The Role of Cardiac MRI and Echocardiography in the Treatment of Cardiac Disorders in the Palestinian Health System

Cardiac magnetic resonance imaging (CMRI) can detect acute and chronic cardiac problems. This research compared CMRI to echocardiography (Echo). MRI technologists, cardiologists, radiologists, and cardiac surgeons at Palestinian hospitals received a questionnaire. CMRI's efficacy, usefulness in diagnosis and treatment and availability and utilization in the Palestinian health system were discussed. Researchers compared cardiac MRI and ECHO data. Forty patients from Jerusalem's Al-Makassed Hospital received both imaging modalities. Both techniques were able to identify heart problems differently. High-contrast CMRI revealed additional cardiac chambers and soft tissues. To enhance Palestinian healthcare, other hospitals should include CMRI testing. CMRI's correct diagnosis improves patient therapy. CMRI is expensive and takes longer than ECHO.


INTRODUCTION
With the advancement of technology in applications and tools, medical teams can diagnose illnesses, detect infections, establish a suitable treatment plan, and maintain an inventory.The imaging modalities were allowed to evolve, with the participation and inclusion of numerous diagnostic and functional applications in the practical scope of the doctor's and patients' service, the most significant of which is magnetic resonance imaging (MRI) [1].
MRI generates images based on the distribution of hydrogen atoms inside the human body using radio waves.When compared to other imaging modalities such as echocardiogram (ECHO), computed tomography (CT) [2], or single-photon emission tomography (SPECT), accurate images of the various tissues of the human body are obtained with excellent contrast and spatial resolution [3], [4].In fact, Tomography found its applications in diverse fields including medical applications, digital rock physics, image processing, and others, for instance [5][6][7][8][9].
The most recent developments in MRI technology have led to the development of practical applications for the device and its widespread usage.This is owing to the MRI's contribution to the correct diagnosis of disorders in the majority of medical areas as well as its ability to speed up the treatment process for patients [10-13 ,14, 15].
Echocardiography (ECHO) is essential for diagnosing structural and functional cardiac disorders.Its diagnostic and monitoring capabilities may aid acute cardiovascular disease patients.In hemodynamically unstable patients, echocardiography may measure global ejection fraction, wall motion abnormalities, cardiac output, and tamponade.At the bedside, these measures may be collected quickly and painlessly.Echocardiography is the initial imaging test for many heart conditions.ECHO is safe, versatile, and sensitive for measuring heart chamber size, wall thickness, ventricular function, and pericardial effusion.It lacks myocardial tissue characterization and field of view, particularly with poor acoustic windows.Echocardiography suffers from substantial interobserver variability.Post-processing advanced echocardiography (strain, strain rate, speckle tracking) may evaluate ventricular tractility.However, it is tedious and only helpful for prognosis and research [16], [17].
Cardiac Magnetic Resonance Imaging (C-MRI) is a novel creative integrated technique for detecting heart illness.Conventional cardiac imaging modalities may fail to identify certain pathology, which prevents doctors from making key choices about a patient's treatment plan, which might save the patient's life and end the patient's suffering.C-MRI is a method that can detect this pathology [18].C-MRI for heart disease diagnosis and tracking is growing.It helps in tissue characterisation and functional and morphological studies.Several guidelines now promote c-MRI scanning due to these advantages [19].
Tissue, morphological and characterization sequences like T2 STIR (short tau inversion recovery) on both short and long axes, T1 pre-and post-contrast mappings, T2 mapping, and LGE (late gadolinium enhancement), can be acquired, as can functional sequences like white cine blood steady-state free precession (SSFP) on the short and long axes (2 chambers, three chambers, and four chambers).Myocarditis may help distinguish non-ischemic acute myocardial injury [20].C-MRI may also help diagnose, treat, and prognosis.Parametric approaches, including T2 mapping, T1 mapping, and ECV, may increase c-MRI diagnostic precision.T2 mapping can accurately detect myocardial edema, unlike qualitative T2W imaging [12].Acute inflammation, vasodilation, and hyperemia enhance native T1 relaxation time, sensitive to intracellular and extracellular free water concentration.Finally, ECV may assess widespread fibrosis, inflammation, and cardiac tissue remodeling.
LGE detects of focal fibrosis [22].Researchers explored the efficiency of CMRI in identifying unreachable cardiac disorders via routine diagnostic procedures, as well as the readiness and willingness of the Palestinian health system to execute the operation in this research.In addition to CMRI and echocardiography compatibility.

