CHAPTER 10
10 USE OF NAVIGATOR ECHOES IN CARDIOVASCULAR MAGNETIC RESONANCE AND FACTORS AFFECTING THEIR IMPLEMENTATION
Use of Navigator Echoes
in Cardiovascular Magnetic
Resonance and Factors Affecting
Their Implementation
David Firmin and Jennifer Keegan
Respiration has been shown to be an important factor influ
encing the quality of cardiovascular magnetic resonance
(CMR) images. In addition to cardiac motion, which can
be addressed reasonably well by electrocardiographic
(ECG) triggering, respiratory motion moves the position
and distorts the shape of the heart by several millimeters
between inspiration and expiration. In 1991, Atkinson
and Edelman1 showed the detrimental effects of breathing
on the quality of cardiac studies by showing improved
detail (fast low angle shot) in breath hold segmented fast
gradient echo images compared with conventional non
breath hold images. Although breath holding produces
images that are free of respiratory motion artifact, it is
not without problems. The breath hold position may vary
from one breath hold scan to the next, giving rise to mis
registration effects, and it may also vary during the breath
hold period itself,2 resulting in image blurring and arti
facts. In addition, the scan parameters are limited by the
need to perform imaging within the duration of a comfort
able breath hold period, and for a number of patients, this
period may be very short.
An alternative to breath holding is to monitor respira
tory motion throughout the data acquisition period and
to correct the data for that motion, either in real time or
through postprocessing, with the efficacy of both techni
ques being strongly dependent on the accuracy of the
method of motion assessment. During normal tidal respira
tion, the superior inferior (SI) motion of the diaphragm is
approximately four to five times the anterior posterior
motion of the chest wall,3 and consequently, diaphragm
motion is the most sensitive measure of respiratory motion.
In 1989, Ehman and Felmlee4 were the first to introduce
navigator echoes for measuring the displacement of a
moving structure and to demonstrate their use in determin
ing diaphragm motion during respiration. The navigator
echo is the signal from a column of material oriented per
pendicular to the direction of the motion to be monitored.
On Fourier transformation, this signal results in a well
defined edge of the moving structure. The navigator echoes
may be interleaved with the imaging sequence and conse
quently enable the motion to be determined throughout
the data acquisition period.
In CMR, there have been a number of developments in
the use of navigator measurement to reduce the problems
of respiratory motion. This chapter discusses these devel
opments, considers the various choices that have been
studied in the implementation of navigators, and discusses
their importance. There are many variables in the applica
tion and use of navigator echoes, and although there have
been some attempts to study these, it is unlikely that we
are close to optimizing their application.
USE OF NAVIGATOR
INFORMATION
There are two distinct ways of using navigator echoes to
reduce the problems of respiratory motion in CMR, which
are multiple breath holding with feedback and free breath
ing methods. The first of these uses the navigator informa
tion to provide visual feedback on the diaphragm position
to subjects to allow them to hold their breath at the same
point repeatedly.5 The second uses the navigator echo mea
surement as an input to some form of respiratory gating
algorithm while the patient breathes normally. Figure 10 1
shows actual respiratory trace data in a subject when
performing multiple breath holds and when free breathing.
In both cases, a navigator acceptance window, typically
5 mm wide, is defined, and all data acquired when the nav
igator is outside of this window are ignored. The resulting
image therefore consists of data acquired over a narrow
range of respiratory positions. The respiratory or scan effi
ciency is defined as the percentage of ECG triggers that fall
within the navigator acceptance window and is a measure
of the data rejection rate, which in turn determines the
overall scan duration. As the navigator acceptance window
is reduced, the rejection rate increases and the scan
efficiency decreases. Figure 10 2 shows the residual dia
phragm displacements that occurred during data acquisi
tions performed during conventional breath holding,
breath holding with navigator feedback, and navigator free
breathing in normal subjects.6 Both navigator techniques
result in images acquired over a reduced range of
Cardiovascular Magnetic Resonance 129
