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Kakareka JW, Faranesh AZ, Pursley RH, Campbell-Washburn A, Herzka DA, Rogers T, Kanter J, Ratnayaka K, Lederman RJ, Pohida TJ. Physiological Recording in the MRI Environment (PRiME): MRI-Compatible Hemodynamic Recording System. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE-JTEHM 2018; 6:4100112. [PMID: 29552426 PMCID: PMC5849467 DOI: 10.1109/jtehm.2018.2807813] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/20/2017] [Accepted: 02/01/2018] [Indexed: 12/26/2022]
Abstract
Hemodynamic recording during interventional cardiovascular procedures is essential for procedural guidance, monitoring patient status, and collection of diagnostic information. Recent advances have made interventions guided by magnetic resonance imaging (MRI) possible and attractive in certain clinical scenarios. However, in the MRI environment, electromagnetic interference (EMI) can cause severe distortions and artifacts in acquired hemodynamic waveforms. The primary aim of this paper was to develop and validate a system to minimize EMI on electrocardiogram (ECG) and invasive blood pressure (IBP) signals. A system was developed which incorporated commercial MRI compatible ECG leads and pressure transducers, custom electronics, user interface, and adaptive signal processing. Measurements were made on pediatric patients (N = 6) during MRI-guided catheterization. Real-time interactive scanning, which is known to produce significant EMI due to fast gradient switching and varying imaging plane orientations, was selected for testing. The effectiveness of the adaptive algorithms was determined by measuring the reduction of noise peaks, amplitude of noise peaks, and false QRS triggers. During real-time gradient-intensive imaging sequences, peak noise amplitude was reduced by 80% and false QRS triggers were reduced to a median of 0. There was no detectable interference on the IBP channels. A hemodynamic recording system front-end was successfully developed and deployed, which enabled high-fidelity recording of ECG and IBP during MRI scanning. The schematics and assembly instructions are publicly available to facilitate implementation at other institutions. Researchers and clinicians are provided a critical tool in investigating and implementing MRI guided interventional cardiovascular procedures.
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Fischer P, Faranesh A, Pohl T, Maier A, Rogers T, Ratnayaka K, Lederman R, Hornegger J. An MR-Based Model for Cardio-Respiratory Motion Compensation of Overlays in X-Ray Fluoroscopy. IEEE TRANSACTIONS ON MEDICAL IMAGING 2018; 37:47-60. [PMID: 28692969 PMCID: PMC5750091 DOI: 10.1109/tmi.2017.2723545] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In X-ray fluoroscopy, static overlays are used to visualize soft tissue. We propose a system for cardiac and respiratory motion compensation of these overlays. It consists of a 3-D motion model created from real-time magnetic resonance (MR) imaging. Multiple sagittal slices are acquired and retrospectively stacked to consistent 3-D volumes. Slice stacking considers cardiac information derived from the ECG and respiratory information extracted from the images. Additionally, temporal smoothness of the stacking is enhanced. Motion is estimated from the MR volumes using deformable 3-D/3-D registration. The motion model itself is a linear direct correspondence model using the same surrogate signals as slice stacking. In X-ray fluoroscopy, only the surrogate signals need to be extracted to apply the motion model and animate the overlay in real time. For evaluation, points are manually annotated in oblique MR slices and in contrast-enhanced X-ray images. The 2-D Euclidean distance of these points is reduced from 3.85 to 2.75 mm in MR and from 3.0 to 1.8 mm in X-ray compared with the static baseline. Furthermore, the motion-compensated overlays are shown qualitatively as images and videos.
