we perform them, and how to set them up.

This article only focuses on sequences related to cardiac function and morphology. For cardiac tissue characterization, we will run additional sequences such as perfusion and early/late gadolinium enhancement.

The 8 Sequences of a Standard Cardiac Viability Protocol:

Function & Morphology

1. Black Blood (Extra-Cardiac Anatomy, IR-bSSFP)
2. Bright Blood (Intra-Cardiac Anatomy, IR-TSE)
3. Pseudo 2-chamber View (bSSFP)
4. Pseudo Short-Axis (SAX) View (bSSFP)
5. 4-chamber CINE Imaging (SSFP)
6. 2-chamber CINE Imaging (SSFP)
7. LVOT / 3-chamber CINE Imaging (SSFP)
8. SAX Stack CINE Imaging (SSFP)

We mainly use Inversion Recovery Gradient Echo (IR-GRE) sequences for this study. This type of sequence makes scarred tissue appear bright, while normal heart muscle appears dark, which makes it easy to spot areas of scarred heart muscle.

These sequences also work with ECG-gating to take pictures between heartbeats, which reduces blurring from heart motion and gives clearer images.

In the sections below, we go through how to plan and set up each sequence.

1. Black Blood (Extra-Cardiac Anatomy, IR-bSSFP)

The black blood sequence helps us see extra-cardiac structures, pericardial effusions, and fat infiltration.

✅ Correct Planning:

Planning Instructions:

• Add enough slices to cover from the cardiac apex up to the base of the heart, near the mitral valve plane.
• Use appropriate slice parameters:
  • Slice thickness: 6-8 mm
  • Slice gap: 1-2 mm
• Align the slices as follows:
  • Sagittal localizer: Horizontally through the long axis of the left ventricle, centered at the level of the papillary muscles. Ensure slices extend from apex to base.
  • Coronal localizer: Perpendicular to the septum, centered through the mid-left ventricle for symmetric short-axis coverage.
• Set the fold-over direction (phase encoding) to anterior–posterior to reduce respiratory artifacts.

Parameters for Black Blood (IR-bSSFP):

2. Bright Blood (Intra-Cardiac Anatomy, IR-TSE)

The bright blood sequence shows intra-cardiac anatomy and chamber dimensions.

✅ Correct Planning:

Planning Instructions:

• Copy the slice geometry and planning from the black blood sequence.
• Keep the same slice angulation, coverage, and positioning to ensure images of different contrasts can be clearly compared.

Parameters for Bright Blood (Intra-Cardiac Anatomy, IR-TSE):

3. Pseudo 2-Chamber View (bSSFP)

This localizer helps us plan the actual diagnostic sequences by capturing a preliminary view of the left atrium and left ventricle.

✅ Correct Planning:

Planning Instructions:

• Use the left ventricle, mitral valve, and left atrium as your anatomical references.
• Use appropriate slice parameters:
  • Slice thickness: 6–8 mm
  • Slice gap: 0–2 mm
• Align the slices as follows:
  • Axial localizer: Rotate the slice so it passes through the apex of the left ventricle and the center of the mitral valve, forming a clean long-axis line through both left-sided chambers.
  • Coronal localizer: Center the slice over the left heart, avoiding the right-sided chambers.
• Set the fold-over direction (phase encoding) to anterior–posterior to minimize respiratory motion artifacts.

Parameters for Pseudo 2-Chamber View (bSSFP):

✅ Pseudo 2-Chamber View – Correct Image Example:

🔍 Things to Look for:

• Slice runs from mitral valve to apex
• Left atrium and left ventricle are clearly visualized
• Bright blood pool with minimal artifact
• No wrap or banding artifacts
• Chamber walls appear uniform and symmetric

4. Pseudo Short-Axis (SAX) View (bSSFP)

This localizer creates a perpendicular reference to the two-chamber view for planning the cine sequences. This stack helps identify structures to exclude later when refining the final 2-chamber view.

✅ Correct Planning:

Planning Instructions:

• Clone the previous pseudo 2-chamber sequence and copy the same slice geometry to use as a starting point.
• Use the mitral valve plane, left atrium, and proximal left ventricle as your anatomical references.
• Align the slices as follows:
  • Sagittal pseudo 2-chamber: Rotate the slice so it runs parallel to the mitral valve plane. This defines the pseudo short-axis orientation.
  • Axial localizer: Confirm the slices remain parallel to the mitral valve plane, perpendicular to the long axis of the heart. Plan to include 3–4 slices:
    • One slice at the mitral valve
    • One slice above to include the aorta, pulmonary artery, and left atrial appendage
    • One or two slices below to include part of the left ventricle
• Set the fold-over direction (phase encoding) to anterior–posterior to minimize respiratory motion artifacts.

