Advertisement

Current Radiology Reports

, 6:41 | Cite as

MR Imaging of Patients with Cardiac Implantable Electronic Devices (CIEDs): Implementing a Program and Optimizing CMR

  • Avanti Gulhane
  • Harold Litt
Cardiovascular Imaging (K Ordovas, Section Editor)
Part of the following topical collections:
  1. Cardiovascular Imaging

Abstract

Purpose of review

How to implement a program for MRI in patients with conditional and non-conditional (“legacy”) CIED. How to optimize safety and image quality in CMR? What the radiologists need to know: device programming, pre- and post-MRI CIED parameters.

Recent findings

New Center for Medicare and Medicaid Services (CMS) guidelines have opened MRI to many patients with nonconditional devices. Newer pulse sequences for cardiac MRI (CMR) in device patients, including modified cine, late gadolinium enhancement and T1 mapping sequences, have resulted in improved image quality in device patients. We present several cases of CMR in device patients, including imaging of leadless pacemakers subcutaneous ICDs. Imaging pitfalls/artifacts in CMR interpretation are also presented.

Summary

An organized institutional workflow with an established protocol involving proper patient screening, device programming, scan monitoring, and pre- and post-ICD interrogation minimizes risk in patients with conditional and non-conditional CIEDs. Although rare, significant changes in lead performance, power-on/reset, inappropriate pacing or ICD discharges and battery voltage depletion should be documented. High-quality scans with accurate scar characterization in CIED patients require the use of wideband sequences. CMS has recently acknowledged MRI as a reasonable test necessary for the diagnosis and treatment of beneficiaries with implanted CIEDs, improving the financial prospects and encouraging future developments.

Keywords

Cardiac implantable electronic device Safety concerns CMR protocol Device programming Wideband LGE Image quality 

Notes

Compliance with Ethical Guidelines

Conflict of interest

Avanti Gulhane and Harold Litt each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Supplementary material

40134_2018_301_MOESM1_ESM.avi (1.4 mb)
Video 1: Non conditional pacemaker cine 4ch. Supplementary material 1 (AVI 1391 kb)
40134_2018_301_MOESM2_ESM.avi (1.4 mb)
Video 2: Non conditional pacemaker cine SAX. Supplementary material 2 (AVI 1386 kb)

References

Recently published papers of particular interest have been highlighted as: • Of importance •• Of importance