BASIC PRINCIPLES OF CARDIOVASCULAR MAGNETIC RESONANCE
5mm NE acceptance window
Diaphragm displacement (mm) 0 30
20
40
60
A 0 Time (s)
Diaphragm displacement (mm)
0
20
40
B Figure 10 2 Mean diaphragm displacement in 17 normal subjects
Figure 10 1 Navigator echo respiratory trace data during multiple
breath holding with navigator feedback (A) and free breathing
(B). In each case, the shaded region shows the position of a 5 mm
navigator acceptance window outside of which data is rejected.
(Adapted from Taylor AM, Keegan J, Jhooti P, Gatehouse PD,
Firmin DN, Pennell DJ. Differences between normal subjects and
patients with coronary artery disease for three different MR coronary
angiography respiratory suppression techniques. J Magn Reson
Imaging. 1999;9:786 793, with permission.)
diaphragm displacement compared with those acquired
using repeated conventional breath holding. In addition,
they allow a longer overall scan time. This allows for aver
aging of data to improve the signal to noise ratio, increas
ing the k space coverage for improved spatial resolution
and increasing the temporal resolution by reducing the
number of individual image views acquired per cardiac
cycle.
Multiple Breath Hold Methods
Wang and colleagues7 were the first to show the use of a
respiratory feedback monitor to reduce misregistration arti
facts in consecutive breath hold segmented fast gradient
echo coronary artery images and to show improved image
quality from averaging scans acquired over multiple breath
holds. When used in informed healthy volunteers, this tech
nique has been shown to produce good results with reason
able scan efficiency.8 However, a period of training is
required, and the process can be problematic, particularly
with patients who have difficulty holding their breath
because of a combination of illness and anxiety.6 Although
130 Cardiovascular Magnetic Resonance
Standard deviation
±2.4 mm ±0.7 mm ±0.7mm
20
Diaphragm displacement (mm)
10
0
60
−10
BH
LED
−20
+ FR
−30
with conventional breath holding (open circles), breath holding
with navigator feedback (closed circles), and free breathing (plus
marks). The navigator controlled studies used a 5 mm navigator
acceptance window. (Adapted from Taylor AM, Keegan J, Jhooti P,
Gatehouse PD, Firmin DN, Pennell DJ. Differences between
normal subjects and patients with coronary artery disease for
three different MR coronary angiography respiratory suppression
techniques. J Magn Reson Imaging. 1999; 9:786 793, with permission.)
it might be expected that breath holding with respiratory
feedback would enable the completion of a cardiac study
much more quickly than when using the free breathing
methods described later, because of the time required for
training and the required rest periods between breath holds,
the overall examination times are longer than anticipated. In
fact, in a group of patients with coronary artery disease,
there was no significant difference between the overall
examination times with the two techniques,6 although the
same study showed that, in a group of normal healthy sub
jects, multiple breath holding resulted in a time reduction of
20%.
Free Breathing Methods
Free breathing methods require very little cooperation from
the patient. The main disadvantage is the potential for
respiratory drift, which can cause considerably reduced
scan efficiency.9 Recently, therefore, most effort has gone
toward improving scan efficiency with this approach.
Much of the early work used retrospective respiratory
gating.10 With this method, data acquisition was over
sampled, typically by a factor of five, and then sorted retro
spectively so that the final image was constructed from data
acquired over the narrowest possible range of respiratory
positions. In 1995, Hofman and associates11 showed that,
using this approach, the image quality of three dimensional
(3D) coronary acquisitions was improved over those
acquired with multiple averages. However, scan efficiency
was poor (20% for an oversampling ratio of five), and
although the final image was constructed from the narrow
est respiratory window possible, the range was highly
dependent on the subject’s breathing pattern during the
long acquisition period and was often still unacceptably
high.
After the introduction of prospective control techni
ques, navigators have most commonly been used with a
simple accept reject algorithm where data are acquired
or not, depending on whether the navigator measurement
is within a predefined acceptance window. Oshinski
and coworkers12 were the first investigators to show
high quality coronary artery images with such an
approach. The problem with this method, however, is that
