Clinical application of free-breathing compressed sensing in cardiac magnetic resonance cine sequences for assessing left ventricular function and strain

Introduction

Cardiac magnetic resonance (CMR) cine sequences can be used to accurately evaluate cardiac volume and function (1), which play important roles in the diagnosis and prognosis of cardiovascular diseases (2,3) and have been widely used in clinical practice. As a novel indicator for evaluating cardiac systolic and diastolic function, myocardial strain can be analyzed by CMR feature tracking on the basis of the conventional cine sequences without the need for additional strain-specific image sequences. However, conventional balanced steady-state free precession (bSSFP) requires segmented acquisition in the breath-hold (BH) state, resulting in a long scan time. It is difficult for most patients with cardiac diseases to perform cine sequences with multiple prolonged BHs, which leads to severe artifacts in cine images or examination failure. Therefore, an accelerated acquisition technique with free breathing for patients in CMR cine scanning is urgently needed.

In recent years, compressed sensing (CS) technology, incorporating sparsity, incoherent undersampling, and iterative reconstruction methods, has improved signal acquisition speed (4) and has been widely applied in the field of accelerated magnetic resonance (MR) imaging (5-7), showing particular potential in CMR imaging. The application of CS technology in CMR cine sequences can greatly reduce the scanning time, thereby improving patient cooperation and examination efficiency. Previous studies have reported that the CS cine has good agreement with the conventional BH cine in terms of left ventricular (LV) function and strain (8-10), but the majority of these studies were performed under BH conditions (11-15). In this study, a novel motion-correction free-breathing (FB) CS cine technique was applied in clinical CMR examinations. The aim of this study was to assess the feasibility of its application by evaluating the image quality, LV function, and strain parameters of the FB CS cine and compare them with those of the conventional BH cine. We present this article in accordance with the STROBE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-826/rc).

Methods

Study participants

From January 2023 to August 2023, patients referred to Tongji Hospital for CMR examination were prospectively enrolled in this study. The inclusion criterion was patients who completed both conventional BH cine and FB CS cine sequences. The exclusion criterion was poor image quality that did not meet the requirements of postprocessing analysis or clinical diagnosis. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments and was approved by Institutional Ethics Board of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (No. 2020, S155). Informed consent was obtained from all patients.

MR imaging protocol

All cardiac MR scans were performed on a 3-T scanner (uMR 790, United Imaging Healthcare, Shanghai, China) with a dedicated 24-channel cardiac coil. The scanning protocol included short-axis and four-chamber views of conventional BH cines as well as FB CS cines with retrospective electrocardiographic gating. The FB CS cine sequence is a commercial product of United Imaging, installed on our scanner. The details of CS and motion-correction FB can be found in our previous work (16,17). Both the cine sequences were acquired before contrast medium injection. The scanning range, number of slices, and thickness of both cine sequences were the same. The conventional cine sequence was scanned with a BH at the end of expiration, and the FB CS cine sequence was scanned in the FB state. Scan times were recorded. The imaging parameters are summarized in Table 1.

Image analysis

All qualitative and quantitative image analyses were performed independently by two radiologists with 9 and 3 years of CMR diagnostic experience, respectively. Subjective image quality was rated for all short-axis and four-chamber views of both the conventional BH and FB CS cine sequences on a 5-point rating scale regarding three image criteria: blood-pool-to-myocardium contrast, endocardial edge definition, and artifacts (18). An overall score was determined by the equal-weighted average of all three criteria. The 5-point scale was determined as follow: 1, nondiagnostic; 2, poor; 3, medium; 4, good; and 5, excellent.

