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ACUSON Sequoia™ Ultrasound System BioAcoustic Technology

This white paper contains information on the features on the ACUSON Sequoia system that contribute to BioAcoustic Technology.

White Paper BioAcoustic Technology ACUSON Sequoia Ultrasound System John Benson BS, RDMS, RDCS; Rick Loftman, PhD; Stirling Dodd, PhD; Dave Petersen, PhD; Dave Duncan, PhD; Stephen Rosenzweig, PhD; Paul Reynolds, PhD; Anthony Sottile, MS; Andy Milkowski, MS Siemens Medical Solutions USA, Inc., Ultrasound siemens-healthineers.com/sequoia HOOD05162003028886 · Effective Date: 2-Aug-2019 SIEMENS Healthineers ACUSON Sequoia BioAcustic Technology · White Paper The new ACUSON Sequoia™ ultrasound system was • Breakthrough B-mode, color flow Doppler, and designed from the beginning to provide ultrasound users spectral Doppler image quality to reduce operator with an integrated user experience, with detailed and dependence and provide consistently high exam information-rich images that dramatically improve the quality across operators in an ultrasound lab or way ultrasound is performed today. practice • Introducing important design elements that are built A total user experience to enhance productivity in in rather than added on, the ACUSON Sequoia system very busy labs overcomes limitations and design compromises of • A new level of quantitative shear wave elastography previous ultrasound system technology. These design (SWE) performance, with excellent precision and elements integrated into the ultrasound imaging engine accuracy over a large population of patients will carry far into the future as applications expand • and computing technology continues to advance. Superb sensitivity and specificity in contrast imaging to reliably provide definitive answers An important design goal for the ACUSON Sequoia system was to introduce an ultrapremium ultrasound system that meets and exceeds demanding requirements in four critical clinical capabilities: ACUSON Sequoia BioAcoustic System Architecture The new ACUSON Sequoia system is the result of Attention to detail was paid to every step in the more than three decades of experience in ultrasound ultrasound signal processing chain, starting with a new engineering. Engineers that specialize in acoustics, low-noise dual-transmit power supply and carrying those low-noise analogue and digital RF design, computer benefits through the system with additional low-noise and graphics design, artificial intelligence, software design elements and precision clocking throughout architecture, and advanced visualization set out to the system. 14-bit analogue-to-digital conversion address the fundamentals that would result in ultrasound has increased dynamic range by more than 18 dB over images with extremely high signal-to-noise ratio (SNR) prior-generation systems*, improving penetration, and reduce the limitations of traditional beamforming. Doppler and contrast sensitivity as well as image contrast-to-noise ratio. State-of-the-Art InTune InTune InFocus Hardware Pulser Transducers Coherent Image Formation MMCCCICOM Signal Transmit & Transmit & From Signal to Generation Receive Signal Receive Signal Image Formation Figure 1: ACUSON Sequoia system imaging engine with BioAcoustic™ imaging technology. * Compared to ACUSON S3000 and ACUSON Sequoia 512 ultrasound systems 2 siemens-healthineers.com/sequoia HOOD05162003028886 · Effective Date: 2-Aug-2019 White Paper · ACUSON Sequoia BioAcustic Technology Eliminating weak links in the critical data path that can Another key aspect of the ACUSON Sequoia system’s create noise and electronic distortion in the ultrasound architectural design is the partitioning of the compute image, results in increased image fidelity with higher engine from the ultrasound imaging engine. This enables dynamic range and processing speed than ever before. the system to continually take advantage of CPU and Massive parallel-receive beamforming provides high GPU processing power developments over time that beam bandwidth, i.e. the ability to densely sample large will continue to enhance the capabilities of the overall areas of anatomy simultaneously with a single transmit. system, including the imaging engine. In the future, Digital RF information throughput during acquisition these improvements will extract even more information that is equivalent to 3 DVDs each second provides from the ultrasound signal. high-resolution images at high frame rates, even in mixed modes. Dual transmit power supply and high dynamic range signal processing with low noise design elements Image Display InTune Beam Bandwidth equivalent to 3 DVDs per second Precision Wave Shaping Pulse Generator Precision InFocus Coherent Image Formation Clocking Synthesized, Coherent blending Software Programmable retrospective of massive groups High Density Transmit Focus of beams with Graphics Central Receive Beam synthesized Processing Processing Former Sampling analytic beam Unit (GPU) Unit (CPU) lines Modular Compute Engine V V Figure 2: Partitioning the ACUSON Sequoia system’s compute engine from the ultrasound imaging engine is a key aspect of the system’s architectural design. The modular compute engine allows frequent upgrades to the latest computing technology over the expected lifecycle of the imaging