  1. 1.
    Kusumoto FM, Schoenfeld MH, Wilkoff BL, Berul CI, Birgersdotter-Green UM, Carrillo R, et al. 2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm. 2017;14(12):e503–51.  https://doi.org/10.1016/j.hrthm.2017.09.001.CrossRefPubMedGoogle Scholar
  2. 2.
    Dickfeld T, Tian J, Ahmad G, Jimenez A, Turgeman A, Kuk R, et al. MRI-guided ventricular tachycardia ablation: integration of late gadolinium-enhanced 3D scar in patients with implantable cardioverter-defibrillators. Circ Arrhythm Electrophysiol. 2011;4(2):172–84.  https://doi.org/10.1161/CIRCEP.110.958744.CrossRefPubMedGoogle Scholar
  3. 3.
    • Stevens SM, Tung R, Rashid S, Gima J, Cote S, Pavez G et al. Device artifact reduction for magnetic resonance imaging of patients with implantable cardioverter-defibrillators and ventricular tachycardia: late gadolinium enhancement correlation with electroanatomic mapping. Heart Rhythm. 2014;11(2):289–98.  https://doi.org/10.1016/j.hrthm.2013.10.032. The paper highlights the importance of wideband technique to accurately characterize myocardial scar and its correlation to EAM findings.CrossRefPubMedGoogle Scholar
  4. 4.
    Nazarian S, Reynolds MR, Ryan MP, Wolff SD, Mollenkopf SA, Turakhia MP. Utilization and likelihood of radiologic diagnostic imaging in patients with implantable cardiac defibrillators. J Magn Reson Imaging. 2016;43(1):115–27.  https://doi.org/10.1002/jmri.24971.CrossRefPubMedGoogle Scholar
  5. 5.
    Nazarian S, Reynolds MR, Ryan MP, Wolff SD, Mollenkopf SA, Turakhia MP. Estimating the likelihood of MRI in patients after ICD implantation: a 10-year prediction model (abstr). J Am Coll Cardiol. 2015;65(Suppl 10):A1090.CrossRefGoogle Scholar
  6. 6.
    Kaasalainen T, Pakarinen S, Kivisto S, Holmstrom M, Hanninen H, Peltonen J, et al. MRI with cardiac pacing devices—safety in clinical practice. Eur J Radiol. 2014;83(8):1387–95.  https://doi.org/10.1016/j.ejrad.2014.04.022.CrossRefPubMedGoogle Scholar
  7. 7.
    Mason S, Osborn JS, Dhar R, Tonkin A, Ethington JD, Le V, et al. Real world MRI experience with nonconditional and conditional cardiac rhythm devices after MagnaSafe. J Cardiovasc Electrophysiol. 2017;28(12):1468–74.  https://doi.org/10.1111/jce.13351.CrossRefPubMedGoogle Scholar
  8. 8.
    •• Russo RJ, Costa HS, Silva PD, Anderson JL, Arshad A, Biederman RW et al. Assessing the risks associated with MRI in patients with a pacemaker or defibrillator. N Engl J Med. 2017;376(8):755–64.  https://doi.org/10.1056/nejmoa1603265. This is a major study which established safety of MRI (non thoracic) at 1.5T in a large number of patients with non conditional devices.CrossRefPubMedGoogle Scholar
  9. 9.
    Duru F, Luechinger R, Scheidegger MB, Luscher TF, Boesiger P, Candinas R. Pacing in magnetic resonance imaging environment: clinical and technical considerations on compatibility. Eur Heart J. 2001;22(2):113–24.  https://doi.org/10.1053/euhj.2000.2149.CrossRefPubMedGoogle Scholar
  10. 10.
    Cohen JD, Costa HS, Russo RJ. Determining the risks of magnetic resonance imaging at 1.5 tesla for patients with pacemakers and implantable cardioverter defibrillators. Am J Cardiol. 2012;110(11):1631–6.  https://doi.org/10.1016/j.amjcard.2012.07.030.CrossRefPubMedGoogle Scholar
  11. 11.
    Higgins JV, Sheldon SH, Watson RE Jr, Dalzell C, Acker N, Cha YM, et al. “Power-on resets” in cardiac implantable electronic devices during magnetic resonance imaging. Heart Rhythm. 2015;12(3):540–4.  https://doi.org/10.1016/j.hrthm.2014.10.039.CrossRefPubMedGoogle Scholar
  12. 12.
    Yadava M, Nugent M, Krebsbach A, Minnier J, Jessel P, Henrikson CA. Magnetic resonance imaging in patients with cardiac implantable electronic devices: a single-center prospective study. J Interv Card Electrophysiol. 2017;50(1):95–104.  https://doi.org/10.1007/s10840-017-0262-6.CrossRefPubMedGoogle Scholar
  13. 13.
    Nazarian S, Hansford R, Rahsepar AA, Weltin V, McVeigh D, Gucuk Ipek E, et al. Safety of magnetic resonance imaging in patients with cardiac devices. N Engl J Med. 2017;377(26):2555–64.  https://doi.org/10.1056/NEJMoa1604267.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Friedman HL, Acker N, Dalzell C, Shen WK, Asirvatham SJ, Cha YM, et al. Magnetic resonance imaging in patients with recently implanted pacemakers. Pacing Clin Electrophysiol. 2013;36(9):1090–5.  https://doi.org/10.1111/pace.12213.CrossRefPubMedGoogle Scholar