for reasonably high scan quality, a narrow acceptance win
dow of 5 mm or less is required, and this generally results
in relatively poor scan efficiency. In addition, as noted ear
lier, many subjects and patients undergo a drift in dia
phragm position over time,9 such that the predefined
acceptance window becomes less and less suitable as the
study progresses. The diminishing variance algorithm
overcomes this problem because it does not use a prede
fined acceptance window.13 With this method, one com
plete scan is acquired and the navigator positions are
saved for each line of data. At the end of the initial scan,
the most frequent diaphragm position during that scan
is determined, and a process of reacquiring lines of data
that were acquired with diaphragm positions furthest off
set from this position begins. As time progresses, the
range of diaphragm positions for the data making up the
final set is considerably reduced. In addition to the lack
of requirement of an acceptance window, this method
has the advantage that an image can be reconstructed at
any time after the initial dataset is complete.
Another alternative to the simple accept reject algorithm
that can improve both image quality and scan efficiency is
to use a k space ordering that depends on diaphragm posi
tion. Two similar approaches have been suggested, based
on the finding that the center of k space appears to be more
sensitive to motion than the edges.14 Jhooti and colleagues
developed a phase encode ordered method that used a dual
acceptance window of 5 mm for the center of k space and
10 mm for the outer regions.15 This approach allowed
Table 10-1 Image Quality Scores and Scan Efficiencies{ for Three-Dimensional Magnetic Resonance
Angiography*
Phase Ordered
Image Quality Mean Score 4.4
Scan Efficiency 72 ( 11.6)
*Mean image quality scores (1 ¼ excellent, 10 ¼ very poor) and scan efficiencies{ ( SD) for data acquired using phase ordering, an accept/reject algorithm
(ARA), the diminishing variance algorithm (DVA), and retrospective respiratory gating (RRG) in 15 subjects.
{
Scan time for the DVA technique is set to that of the phase ordered technique.
(Adapted from Jhooti P, Keegan J, Gatehouse PD, et al. 3D coronary artery imaging with phase reordering for improved scan efficiency. Magn Reson Med.
1999; 41: 555.)
much greater scan efficiency than other methods, while
10 USE OF NAVIGATOR ECHOES IN CARDIOVASCULAR MAGNETIC RESONANCE AND FACTORS AFFECTING THEIR IMPLEMENTATION
retaining scan quality (Table 10 1 and Figure 10 3). An
alternative method, initially developed by Sinkus and
Bornert to address general respiratory motion16 and more
recently applied to imaging of the coronary arteries, used
a tailored acceptance window through k space as opposed
to phase encode ordering to obtain a very similar result.17
Both of these phase ordering or windowing techniques
use a predefined navigator acceptance window, and scan
efficiency is reduced when the respiratory pattern changes
during study acquisition. This has been more recently
addressed by Jhooti and colleagues, who developed a tech
nique that combines the benefits of phase ordering with an
automatic window selection that enables the highly effi
cient acquisition of high quality coronary artery images
without the need for a predefined acceptance window.18
Three dimensional motion adapted gating19 is a similar
technique that yields images comparable to standard pro
spective navigator gating, with significantly improved scan
efficiency.20
NAVIGATOR ECHO
IMPLEMENTATION
Method of Column Selection
Two methods have been used for the generation of a navi
gator echo.
With the spin echo technique, a spin echo signal is gen
erated from the column of material formed by the intersec
tion of two planes, one excited by a 90
radiofrequency
(RF) pulse and the other by a 180
RF pulse. The column
cross section may be either rectangular or rhombic,
depending on the orientation of the two planes. This
approach is very robust and produces an extremely well
defined column. However, it cannot be repeated rapidly,
and care must be taken to ensure that the column selection
planes do not impinge on the region of interest.
The alternative approach is to use a selective two
dimensional (2D) RF pulse to excite a column of approxi
mately circular cross section.21 Although this technique is
much more sensitive to factors such as shimming errors,
which can potentially cause blurring and distortion of the
column, with a reduced flip angle, it can be repeated more
rapidly and the navigator artifact is less extensive.
ARA DVA{ RRG
4.7 6.6 6.8
48 ( 11.5) 72 ( 11.6) 20
Cardiovascular Magnetic Resonance 131