MATERIALS AND METHODS
This study begins with a descriptive and retrospective analysis of forty patients admitted to Makassed Hospital in Jerusalem, a medium-sized non-governmental hospital, for heart surgery and cardiac critical care from June 2018 to February 2020.
All patients who had an echocardiogram were referred to the same hospital for a CMRI to compare their final echo and CMRI report results, including points of concordance, differences, and additional information on each examination, as well as modality outcome deficiencies.The second part of this study, a questionnaire and survey, targeted the Palestinian health system's CMRI team (MR technicians, MRIT, radiologists, cardiologists, and cardiac surgeons).
The questionnaire examined CMRI availability, medical staff knowledge of the procedure, its benefits and ability to diagnose cardiac diseases, Palestinian health system MRI departments' readiness to conduct CMRI, and the Palestinian radiologist's ability and willingness to evaluate and report CMRI procedures.40 individuals were admitted to Makassed Hospital for CMRI and ECHO evaluations.In the second section, 49 Palestinian Health System MR technologists, cardiologists, cardiac surgeons, and radiologists were questioned.All patients referred for ECHO had successful CMRIs.
All MRI radiologists, cardiologists, and cardiac surgeons in Palestine were polled.All patients who should not have an MRI and non-MRI radiologists and medical imaging technologists.PACS and HIS were used to collect data and compare CMRI and echocardiogram results.The relevant medical professionals collected the questionnaire in person.SPSS®23 (IBM, Armonk, New York, USA) was used for statistical analysis.The challenge is maximizing prostate cancer treatment, particularly radiation therapy, and avoiding side effects including sexual dysfunction and incontinence.New technologies like IMRT deliver radiation more accurately.However, bladder and rectum volume changes during treatment may dramatically affect dose accuracy and patient results.This research investigates bladder and rectum volume stability using routine preparation and clearance procedures and prostate cancer treatment volume fluctuations' dosimetric effects.The study aims to enhance prostate cancer treatment accuracy and side effects.

RESULT AND DISCUSSION 3.1 Analyzing CMRI and ECHO Report Results
Table 1 In the first section of this research that included a study comparing CMRI and ECHO findings, the total cases included in the sample were forty cases, thirty adult patients and ten paediatric patients.

Analyzing of MRI Questionnaire results for technologist
The 15 MRI facilities that make up the Radiologist's Assessment of CMRI Efficiency and Diagnostic Value.The questionnaire shows that 57.8% of centers refuse to make CMRI images because they cannot be done in the center, 46.7% of centers develop a program to make a CMRI image within their protocols, 17.8% of centers perform a CMRI image as a routine procedure, 4.4% of radiologists participated in and obtained a degree of proficiency in specialized CMRI courses, and there is no specialty program or required training program in Palestine.
Only 39.3% of doctors were refused referral to CMRI because the examination was not performed in the department, 36.1% of specialists wanted to include the CMRI examination in the program of specialization and application in the hospital, and 29.5% considered the CMRI examination to be common in your department and used for diagnosis effectively and without hindrance.
Problems with CMRI application in Palestinian health care can summarized in Table 3.Approximately 59.2% of participants expressed the need to open the door to training in the Palestinian health system to cover cardiac disorders diagnosis; 49% believe that the failure of heart-related tests is due to a lack of exchange of experiences; 51% believe that CMRI is not developed because it is limited to local experiences in interns and cardiology; 42.9% agree that the presence of cardiac image courses; and 40.8% believe that medical staff contributed to the failure of heart-related tests.The CMRI image integrated technique assists global health systems in implementing novel methods.The treatment takes a long time  4 shows the Radiologist's and Specialists evaluation of the factors affecting CMRI and its diagnostic, while Table 5 shows the questions from Q1-Q13 which involved in questionnaire.The result displays that 53.3% and 73.8% of Radiologist and Specialist participants, respectively, believe that CMRI impacts patient therapy, whereas 46.6% and 59% agree that CMRI helps diagnose cardiac diseases.A lack of experience exchange hurts CMRI exams, and 53.3% and 67.2% of radiologists and specialists, respectively, agree that depending on local competence in internal medicine and cardiology lowers CMRI exams.Only 48.9% of radiologists and 39.3% of specialists realize the need of including CMRI testing into residency program curriculum.Radiologists and experts had identical results, proving that CMRI specialists must work together.Only 26.6% of radiologists and 24.5% of specialists believe that not performing CMRI examinations is not limited to referrals from internal medicine and cardiology departments, while 62.2% and 45.9%, respectively, blame a lack of radiology technicians and 46.7% and 31.1% blame a lack of equipment.The long test period is over.
CMRI reports include additional details indicating the presence of illnesses in the wall of the heart chambers in addition to verifying the diseases discovered by ECHO, and CMRI reports contain new information showing the presence of diseases in the wall of the heart chambers in addition to confirming the diseases found by ECHO.A CMRI comprised measurements of the heart's internal configurations.The functional description of the heart's sections is given digitally in the reports.Whereas the use of a contrast medium contributed numerous information regarding disorders that damage the heart wall, the CMRI scan assisted in developing an effective treatment plan for the patient.
The CMRI and ECHO examination final outputs were compared, and as a result of this comparison, which included the detection of undiagnosed disease cases with the ECHO examination, in addition to a functional and anatomical study of the soft tissue extensively and with excellent contrast, and this is consistent with the opinion of the doctor Haojie Wang, M.D. [23], director of advanced cardiovascular MRI and a member of the heart valve clinic at Baylor Scott Whitaker.Many people have said that MRI is a collection of models that can provide more detailed information about the status of the heart and can study certain regions that are tough to monitor effectively using other media [24].
The difference between instances of congestive heart failure and their categorization as ischemia or non-ischemic based on scarring of the heart muscle is one of the most critical pathological signs that may be controlled using CMRI.Detection of myocardial infarction in patients with coronary artery disease, as monitored with CMRI, and measurement of perfusion rate deficiency, according to data from a study conducted in the United States of America, which included 13 centers of heart diseases, as was conducted by doctor Raymond Y. Kwong, M.D. MPH, director of cardiac MRI and associate professor at Harvard Medical School [25].
The CMRI enabled clinicians to identify and diagnose cardiac problems such as cardiac abnormalities, including heart disease, birth defects, structural flaws, valve failure, and coronary artery tumors [26].It is also credited with identifying cardiac irregularities that mask the bone, allowing other medical imaging technologies, such as ionizing radiation or ultrasound, to show it.

