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Validating new techniques for fetal cardiovascular magnetic resonance (CMR) is challenging due to random fetal movement that precludes repeat measurements. Consequently, fetal CMR development has been largely performed using physical phantoms or postnatal volunteers. In this work, we present an open-source simulation designed to aid in the development and validation of new approaches for fetal CMR. Our approach, fetal extended Cardiac-Torso cardiovascular magnetic resonance imaging (Fetal XCMR), builds on established methods for simulating CMR acquisitions but is tailored toward the dynamic physiology of the fetal heart and body. We present comparisons between the Fetal XCMR phantom and data acquired in utero, resulting in image quality, anatomy, tissue signals and contrast.

The fetal CMR phantom provides a new method for evaluating fetal CMR acquisition and reconstruction methods by simulating the underlying anatomy and physiology. As the field of fetal CMR continues to grow, new methods will become available and require careful validation. The fetal CMR phantom is therefore a powerful and convenient tool in the continued development of fetal cardiac imaging.

Assessing the human fetal heart with cardiovascular magnetic resonance (CMR) requires high-resolution acquisitions and reconstructions that are robust to artifacts from maternal respiration and gross fetal movement. Additionally, a fetal electrocardiogram signal for cardiac gating is not readily available in the CMR environment, requiring alternative strategies for conventional CINE imaging of the fetal heart. As a result, a growing number of studies have proposed methods for accelerated imaging, motion compensation, and image-based gating strategies to enable diagnostically useful fetal CMR images [1,2,3,4,5,6,7]. Still, validating new fetal CMR techniques is challenging, as stochastic fetal motion precludes repeat measurements, making it difficult to evaluate the parameter space for a given acquisition or reconstruction routine. Consequently, fetal CMR development has been largely performed using physical phantoms or postnatal healthy subjects, resulting in a lack of widely available fetal-specific reference models and minimal inter-study validation.

Numerical phantoms, including analytical and voxel-based models have been widely used to validate advanced acquisition and image reconstruction strategies in the broader CMR community [8,9,10,11,12,13]. Analytical phantoms, based on the continuous Fourier transform, provide an accurate depiction of k-space acquisitions. However, analytical phantoms are generally confined to simplistic shapes and rarely incorporate motion. Conversely, voxel-based phantoms provide more realistic simulations of dynamic anatomy but are limited by the discrete Fourier transform, and are constrained to the resolution and acquisition parameters of the images from which the phantom is derived.

Recently, a combined analytical and voxel-based approach for simulating CMR acquisitions called MRXCAT has been used to validate a variety of CMR strategies [14]. MRXCAT simulates a CMR acquisition based on user-supplied scan parameters, where the anatomy is defined by the extended Cardiac-Torso (XCAT) phantom, a high-resolution depiction of anatomical objects derived from the Visible Human Project of the National Library of Medicine [12, 15]. The MRXCAT phantom maps the realistic anatomical regions simulated by XCAT to CMR images using known CMR relaxation times for a variety of tissues. Additionally, it can generate multiple time points representing variable respiratory and cardiac motion. Still, the size of the fetal cardiac anatomy, relatively high fetal heart rate, range of motion, and large field of view required to capture the maternal abdomen, is not currently represented by the MRXCAT phantom, Furthermore, while numerical models of pregnant women have been used to assess radiofrequency exposure and temperature increases in CMR, a framework for fetal CMR image reconstruction does not currently exist [16, 17].

In this work, we present an open-source numerical phantom designed to aid in the development and validation of new approaches for fetal CMR. Our phantom referred hereafter as the fetal extended Cardiac-Torso cardiovascular magnetic resonance imaging (Fetal XCMR) phantom, combines two independent four-dimensional (4D, x, y, z, t) XCAT models of human anatomy (maternal and fetal) with a flexible simulation of two-dimensional (2D) multi-slice Cartesian and radial CMR acquisitions. It can be downloaded from: -XCMR/.

Variable physiological parameters are included to control the level of maternal respiration and fetal movement. We present comparisons between the Fetal XCMR phantom and fetal CMR data acquired in utero. Additionally, reconstructions of undersampled acquisitions (compressed sensing) with imaged-based motion (translational registration) and gating estimates (metric optimized gating) are presented to highlight potential applications of the phantom [3].

Figure 1 provides an overview of the proposed workflow for simulating Fetal XCMR acquisitions, organized into four stages. First, existing XCAT models are modified to create maternal and approximate fetal anatomy (Fig. 1a). Second, 4D image arrays are generated from the modified XCAT models to form the basis of the Fetal XCMR phantom (Fig. 1b). Third, independent 4D XCAT arrays are combined and XCAT tissue values are mapped to CMR contrast (Fig. 1c). Fourth, CMR data is calculated from the image in the previous stage (Fig. 1d). In principle, stages one and two are performed once to generate the numerical models for a given base resolution, while stages three and four are repeated to generate simulated k-space according to a user-selected sampling trajectory and reordering scheme. The following describes, in greater detail, the individual steps of the proposed simulation workflow.

Workflow for creating fetal CMR phantom data. a High resolution numerical phantoms of maternal and fetal anatomy are derived from a female XCAT model modified to include an extended abdomen and amniotic fluid (maternal), and an infant XCAT model with modified limbs. b Using the models from (a), independent 4D images are generated that cover the maternal abdomen and full fetal anatomy over a complete maternal respiratory cycle and fetal cardiac cycle. c For each time point in the simulated acquisition, a Fetal XCMR image with CMR contrast and physiological motion is defined by user-selected acquisition parameters and motion amplitudes respectively. Fetal XCMR k-space data is then generated from the previously defined image and time point and steps iii-x are repeated to create a complete Fetal XCMR data set. All steps from (c) contain user modifiable parameters as listed in Table 1

High resolution numerical phantoms of normal human maternal and fetal anatomy were created by modifying XCAT tissue models of adult female and infant male anatomy respectively [12]. The maternal tissue model includes an extended abdomen and amniotic fluid while the fetal model features fluid filled lungs, flexed limbs and approximate fetal lie (Fig. 1a). Additional features such as the placenta, fetal-specific blood vessels and shunts, and morphology of the right ventricle, were not included in the current implantation but may be of interest in cases where complex pathologies need to be simulated. As fetal-specific XCAT tissue models become available, their incorporation into the Fetal XCMR phantom will be straightforward due to the modular nature of the proposed framework. Nevertheless, the current model was designed to develop and validate acquisition and reconstruction methods rather than evaluate specific cardiac abnormalities.

Example motion states using the Fetal XCMR phantom. Fetal XCMR images in a short-axis orientation (a) were generated over multiple timepoints to illustrate the temporal dynamics (M-mode) along the dashed-line in (a) for a simulated maternal breath-hold (b) demonstrating only fetal cardiac motion, a simulated free-breathing acquisition (c) demonstrating both maternal respiration and fetal cardiac motion, and a free-breathing acquisition with gross fetal movement (d) demonstrating three independent motions

Figure 3 displays representative static image reconstructions using the total number of acquired spokes from Fetal XCMR phantom and in utero fetal data sets. Overall, the morphologies and relative proportions of the maternal and fetal anatomy are well represented by the Fetal XCMR images in transverse (Fig. 3a), sagittal (Fig. 3b), coronal (Fig. 3c), and short-axis (Fig. 3d) orientations when compared to their in utero fetal image counterparts (Fig. 3e-h). Similarly, the CMR contrast is comparable between the two data types. Note that the fetal heart is relatively blurred in both simulate d and real data due to the underlying motion that is not resolved by the static reconstructions. 2ff7e9595c