LV function and strain analysis were conducted via cvi 42 software (v. 5.3, Circle Cardiovascular Imaging, Calgary, Canada). LV endocardial and epicardial contours were automatically contoured by artificial intelligence at the end-diastolic and end-systolic phases, and two radiologists manually adjusted the contours slice by slice when the contour identification was inaccurate. LV volume and functional parameters, including the end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), ejection fraction (EF), cardiac output (CO), and end-diastolic mass (EDM), were then calculated. Myocardial strain analysis involved the use of the feature tracking module to automatically delineate the four-chamber view and short-axis cine images of the LV endocardial and epicardial contours at end-diastole and then extended to the entire cardiac cycle automatically. After manual adjustments, the software automatically calculated the LV strain and corresponding time to peak strain, including the global peak radial strain (GRS), global peak circumferential strain (GCS), global peak longitudinal strain (GLS), time to peak radial strain (TPRS), time to peak circumferential strain (TPCS), and time to peak longitudinal strain (TPLS). The GRS, GCS, and corresponding peak times were obtained from short-axis images, whereas the GLS and corresponding peak times were obtained from four-chamber images.

Statistical analysis

Statistical analysis was conducted via SPSS 25.0 software (IBM Corp., Armonk, NY, USA). Continuous data are described as the mean ± standard deviation or as the median with the 25^th and 75^th percentiles. Meanwhile, categorical variables are presented as frequencies and percentages. Prior to statistical analysis, image quality scores and quantitative parameters from the two radiologists were averaged. The Shapiro-Wilk test was used to assess the normal distribution of the data. For normally distributed data, a paired t-test was applied to assess the quantitative data. The paired Wilcoxon signed-rank test was used for comparing quantitative and qualitative scoring data with a nonnormal distribution between the two groups. The agreement of the quantitative parameters between the two sequences was evaluated via the intraclass correlation coefficient (ICC) and Bland-Altman analysis. Interobserver agreement analysis of the quantitative parameters and scoring data was assessed via the ICC and weighted kappa coefficient, respectively. ICC consistency was evaluated as follows: <0.50 for poor consistency, 0.50–0.75 for moderate consistency, >0.75–0.90 for good consistency, and >0.90 for excellent consistency. The weighted kappa consistency criteria were as follows: ≤0.20 for poor consistency, >0.20–0.40 for general consistency, >0.40–0.60 for moderate consistency, >0.60–0.80 for good consistency, and >0.80 for excellent consistency. P<0.05 was considered statistically significant.

Results

This study initially included 34 patients, all of whom were ultimately enrolled, with none being excluded. The clinical characteristics of the patients are summarized in Table 2.

Scan time and image quality score

The total scan time of the FB CS cine sequence (14.8±2.0 s) was significantly shorter (82.3%) than that of the conventional BH cine sequence (83.6±10.9 s; P<0.001). The overall image quality score of the FB CS cine (4.0±0.6) was comparable to that of the conventional BH cine (4.1±0.7), with no statistically significant difference (P=0.561). Except for one patient with noticeable artifacts in conventional BH cine images, which was rated as 2 points by one radiologist, all patients received a score of ≥3 points from two radiologists for both cine sequences. Figure 1 illustrates the distribution of image quality scores of the two cine sequences among patients, expressed as the percentage of patients. Figure 2 shows representative images of two cine sequences.

Figure 1 Distribution of image quality scores (percentages of patients). FB CS, free-breathing compressed sensing.

Figure 2 A patient with connective tissue disease with myocardial involvement. (A,B) End-diastolic images of the midventricular short-axis and four-chamber long-axis end-diastolic images of conventional breath-hold cine. (C,D) The corresponding short-axis and four-chamber long-axis slices of the FB CS cine. FB CS, free-breathing compressed sensing.

Quantitative parameter analysis of LV function and strain

The comparisons of the quantitative parameters of LV function and strain are shown in Table 3. In the analysis of LV functional parameters, there were no statistically significant differences in the LVEDV, LVCO, or LVEDM between the two sequences (P>0.05). However, the LVESV of the FB CS cine was overestimated by 2.7 mL (P=0.003), and the LVSV and LVEF were underestimated by 2.8 mL (P=0.004) and 0.3% (P<0.001), respectively, as compared to conventional BH cine. ICC analysis demonstrated good agreement between the two sequences in terms of the LV function parameters (ICC >0.95) (Table 3).