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Ratnayaka K, Kanter JP, Faranesh AZ, Grant EK, Olivieri LJ, Cross RR, Cronin IF, Hamann KS, Campbell-Washburn AE, O’Brien KJ, Rogers T, Hansen MS, Lederman RJ. Radiation-free CMR diagnostic heart catheterization in children. J Cardiovasc Magn Reson 2017; 19:65. [PMID: 28874164 PMCID: PMC5585983 DOI: 10.1186/s12968-017-0374-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 07/17/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Children with heart disease may require repeated X-Ray cardiac catheterization procedures, are more radiosensitive, and more likely to survive to experience oncologic risks of medical radiation. Cardiovascular magnetic resonance (CMR) is radiation-free and offers information about structure, function, and perfusion but not hemodynamics. We intend to perform complete radiation-free diagnostic right heart catheterization entirely using CMR fluoroscopy guidance in an unselected cohort of pediatric patients; we report the feasibility and safety. METHODS We performed 50 CMR fluoroscopy guided comprehensive transfemoral right heart catheterizations in 39 pediatric (12.7 ± 4.7 years) subjects referred for clinically indicated cardiac catheterization. CMR guided catheterizations were assessed by completion (success/failure), procedure time, and safety events (catheterization, anesthesia). Pre and post CMR body temperature was recorded. Concurrent invasive hemodynamic and diagnostic CMR data were collected. RESULTS During a twenty-two month period (3/2015 - 12/2016), enrolled subjects had the following clinical indications: post-heart transplant 33%, shunt 28%, pulmonary hypertension 18%, cardiomyopathy 15%, valvular heart disease 3%, and other 3%. Radiation-free CMR guided right heart catheterization attempts were all successful using passive catheters. In two subjects with septal defects, right and left heart catheterization were performed. There were no complications. One subject had six such procedures. Most subjects (51%) had undergone multiple (5.5 ± 5) previous X-Ray cardiac catheterizations. Retained thoracic surgical or transcatheter implants (36%) did not preclude successful CMR fluoroscopy heart catheterization. During the procedure, two subjects were receiving vasopressor infusions at baseline because of poor cardiac function, and in ten procedures, multiple hemodynamic conditions were tested. CONCLUSIONS Comprehensive CMR fluoroscopy guided right heart catheterization was feasible and safe in this small cohort of pediatric subjects. This includes subjects with previous metallic implants, those requiring continuous vasopressor medication infusions, and those requiring pharmacologic provocation. Children requiring multiple, serial X-Ray cardiac catheterizations may benefit most from radiation sparing. This is a step toward wholly CMR guided diagnostic (right and left heart) cardiac catheterization and future CMR guided cardiac intervention. TRIAL REGISTRATION ClinicalTrials.gov NCT02739087 registered February 17, 2016.
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Rogers T, Ratnayaka K, Khan JM, Stine A, Schenke WH, Grant LP, Mazal JR, Grant EK, Campbell-Washburn A, Hansen MS, Ramasawmy R, Herzka DA, Xue H, Kellman P, Faranesh AZ, Lederman RJ. CMR fluoroscopy right heart catheterization for cardiac output and pulmonary vascular resistance: results in 102 patients. J Cardiovasc Magn Reson 2017; 19:54. [PMID: 28750642 PMCID: PMC5530573 DOI: 10.1186/s12968-017-0366-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 06/21/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Quantification of cardiac output and pulmonary vascular resistance (PVR) are critical components of invasive hemodynamic assessment, and can be measured concurrently with pressures using phase contrast CMR flow during real-time CMR guided cardiac catheterization. METHODS One hundred two consecutive patients underwent CMR fluoroscopy guided right heart catheterization (RHC) with simultaneous measurement of pressure, cardiac output and pulmonary vascular resistance using CMR flow and the Fick principle for comparison. Procedural success, catheterization time and adverse events were prospectively collected. RESULTS RHC was successfully completed in 97/102 (95.1%) patients without complication. Catheterization time was 20 ± 11 min. In patients with and without pulmonary hypertension, baseline mean pulmonary artery pressure was 39 ± 12 mmHg vs. 18 ± 4 mmHg (p < 0.001), right ventricular (RV) end diastolic volume was 104 ± 64 vs. 74 ± 24 (p = 0.02), and RV end-systolic volume was 49 ± 30 vs. 31 ± 13 (p = 0.004) respectively. 103 paired cardiac output and 99 paired PVR calculations across multiple conditions were analyzed. At baseline, the bias between cardiac output by CMR and Fick was 5.9% with limits of agreement -38.3% and 50.2% with r = 0.81 (p < 0.001). The bias between PVR by CMR and Fick was -0.02 WU.m2 with limits of agreement -2.6 and 2.5 WU.m2 with r = 0.98 (p < 0.001). Correlation coefficients were lower and limits of agreement wider during physiological provocation with inhaled 100% oxygen and 40 ppm nitric oxide. CONCLUSIONS CMR fluoroscopy guided cardiac catheterization is safe, with acceptable procedure times and high procedural success rate. Cardiac output and PVR measurements using CMR flow correlated well with the Fick at baseline and are likely more accurate during physiological provocation with supplemental high-concentration inhaled oxygen. TRIAL REGISTRATION Clinicaltrials.gov NCT01287026 , registered January 25, 2011.