BASIC PRINCIPLES OF CARDIOVASCULAR MAGNETIC RESONANCE
A C
Phase reordered (scan eff. = 73%) DVA (scan eff. = 73%)
B D
ARA (scan eff. = 49%) RRG (scan eff. = 20%)
Both methods are used routinely for research studies on
coronary imaging, without any reported problems.
Correction Factors
In CMR, navigator echoes are most frequently used to mea
sure the position of the diaphragm. However, the motion of
the heart is not straightforward, and only the inferior bor
der that sits on the diaphragm will move to the same
extent, whereas superiorly, the relative motion will be
reduced. This was first studied by Wang and associates,3
who measured the displacement of the right coronary
artery root, the origin of the left anterior descending artery,
and the superior and inferior margins of the heart relative
to the diaphragm in 10 healthy subjects. For the right cor
onary artery origin, the mean ( SD) relative displacement
(or correction factor) was 0.57 ( 0.26). McConnell and
coworkers22 first used this correction factor to track the
position of the imaging slice during breath holding and
showed improved image registration relative to untracked
acquisitions. In free breathing studies, the correction factor
was first applied by Danias and colleagues,23 who showed
that tracked image quality was maintained as the navigator
acceptance window increased from 3 mm to 7 mm,
whereas in untracked images, it decreased significantly.
This technique, called real time prospective slice following,
132 Cardiovascular Magnetic Resonance
Figure 10 3 A single slice from a
three dimensional dataset showing
a long section of the right coronary
artery. The phase ordered images
(A) are of comparable quality to
those acquired with the accept
reject algorithm (B) and better than
those acquired with both the
diminishing variance algorithm
(C) and retrospective respiratory
gating (D). Scan efficiency is also
significantly higher for phase
ordering than for both the accept
reject algorithm and retrospective
respiratory gating techniques.
(Adapted from Jhooti P, Keegan J,
Gatehouse PD, Collins S, Rowe A,
Taylor AM, Firmin DN. 3D coronary
artery imaging with phase
reordering for improved scan
efficiency. Magn Reson Med 1999.
41:555 562, with permission.)
or slice tracking, is now used routinely for both 2D and
3D methods of acquisition. Of note, however, is the rela
tively high standard deviation of the correction factor noted
earlier, which reflects considerable intersubject variation in
the degree of cardiac motion with respiration. This was also
observed by Danias and coworkers, who used real time 2D
echo planar imaging to study the SI motion of the heart as a
function of navigator position.24 The accuracy of slice fol
lowing techniques will obviously depend on the accuracy
of the correction factor implemented. In 1997, Taylor and
colleagues25 showed how a subject specific factor could
be measured rapidly with end inspiratory and end expira
tory breath hold scans before the coronary imaging proto
col. Figure 10 4 shows the relationship between the
motion of the right hemi diaphragm and the coronary ostia
measured in one subject, with the slope of the graph giving
the correction factor. Figure 10 5 shows two examples of
subjects with very different correction factors, showing
how a wider acceptance window can be used, thus improv
ing scan efficiency. The need for a subject specific correc
tion factor has further been confirmed in 3D coronary
angiography, where its use was found to yield optimal
image quality.26 In 2002, Keegan and associates further
developed this area of work by studying the variability of
correction factors in the SI, anterior posterior, and right left
directions for both breath holding and free breathing.27
The study concluded that subject variability in correction

