title: 4D MUSIC CMR: value-based imaging of neonates and infants with congenital heart disease.
abstract: BACKGROUND
  4D Multiphase Steady State Imaging with Contrast (MUSIC) acquires high-resolution volumetric images of the beating heart during uninterrupted ventilation. We aim to evaluate the diagnostic performance and clinical impact of 4D MUSIC in a cohort of neonates and infants with congenital heart disease (CHD).
  
  
  METHODS
  Forty consecutive neonates and infants with CHD (age range 2 days to 2 years, weight 1 to 13 kg) underwent 3.0 T CMR with ferumoxytol enhancement (FE) at a single institution. Independently, two readers graded the diagnostic image quality of intra-cardiac structures and related vascular segments on FE-MUSIC and breath held FE-CMRA images using a four-point scale. Correlation of the CMR findings with surgery and other imaging modalities was performed in all patients. Clinical impact was evaluated in consensus with referring surgeons and cardiologists. One point was given for each of five key outcome measures: 1) change in overall management, 2) change in surgical approach, 3) reduction in the need for diagnostic catheterization, 4) improved assessment of risk-to-benefit for planned intervention and discussion with parents, 5) accurate pre-procedural roadmap.
  
  
  RESULTS
  All FE-CMR studies were completed successfully, safely and without adverse events. On a four-point scale, the average FE-MUSIC image quality scores were >3.5 for intra-cardiac structures and >3.0 for coronary arteries. Intra-cardiac morphology and vascular anatomy were well visualized with good interobserver agreement (r = 0.46). Correspondence between the findings on MUSIC, surgery, correlative imaging and autopsy was excellent. The average clinical impact score was 4.2 ± 0.9. In five patients with discordant findings on echo/MUSIC (n = 5) and catheter angiography/MUSIC (n = 1), findings on FE-MUSIC were shown to be accurate at autopsy (n = 1) and surgery (n = 4). The decision to undertake biventricular vs univentricular repair was amended in 2 patients based on FE-MUSIC findings. Plans for surgical approaches which would have involved circulatory arrest were amended in two of 28 surgical cases. In all 28 cases requiring procedural intervention, FE-MUSIC provided accurate dynamic 3D roadmaps and more confident risk-to-benefit assessments for proposed interventions.
  
  
  CONCLUSIONS
  FE-MUSIC CMR has high clinical impact by providing accurate, high quality, simple and safe dynamic 3D imaging of cardiac and vascular anatomy in neonates and infants with CHD. The findings influenced patient management in a positive manner.
authors.affiliation: Diagnostic Cardiovascular Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.|Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
authors.forename: Kim-Lien
authors.initials: KL
authors.lastname: Nguyen
authors.affiliation: Diagnostic Cardiovascular Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.|Department of Biomedical Physics, University of California, Los Angeles, CA, USA.|Department of Radiological Sciences, University of California at Los Angeles, Peter V. Ueberroth Building Suite 3371, 10945 Le Conte Ave., Los Angeles, CA, 90095-7206, USA.
authors.forename: Fei
authors.initials: F
authors.lastname: Han
authors.affiliation: Diagnostic Cardiovascular Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.|Department of Biomedical Physics, University of California, Los Angeles, CA, USA.|Department of Radiological Sciences, University of California at Los Angeles, Peter V. Ueberroth Building Suite 3371, 10945 Le Conte Ave., Los Angeles, CA, 90095-7206, USA.
authors.forename: Ziwu
authors.initials: Z
authors.lastname: Zhou
authors.affiliation: Diagnostic Cardiovascular Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.|Department of Radiological Sciences, University of California at Los Angeles, Peter V. Ueberroth Building Suite 3371, 10945 Le Conte Ave., Los Angeles, CA, 90095-7206, USA.
authors.forename: Daniel Z
authors.initials: DZ
authors.lastname: Brunengraber
authors.affiliation: Department of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
authors.forename: Ihab
authors.initials: I
authors.lastname: Ayad
authors.affiliation: Division of Pediatric Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Levi
authors.affiliation: Division of Pediatric Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
authors.forename: Gary M
authors.initials: GM
authors.lastname: Satou
authors.affiliation: Division of Cardiothoracic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
authors.forename: Brian L
authors.initials: BL
authors.lastname: Reemtsen
authors.affiliation: Diagnostic Cardiovascular Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.|Department of Biomedical Physics, University of California, Los Angeles, CA, USA.|Department of Radiological Sciences, University of California at Los Angeles, Peter V. Ueberroth Building Suite 3371, 10945 Le Conte Ave., Los Angeles, CA, 90095-7206, USA.
authors.forename: Peng
authors.initials: P
authors.lastname: Hu
authors.affiliation: Diagnostic Cardiovascular Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. pfinn@mednet.ucla.edu.|Department of Biomedical Physics, University of California, Los Angeles, CA, USA. pfinn@mednet.ucla.edu.|Department of Radiological Sciences, University of California at Los Angeles, Peter V. Ueberroth Building Suite 3371, 10945 Le Conte Ave., Los Angeles, CA, 90095-7206, USA. pfinn@mednet.ucla.edu.
authors.forename: J Paul
authors.initials: JP
authors.lastname: Finn
mesh_terms: D001344:Autopsy; D006328:Cardiac Catheterization; D002675:Child, Preschool; D003287:Contrast Media / Q000008:administration & dosage; D017023:Coronary Angiography; D005260:Female; D052203:Ferrosoferric Oxide / Q000008:administration & dosage; D006321:Heart / Q000000981:diagnostic imaging* / Q000503:physiopathology; D006330:Heart Defects, Congenital / Q000000981:diagnostic imaging* / Q000401:mortality / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D007090:Image Interpretation, Computer-Assisted / Q000379:methods*; D007223:Infant; D007231:Infant, Newborn; D015141:Los Angeles; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D015588:Observer Variation; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D015203:Reproducibility of Results
chemical_list: D003287:Contrast Media; D052203:Ferrosoferric Oxide
keywords: 4-D imaging; Cardiovascular magnetic resonance; Congenital heart disease; Ferumoxytol; Magnetic resonance angiography