  15. 15.
    Gold MR, Kanal E, Schwitter J, Sommer T, Yoon H, Ellingson M, et al. Preclinical evaluation of implantable cardioverter-defibrillator developed for magnetic resonance imaging use. Heart Rhythm. 2015;12(3):631–8.  https://doi.org/10.1016/j.hrthm.2014.12.012.CrossRefPubMedGoogle Scholar
  16. 16.
    Shah AD, Patel AU, Knezevic A, Hoskins MH, Hirsh DS, Merchant FM, et al. Clinical performance of magnetic resonance imaging conditional and nonconditional cardiac implantable electronic devices. Pacing Clin Electrophysiol. 2017;40(5):467–75.  https://doi.org/10.1111/pace.13060.CrossRefPubMedGoogle Scholar
  17. 17.
    Sheldon SH, Bunch TJ, Cogert GA, Acker NG, Dalzell CM, Higgins JV, et al. Multicenter study of the safety and effects of magnetic resonance imaging in patients with coronary sinus left ventricular pacing leads. Heart Rhythm. 2015;12(2):345–9.  https://doi.org/10.1016/j.hrthm.2014.11.037.CrossRefPubMedGoogle Scholar
  18. 18.
    Luechinger R, Duru F, Zeijlemaker VA, Scheidegger MB, Boesiger P, Candinas R. Pacemaker reed switch behavior in 0.5, 1.5, and 3.0 Tesla magnetic resonance imaging units: are reed switches always closed in strong magnetic fields? Pacing Clin Electrophysiol. 2002;25(10):1419–23.CrossRefPubMedGoogle Scholar
  19. 19.
    Muehling OM, Wakili R, Greif M, von Ziegler F, Morhard D, Brueckmann H, et al. Immediate and 12 months follow up of function and lead integrity after cranial MRI in 356 patients with conventional cardiac pacemakers. J Cardiovasc Magn Reson. 2014;16:39.  https://doi.org/10.1186/1532-429X-16-39.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Awad K, Griffin J, Crawford TC, Lane Cox S, Ferrick K, Mazur A, et al. Clinical safety of the Iforia implantable cardioverter-defibrillator system in patients subjected to thoracic spine and cardiac 1.5-T magnetic resonance imaging scanning conditions. Heart Rhythm. 2015;12(10):2155–61.  https://doi.org/10.1016/j.hrthm.2015.06.002.CrossRefPubMedGoogle Scholar
  21. 21.
    Gold MR, Sommer T, Schwitter J, Al Fagih A, Albert T, Merkely B, et al. Full-body MRI in patients with an implantable cardioverter–defibrillator: primary results of a randomized study. J Am Coll Cardiol. 2015;65(24):2581–8.  https://doi.org/10.1016/j.jacc.2015.04.047.CrossRefPubMedGoogle Scholar
  22. 22.
    Ono M, Suzuki M, Isobe M. Feasibility, safety, and potential demand of emergent brain magnetic resonance imaging of patients with cardiac implantable electronic devices. J Arrhythm. 2017;33(5):455–8.  https://doi.org/10.1016/j.joa.2017.01.002.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Baher A, Kodali S, Shah DJ. Cardiac MRI is safe in patients with pacemakers and defibrillators. J Cardiovasc Magn Reson. 2012;14(Suppl 1):O102.CrossRefPubMedCentralGoogle Scholar
  24. 24.
    Do DH, Eyvazian V, Bayoneta AJ, Hu P, Finn JP, Bradfield JS, et al. Cardiac magnetic resonance imaging using wideband sequences in patients with nonconditional cardiac implanted electronic devices. Heart Rhythm. 2018;15(2):218–25.  https://doi.org/10.1016/j.hrthm.2017.10.003.CrossRefPubMedGoogle Scholar
  25. 25.
    Dandamudi S, Collins JD, Carr JC, Mongkolwat P, Rahsepar AA, Tomson TT, et al. The safety of cardiac and thoracic magnetic resonance imaging in patients with cardiac implantable electronic devices. Acad Radiol. 2016;23(12):1498–505.  https://doi.org/10.1016/j.acra.2016.08.016.CrossRefPubMedGoogle Scholar
  26. 26.
    Hwang YM, Kim J, Lee JH, Kim M, Nam GB, Choi KJ, et al. Cardiac implantable electronic device safety during magnetic resonance imaging. Korean Circ J. 2016;46(6):804–10.  https://doi.org/10.4070/kcj.2016.46.6.804.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    • Padmanabhan D, Kella DK, Mehta R, Kapa S, Deshmukh A, Mulpuru S et al. Safety of magnetic resonance imaging in patients with legacy pacemakers and defibrillators and abandoned leads. Heart Rhythm. 2018;15(2):228–33.  https://doi.org/10.1016/j.hrthm.2017.10.022. This study analyzed safety of MRI in devices with abandoned leads considered to be an absolute contraindication by assessing myocardial injury with troponin assessment, thus established a low risk for these patients.CrossRefPubMedGoogle Scholar
  28. 28.