0
Downward coronary displacement (mm) y = –0.08 – (0.45 x)
r = 0.99
4
8 advantage of the latter navigator position is that it would
12
16
0 10 20 30
Downward diaphragm displacement (mm)
Figure 10 4 Plot of superior inferior right coronary artery
displacement against superior inferior diaphragm displacement for a
single subject. The gradient of the linear regression line is the subject
specific correction factor. (Modified from Taylor AM, Keegan J, Jhooti P,
Firmin DN, Pennell DJ. Calculation of a subject specific adaptive
motion correction factor for improved real time navigator echo gated
magnetic resonance coronary angiography. J Cardiovasc Magn Reson.
1999; 1:131 138, with permission.)
factors, together with within subject differences between
breath holding and free breathing, is such that slice follow
ing should be performed with subject specific factors deter
mined from free breathing acquisitions.
An additional or alternative approach to the real time slice
following described earlier is to use a postprocessing adap
tive motion correction technique4 to correct an image retro
spectively for movement occurring during data acquisition.
This technique, which can be used to correct a 2D acquisi
tion for in plane displacement or a 3D acquisition for in
plane and through plane displacement, may not appear to
be an attractive option initially, but it has the advantages of
allowing the correction factor to be optimized for each indi
vidual patient and provides an alternative approach to those
centers with scanners that do not have a real time decision
making capability. This approach has been implemented
with both segmented gradient echo28 and interleaved spi
ral29 coronary artery acquisitions, with promising results.
Column Positioning
The degree of diaphragm motion detected by the navigator
echo is dependent on the positioning of the navigator col
umn. The dome of the right hemi diaphragm is higher than
that of the left, and the two move coherently with respira
tion, but to differing degrees.30 Motion of the diaphragm is
also greater posteriorly than anteriorly (anterior and dome
excursions are 56% and 79%, respectively, of posterior
excursions), and at the level of the dome, it is greater later
ally than medially.31 The correction factor implemented in
real time slice following or postprocessing adaptive motion
correction, as described earlier, is strongly dependent on
the positioning of the navigator column and further
supports the use of a subject specific factor, as described
10 USE OF NAVIGATOR ECHOES IN CARDIOVASCULAR MAGNETIC RESONANCE AND FACTORS AFFECTING THEIR IMPLEMENTATION
in the previous section.
McConnell and colleagues32 studied the effects of vary
ing the navigator location on the image quality of coronary
artery studies. Navigators were positioned through the
dome of the right hemi diaphragm, through the posterior
portion of the left hemi diaphragm, through the anterior
and posterior left ventricular walls, and through the ante
rior left ventricular wall, as shown in Figure 10 6. The
eliminate the need for a correction factor, as described
in the previous section, relating the navigator echo
measured displacement to the coronary artery motion.
The results are summarized in Table 10 2 and show no
significant differences in the image quality scores obtained
with varying navigator location. There was a tendency for
the anterior left ventricular wall navigator scans to be lon
ger in duration, but the difference did not reach statistical
significance. One of the problems with monitoring the
heart itself is the complex anatomy, making it more diffi
cult to find a suitable position for the navigator column.
More sophisticated methods of positioning the column
may further improve this method of monitoring cardiac
motion.
MULTIPLE COLUMN
ORIENTATIONS
There is a linear relationship between the SI and anterior
posterior motions of the heart, with the SI motion being
approximately five times that of the anterior posterior
motion.3 For this reason, the real time slice following
methods first used by McConnell and colleagues22 and
by Danias and associates23 included a correction for
anterior posterior motion of the heart, assuming it to be
equal to 20% of the SI motion. Unfortunately, there is
not always such a strong relationship between the direc
tions of motion of the heart with respiration. Sachs and
colleagues showed this by using three navigators to
measure the SI, anterior posterior, and right left motions
of the heart.33 Figure 10 7 shows an example from this
study illustrating the scatter of SI, right left, and anterior
posterior measurements, made over a period of approxi
mately 10 minutes. The group went on to compare the
use of one, two, and three navigators for imaging the
right coronary artery and showed an improvement when
multiple directions of motion were considered. This
improvement in image quality, however, must be offset
against the main disadvantage, which is that scan effi
ciency is reduced, potentially introducing more problems
associated with long term drift in the breathing pattern. A
more recent study by Jahnke and coworkers used a new
cross correlation based approach and showed the poten
tial advantage of combining three orthogonal navigators.34
Navigator Timing
Navigator timing is one of the more important parameters;
however, flexibility to alter this is often limited by the com
puting architecture of the scanner being used (discussed
Cardiovascular Magnetic Resonance 133
BASIC PRINCIPLES OF CARDIOVASCULAR MAGNETIC RESONANCE