Parameters for Pseudo Short-Axis (SAX) View (bSSFP):

✅ Pseudo 2-Chamber View – Correct Image Example:

🔍 Things to Look for:

• Image aligned perpendicular to mitral valve plane
• Visualizes mitral valve, aortic root, and base of LV
• Bright blood with sharp chamber walls
• Clear view of left atrial appendage and PA
• Minimal motion or off-axis distortion

5. 4-Chamber CINE Imaging (SSFP)

This diagnostic view shows all four heart chambers simultaneously, allowing assessment of their relationship.

✅ Correct Planning:

Planning Instructions:

Parameters for 4-Chamber CINE Imaging (SSFP):

6. 2-Chamber CINE Imaging (SSFP)

The 2-Chamber view focuses specifically on the left atrium and left ventricle.

✅ Correct Planning:

Planning Instructions:

• Clone the previous 4-chamber CINE sequence and copy the slice geometry as a starting point.
• Keep the same sequence parameters to ensure the different CINE views maintain the same contrast so they can be clearly compared.
• Use the left atrium, left ventricle, and mitral valve as your anatomical references.
• Align the slices as follows:
  • Axial CINE 4-chamber: Adjust the angulation of the field of view to follow the long axis of the left heart, avoiding overlap with the right-sided chambers. Ensure the slice remains centered on the left atrium and ventricle.
  • Coronal pseudo SAX: Slightly rotate the slice clockwise to avoid the pulmonary artery. Center the slice to run cleanly through the mitral valve and the left ventricle apex.

Parameters for 2-Chamber CINE Imaging (SSFP):

7. LVOT / 3-chamber CINE Imaging (SSFP)

The 3-Chamber view shows the left ventricular outflow tract (LVOT), providing important information about the aorta.

✅ Correct Planning:

Planning Instructions:

• Clone the previous 2-chamber CINE sequence and copy the slice geometry as a starting point.
• Use the left atrium, left ventricle, aortic root, and apex as your anatomical references.
• Align the slices as follows:
  • Coronal pseudo SAX: Angle the slice through the center of the aorta and the middle of the left atrium, following the outflow tract. Avoid including the pulmonary artery or right ventricle.
  • Sagittal 2-chamber CINE: Fine-tune the angle so the slice also passes through the apex of the left ventricle and the mitral valve, following the left ventricle’s long axis.
• This produces a true LVOT (3-chamber) view, showing the left ventricle, aortic valve, ascending aorta, and left atrium in one plane.

Parameters for LVOT / 3-chamber CINE Imaging (SSFP):

8. Short-Axis (SAX) Stack CINE (SSFP)

The Short-Axis stack provides multiple slices from the base to the apex of the heart, allowing for volumetric measurements.

✅ Correct Planning:

Planning Instructions:

• Plan the stack using the 2-chamber cine, 4-chamber cine, and pseudo short-axis views.
• Use the left ventricle, posterior wall, and interventricular septum as your anatomical references.
• Align the slices as follows:
  • Sagittal 2-chamber CINE: Rotate the slice package so it is perpendicular to the posterior wall of the left ventricle. Position the slice stack through the center of the left ventricle and move it slightly downward to optimize coverage.
  • Axial 4-chamber CINE: Align slices perpendicular to the interventricular septum, to follow the heart’s true short axis.
• Set the fold-over direction (phase encoding) to foot–head (FH) to reduce wrap and respiratory motion artifacts.
• Plan for short breath-hold durations:
  • Total acquisition time should stay under 1.5 minutes.
  • Each breath-hold should last 10–12 seconds, matching the time per slice.

Parameters for Short-Axis (SAX) Stack CINE (SSFP):

How to Avoid Artifacts When Planning the Sequences

The table below lists the 6 common cardiac artifacts, and what techniques you can use to avoid them:

Part 3: Review the Images

Finally, we will review the images to ensure all the anatomical information we need is clear.

In a cardiac viability MRI focused on morphology and function, these structures must be clearly visible:

1. Left and right ventricles – including clear borders of the endocardium and epicardium
2. Interventricular septum – check position, motion, and thickness
3. Left and right atria – with visible appendages if possible
4. Aorta and pulmonary artery – including outflow tracts and valve motion
5. Pericardium – assess for effusion or thickening
6. Diaphragm and posterior lung bases – to check for pleural effusion

Below, we will go through all the different image contrasts and explain their specific role in imaging the heart.

Black Blood IR-bSSFP – Nulls Blood Signal for Clear Morphological Borders

This sequence applies inversion recovery to null the signal from flowing blood.

This makes moving blood appear black, while static tissues like myocardium and fat appear gray to bright. This strong contrast lets us inspect extra-cardiac anatomy, vessel walls, and tissue boundaries.

In cardiac viability imaging, black blood is essential for assessing morphology. It helps identify pericardial thickening, pleural effusion, and fat infiltration. It also confirms proper planning and helps visualize lung bases, diaphragm, and adjacent chest anatomy.