In the analysis of the LV strain parameters, there was no statistically significant difference in TPLS between the two sequences (P>0.05), whereas the GRS, GCS, GLS, TPRS, and TPCS of FB CS cine were underestimated as compared to conventional BH cine (P<0.05). Additionally, ICC analysis demonstrated good agreement of strain values and time-to-peak parameters between the two sequences (ICC =0.841–0.951) (Table 3).

Bland-Altman analysis revealed that the mean differences in all LV function and strain quantitative parameters between the FB CS cine and conventional BH cine sequences were close to zero, with small ranges of variability, and that the majority of the points fell within the 95% limits of agreement (Figure 3).

Figure 3 Bland-Altman plots of left ventricular function and strain parameters between the FB CS cine and conventional breath-hold cine. The solid line represents the mean difference (FB CS cine—conventional breath-hold cine). The dashed lines represent the limits of agreement (mean difference ± 1.96 SD). FB CS, free-breathing compressed sensing; GCS, global peak circumferential strain; GLS, global peak longitudinal strain; GRS, global peak radial strain; LVEDM, left ventricular end-diastolic mass; LVEDV, left ventricular end-diastolic volume; LVCO, left ventricular cardiac output; LVEF, left ventricular ejection fraction; LVESV, left ventricular end-systolic volume; LVSV, left ventricular stroke volume; SD, standard deviation; TPCS, time to peak circumferential strain; TPLS, time to peak longitudinal strain; TPRS, time to peak radial strain.

Interobserver agreement of image quality scores and quantitative parameter measurements

The overall image quality scores for conventional BH cine and FB CS cine sequences demonstrated good interobserver agreement (weighted kappa values of 0.799 and 0.755, respectively; P<0.001). ICC analysis revealed excellent interobserver agreement for the quantitative parameters (ICC >0.90; P<0.001; Table 4).

Discussion

In this study, the first major finding was that compared with the conventional BH cine sequence, the FB CS cine sequence could be used without repeated breath-holding and significantly reduce the overall scanning time. The second finding was that motion correction effectively mitigated respiratory motion artifacts and improved image quality, which was comparable to that of conventional BH cine. The third finding was that the agreement of the LV function and strain parameters between the FB CS sequence and conventional BH cine sequence was good, which suggested that the FB CS cine sequence could be used to assess cardiac function and strain reliably. In clinical practice, the FB CS cine sequence offers several advantages, such as eliminating the time of patient BH training, reducing the time of repeated breath-holding during the examination, and improving patient cooperation. These improvements contribute to a more efficient workflow in CMR examinations.

CS technology is feasible for CMR cine imaging because of its ability to substantially reduce the scanning time with comparable image quality and accurate assessment of cardiac volumetric and functional parameters. Recent advancements in CS have led to innovative frameworks aimed at enhancing the utility of FB CMR cine sequences. Usman et al. (19) proposed a novel motion-corrected CS framework specifically tailored for FB dynamic CMR. This approach integrates general motion correction algorithms directly into CS reconstruction, which is validated through both simulated and in vivo data via golden-angle radial sampling. The study demonstrated that image quality was comparable to that of BH acquisitions, highlighting the potential of CS to effectively mitigate motion artifacts. Similarly, Takakado et al. (20) combined CS with retrospective motion correction in FB CMR cine imaging and compared it with conventional BH cine sequences. Their findings revealed that FB CS cine imaging provided a significant reduction in examination time and comparable image quality scores as compared with conventional methods. This aligns closely with the outcomes of our study, supporting the robustness and feasibility of FB CS techniques in clinical settings.