    Ranjan R, McGann CJ, Jeong EK, Hong K, Kholmovski EG, Blauer J, et al. Wideband late gadolinium enhanced magnetic resonance imaging for imaging myocardial scar without image artefacts induced by implantable cardioverter-defibrillator: a feasibility study at 3 T. Europace. 2015;17(3):483–8.  https://doi.org/10.1093/europace/euu263.CrossRefPubMedGoogle Scholar
  29. 29.
    Schwitter J, Gold MR, Al Fagih A, Lee S, Peterson M, Ciuffo A, et al. Image quality of cardiac magnetic resonance imaging in patients with an implantable cardioverter defibrillator system designed for the magnetic resonance imaging environment. Circ Cardiovasc Imaging. 2016.  https://doi.org/10.1161/circimaging.115.004025.CrossRefPubMedGoogle Scholar
  30. 30.
    Mesubi O, Ahmad G, Jeudy J, Jimenez A, Kuk R, Saliaris A, et al. Impact of ICD artifact burden on late gadolinium enhancement cardiac MR imaging in patients undergoing ventricular tachycardia ablation. Pacing Clin Electrophysiol. 2014;37(10):1274–83.  https://doi.org/10.1111/pace.12405.CrossRefPubMedGoogle Scholar
  31. 31.
    Sasaki T, Hansford R, Zviman MM, Kolandaivelu A, Bluemke DA, Berger RD, et al. Quantitative assessment of artifacts on cardiac magnetic resonance imaging of patients with pacemakers and implantable cardioverter-defibrillators. Circ Cardiovasc Imaging. 2011;4(6):662–70.  https://doi.org/10.1161/CIRCIMAGING.111.965764.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Rahsepar AA, Collins JD, Knight BP, Hong K, Carr JC, Kim D. Wideband LGE MRI permits unobstructed viewing of myocardial scarring in a patient with an MR-conditional subcutaneous implantable cardioverter-defibrillator. Clin Imaging. 2018;50:294–6.  https://doi.org/10.1016/j.clinimag.2018.05.005.CrossRefPubMedGoogle Scholar
  33. 33.
    • Nam Ju Lee, Litt HI. Imaging of patients with implanted devices and arrhythmia. S Afr J Radiol. 2016.  https://doi.org/10.4102/sajr.v20i2.1046. This review paper discusses the various CMR pulse sequences for imaging patients with devices and illustrates the utility of GRE and wideband techniques for MR in patients with CIEDs.
  34. 34.
    •• Indik JH, Gimbel JR, Abe H, Alkmim-Teixeira R, Birgersdotter-Green U, Clarke GD et al. 2017 HRS expert consensus statement on magnetic resonance imaging and radiation exposure in patients with cardiovascular implantable electronic devices. Heart Rhythm. 2017;14(7):e97–e153.  https://doi.org/10.1016/j.hrthm.2017.04.025. This paper provides a detailed expert opinion on MRI imaging in patients with devices and provides practical recommendations in appropriate detail for health care providers of various backgrounds for the management of patients with CIEDs so they can undergo imaging and treatments in a manner that balances benefit and risk.CrossRefPubMedGoogle Scholar
  35. 35.
    Rashid S, Rapacchi S, Shivkumar K, Plotnik A, Finn JP, Hu P. Modified wideband three-dimensional late gadolinium enhancement MRI for patients with implantable cardiac devices. Magn Reson Med. 2016;75(2):572–84.  https://doi.org/10.1002/mrm.25601.CrossRefPubMedGoogle Scholar
  36. 36.
    •• https://www.cms.gov/medicare-coverage-database Decision Memo for Magnetic Resonance Imaging (MRI) (CAG-00399R4). This is the decision memo by CMS acknowledging MRI as being reasonable for CMS beneficiaries with an implanted device and necessary for diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member under section 1862(a)(1)(A) of the Social Security Act.
  37. 37.
    Rashid S, Rapacchi S, Vaseghi M, Tung R, Shivkumar K, Finn JP, et al. Improved late gadolinium enhancement MR imaging for patients with implanted cardiac devices. Radiology. 2014;270(1):269–74.  https://doi.org/10.1148/radiol.13130942.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Piehler KM, Wong TC, Puntil KS, Zareba KM, Lin K, Harris DM, et al. Free-breathing, motion-corrected late gadolinium enhancement is robust and extends risk stratification to vulnerable patients. Circ Cardiovasc Imaging. 2013;6(3):423–32.  https://doi.org/10.1161/CIRCIMAGING.112.000022.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Bhuva A, Ramlall M. C. M. Wideband free breathing MOCO LGE changes patient care in patients with implantable cardiac defibrillators. Heart. BMJ. 2017;103(Suppl 1):A1–25.  https://doi.org/10.1136/heartjnl-2017-311399.14.CrossRefGoogle Scholar
  40. 40.