✅ Black Blood IR-TSE – Correct Image Example:

🔍 Things to Look for:

• Vessels (aorta, vena cava) should be fully black, with no residual signal.
• No pleural effusion, which would appear as bright fluid in the lower back part of the lungs.
• Liver and biliary ducts may appear bright, as these contain static fluids.
• Diaphragm and lung apices should be visible with no distortion.
• Clear view of pericardium and adjacent fat or thickening.
• Motion artifacts near anterior chest if patient was not breathing consistently.

Bright Blood IR-TSE – Enhances Blood Signal to Show Chamber Structure

This sequence uses an inversion pulse with a TSE readout, which makes flowing blood appear bright while suppressing background tissue.

It shows the blood pool, chamber size, and great vessels clearly, with sharp contrast and reduced motion artifacts.

In viability protocols, bright blood focuses on morphology. We use it to assess intra-cardiac anatomy, detect dilation, septal shift, and identify large effusions.

✅ Bright Blood IR-TSE – Correct Image Example:

🔍 Things to Look for:

• Aorta, pulmonary artery, and chambers should appear uniformly bright.
• All four chambers must be visible without distortion or wrap artifacts.
• Check for clear boundary between blood pool and myocardium.
• Look for signs of chamber enlargement or septal shift.
• Fluid (pleural or pericardial) may appear brighter than on black blood.
• No significant banding artifacts, especially at 3T.

Cine Imaging – Evaluate Cardiac Motion and Chamber Contraction

CINE MRI uses a fast, ECG-gated sequence to capture the heart through multiple cardiac phases. It shows the heart beating—like a movie—across systole and diastole.

CINE is the gold standard for evaluating global function, such as ejection fraction, wall motion, and ventricular contractility.

In cardiac viability studies, CINE images are essential to:

• Track ventricular wall thickening and motion.
• Visualize valve function and blood flow direction.
• Compare end-diastolic and end-systolic phases to calculate EF (Ejection Fraction).

✅ 4-Chamber CINE SSFP of the Heart – Correct Image Example:

Note that the 4-chamber CINE image above shows a minor wrapping artifact at its top. But since it doesn’t interfere with the anatomy of the heart, it still meets diagnostic quality.

🔍 Things to Look for:

• All four chambers should be visible and centered.
• Mitral and tricuspid valves should open and close fully.
• Ventricular walls should contract evenly, especially in the left ventricle.
• Blurring or ghosting, which may indicate missed ECG triggering.
• Artifacts from metal devices like pacemakers or loop recorders.
• Endocardial and epicardial contours are sharp and traceable.

✅ 2-Chamber CINE SSFP of the Heart – Correct Image Example:

🔍 Things to Look for:

• Slice must run through mitral valve and apex.
• Left atrial appendage should be visible (shows good alignment).
• Avoid including the right ventricle—keep view clean.
• Myocardium should thicken in systole and relax in diastole.
• Crisp motion, without delay or double-exposure.

✅ 3-Chamber (LVOT) CINE SSFP of the Heart – Correct Image Example:

🔍 Things to Look for:

• Slice must pass through left atrium, aortic valve, and apex.
• Aortic outflow tract should show clearly, including valve opening.
• Smooth transition of blood into the aorta.
• Mitral-aortic continuity—no distortion or artifacts.
• Basal septal motion and LVOT narrowing.

✅ Short-Axis Stack CINE of the Heart – Correct Image Example:

🔍 Things to Look for:

• Stack should cover apex to base without missing slices.
• Wall motion must be smooth and symmetric across all levels.
• Endocardial and epicardial contours should be easy to trace.
• Hypokinetic or akinetic segments that do not contract fully.
• Systolic thickening should be visible in healthy myocardium.
• Breathing artifacts (check anterior-posterior motion blur).

Final Checks:

Before finishing a cardiac viability MRI, always check these 6 points to ensure diagnostic quality:

1. Wall Motion and Thickness – Ventricular walls must thicken during systole. Look for areas that move poorly or stay thin. These may be scars.
2. Chamber and Valve Clarity – All four chambers and major valves must be visible, and should open and close smoothly in CINE views.
3. Septal and Global Motion – The interventricular septum should move inward with each beat.
4. Stack Coverage – SAX slices must fully cover apex to base. Avoid gaps or missing regions, especially near papillary muscles.
5. Image Quality and Artifacts – Images must have strong SNR, sharp borders, and minimal artifacts.
6. Pericardium and Lung Bases – Check that the pericardium is intact and look for effusions in the black blood image.

These checks help confirm scan success before contrast or treatment decisions.

This completes the planning phase of our cardiac viability MRI protocol focusing on function and morphology.

In Part 2, we'll cover cardiac tissue characterization with perfusion and late gadolinium enhancement sequences to complete the full viability study.