engine, maximizing return on investment. The new system architecture of the ACUSON Sequoia sensitivity to a new level by using new materials and system dramatically reduces size, electronics and system construction techniques. When coupled with high SNR weight, allowing technicians to easily transport this signal processing, the ACUSON Sequoia system yields unique ultrasound technology to a patient’s bedside or penetration improvements in harmonic imaging of up any other point of care. to 65% over prior systems with comparable transducer types. Next-generation micropinless transducer One of the most important factors in ultrasound image connectors maintain low noise and signal fidelity and quality is the transducer. The ACUSON Sequoia system are easy to use. The system architecture is the foundation offers several new transducers that take ultrasound of present and future performance breakthroughs. siemens-healthineers.com/sequoia 3 HOOD05162003028886 · Effective Date: 2-Aug-2019 ACUSON Sequoia BioAcustic Technology · White Paper Imaging Performance The increasing prevalence of obesity in many countries With the ability to penetrate as deep as 40 cm, DAX will 1,2 can present a problem when evaluating technically expand the population of patients that can successfully difficult patients with ultrasound as a first line imaging be diagnosed with ultrasound. The benefits extend to modality. Concerns about long-term effects of radiation all imaging modes, including contrast and shear wave exposure from X-ray and computed tomography (CT) elastography, making DAX a powerful transducer for scans, have made the ability to image large patients larger and technically difficult patients. more important than ever. One of the breakthroughs introduced with the ACUSON Sequoia system is the Deep Abdominal Transducer (DAX). Abdomen Abdomen TIB:0.20 TIB:0.53 TIC:1.27 TIC:2.77 TIS:0.20 TIS:0.53 MI:1.12 37 12fps 12fps 2D 2D H Low H Low 3dB/DR60 1dB/DR60 30cm *30cm Figure 3: The DAX transducer provides a 30 % improvement in penetration for imaging larger patients, as shown in this comparison between a standard 5C1 transducer (left image) and DAX (right image) using a tissue-equivalent phantom. InTune Coherent Pulse Formation performance and penetration on all transducers. For example, in 4.0 MHz harmonic mode, sensitivity 3x Sensitivity is increased 3 times over previous systems through precision transmit wave shaping and higher receive sensitivity. This allows harmonic imaging to be used as a default mode for most ultrasound exams, improving spatial and contrast resolution. InTune Coherent Pulse Formation Sensitivity is a key factor in improved harmonic and contrast imaging ƒ Frequency 2ƒ Key acoustic performance elements in contrast and InTune coherent pulse formation is also an important harmonic imaging are the agile, dual-linear transmitters factor in contrast imaging, with increased tissue of the ACUSON Sequoia system. With the flexible cancellation and maximum bubble response for higher programmability of the InTune™ pulse former that can specificity. Extremely low distortion of the transmit pulse closely approximate arbitrary waveforms, ultrasound and precise phase control achieve 10 times the acoustic pulses can be precisely tuned for superior harmonic fidelity of previous systems. 4 siemens-healthineers.com/sequoia HOOD05162003028886 · Effective Date: 2-Aug-2019 White Paper · ACUSON Sequoia BioAcustic Technology Support for a wide frequency range improves high- InFocus uses synthesized, retrospectively focused frequency imaging and allows third harmonics imaging transmit beams throughout the field of view. on some transducers for improved near-field contrast resolution. Another design improvement is the ability to Massive parallel beamforming in combination with the maintain a constant and sustainable energy delivery over new coherent image formation maximizes information deep depths and with long pulses, such as those used in from the transducer to the image display. Frame rates shear wave elastography employing Acoustic Radiation can be maximized in coherent image forming by a Force Impulse (ARFI) techniques. A capable transmit coherent blending of massive groups of beams (image power supply helps overcome many limitations of forming rather than simple beamforming). Analytic conventional systems to provide uniform, consistent lines can be synthesized rather than acquired. Tuned acoustic energy over the field of view. This results in filters and diffraction-effects compensation also help better contrast studies and more accurate, repeatable to address image distortion. and reproducible stiffness measurements. InFocus coherent image formation focuses the image at InFocus Coherent Image Formation all depths and exploits high beamformer output capacity, which increases image uniformity compared to prior systems. More information is harvested from the usual Coherent image forming was first pioneered on the transmit sequence, using massive overlapping multi- original ACUSON Sequoia 512™ ultrasound system by beam groups rather than individual or close parallel using phase and amplitude information to improve signal beam lines as in conventional systems. This secondary quality at the focus and suppress unwanted signal away beamforming enabled with InFocus, physics-based