    Hong K, Jeong EK, Wall TS, Drakos SG, Kim D. Wideband arrhythmia-Insensitive-rapid (AIR) pulse sequence for cardiac T1 mapping without image artifacts induced by an implantable-cardioverter-defibrillator. Magn Reson Med. 2015;74(2):336–45.  https://doi.org/10.1002/mrm.25712.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Fitts M, Breton E, Kholmovski EG, Dosdall DJ, Vijayakumar S, Hong KP, et al. Arrhythmia insensitive rapid cardiac T1 mapping pulse sequence. Magn Reson Med. 2013;70(5):1274–82.  https://doi.org/10.1002/mrm.24586.CrossRefPubMedGoogle Scholar
  42. 42.
    Rashid S, Tung RH, Hu P. Improved inversion time (TI) scout sequence for late gadolinium enhancement MRI of patients with implantable cardiac devices. J Cardiovasc Magn Reson. 2014;16(Suppl 1):19.CrossRefGoogle Scholar
  43. 43.
    Roguin A, Schwitter J, Vahlhaus C, Lombardi M, Brugada J, Vardas P, et al. Magnetic resonance imaging in individuals with cardiovascular implantable electronic devices. Europace. 2008;10(3):336–46.  https://doi.org/10.1093/europace/eun021.CrossRefPubMedGoogle Scholar
  44. 44.
    Nazarian S, Hansford R, Roguin A, Goldsher D, Zviman MM, Lardo AC, et al. A prospective evaluation of a protocol for magnetic resonance imaging of patients with implanted cardiac devices. Ann Intern Med. 2011;155(7):415–24.  https://doi.org/10.7326/0003-4819-155-7-201110040-00004.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Nazarian S, Halperin HR. How to perform magnetic resonance imaging on patients with implantable cardiac arrhythmia devices. Heart Rhythm. 2009;6(1):138–43.  https://doi.org/10.1016/j.hrthm.2008.10.021.CrossRefPubMedGoogle Scholar
  46. 46.
    Schwitter J, Kanal E, Schmitt M, Anselme F, Albert T, Hayes DL, et al. Impact of the Advisa MRI pacing system on the diagnostic quality of cardiac MR images and contraction patterns of cardiac muscle during scans: advisa MRI randomized clinical multicenter study results. Heart Rhythm. 2013;10(6):864–72.  https://doi.org/10.1016/j.hrthm.2013.02.019.CrossRefPubMedGoogle Scholar
  47. 47.
    Ferreira AM, Costa F, Tralhao A, Marques H, Cardim N, Adragao P. MRI-conditional pacemakers: current perspectives. Med Devices (Auckl). 2014;7:115–24.  https://doi.org/10.2147/MDER.S44063.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Mark S, Maggie M, Manan V, Jeremy W. Cardiac magnetic resonance with a conditional pacemaker at three tesla field strength. Cardiovasc Imaging Asia. 2018;2(1):28–30.  https://doi.org/10.22468/cvia.2017.00171.CrossRefGoogle Scholar
  49. 49.
    Lee YH, Hahn S, Kim E, Suh JS. Fat-suppressed MR imaging of the spine for metal artifact reduction at 3T: comparison of STIR and slice encoding for metal artifact correction fat-suppressed T2-weighted images. Magn Reson Med Sci. 2016;15(4):371–8.  https://doi.org/10.2463/mrms.mp.2015-0055.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    • van der Graaf AW, Bhagirath P, Scheffer MG, de Medina RR, Gotte MJ. MR feature tracking in patients with MRI-conditional pacing systems: the impact of pacing. J Magn Reson Imaging. 2016;44(4):964–71.  https://doi.org/10.1002/jmri.25229. The study on patients with MR-conditional pacemaker systems shows the feasibility for developing a feature tracking (FT) software to perform strain analysis for determining the effects of cardiac pacing on myocardial strain and demonstrates reduced myocardial strain during pacing.CrossRefPubMedGoogle Scholar
  51. 51.
    Strom JB, Whelan JB, Shen C, Zheng SQ, Mortele KJ, Kramer DB. Safety and utility of magnetic resonance imaging in patients with cardiac implantable electronic devices. Heart Rhythm. 2017;14(8):1138–44.  https://doi.org/10.1016/j.hrthm.2017.03.039.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Taylor AJ, Ellims A, Lew PJ, Murphy B, Pally S, Younie S. Impact of cardiac magnetic resonance imaging on cardiac device and surgical therapy: a prospective study. Int J Cardiovasc Imaging. 2013;29(4):855–64.  https://doi.org/10.1007/s10554-012-0131-4.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Cardiovascular Imaging Section, Department of RadiologyPerelman School of Medicine of the University of PennsylvaniaPhiladelphiaUSA
  2. 2.Cardiothoracic Imaging Division, Department of RadiologyPerelman School of Medicine of the University of PennsylvaniaPhiladelphiaUSA

Personalised recommendations