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Grant EK, Berul CI, Cross RR, Moak JP, Hamann KS, Sumihara K, Cronin I, O'Brien KJ, Ratnayaka K, Hansen MS, Kellman P, Olivieri LJ. Acute Cardiac MRI Assessment of Radiofrequency Ablation Lesions for Pediatric Ventricular Arrhythmia: Feasibility and Clinical Correlation. J Cardiovasc Electrophysiol 2017; 28:517-522. [PMID: 28245348 PMCID: PMC5444970 DOI: 10.1111/jce.13197] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 12/28/2016] [Accepted: 01/18/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Arrhythmia ablation with current techniques is not universally successful. Inadequate ablation lesion formation may be responsible for some arrhythmia recurrences. Periprocedural visualization of ablation lesions may identify inadequate lesions and gaps to guide further ablation and reduce risk of arrhythmia recurrence. METHODS This feasibility study assessed acute postprocedure ablation lesions by MRI, and correlated these findings with clinical outcomes. Ten pediatric patients who underwent ventricular tachycardia ablation were transferred immediately postablation to a 1.5T MRI scanner and late gadolinium enhancement (LGE) imaging was performed to characterize ablation lesions. Immediate and mid-term arrhythmia recurrences were assessed. RESULTS Patient characteristics include median age 14 years (1-18 years), median weight 52 kg (11-81 kg), normal cardiac anatomy (n = 6), d-transposition of great arteries post arterial switch repair (n = 2), anomalous coronary artery origin post repair (n = 1), and cardiac rhabdomyoma (n = 1). All patients underwent radiofrequency catheter ablation of ventricular arrhythmia with acute procedural success. LGE was identified at the reported ablation site in 9/10 patients, all arrhythmia-free at median 7 months follow-up. LGE was not visible in 1 patient who had recurrence of frequent premature ventricular contractions within 2 hours, confirmed on Holter at 1 and 21 months post procedure. CONCLUSIONS Ventricular ablation lesion visibility by MRI in the acute post procedure setting is feasible. Lesions identifiable with MRI may correlate with clinical outcomes. Acute MRI identification of gaps or inadequate lesions may provide the unique temporal opportunity for additional ablation therapy to decrease arrhythmia recurrence.
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Rogers T, Ratnayaka K, Karmarkar P, Schenke W, Mazal JR, Campbell-Washburn AE, Kocaturk O, Faranesh AZ, Lederman RJ. Real-time magnetic resonance imaging guidance improves the yield of endomyocardial biopsy. J Cardiovasc Magn Reson 2016. [PMCID: PMC5032338 DOI: 10.1186/1532-429x-18-s1-q69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Campbell-Washburn AE, Rogers T, Ratnayaka K, Basar B, Kocaturk O, Xue H, Lederman RJ, Hansen MS, Faranesh AZ. Spiral imaging with off-resonance reconstruction for MRI-guided cardiovascular catheterizations using commercial off-the-shelf nitinol guidewires. J Cardiovasc Magn Reson 2016. [PMCID: PMC5032728 DOI: 10.1186/1532-429x-18-s1-p216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Rogers T, Mahapatra S, Kim S, Eckhaus M, Schenke W, Mazal JR, Campbell-Washburn AE, Sonmez M, Faranesh AZ, Ratnayaka K, Lederman RJ. Transcatheter real-time MRI guided myocardial chemoablation using acetic acid. J Cardiovasc Magn Reson 2016. [PMCID: PMC5032323 DOI: 10.1186/1532-429x-18-s1-q68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Rogers T, Mahapatra S, Kim S, Eckhaus MA, Schenke WH, Mazal JR, Campbell-Washburn A, Sonmez M, Faranesh AZ, Ratnayaka K, Lederman RJ. Transcatheter Myocardial Needle Chemoablation During Real-Time Magnetic Resonance Imaging: A New Approach to Ablation Therapy for Rhythm Disorders. Circ Arrhythm Electrophysiol 2016; 9:e003926. [PMID: 27053637 DOI: 10.1161/circep.115.003926] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 03/07/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Radiofrequency ablation for ventricular arrhythmias is limited by inability to visualize tissue destruction, by reversible conduction block resulting from edema surrounding lesions, and by insufficient lesion depth. We hypothesized that transcatheter needle injection of caustic agents doped with gadolinium contrast under real-time magnetic resonance imaging (MRI) could achieve deep, targeted, and irreversible myocardial ablation, which would be immediately visible. METHODS AND RESULTS Under real-time MRI guidance, ethanol or acetic acid was injected into the myocardium of 8 swine using MRI-conspicuous needle catheters. Chemoablation lesions had identical geometry by in vivo and ex vivo MRI and histopathology, both immediately and after 12 (7-17) days. Ethanol caused stellate lesions with patchy areas of normal myocardium, whereas acetic acid caused homogeneous circumscribed lesions of irreversible necrosis. Ischemic cardiomyopathy was created in 10 additional swine by subselective transcoronary ethanol administration into noncontiguous territories. After 12 (8-15) days, real-time MRI-guided chemoablation-with 2 to 5 injections to create a linear lesion-successfully eliminated the isthmus and local abnormal voltage activities. CONCLUSIONS Real-time MRI-guided chemoablation with acetic acid enabled the intended arrhythmic substrate, whether deep or superficial, to be visualized immediately and ablated irreversibly. In an animal model of ischemic cardiomyopathy, obliteration of a conductive isthmus both anatomically and functionally and abolition of local abnormal voltage activities in areas of heterogeneous scar were feasible. This represents the first report of MRI-guided myocardial chemoablation, an approach that could improve the efficacy of arrhythmic substrate ablation in the thick ventricular myocardium.
