Author + information
- Gerald M. Pohost, MD, FACC, Chair,
- Raymond J. Kim, MD, FACC,
- Christopher M. Kramer, MD, FACC and
- Warren J. Manning, MD, FACC (Society for Cardiovascular Magnetic Resonance Representative)
Cardiovascular magnetic resonance (CMR) (Table 1),one of the newest cardiovascular imaging modalities, provides useful, often unique information with which all cardiologists should be conversant. Training in CMR for cardiology fellows should be divided into three levels.
Level 1—General training (1 month) to provide the cardiovascular trainee with a working knowledge of CMR methods and diagnostic utility.
Level 2—Specialized training (at least 3 months) designed to provide fellows with the skills necessary to independently interpret CMR imaging studies.
Level 3—Advanced training for those who ultimately wish to be responsible for the operation of a CMR laboratory. Level 3 criteria must include appropriate levels of patient care, teaching, and research.
Overview of CMR training
All cardiovascular medicine trainees should be taught the basic types of CMR studies and their indications. Mentored interpretation of CMR studies should be coupled with comparison and integration of test results with other relevant clinical and laboratory data. A mentor is an individual with the equivalent of Level 3 CMR training. This training generally should be acquired through the Accreditation Council for Graduate Medical Education—an approved cardiology or radiology program with expertise in CMR and under the aegis of a Level 3-qualified mentor in a laboratory accredited by an organization such as the Intersocietal Commission on the Accreditation of MR Laboratories (ICAMRL). Occasionally, a Level 3 qualified mentor will not be available in the institution housing the general fellowship program, but is available at a nearby non-academic but medical center accredited for CMR by an organization such as the ICAMRL. Under these circumstances it is acceptable to place the trainee(s) at such a medical center for Level 1 to Level 3 training. The CMR training center and the trainee should maintain a logbook or other specific records to document the trainee’s case review and the didactic hours in which the trainee has participated.
The depth of knowledge should increase with increasing levels of training. In the case of the Level 3 trainee, specialized training and, for academic trainees, research should be offered as a part of an established training program (Table 2).
Level 1: General training (1-month minimum)
The trainee should have exposure to the methods and the multiple applications of CMR for a period of not less than 1 month or its equivalent when interwoven with other training activities. This experience should provide basic background knowledge in CMR sufficient for the practice of adult cardiology and referral for CMR, but not for the practice/independent clinical interpretation of CMR. As a practical matter, many fellowship programs in cardiovascular medicine may not be able to fulfill CMR training. In these instances, fellows should be encouraged to obtain experience in an alternate program with appropriate training and accreditation in the performance of CMR studies.
Interpretation of CMR studies. During their 1-month of training, trainees should actively participate in daily CMR study interpretation under the direction of a Level 2- or Level 3-trained CMR physician-mentor. For all studies in which angiographic, echocardiographic, radionuclide, computed tomography, or hemodynamic data are available, such information should be correlated with CMR studies. Studies should include the range of procedures listed in Table 1. Experience in interpretation (a minimum of 50 cases) may include studies from an established CMR teaching file.
Lectures and self-study in CMR. This component should consist of lectures on the basic aspects of CMR and parallel reading material of selected articles, digital training programs, or CMR text. The lectures and reading should provide the fellow with an understanding of CMR applications. Specificity, sensitivity, diagnostic accuracy, utility in assessing prognosis and use of interventions, costs, artifacts, indications, contraindications, and pitfalls must be included for each cardiovascular diagnostic subset. Such information could be effectively transmitted within a weekly non-invasive or clinical teaching conference during which CMR data are presented.
A basic understanding of magnetic resonance physics should be provided, including the following: 1) the physics of magnetic resonance as it relates to image intensity and contrast, including flow, T1(spin-lattice relaxation time), T2(spin-spin relaxation time) and contrast agents; 2) sources of artifacts, including motion, arrhythmias, and metal objects; contrast agent side effects; 3) safety of devices in the CMR environment; and 4) general post-processing tools and analyses.
Hands-on experience is not necessary for Level 1.
Level 2: Specialized training (at least 3 months)
Training for Level 2 should begin with the CMR experience outlined in Level 1. Level 2 is for those trainees who wish to practice the specialty of CMR, including independent interpretation of CMR studies. Level 2 trainees must have at least 3 months of dedicated CMR training (where 1 month is defined as 4 weeks and a week is defined as 5 h), including the basic elements listed in the following text. The trainee would be expected to become familiar with the CMR techniques listed in Table 1.
In addition to Level 1 training, understanding of CMR physics should be more advanced (see the following text).
Interpretation of CMR studies
During their 3 or more months of experience, trainees should actively participate in daily CMR study interpretation under the direction of a Level 2 or Level 3 (preferred) CMR-qualified physician. For all studies in which other cardiac imaging data are available, such information should be correlated with CMR data. The trainee should interpret at least 150 CMR examinations during this training period, including 50 for which the trainee is present during the scan, ideally as the primary operator and is the primary interpreter. Up to 50 of the 100 examinations for which the trainee is not the primary interpreter can be derived from established teaching files, journals, and/or textbooks or electronic/on-line courses. Careful documentation of all case material and the details of the way in which the case was derived is essential.