delay, from the focus. The system was the first high-quality phase and amplitude corrections can be made across parallel-line imaging system in the industry, gathering transmit events to significantly sharpen the image and “twice the information in half the time.” improve spatial resolution beyond what is typical for a given transducer frequency. Powered by the software acceleration of the new ACUSON Sequoia system’s graphics processing unit(GPU), The ACUSON Sequoia system image former delivers a new standard for coherent image formation was many other benefits, such as adaptive gain processing, created. It supports a new level of beamformer which eliminates the need for frequent gain adjustments performance with InFocus coherent image formation. by the user. The blending of fundamental and harmonic imaging improves both penetration and resolution, delivering more detail with extraordinary clarity. InFocus receive beams ............ Area to be zoomed Point of synthesis Area to be further zoomed Several transmit focus locations Figure 4: InFocus utilizes multiple simultaneous receive beams covering a region with a single transmit (left). Many receive beams per transmit event leads to many interrogations per image point (right). siemens-healthineers.com/sequoia 5 HOOD05162003028886 · Effective Date: 2-Aug-2019 ACUSON Sequoia BioAcustic Technology · White Paper The blending of tissue harmonic imaging with third order induced artifacts and reverberation artifacts, as well as harmonics adds more information to the image for better improved visualization of flow dynamics. Anatomy- visualization of anatomical detail. Additional advantages specific flow states automatically optimize color flow include adaptive artifact reduction and the support of parameters for higher-quality, more consistent exams. spatial compounding in mixed modes and panoramic In pulsed Doppler, continuous wave Doppler, high-PRF imaging. This eliminates the need to compromise B-mode pulsed Doppler, and tissue Doppler modes, similar image quality when performing exams using color flow improvements in sensitivity and penetration are also Doppler, triplex mode, contrast mode, or E-mode. realized. In live duplex mode, higher B-mode frame rates are achieved along with cleaner audio and spectral quality. InFocus coherent image The image former of the ACUSON Sequoia system also formation produces high- provides significant benefits to the Doppler workflow. resolution, uniform images Its new AutoTEQ™ tissue equalization technology automatically optimizes relevant parameters so that and improves image operator adjustments are kept to a minimum. Several acquisition workflow acquisition parameters such as gain, velocity scale, wall filter, AutoTEQ, and other post-processing parameters can now be adjusted on a frozen sweep before images are saved to PACS. The high information density of acquired image data is preserved all the way from the transducer to the image The sensitivity and accuracy of auto-trace flow statistics display in all imaging modes. Benefits in color flow mode can be improved with gain control after the display is include higher sensitivity and greater penetration, higher frozen. Doppler tissue imaging (DTI) is now also available frame rates with higher spatial resolution, fewer motion on all transducers in fetal echo exams. General General TIB:1.10 TIB:1.10 TIC:0.67 TIC:0.67 TIS:0.47 TIS:0.47 MI:0 38 MI:0 38 32fps 32fps 95% 95% 2D 2D H Mid H Mid 0dB/DR65 0dB/DR65 C Res Res -2dB/ High -2dB/ High PRF 7813 PRF 7813 18mm 60" PW 3cm 18mm 60" PW Mid Mid 10 GS 1.0 GS 1.0 PRF 1420 20 PRF 7813 F 64 100 F 352 5 cm/s 10 cm/s -15 AutoTEQ Off AutoTEQ On Figure 5: Workflow automation with Doppler AutoTEQ reduces user interaction and improves exam consistency. 6 siemens-healthineers.com/sequoia HOOD05162003028886 · Effective Date: 2-Aug-2019 White Paper · ACUSON Sequoia BioAcustic Technology UltraArt Universal Image Processing Siemens Healthineers ultrasound engineers have worked closely with sonographers in the clinical practice to A truly unique new capability among diagnostic eliminate a common cause of exam quality variability ultrasound systems, UltraArt™ universal image processing among users by eliminating the complexity, redundancy allows the operator to select preferred image parameter and interplay of conventional image post-processing settings before they are applied by choosing an image features. By unifying multiple parameters into optimal from several choices directly on the touch screen. settings for each individual patient, UltraArt patient- B-mode, color flow mode and pulsed Doppler image specific image processing improves the contrast post-processing parameters can be selected with a single resolution of different organs and supports the touch to instantly optimize images for different patient visualization of small or isoechoic lesions. UltraArt™ types. This allows quick and easy matching of the universal image processing improves exam quality and ACUSON Sequoia system’s BioAcoustic parameters to consistency across different users by avoiding improper individual patients. The effects of several parameter combinations of individual post-processing parameters. changes are displayed on the touchscreen monitor before Reading physicians can look forward to enhanced exam they are applied. quality standardization. 