A portion of patients with heart disease have breath-holding difficulties and cannot tolerate repeated BHs during conventional BH cine sequences in CMR examinations. Additionally, arrhythmia can cause image artifacts, which affect clinical diagnosis and the assessment of cardiac function. Compared with conventional bSSFP cine sequences, the main advantage of CS technology is its ability to reduce imaging time and its relative insensitivity to motion artifacts caused by arrhythmias or respiration (21,22). Longère et al. (23) compared FB CS sequences with standard segmented BH cine sequences in an unselected population, including patients with arrhythmia and respiratory distress. The results showed that FB CS sequences improved image quality in patients with arrhythmias or respiratory distress, with enhanced edge sharpness at end-systole and end-diastole. For patients with sinus rhythm or arrhythmias, there was no difference between the two techniques in ventricular volume, EF, LV mass, or GCS, indicating that the new FB CS technique can effectively address the motion artifacts related to respiration and arrhythmias without compromising the reliability of ventricular function assessment. Other studies have shown that the image quality scores of CS cine imaging in patients with atrial fibrillation are slightly higher than those of conventional cine imaging (24,25). In our study, there was no significant difference in image quality scores between the two techniques among patients with various cardiac diseases, except for one patient whose conventional BH cine images had significant artifacts and who was rated 2 points by one radiologist. However, the images of both cine sequences were rated ≥3 points for all other patients, meeting the clinical diagnostic requirements for cardiac function and myocardial strain analysis. Nevertheless, owing to the small sample size in this study, further subgroup analysis of patients with arrhythmias was not conducted. Future studies with larger sample sizes are needed to validate these findings and clarify the specific benefits of FB CS sequences in subgroups with different types of arrhythmias.

Previous studies have applied the CS cine sequence to evaluate LV function and strain parameters, with some studies indicating that the strain parameters measured by the CS sequence are lower than those measured by the conventional cine sequence (12,26,27), which aligns with the results of our study. Chen et al. (11) compared the LV volume, global strain, and standard deviation of time to peak strain (SD-TPS) of single-shot CS cine imaging and conventional segmented cine imaging. The results revealed that the LV volume and myocardial mass measured by the single-shot CS cine were closely related to those measured by the segmented cine (ICC >0.798). However, the correlation between the global strain and the SD-TPS derived from the single-shot CS and segmented cine methods was poor to moderate (ICC =0.045–0.706). Compared with those of the segmented cine, all the global strain values of the single-shot CS cine were underestimated, although there was no significant difference in the radial and longitudinal SD-TPSs between the two sequences. In our study, some quantitative LV function and strain parameters measured by the two sequences were significantly different: the LVESV was overestimated, the LVSV and LVEF were underestimated, and the strain values in all three directions were underestimated. Although the differences were statistically significant, the ICCs and Bland-Altman analyses revealed high consistency between the parameters measured by the two sequences. This discrepancy may be due to the reduced effective temporal resolution of CS imaging caused by undersampled acquisition or the weakened contrast between the myocardium and surrounding tissues, which can make the endocardial and epicardial borders less distinct. Additionally, the different breathing states of patients during the acquisition of the two cine sequences could have contributed to these differences. Although both cine scans in this study were located at the same matching slice, minor deviations in the actual scanning slice due to respiratory motion are possible. However, these deviations remain within a clinically acceptable range and are unlikely to influence diagnostic decisions in clinical practice. Therefore, for patients with cardiac diseases who cannot tolerate or cooperate with multiple breath-holding maneuvers, the FB CS cine sequence has the potential to serve as an alternative to conventional multiple breath-holding cine sequences for evaluating LV function and strain.

Limitations

This study involved certain limitations that should be addressed. First, a small sample size was used—with only 34 patients being included—subgroup analysis on the basis of different etiologies of heart function parameters and strain was not conducted, and the influence of heart rate on cine sequence acquisition was not considered. Future studies need to include larger sample sizes for further subgroup analysis. Second, in this study, only LV global myocardial strain parameters were evaluated, while regional myocardial strain was not assessed by specific myocardial segments, and the right ventricular myocardial strain was not analyzed.

Conclusions

This study demonstrated the feasibility of the FB CS cine sequence in clinical practice. Compared with conventional multiple BH cine sequences, this sequence significantly shortens the scanning time while providing comparable image quality and good agreement in LV function and strain parameters. This sequence has the potential to be used as an alternative method to conventional BH cine in clinical practice, simplifying the scanning process, and is especially suitable for patients with cardiac diseases who cannot tolerate multiple BHs or long examinations.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-826/rc

Data Sharing Statement: Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-826/dss

Funding: This work was supported by the National Natural Science Foundation of China (No. 82272109).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-826/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by institutional ethics board of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (No. 2020, S155) and informed consent was taken from all the patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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