Lectures and self-study in CMR
Course work would include the components for Level 1 training but also should include more advanced lectures and reading materials. This work, with parallel reading, should continue for the duration of the traineeship. Course work should include the following:
1. Physics: trainees should receive didactic lectures from a CMR-trained physician and/or physicist on the basic physics of magnetic resonance in general and CMR in particular. The content should include the same materials as in Level 1 (basic) plus lectures with supportive reading on the following topics:
a. Image formation, including k-space, gradient echo, spin echo, fast spin echo, echo planar, spiral, steady-state free precession (SSFP), and parallel imaging.
b. Specialized imaging sequences, including flow and motion, phase imaging, time of flight, contrast agents, and radiofrequency tagging.
c. Hardware components, including the elements of gradient coil design, receiver coils, and digital sampling.
2. Applications, interpretation, indications, and contraindications: Level 2 didactic activities should include an understanding of the sensitivity, specificity, accuracy, utility, costs, acquisition approaches, and disadvantages of all of the contemporary techniques in CMR. The following techniques should be covered in the didactic program:
a. Imaging of structure and tissue characterization (T1, T2, spin echo, gradient echo, SSFP, and fat suppression).
b. Imaging of function (cine and tagged cine magnetic resonance including SSFP imaging).
c. Volumetric imaging of mass, biventricular volumes, and ejection fraction (using cine magnetic resonance imaging).
d. Flow imaging (e.g., velocity-encoded techniques).
e. Imaging of myocardial infarction, scarring, and viability assessment (delayed contrast-enhancement imaging).
f. Pharmacologic stress-testing with evaluation of ventricular function and/or first-pass perfusion using a contrast agent.
g. Magnetic resonance angiography (vascular).
h. Electrocardiogram and peripheral pulse gating and triggering including timing of image acquisition within the R-R interval, motion artifacts and their effects on CMR images; respiratory motion suppression methods (e.g., breath-holding and navigators).
i. Magnetic resonance spectroscopy methods (e.g., depth resolved surface coil spectroscopy or DRESS).
j. Cardiovascular magnetic resonance image analysis and post-processing tools.
k. Contraindications for CMR study.
l. Incidental findings suggesting pathology outside of the cardiovascular system.
The person responsible for the CMR training program must be responsible for assessing the competence of the CMR trainee at the completion of the program. This is accomplished by examining the ability of the trainee in the understanding of the acquisition methods and the interactive role of the operator during the performance of studies and in the interpretation of the data acquired during daily reading sessions. This may be supplemented by formal testing.
Level 3: Advanced training (12 months or more for those interested in running an academic program)
Level 3 CMR training represents the highest level of training and would enable the trainee to pursue a clinical or academic career in CMR and to direct a CMR laboratory. Level 3 training in CMR could be obtained as part of a 3- or 4-year cardiology fellowship. In addition to the recommendation for Level 2, the Level 3/academic program should include active participation in ongoing basic or clinical CMR research or both, with individual responsibility for a specific portion of that research. Focused research work with publication of one or more manuscripts is an important part of Level 3 training. Level 3 training must be performed under the guidance of at least one Level 3-trained CMR physician.
In parallel with research activities, the Level 3 trainee must participate in clinical imaging that should include supervised interpretation of at least 300 CMR cases. The trainee must be physically present and involved in the acquisition and the primary interpretation of at least 100 CMR cases. In the remaining 200 cases, the trainee should review at least 100 of these with the Level 3 mentor at the training facility. The remaining cases can be derived from established teaching files, journals, and/or textbooks or electronic/on-line courses. Careful documentation of all case material and the details of the way in which the case was derived are essential.
Knowledge of magnetic resonance physics must be more advanced than Level 2 and include the following:
1. Analysis of why certain specialized imaging sequences are applicable for specific clinical protocols, including imaging of heart function, coronary arteries, perfusion, delayed enhancement, and peripheral arteries.
2. Basic understanding of the clinically applicable spectroscopic methods.
3. The essentials of data collection, including capturing of digital data, the maintenance of accurate databases and records, signal processing, and the approach for obtaining quantitative data.
Evaluation should be similar to that of Level 2.
Summary of Recommendations
The overall requirements for training in CMR are summarized in Table 3.
This is an update of the 2002 document that was written by Gerald M. Pohost, MD, FACC, Raymond J. Kim, MD, FACC, Christopher M. Kramer, MD, FACC, and Nathaniel Reichek, MD, FACC.
|Name||Consultant||Research Grant||Scientific Advisory Board||Speakers’ Bureau||Steering Committee||Stock Holder||Other|
|Dr. Raymond J. Kim||Mallinckrodt||None||None||None||None||None||Siemens-Educational Grant|
|Dr. Christopher M. Kramer||None||Fujisawa Novartis||None||GE Healthcare||None||None||Siemens, Merck-Research materials support|
|Dr. Warren J. Manning||None||None||None||None||None||None||None|
|Dr. Gerald M. Pohost||None||None||None||Takeda Pharmaceuticals||None||None||None|
This table represents the relationships of committee members with industry that were reported by the authors as relevant to this topic. It does not necessarily reflect relationships with industry at the time of publication.
- American College of Cardiology Foundation