18L6 Patient 20 Imaging Review Report End Exam Off X Left Margin Figure 6: Touchscreen display in UltraArt-enabled mode. Operator selection of the image that best matches the patient’s bioacoustic characteristics. This helps to avoid manual adjustment of multiple individual image parameters, reducing exam time and improving exam quality. siemens-healthineers.com/sequoia 7 HOOD05162003028886 · Effective Date: 2-Aug-2019 ACUSON Sequoia BioAcustic Technology · White Paper Advanced Visualization The use of single-crystal material provides extra capability where it is most needed in each clinical The entire critical data path of the ACUSON Sequoia application for abdominal and cardiac transducers ultrasound system has been optimized from transducer (5C1 and 5V1 respectively), providing improved to viewing monitor. To realize the benefits of the acoustic sensitivity and bandwidth compared to their signal processing improvements, a 21.6-inch OLED predecessors. Advanced processing methods to high-dynamic range viewing monitor with pure black and match the quality of the material were developed, high viewing contrast is standard. Careful calibration of with the transducer built around the single crystal, the monitor characteristics to the video signal maintains each component carefully scrutinized for performance linearity over a large dynamic range. and reliability. Extended cineloop memory with “raw data” post- The ACUSON Sequoia system’s InTune transducer processing and post-freeze measurement capabilities technology was developed to produce the best acoustics expands workflow flexibility. Present and future for each clinical use case. With advanced materials, advanced visualization features and image rendering simulation, manufacturing and testing, the acoustic are supported by a fast and flexible graphics processor matching between transducer and patient was optimized, (GPU), minimizing the occurrence of many workflow together with the electrical signal path between delays during the exam. transducer and system cart, resulting in the highest signal fidelity throughout. InTune Transducer Technology A limiting factor in transducer design has been temperature. The Food and Drug Administration (FDA) One of the key advances of the ACUSON Sequoia system’s and other international regulatory bodies that define transducer technology is the addition of single-crystal transducer performance requirements allow the piezoelectric transducers for both cardiac and general ultrasound probe to only warm by a few degrees to imaging. Piezoelectric material is at the heart of any protect both patient and sonographer. By concentrating transducer, transforming electricity into ultrasound, and on the thermal design of the transducers, incorporating then back into electrical image signals. When compared novel thermal technology, and optimizing acoustic with standard piezoelectric elements, the latest generation stack design, the new transducers operate significantly single-crystal designs offer wider bandwidths for better cooler compared to their predecessors for any given harmonic imaging and axial resolution, and greater ultrasound signal. sensitivity for deeper penetration and clearer imaging. With ultrasound being the most operator-dependent imaging modality, Siemens Healthineers considered Sensitivity Single Crystal biological and technological aspect, and user- dependencies when creating the new InTune Piezoceramic transducers. Special focus was given to their industrial design to improve patient experience, scan experience and imaging needs of sonographers, with the goal to obtain a clinically useful image in the shortest possible time. Molding the InTune transducer casing to fit the hand of a sonographer, the use of textured plastics for grip, and the redesign of cables help to reduce strain and repetitive stress for the operator while increasing More Sensitivity Frequency comfort and accessibility. K More Bandwidth Figure 7: The latest generation single-crystal designs offer wider bandwidths for better harmonic imaging and axial resolution, and greater sensitivity for deeper penetration and clearer imaging. 8 siemens-healthineers.com/sequoi HOOD05162003028886 · Effective Date: 2-Aug-2019a White Paper · ACUSON Sequoia BioAcustic Technology ACUSONACUSON Figure 8: Thermal images show the concentration of heat build-up Figure 9: The unique gesture detecting technology recognizes in the transducer footprint in the left image, and a cooler footprint sonographer interaction with the transducer to support clinical with better heat distribution into the transducer housing in the right workflows. image, resulting in improved transducer efficiency. Performed many times a day and often multiple times of interest, such as small vessels and focal lesions. throughout a single patient exam, the continual need Minimal elevation slice thickness throughout is necessary to select transducers for imaging is one of the common to achieve excellent imaging performance from shallow challenges for sonographers. To resolve this challenge, through deep regions of interest. On this account, several of the ACUSON Sequoia system’s InTune Siemens Healthineers has expanded its portfolio of transducers feature gesture detecting technology. Multi-D and