DECLARATION OF CONFLICT OF INTEREST

CONFLICT OF INTEREST

No conflict of interest relevant

to this talk

Cardiovascular MRI, analysis of safety

and image quality in patients with

implantable cardiac arrhythmia devices

Author Block

B. Igual*†, MJ. Sancho-Tello†, F. Buendía†, A. Maceira*, O. Cano†‡, J.

Estornell*, JM. Sánchez†, J. Olagüe†, A. Salvador†

† Servicio Cardiología Hospital Universitari i Politècnic La Fe, Valencia

* ERESA. Unidad Imagen Cardíaca. Valencia, Spain.

cano_osc@gva.es

‡ Instituto Investigación Sanitaria La Fe, Valencia

Animal experiments showing significant heating effects of over 15ºC

At least 17 pacemaker patient deaths worldwide thought to be

attributable to MRI

Martin ET. et al. Cur Cardiol Reports 2007;9:63-71.

Background

Adverse Events During MRI in Pacemaker Patients Evidence Against Performance of MRI in Patients with ICADs

Ferris RJ. et al. Am J Roentgenol 2007;188:1388-1394.

More than 500 patients with ICADs have undergone MRI at 1.5T

without severe complications

Background

Evidence Favoring Performance of MRI in Patients with ICADs

- Shinbane JS. J. Cardiovasc Magn Reson. 2007;9:5-13

- Sommer T, et al. Circulation. 2006;114:1277-1284

- Martin ET, et al. J Am Coll Cardiol. 2004;43:1315-1324

- Nazarian S, et al. Circulation. 2006;114:1277-1284

Previously reported pacemaker patient deaths only with “old

generation” pacemakers (< year 2000) and in the absense of adequate

monitoring and supervision

Cardiovascular MRI in this setting can be technically

demanding and the signal loss and magnetic field inhomogeneity

induced by the device may limit the diagnostic yield of this

imaging technique

Background

Cardiovascular MRI in patients with ICADs

Little data available in the literature

Background

We hypothesized that specific cardiovascular

MRI in patients with pacemakers or ICDs can

be safely performed

Objective

To evaluate the safety, feasibility and

diagnostic utility of cardiovascular MRI in

patients with ICADs not specifically designed

for the MRI enviroment

Consecutive patients with PM/ICDs from September 2007 to January

2011 referred for medically necessary cardiovascular MRI

MRI system: Siemmens Magneton-Avanto MR-2004-V 1.5T

Devices should be in place for at least 6 weeks

Epicardial and abandoned leads excluded

Systematic safety protocol (pre-, during and post-MRI)

Methods

Adverse events, symptoms

Changes in electrical parameters

Variables

Device weight and volume

Change of MRI acquisition protocol to avoid device artifacts

Signal Loss Area (SLA)

Safety and Feasibility

Effects on Image Quality

Indication for cardiovascular MRI

Signal Loss Area (SLA): analysed in basal slice of cardiac short axis

in steady-state free-precession sequences (True Fisp) by a ROI whose

center is located in the center of the device and includes any signal loss

Methods

Image Quality Evaluation

- Repetition time 2.8 ms

- Echo time 1.2 ms

- Flip angle 58º

- Matrix size 225x192

- FOV 370-270mm

Empirically if a great SLA was observed:

Methods

Protocol Change

1. Change of sequences: True Fisp for Turbo Flash sequences (spoiled

gradient echo sequence)

2. Use of magnetic field homogenitation tools (SHIM)

MRI was considered non-conclusive when it failed to solve the clinical

questions raised for each individual patient.

DEVICE INTERROGATION -Battery Voltage and

Impedance

-Lead capture threshold

-Sensing parameters

-Pacing Impedance

Pre-MRI Evaluation

Absense of intrinsic

rhythm with PM

programmed in VVI mode

with LRL 40 bpm

ASSESSMENT OF PM DEPENDENCY

PM-DEPENDENT PATIENTS

NOT PM-DEPENDENT PATIENTS

VOO or DOO

VVI or DDI mode

ICDs Tachycardia sensing and

therapies OFF

HEART RATE AND O2 SATURATION MONITORING

MR compatible optically

encoded ECG and

pulse oximetry

(Invivo® 3155MVS)

Evaluation During-MRI

CONTINOUS AUDIO CONTACT

EXPERIENCED CARDIOLOGIST PRESENT

DURING THE SCAN

FULL RESUSCITATION EQUIPMENT

DEVICE INTERROGATION -Battery Voltage and

Impedance

-Lead capture threshold

-Sensing parameters

-Pacing Impedance

Post-MRI Evaluation

Pain, dizziness, torque,

heating sensation

Palpitations

Any other symptoms

ASSESSMENT OF PATIENT SYMPTOMS

PM-DEPENDENT PATIENTS Return to original pacing

mode

ICDs Activation of therapies

DF testing NOT performed

Results

Baseline characteristics of the population sample

42 cardiovascular MRI were performed in 41 patients (35 PM and 7 ICDs)

11 patients were PM-dependent

No serious MRI-related adverse events occurred in any patient

All the scans were completed

Results

Baseline characteristics of the population sample

Results

Baseline characteristics of the population sample

Results

Electrical Parameters Pre- and Post-MRI

Maximal AP threshold increase 0.12V in 1 patient

Maximal VP threshold increase 0.25V in 1 patient

Results

Change of the Acquisition Protocol

Globally, change of acquisition protocol was necessary in 56% cases

Diagnostic Utility and Type of CMRI

Non-Conclusive in 45% MPV studies vs. 15% RVF studies, p=0.05

Results

Diagnostic Utility

Results

Non-Conclusive in 12% PM vs. 57% ICDs, p=0.02

Image Artifacts during Cardiac MRI

Results

Results

Image Artifacts during Cardiac MRI

Spatial distorsion of

surrounding anatomy

without limiting diagnosis

Pronounced artifacts

preventing an adequate

diagnosis

Little bright and dark

artifacts just around the

generator

Cardiovascular MRI can be safely performed in patients with PM or ICD

No significant MRI-related complications occurred during or after MRI

Electrical parameter changes were minimal and comparable pre- and

post-MRI examinations

Conclusions

Myocardial perfusion/viability MRI scans in patients with high volume

devices should not be advised, due to the high incidence of non-

conclusive scans

Diagnostic utility depends on the device (ICD vs PM) and the clinical

indication of the MRI