CONCLUSION
The use of CMRI is important and necessary for a successful medical operation, which must be integrated into the Palestinian health system and represents promising future in cardiac surgery, catheter operations and therapeutic interventions and CMRI examination has a high ability to detect diseases associated with soft cardiac tissue, cardiomyopathy and perfusion rates, which are difficult to detect with other medical imaging media.The specialist system is keen to include CMRI examination within the specialty program and the applied aspect in the hospital 36.1 63.9 The CMRI referral of the doctor to the MRI department was rejected because the examination is not performed in the department 39.3 60.7 The integration of CMRI examination greatly contributes to the diagnosis of heart disease and reduces medical transfers outside the Palestinian health system Q3 One of the most important things that contribute to the failure of the CMRI examination is the lack of exchange of experiences with the global health system Q4 Relying heavily on local experiences in the field of esoteric and cardiac contributes greatly to the limited experiences in making the tests developed in advanced health systems Q5 The existence of courses related to the conducting of tests for cardiac imaging using magnetic resonance, which contributes within the university plans in the field of medical imaging and contributes significantly to integrating the examination into the Palestinian health system Q6 The integrative process between radiologists, medical imaging technologists, cardiologists and cardiac surgeons contributes greatly to integrating what is new in global health systems.Q7 The necessity of incorporating the examination into the Palestinian health system contributes to changing the treatment plan and gives additional results that outweigh other imaging media such as ECHO Q8 Limited transferring from the departments of cardiac care and cardiac surgery to the work of CMRI examination and lack of reliance on diagnosis is the reason for the failure to perform the examination in the departments of magnetic resonance imaging Q9 There is a deficiency in the technical factor of medical imaging technicians due to the lack of benefit of training courses for doing CMRI examination Q10 The examination time is relatively long, which does not provide an opportunity to perform other tests Q11 The high cost of CMRI precludes increased screening opportunities Q12 It needs a diverse team of doctors and technicians, and the opportunity to provide staff in private centers and some hospitals is somewhat complicated Q13 CMRI is not something of value it can be replaced by other imaging media and give the same result Palestinian health system's magnetic resonance imaging division are staffed by a total of 49 MRI technologists.Five in Hebron, one in Jerusalem, four in Ramallah, one in Jenin, and two in Nablus and Bethlehem.The first portion of the MRI questionnaire assessed the preparedness of the MRI departments at the aforementioned institutions in light of the specific hardware and software prerequisites for the CMRI assessment.While only 40.8% of facilities have a cardiac coil, 65.3% have EEG gating, 73.5% have respiratory gating, and 61.2% have anesthesia equipment with a cardiac sequence and protocol.All results shown in Table2.The second portion of the questionnaire which shown in Table2examines if CMRI is commonly done at the institution and whether trained experts are available to perform CMRI.According to the questionnaire, 59.2% of the centers refuse CMRI examinations, only 40.9% of the centers have the CMRI protocol, only 30.6% of the specialists in charge of the centers can write CMRI image reports, and only 29.2% of the centers work the image inside the center, only 10.2% of CMRI images are requested as a routine procedure in the center, and only 4.1% of the centers have trained medical specialists.

Table 1 :
The distribution of cases diagnosed by CMRI.As a result, more testing is not possible.Screening opportunities are restricted due to the high cost of CMRI.Table

Table 2 :
Availability of Equipment to Carry Out CMRI Exams Within MRI Units.Percentages Of Equipment Availability to Perform CMRI At MRI Units.The Section on The Technical Part and The Availability of Qualified Personnel to Carry Out the Examination.

Table 3 :
MRIT assessment on the importance of CMRI procedures and obstacles in the Palestinian health system.

Table 4 :
Radiologist's and Specialists evaluation of the factors affecting CMRI and its diagnostic.

Table 5 :
Radiologist's Assessment of CMRI Efficiency and Diagnostic Value.