high-element density transducers to allow Incorporating advanced accelerometer technology and a dynamic elevation aperture change according to proprietary software, gesture detecting technology imaging needs. recognizes sonographer interaction with a transducer. This can support clinical workflows by reducing Especially important for use in high-BMI patients, unwanted keyboard interactions allowing sonographers the new deep abdominal transducer (DAX) addresses to increasingly focus on the patient. deep-depth imaging by enabling imaging throughout a 40-cm-depth range. This is made possible by employing Taking advantage of ongoing transducer advancements, an advanced form of Multi-D beam formation that signals are able to penetrate deeper into the body controls the beam thickness and beam formation in enabling, in parallel, the visualization of smaller regions both transmission and receive phases. 1D Transducer Multi-D Transducer Depth Figure 10: The advanced Multi-D beam formation of the Deep Abdominal Transducer (DAX) enables thinner slice thickness enabling imaging throughout a range of up to 40 cm. siemens-healthineers.com/sequoia 9 HOOD05162003028886 · Effective Date: 2-Aug-2019 ACUSON Sequoia BioAcustic Technology · White Paper User Experience The unified user experience concept of the ACUSON The system’s large, easy-to-read articulating touch screen Sequoia system allows new users to simply walk up is a key element of the user interface design. Designed and use the system due to an enhanced articulating to integrate future applications, the large screen area touchscreen user interface, simplified control panel, can be expanded as applications evolve and innovative improved on-screen messaging and feedback as well features are developed. The design of the touch screen as a trackball hot zone designed for both left- and features a consistent and predicable structure so right-handed use. operators can immediately find what they need for a specific exam. The touch screen also provides controls The system’s user experience is the result of five years of in logical groupings based on frequency of use, similarity research with professional scanners (both sonographers to other features and easy access for the operator. and physicians) as well as leading ultrasound researchers In addition, the system uses state-of-the-art gesture across North America, Europe, and Asia. User research functionality for initializing transducers to reduce strain occurred in realistic clinical settings, third party usability and optimize reach. laboratories and engineering environments to maximize the understanding of today’s workflows and user needs. Sonographers General Imaging Users Radiologists Exams Cardiology Physicians Clinical Shared Services Sales Specialists Vascular/ OB Field Research 229 Participants Web Surveys 390 Methods Expert Reviews 12 706 Total Usability Tests 62 User Tests Ergonomics Tests 13 Sessions * * Figure 11: 706 user test sessions were conducted over the period of five years in the United States, China, Germany, and France to comprehend and include findings to improve today’s clinical workflows and adapt to user needs in ultrasound. 10 siemens-healthineers.com/sequoia HOOD05162003028886 · Effective Date: 2-Aug-2019 White Paper · ACUSON Sequoia BioAcustic Technology 20 Capture By 100% Maps Figure 12: Minimalistic design of the ACUSON Sequoia control panel reduces complexity and promotes ease of use. The functions of the control panel are close to the operator to reduce strain and improve reach. The control panel, designed to reduce complexity, the clinician to concentrate on the ultrasound image. contains only the most important functions that support The main display contains minimal user controls for clinical workflow and diagnosis. The remaining functions reduced complexity and clutter. It also features an reside on the touchscreen for those who want more improved trackball feedback area to let the user observe control over image acquisition and visualization. The and control trackball movements at a glance. Areas trackball hot zone contains two select buttons along with are also reserved for future applications, features, some of the most frequently used functions Clip, Image, and functions. Update, Caliper, and Annotations. This allows operators to get through the main portions of an exam without New exam protocols enable greater standardization in needing to move their hand away from the hot zone. busy ultrasound departments. New factory protocols include cardiac exams with a full suite of cardiac Overall, the functions on the control panel have been measurements. Series measurements are supported in moved closer to the operator to reduce strain and all exam types. Operators can program their own options improve reach. and ease-of-use enhancements that best fit their exam workflow. A new capability for an offline protocol editor The main display was designed to accentuate the allows a centrally designed protocol to be easily deployed diagnostic image by muting the color palette and across multiple ACUSON Sequoia systems using a USB brightness of the surrounding user interface to allow drive for departmental standardization. siemens-healthineers.com/sequoia 11 HOOD05162003028886 · Effective Date: 2-Aug-2019 ACUSON Sequoia BioAcustic Technology · White Paper Clinical Applications Contrast Imaging: Overcoming Technical Barriers 10x Acoustic Fidelity Average Contrast Sensitivity as a Function of Time 1:50000 Dose of Sonovue / Lumason 25 20 15 10 Voltage 5 Previous Sequoia Contrast Sensivity (dB) Time Time 0 5 10 15 20 25 30 35 Figure 13: Tissue cancellation has been improved ten times over Figure 14: The ACUSON Sequoia (blue line) has approximately the original ACUSON Sequoia S512 system resulting in improved 6 dB (2 times) more sensitivity at depth in contrast imaging than acoustic fidelity. its predecessor, the ACUSON Sequoia S512 system (orange line), in the first 10 minutes post-injection, with 10 times better tissue cancellation, potentially leading to higher diagnostic confidence. The enormous architectural power of the ACUSON Multiple independent transmit beams using massive Sequoia system can provide visualization of contrast parallel beamforming are used for a more uniform deeper and with greater clarity than ever before. Tissue insonation, minimizing inadvertent bubble destruction cancellation has been improved ten times over even from localized higher- intensity zones that would the original ACUSON Sequoia S512 ultrasound system. otherwise occur with conventional technologies. The This is achieved with InTune pulse formation and dual InTune coherent pulse former also improves waveform transmit power supplies with high-voltage scale agility, generation fidelity which significantly reduces contributing to a high linear response rejection ratio. undesirable harmonics and other transmissions while precise transmit apodization better suppresses off- Contrast sensitivity two times higher than the original axis echoes. ACUSON Sequoia 512 system allows the visualization of small vessel perfusion, and in many cases the ability Flash sequencing with tissue motion stabilization using to visualize a diagnostic level of contrast agent for a proprietary algorithms produces images with better much longer late-phase contrast perfusion assessment. small-vessel arterial phase imaging. (Figure 16) This may increase diagnostic confidence by offering a differentiation of focal liver lesions using the contrast- Independent coherent image formation with signal paths enhanced ultrasound (CEUS) LI-RADS algorithm3. and control parameters separated from B-mode allow (Figure 15) contrast images to be independently optimized, resulting in high quality B-Contrast live dual mode images without B-mode image degradation. 12 siemens-healthineers.com/sequoia HOOD05162003028886 · Effective Date: 2-Aug-2019 White Paper · ACUSON Sequoia BioAcustic Technology Elastography The ACUSON Sequoia system is Ultrasound elastography using strain imaging techniques designed to meet the new QIBA was once a research area. The number of users has profile for shear wave speed recently grown from a small group of “super users” in radiology to a large installed base of users in different measurements in the liver, with clinical specialties. With the advent of less user dependent design improvements intended to quantitative shear wave measurement techniques, ultrasound elastography has become an important tool solve many of the earlier problems in the assessment and management of disease. with shear wave technology. Operator, patient and system differences are all confounders that can influence measurement results using shear wave technology. In fact, system differences One of the design elements built into the ACUSON across the industry have created awareness that Sequoia system specifically for shear wave elastography measurement results from different systems are not is dedicated hardware in the dual linear transmitter. This interchangeable with respect to a patient’s condition. provides more consistent energy transmission in ARFI For this reason, the Radiological Society of North America transmit modes used in shear wave imaging. While the (RSNA) formed a Quantitative Imaging Biomarker Alliance mechanical index limit mandated by regulatory agencies (QIBA) Technical Committee that focuses specifically on is never exceeded, the longer-duration “push pulses” shear wave speed measurement in liver fibrosis as the required to generate shear waves in tissue require a large first quantitative marker. A goal of the committee is to amount of energy from the transmit power supplies. partner with academic research institutions, regulatory Without an adequate transmit power supply, the transmit bodies and industry representatives to solve problems voltage can decay from the beginning to the end of the that are hindering the adoption of new quantitative transmit pulse, deteriorating the amplitude of tissue imaging technologies. A planned outcome of the SWS displacement and resulting in more measurement Technical Committee is the establishment of a profile for variability. shear wave speed with proposed standards of measure- ment accuracy, repeatability and reproducibility. In this way, QIBA compliant systems can then be trusted to produce similar and satisfactory results in the hands of trained operators. DAX : Abdomen AN "ABD TIB:0.00 TIB:0,00 TIC:0.01 TIC:0.00 TIS:0.00 TIS:0,00 MI:0.08 MI:0.09 8fps 5B/Sek 0.2% 0,5% 2D 2D Low OdB/DREO Mittel -5dB/ DB60 Contrast LD 1 Mid JA 3 14B/DR70 Ska aD/T5 P2 D2 Kontrast Niedrig -6dB/DB70 LD 1 UA