6 mm
16 mm

A
CF 0.70 0.00 1.00
6 mm
16 mm

B
CF 0.25 0.00 1.00

Figure 10 5 Right coronary artery origin images acquired with navigator acceptance windows of 6 mm and 16 mm in subjects with subject
specific correction factors (CFs) of 0.7 (A) and 0.25 (B). For both subjects, images were also acquired with CFs of 0 and 1. In the absence
of slice following (CF 0), image quality is reduced as the navigator acceptance window increases from 6 mm to 16 mm. When slice
following with a subject specific CF is used, however, image quality is maintained. (Modified from Taylor AM, Keegan J, Jhooti P, Firmin DN,
Pennell DJ. Calculation of a subject specific adaptive motion correction factor for improved real time navigator echo gated magnetic
resonance coronary angiography. J Cardiovasc Magn Reson. 1999; 1:131 138, with permission.)

134 Cardiovascular Magnetic Resonance

 10 USE OF NAVIGATOR ECHOES IN CARDIOVASCULAR MAGNETIC RESONANCE AND FACTORS AFFECTING THEIR IMPLEMENTATION
A B C D

Figure 10 6 Navigator column locations positioned on tranverse, coronal and sagittal pilot images: (A) through the dome of the right hemi
diaphragm, (B) through the posterior left hemi diaphragm, (C) through both anterior and posterior left ventricular walls and (D) through the
anterior left ventricular wall.

Table 10-2 Image Quality Scores, Registration Errors, and Total Scan Times*
Right Diaphragm Left Diaphragm Left Ventricle Anterior LV Wall
Parameter Navigator Navigator Navigator Navigator
Image Quality Score (0 4) 2.3  0.1 2.3  0.1 2.4  0.1 2.2  0.2
Registration error (mm)
Craniocaudal 0.5  0.1 0.4  0.1 0.6  0.1 0.4  0.1
Anteroposterior 0.3  0.1 0.3  0.1 0.3  0.1 0.4  0.1
Total Scan Time{ (sec) 294  28 314  30 342  62 427  111

*Image quality scores (0 ¼ very poor, 4 ¼ excellent) registration errors, and total scan times for different navigator column positions during free breathing
MR coronary angiography. There were no significant differences between the navigator column locations. Data are presented as mean  standard error of
the mean (SEM); LV ¼ left ventricle
{
Total scan time is the time from start to finish for 6 scans.
Adapted from McConnell MV, Khasgiwala VC, Savord BJ, et al. Comparison of respiratory suppression methods and navigator locations for MR coronary
angiography. Am J Roentgenol. 1997;168:1369.

Figure 10 7 Anterior posterior

(A/P; A) and right left (R/L; B) 80
navigator echo measurements as a 60
function of superior inferior
navigator echo measurements in a
healthy subject. (Data provided by
Todd Sachs, Stanford University.)

R/L A/P

40

A 0 S/I 150 B 0 S/I 150

later). Figure 10 8 shows the three main alternatives: (1)
pre , (2) pre and post , and (3) navigators repeated regu
larly throughout the cardiac cycle. A simple prenavigator
provides the highest scan efficiency when a navigator
acceptance window is used, but may not be reliable if there
is a sudden change in breathing between the navigator
measurement and image data acquisition. Pre and
postnavigators overcome this problem, but of course, they
also reduce scan efficiency. In our experience, the use of
prenavigators only produces acceptable results for free
breathing studies, whereas multiple breath hold acquisi
tions certainly require both pre and postnavigators. An
important factor that depends on the computer hardware
and architecture is the time required after the navigator

