Cardiac Magnetic Resonance Imaginag (MRI)
FINDINGSVentricle FindingsTable SEQ Table \* ARABIC 1 Ventricle FindingsVentricleEjection Fraction (%)Systolic FunctionEnd Diastolic DimensionEnd Systolic DimensionEnd Diastolic Volume (ml)End Diastolic Volume Index (ml/m2)End Systolic Volume (ml)End Systolic Volume Index (ml/m2)Septal thicknessPosterior Wall thicknessLV massLV mass indexLeft VentricleData to be entered by site FORMCHECKBOX Normal FORMCHECKBOX AbnormalData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by siteRight VentricleData to be entered by site FORMCHECKBOX Normal FORMCHECKBOX AbnormalData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by siteLeft Ventricular Non-Compaction DetailsTable SEQ Table \* ARABIC 2 Left Ventricular Non-Compaction DetailsNon-Compaction?Number of TrabeculationsRatio of Noncompacted LV Myocardial Thickness to Compacted LV Myocardial Thickness at End-DiastolePosition FORMCHECKBOX Present FORMCHECKBOX Absent (leave rest of table blank)Data to be entered by siteData to be entered by site FORMCHECKBOX Lateral FORMCHECKBOX Apical FORMCHECKBOX Septal FORMCHECKBOX Free wall FORMCHECKBOX Not specifiedAtrial sizeArea: RightArea: LeftGadolinum-based contrast used? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownMyocardial Delayed Enhancement for VentriclesTable SEQ Table \* ARABIC 3 Myocardial Delayed Enhancement for VentriclesVentricleMyocardial Scar Left Ventricle FORMCHECKBOX Present FORMCHECKBOX AbsentRight Ventricle FORMCHECKBOX Present FORMCHECKBOX AbsentIndicate in what segment the myocardial scar is present.Figure SEQ Figure \* ARABIC 1 Myocardial scar locationVeins and Other Cardiac FindingsTable SEQ Table \* ARABIC 4 Veins and Other Cardiac FindingsOther FindingsStructureCommentsAorta FORMCHECKBOX Normal FORMCHECKBOX AbnormalData to be entered by sitePulmonary Venous Anatomy FORMCHECKBOX Normal FORMCHECKBOX AbnormalData to be entered by siteSystemic Venous Anatomy FORMCHECKBOX Normal FORMCHECKBOX AbnormalData to be entered by sitePericardium FORMCHECKBOX Normal FORMCHECKBOX AbnormalData to be entered by siteExtracardiac Findings FORMCHECKBOX Normal FORMCHECKBOX AbnormalData to be entered by siteIntracardiac Findings FORMCHECKBOX Thrombosis – Right FORMCHECKBOX Thrombosis – Left FORMCHECKBOX Mass – Right FORMCHECKBOX Mass – Left FORMCHECKBOX Device – Right FORMCHECKBOX Device – LeftData to be entered by siteQuality of Study: FORMCHECKBOX Technically difficult FORMCHECKBOX Suboptimal FORMCHECKBOX Fair FORMCHECKBOX Good FORMCHECKBOX ExcellentOverall Impression:General InstructionsThis form contains data elements that are collected to assess ventricular volume and function, as well as delineating myocardial involvement by delayed enhancement imaging.Specific InstructionsPlease see the Data Dictionary for definitions for each of the data elements included in this CRF Module.Ejection fraction – Answer for left ventricle. Record value as a percent (%). Value for right ventricle is optional.Ventricle end systolic dimension – Answer for left ventricle. Record value in millimeters (mm). Value for right ventricle is optional.End diastolic dimension – Answer for left ventricle. Record value in millimeters (mm). Value for right ventricle is optional.End systolic dimension – Answer for left ventricle. Record value in millimeters (mm). Value for right ventricle is optional.End diastolic volume – Answer for left ventricle. Record value in milliliters (ml). Value for right ventricle is optional.End diastolic volume index number – Answer for left ventricle. Record value in milliliters per meter squared (ml/m2). Value for right ventricle is optional.End systolic volume – Answer for left ventricle. Record value in milliliters (ml). Value for right ventricle is optional.End systolic volume index number – Answer for left ventricle. Record value in milliliters per meter squared (ml/m2). Value for right ventricle is optional.Left ventricle mass – Record the value as an integer to two decimal places in grams (gm). ................
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