Aus SkalaF /T1 D2 Nur Kontrast 14cm 16cm Figure 15: Extended late phase contrast ultrasound of cirrhotic liver. Figure 16: Focal nodular hyperplasia (FNH) in the arterial phase using flash sequencing technology. siemens-healthineers.com/sequoia 13 HOOD05162003028886 · Effective Date: 2-Aug-2019 ACUSON Sequoia BioAcustic Technology · White Paper As an example, typical B-mode transmit pulses use about Therefore, a dedicated Virtual Touch technology power 7.7 millijoules (mJ) of energy, while Siemens Healthineers bank was implemented. It uses 35 capacitors that can proprietary Virtual Touch™ shear wave technology quickly store about 15 Joules of energy and provides push pulses demand a much larger amount of energy. more than 6 times the energy storage capacity when ACUSON Sequoia system ARFI pulses can consume in pSWE or SWE mode. More push energy is deposited several hundred times the energy of B-mode pulses. over a deeper range in tissue than ever before, resulting in better accuracy and precision over a larger patient population. + Rail 6x Energy for Shear Wave Imaging Voltage Drop ARFI Transmit Pulse Length Energy Voltage Drop Depth Rail – Figure 17: In a traditional ultrasound system, transmit voltage drop Figure 18: Dedicated E-mode hardware for sustainable energy during ARFI push pulses can deteriorate SWE results, especially in delivery in shear wave elastography. technically difficult patients. 14 siemens-healthineers.com/sequoia HOOD05162003028886 · Effective Date: 2-Aug-2019 White Paper · ACUSON Sequoia BioAcustic Technology Massive parallel receive beamforming enables more In Virtual Touch pSWE, bench-tested accuracy and samples to be acquired for a given area with less precision over the depth range in elastic phantoms has variability of measurements over the depth range in been improved from ± 20% of the reference value of prior homogeneous tissue, such as liver and spleen. Robust systems to within ± 5% within the clinical range of shear tracking of shear waves in viscoelastic tissue, where wave speeds in the liver. The ACUSON Sequoia has higher shear wave frequencies are first attenuated, helps superior accuracy and precision, as measured in bench to overcome patient dependent variability. As in all testing using the same phantoms and equivalent ACUSON Sequoia system mixed modes, independent transducer types. B-mode, ARFI, and, shear wave signal processing prevents degradation of the B-mode reference image during acquisition and recording. ACUSON Sequoia 5C1 ACUSON Sequoia DAX A 4 4 4 3 3 3 2 2 2 ............ Shear Wave Speed (m/s) Shear Wave Speed (m/s) Shear Wave Speed (m/s) 1 1 1 0 5 10 15 0 5 10 15 0 5 10 15 Depth (cm) Depth (cm) Depth (cm) B C D 4 4 4 3 3 3 2 2 2 ................................ Shear Wave Speed (m/s) Shear Wave Speed (m/s) Shear Wave Speed (m/s) 1 1 1 0 5 10 15 0 5 10 15 0 5 10 15 Depth (cm) Depth (cm) Depth (cm) Figure 19: Accuracy and precision with minimal bias of the ACUSON Sequoia system pSWE compared to four premium ultrasound systems with current software available at the time of writing (A-D). Note that DAX allows shear wave speed and stiffness measurements 75% deeper than conventional systems and transducers. The dotted lines represent the calibrated elastic phantom reference values. In Virtual Touch technology 2D SWE, high sampling to red areas indicating areas where the shear wave density provides high spatial and stiffness resolution for displacement signal-to-noise ratio was too low to imaging focal lesions and heterogeneous tissue, such produce a reliable estimate. The displacement map as in breast and in thyroid nodules. Stiff lesions as small has been updated in the ACUSON Sequoia system to as 3 mm can be clearly visualized with less background represent the ARFI on-axis displacement magnitude at variation than in the prior system, increasing diagnostic the location of push pulses, rather than off-axis shear confidence. Reduced artifacts provide for better wave amplitude. This dramatically improves the dynamic visualization of stiffness variations in the body. A quality range of the displacement image, which can be helpful map is important in interpreting the reliability of shear in visualization of lesion boundaries compared to the wave measurements, with high confidence estimations B-mode image. indicated by green areas of the quality image and yellow siemens-healthineers.com/sequoia 15 HOOD05162003028886 · Effective Date: 2-Aug-2019 ACUSON Sequoia BioAcustic Technology · White Paper a b Figure 20: SWE improvements have made it possible to visualize small stiff lesions, such as in this example. In this elastic phantom with a 3 mm target, the elasticity difference is clearly seen in the ACUSON Sequoia system image on the left (a), compared to a predecessor system using a similar transducer type on the right (b), where the target is difficult to discern from the background. In addition to improved shear wave elastography images, Fewer steps are involved in performing the elastography fast and flexible workflow minimizes measurement time study and measurement results can be displayed and during the ultrasound study. Measurement labels can be reported as stiffness in kiloPascal (kPa) or as shear wave quickly selected on the touch screen and the acquisition velocity in meters per second (m/s). time for measurements has been reduced. 