Cardiovascular Magnetic Resonance 135


BASIC PRINCIPLES OF CARDIOVASCULAR MAGNETIC RESONANCE
D. acq.
Pre-
Pre- and post-
D. acq. D. acq. D. acq. D. acq.
Rep.
Figure 10 8 Timing of the navigators for pre , pre and post ,
and repeated (Rep.) navigator echo controlled data acquisition
(D. acq.).
acquisition before the start of the imaging sequence. Partic
ularly if prenavigators only are being used, the longer this
interval, the greater the potential for errors caused by respi
ratory motion. Also, for ECG R wave triggered scans, this
may also have implications for the minimum gating delay
that can be obtained and for short gating delay or cine
scans, post only navigators can be used as an alternative.
This approach was recently implemented in left ventricular
function studies, where it was found that image quality in a
group of patients with heart failure was significantly improved
over conventional breath hold scans.35
Repeated navigators allow for improved cine or multi
slice imaging and also provide some potential for estimat
ing internavigator respiratory motion. The potential prob
lem with this is that the navigator signal to noise ratio
could be reduced and this may affect the accuracy of navi
gator edge detection. In addition, as the time for navigator
output increases, the time for imaging decreases and the
number of phases or slices that can be acquired is reduced.
Precision of Navigator
Measurement
Commonly, a spatial resolution of 1 mm is used along the
navigator echo column, for example, having a field of view
of 512 mm and sampling 512 points on the navigator read
out. However, the precision of the measurement is depen
dent to a large extent on the signal to noise ratio of the
navigator measurement. The most important factor affect
ing the signal to noise ratio is the coil arrangement. If, for
example, a single coil is used for imaging and navigator
detection, it must be large enough to cover both the imag
ing area of interest and the region of navigator detection.
On the other hand, if phased array coils are used, it is pos
sible to position one coil specifically for navigator detec
tion, possibly over the region of the right diaphragm.
Another important factor in the precision of the measure
ment is the quality of the edge on the navigator trace. To
obtain a well defined edge of the diaphragm, for example,
it is important to have a reasonably small column cross sec
tion and to position it through the dome of the diaphragm,
so that the column is perpendicular to the diaphragm edge,
rather than more posteriorly, where motion is greatest.
136 Cardiovascular Magnetic Resonance
Finally, the diaphragm edge may be detected by edge detec
tion, correlation, or least squares fit algorithms. For rapid
tracking (repetition time < 100 msec) or narrower col
umns, the signal to noise ratio in the diaphragm trace
could be too poor for simple edge detection methods to
succeed. Of the remaining two techniques, the least squares
fit method has been shown to be more resistant to the
effects of noise and to the diaphragm profile deformation
that occurs during respiration than the correlation method
and therefore would be the technique of choice.36 How
ever, most navigator techniques acquire only one or two
navigators per cardiac cycle, and in such cases, the signal
to noise ratios are usually relatively high and edge detec
tion algorithms are generally adequate.
MORE RECENT APPROACHES
Other Forms of Navigators
As has been mentioned, there are problems with the con
ventional navigators that have been described earlier
because they generally do not give a direct measure of
the respiratory related motion of the heart and they can
not be implemented simply and efficiently to give a mea
sure of this motion in 3D.37 A number of ingenious
alternative approaches have been described. In 2003,
Nguyen and colleagues38 described a method that selec
tively excited the epicardial fat, followed by a rapid read
out scheme that instantaneously gave three 1D images of
its position in the x, y, and z directions. Tested on six sub
jects, the method showed a slight improvement over con
ventional navigators; however, the authors noted a
number of problems that would need to be resolved
before it could be in routine use. In the same year, another
method of rapidly localizing heart signals for measure
ment of its position was suggested by Pai and Wen, who
used a phase contrast angiographic approach to selectively
image the flowing blood in the heart chambers.39 These
blood signals were used to define the heart position in
the SI and anterior posterior directions. Despite the
potential advantages of truly tracking the heart position,
this method does not appear to have been developed fur
ther or used.
Subsequently, Stehning and associates used radial
imaging for “self navigation.” They developed an inter
leaved 3D radial acquisition modified in such a way that
the first readout was always in the SI direction.40 This
readout could then be reconstructed every cardiac cycle
to give an SI projection for motion extraction. In this
work, the authors showed improved definition compared
with conventional navigators when imaging a moving
phantom and similar image quality on initial in vivo cor
onary scans. Hardy and colleagues41 used cross correla
tion of low resolution real time 2D spiral coronary
artery images to accept or reject images for averaging.
This adaptive averaging technique was extended to high
resolution segmented acquisitions by cross correlating subi
mages reconstructed from individual data segments. Breath
ing autocorrection with spiral interleaves (BACSPIN) is a
similar technique42 that involves the acquisition of a multi
slice spiral dataset during breath holding, followed by
repeated acquisition of the same slices during free breathing.
Each heavily undersampled free breathing spiral interleaf is
compared with the same interleaf acquired during breath
holding, and those that match closely are incorporated into