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Lubega S, Aliku T, Daluvoy S, Sable C, Qureshi S, Kumar R, Ratnayaka K, Lwabi P. PT208 Pathway to Independent Interventional Practice: Uganda Heart Institute Pediatric Cardiac Catheterization Program. Glob Heart 2016. [DOI: 10.1016/j.gheart.2016.03.560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Ratnayaka K, Rogers T, Schenke WH, Mazal JR, Chen MY, Sonmez M, Hansen MS, Kocaturk O, Faranesh AZ, Lederman RJ. Magnetic Resonance Imaging-Guided Transcatheter Cavopulmonary Shunt. JACC Cardiovasc Interv 2016; 9:959-70. [PMID: 27085581 DOI: 10.1016/j.jcin.2016.01.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 01/21/2016] [Accepted: 01/22/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The aim of this study was to test the hypothesis that real-time magnetic resonance imaging (MRI) would enable closed-chest percutaneous cavopulmonary anastomosis and shunt by facilitating needle guidance along a curvilinear trajectory, around critical structures, and between a superior vena cava "donor" vessel and a pulmonary artery "target." BACKGROUND Children with single-ventricle physiology require multiple open heart operations for palliation, including sternotomies and cardiopulmonary bypass. The reduced morbidity of a catheter-based approach would be attractive. METHODS Fifteen naive swine underwent transcatheter cavopulmonary anastomosis and shunt creation under 1.5-T MRI guidance. An MRI antenna-needle was advanced from the superior vena cava into the target pulmonary artery bifurcation using real-time MRI guidance. In 10 animals, balloon-expanded off-the-shelf endografts secured a proximal end-to-end caval anastomosis and a distal end-to-side pulmonary anastomosis that preserved blood flow to both branch pulmonary arteries. In 5 animals, this was achieved with a novel, purpose-built, self-expanding device. RESULTS Real-time MRI needle access of target vessels (pulmonary artery), endograft delivery, and superior vena cava shunt to pulmonary arteries were successful in all animals. All survived the procedure without complications. Intraprocedural real-time MRI, post-procedural MRI, x-ray angiography, computed tomography, and necropsy showed patent shunts with bidirectional pulmonary artery blood flow. CONCLUSIONS MRI guidance enabled a complex, closed-chest, beating-heart, pediatric, transcatheter structural heart procedure. In this study, MRI guided trajectory planning and reproducible, reliable bidirectional cavopulmonary shunt creation.
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Rogers T, Ratnayaka K, Schenke WH, Mazal JR, Campbell-Washburn A, Kocaturk O, Faranesh AZ, Lederman RJ. CRT-400.10 Real-time MRI Guidance Improves the Diagnostic Yield of Endomyocardial Biopsy Compared With X-ray Fluoroscopy. JACC Cardiovasc Interv 2016. [DOI: 10.1016/j.jcin.2015.12.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kellman P, Olivieri L, Grant E, Berul CI, O'Brien K, Ratnayaka K, Hansen MS. Dark blood Late Gadolinium Enhancement improves conspicuity of ablation lesions. J Cardiovasc Magn Reson 2016. [PMCID: PMC5032043 DOI: 10.1186/1532-429x-18-s1-p211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Grant EK, Faranesh AZ, Cross RR, Olivieri LJ, Hamann KS, O'Brien KJ, Hansen MS, Donofrio MT, Lederman RJ, Ratnayaka K, Slack MC. Image Fusion Guided Device Closure of Left Ventricle to Right Atrium Shunt. Circulation 2016; 132:1366-7. [PMID: 26438770 DOI: 10.1161/circulationaha.115.013724] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Mazal JR, Rogers T, Schenke WH, Faranesh AZ, Hansen M, O'Brien K, Ratnayaka K, Lederman RJ. Interventional-Cardiovascular MR: Role of the Interventional MR Technologist. Radiol Technol 2016; 87:261-70. [PMID: 26721838 PMCID: PMC4724808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Interventional-cardiovascular magnetic resonance (iCMR) is a promising clinical tool for adults and children who need a comprehensive hemodynamic catheterization of the heart. Magnetic resonance (MR) imaging-guided cardiac catheterization offers radiation-free examination with increased soft tissue contrast and unconstrained imaging planes for catheter guidance. The interventional MR technologist plays an important role in the care of patients undergoing such procedures. It is therefore helpful for technologists to understand the unique iCMR preprocedural preparation, procedural and imaging workflows, and management of emergencies. The authors report their team's experience from the National Institutes of Health Clinical Center and a collaborating pediatric site.