16 siemens-healthineers.com/sequoia HOOD05162003028886 · Effective Date: 2-Aug-2019 White Paper · ACUSON Sequoia BioAcustic Technology Workflow Support in Radiology To improve workflow in radiology departments, The ACUSON Sequoia complies with current MDS2- and ultrasound systems must interface well within a modern DoD requirements. Account management uses a unique networked environment. The ACUSON Sequoia system BIOS and administrative password scheme in which is fully DICOM-compliant, and provides the ability to individual users have a unique name and password. send Structured Report (SR) data to select network nodes “Hardening” of the system is accomplished without at the end of the exam. Data can also be transferred interruption to workflow. To protect from security threats to the report or configured for a Nuance™ reporting as well as malware and intrusion, the ACUSON Sequoia configuration. Both LAN and Wi-Fi support is provided, system uses strong firewall rules, system memory so the system can be used in portable studies without protection and McAfee™ application control for virus interrupting its network connectivity. DICOM SR protection. System hard drive encryption ensures secure measurements have been expanded for all exam types, system boot-up. A kiosk mode prevents access to the so more flexibility is available for a wider variety of local operating system and hard drives by eliminating the measurement protocols. In addition, SR routing can be command line and task bar interface. A dashboard applied to multiple destinations. view for the security configuration is provided on one consolidated location, making it easier to manage The network configuration of the ACUSON Sequoia security settings. Finally, the server and the ACUSON system is easy and uncomplicated, enabling the local IT Sequoia system exchange security certificates in the staff to perform network setup without a technical background to help guard against Man In The Middle service engineer. A single-screen location contains all (MITM) cyberattacks. All of these features always run in worklist configuration settings, and storage commitment the background and will only be noticed by the user can be configured for a different storage server. when logging into the system. Minimizing security risks and protecting medical equipment from cyberattacks have become crucial in today’s connected healthcare environments. Conclusion References The ACUSON Sequoia system is a technically advanced 1. Ezzati M et al. Worldwide trends in body-mass ultrasound system that supports current and future index, underweight, overweight, and obesity advanced diagnostic capabilities. Purpose-built from from 1975 to 2016: a pooled analysis of 2416 the ground up, it is the result of a close collaboration population-based measurement studies in between ultrasound users in the clinical practice and 128·9 million children, adolescents, and adults. Siemens Healthineers ultrasound engineering teams. Lancet. 2017;390:2627-42. The accumulated know-how of decades of premium ultrasound design and development has been leveraged 2. Seidell JC. Obesity, insulin resistance and diabetes – to produce unmatched image quality, user experience, a worldwide epidemic. British Journal of Nutrition n. contrast imaging and elastography capabilities in the 2000, 83(Suppl 1):S5-S8 industry. The longevity of the imaging engine hardware 3. Wilson SR, Lyshchik A, Piscaglia F, Cosgrove D, and flexible upgrade path design of the computing Jang H, Sirlin C, Dietrich C, Kim TK, Willmann JK, engine ensures the integration of future diagnostic Kono Y. CEUS LI-RADS: algorithm, implementation, ultrasound technologies to enhance system performance and key differences from CT / MRI. Abdominal and investment protection. Radiology. 2017; DOI: 10.1007/s00261-017-1250-0. siemens-healthineers.com/sequoia 17 HOOD05162003028886 · Effective Date: 2-Aug-2019 ACUSON Sequoia BioAcustic Technology · White Paper Notes 18 siemens-healthineers.com/sequoia HOOD05162003028886 · Effective Date: 2-Aug-2019 White Paper · ACUSON Sequoia BioAcustic Technology Notes siemens-healthineers.com/sequoia 19 HOOD05162003028886 · Effective Date: 2-Aug-2019 Standalone clinical images may have been cropped to better visualize pathology. The products/features mentioned in this document may not be commercially available in all countries. Due to regulatory reasons, their future availability cannot be guaranteed. Please contact your local Siemens Healthineers organization for further details. ACUSON Sequoia, ACUSON Sequoia 512, AutoTEQ, BioAcoustic, InFocus, InTune, UltraArt, and Virtual Touch are trademarks of Siemens Medical Solutions USA, Inc. McAfee is a trademark of McAfee LLC. Nuance is a trademark of Nuance Communications Inc. Siemens Healthineers Headquarters Legal Manufacturer Siemens Healthcare GmbH Siemens Medical Solutions USA, Inc. Henkestr. 127 Ultrasound 91052 Erlangen, Germany 22010 S.E. 51st Street Phone: +49 9131 84-0 Issaquah, WA 98029 USA siemens-healthineers.com Phone: 1-888-826-9702 siemens-healthineers.com/ultrasound Published by Siemens Medical Solutions USA, Inc. · Order No. A91US-559-1C-4A00 · Printed in Germany · 7868 0819 © Siemens Medical Solutions USA, Inc., 2019 HOOD05162003028886 · Effective Date: 2-Aug-2019