a multi slice, multi average dataset. This technique has been
shown in a group of six healthy volunteers where increased
signal to noise ratio has been achieved with minimal motion
blurring. An alternate approach to respiratory motion cor
rection that has been applied to spiral imaging is to acquire
a low resolution 3D dataset on the fat resonance immedi
ately before a high resolution interleaf on the water reso
nance. Cross correlation of a selected region of interest of
the low resolution fat images from beat to beat is then used
to determine the x, y, and z translations of that region and
can be used to correct the next high resolution interleaf
retrospectively. This approach has been shown in dark
blood coronary vessel wall imaging, where high quality
images have been obtained without the need for a gating
window.43
Motion Models
Because of the complexity of cardiac motion and the diffi
culty in extracting measures to correct for it, there has been
an interest in developing modeling methods to assist with
this process. Manke and coworkers compared one
dimensional (1D) translation (SI direction), 3D translation,
and 3D affine transformation motion models in a group of
healthy subjects.44 By using an elastic image registration
algorithm on 3D coronary images acquired at different
breath hold positions, the superiority of the 3D transla
tional model over the 1D translational model was shown.
The authors also used a fast model based image registration
to extract motion information from a time series of low
resolution 3D images. This was used in conjunction with
conventional navigators to calibrate a respiratory motion
model that allowed the prediction of affine transformation
parameters, including 3D translation, rotation, scale, and
shear motion from the navigator measurements, and was
shown with coronary artery imaging.45 McLeish and col
leagues46 acquired images at a number of breath hold posi
tions and studied the accuracy of both rigid and nonrigid
registration methods in registering the other breath hold
images with those acquired at end expiration. They used
principal component analysis to produce patient specific
statistical motion models and suggest how this could be
used to assist motion correction in CMR. In 2005, Nehrke
and Bornert described their study in which they used
a patient specific model to control the acquisition.47
Initially, multiple low resolution 3D images were preac
quired during free breathing. An affine model of the respi
ratory related cardiac motion was then extracted from these
images, and this was steered by real time navigators to con
trol the high resolution acquisition. The method was
demonstrated in both phantoms and volunteers when a
20 mm navigator acceptance window was used. The results
in the volunteers showed slightly inferior image quality to
images acquired simply with a 5 mm navigator acceptance
window. However, scan efficiency was considerably higher
and image quality was also considerably better than for
10 USE OF NAVIGATOR ECHOES IN CARDIOVASCULAR MAGNETIC RESONANCE AND FACTORS AFFECTING THEIR IMPLEMENTATION
those acquired simply with a 20 mm acceptance window.
A more recent study showed that the residual coronary
artery motion observed using affine navigators with a 10
mm acceptance window is similar to that observed with
conventional navigator gating with a 5 mm window and
that observed using a single breath hold.48
Computer Architecture
The computer architecture of modern CMR scanners can
be very complex, generally incorporating three main com
puters. The host computer runs the user interface and
allows connection to the image database, the reconstruction
computer is a dedicated rapid processor for reconstruction
of the CMR image data, and the scan computer allows con
trol and adjustment of parameters associated with the scan
ning sequence. The architecture of these computers can
significantly affect the potential and usefulness of navigator
echoes. On many systems, for example, the navigator signal
must be reconstructed and processed on the reconstruction
computer, but the measurement made must be passed
through the host to control the parameters on the scan
computer. This arrangement inevitably adds a variable
and unknown delay that is dependent on other tasks being
performed by the host operating system. To overcome this,
either a direct and rapid link is required, allowing transfer
of data from the reconstruction computer to the scan com
puter, or the scan computer itself must be capable of
acquiring and reconstructing the navigator data, so that
no data transfer is required. Newer scanners are generally
being designed with rapid acquisition, processing, and con
trol in mind.
CONCLUSION
Navigator echo has been shown to be an important method
for monitoring respiration that has been used for defining
the position of the heart, enabling improved coronary and
other cardiac imaging. The limited number of studies and
the many parameters and variables involved in their use
suggest that an optimal method of application may not
yet have been developed. With future system development,
there will be minimal cost, in imaging time or other factors,
involved in obtaining this positional information. There
fore, it would seem worthwhile to collect and use it where
appropriate. The methods are not robust, probably because
of their relative lack of sophistication.
One of the major advantages of this technique is that
navigators allow images to be acquired during free respira
tion, eliminating the need for patient cooperation. They
also allow longer acquisition times, enabling higher spatial
and temporal resolution and increasing the potential for
more sophisticated techniques, such as detailed flow imag
ing.49,50 A balance must be maintained, however, and
imaging time should not be increased so much that
increased respiratory drift cancels any potential benefit.
Cardiovascular Magnetic Resonance 137