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Rogers T, Karmarkar P, Kocaturk O, Ratnayaka K, Hansen M, Faranesh AZ, Lederman RJ. Realtime MR guided endomyocardial biopsy with an active visualization bioptome. J Cardiovasc Magn Reson 2015. [PMCID: PMC4328989 DOI: 10.1186/1532-429x-17-s1-p235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Basar B, Campbell-Washburn AE, Rogers T, Sonmez M, Faranesh AZ, Ratnayaka K, Lederman RJ, Kocaturk O. Stiffness-matched segmented metallic guidewire for interventional cardiovascular MRI. J Cardiovasc Magn Reson 2015. [PMCID: PMC4328724 DOI: 10.1186/1532-429x-17-s1-p414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Rogers T, Schenke W, Mazal JR, Sonmez M, Kocaturk O, Ratnayaka K, Hansen M, Faranesh AZ, Lederman RJ. Percutaneous MR guided direct left atrial access to deliver large interventional devices. J Cardiovasc Magn Reson 2015. [PMCID: PMC4328463 DOI: 10.1186/1532-429x-17-s1-o19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Rogers T, Ratnayaka K, Stine A, Grant L, Schenke W, Mazal JR, Hansen M, Faranesh AZ, Lederman RJ. MR guided right heart catheterization - the NIH experience. J Cardiovasc Magn Reson 2015. [PMCID: PMC4328393 DOI: 10.1186/1532-429x-17-s1-o20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Basar B, Rogers T, Ratnayaka K, Campbell-Washburn AE, Mazal JR, Schenke WH, Sonmez M, Faranesh AZ, Lederman RJ, Kocaturk O. Segmented nitinol guidewires with stiffness-matched connectors for cardiovascular magnetic resonance catheterization: preserved mechanical performance and freedom from heating. J Cardiovasc Magn Reson 2015; 17:105. [PMID: 26620420 PMCID: PMC4665398 DOI: 10.1186/s12968-015-0210-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 11/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Conventional guidewires are not suitable for use during cardiovascular magnetic resonance (CMR) catheterization. They employ metallic shafts for mechanical performance, but which are conductors subject to radiofrequency (RF) induced heating. To date, non-metallic CMR guidewire designs have provided inadequate mechanical support, trackability, and torquability. We propose a metallic guidewire for CMR that is by design intrinsically safe and that retains mechanical performance of commercial guidewires. METHODS The NHLBI passive guidewire is a 0.035" CMR-safe, segmented-core nitinol device constructed using short nitinol rod segments. The electrical length of each segment is less than one-quarter wavelength at 1.5 Tesla, which eliminates standing wave formation, and which therefore eliminates RF heating along the shaft. Each of the electrically insulated segments is connected with nitinol tubes for stiffness matching to assure uniform flexion. Iron oxide markers on the distal shaft impart conspicuity. Mechanical integrity was tested according to International Organization for Standardization (ISO) standards. CMR RF heating safety was tested in vitro in a phantom according to American Society for Testing and Materials (ASTM) F-2182 standard, and in vivo in seven swine. Results were compared with a high-performance commercial nitinol guidewire. RESULTS The NHLBI passive guidewire exhibited similar mechanical behavior to the commercial comparator. RF heating was reduced from 13 °C in the commercial guidewire to 1.2 °C in the NHLBI passive guidewire in vitro, using a flip angle of 75°. The maximum temperature increase was 1.1 ± 0.3 °C in vivo, using a flip angle of 45°. The guidewire was conspicuous during left heart catheterization in swine. CONCLUSIONS We describe a simple and intrinsically safe design of a metallic guidewire for CMR cardiovascular catheterization. The guidewire exhibits negligible heating at high flip angles in conformance with regulatory guidelines, yet mechanically resembles a high-performance commercial guidewire. Iron oxide markers along the length of the guidewire impart passive visibility during real-time CMR. Clinical translation is imminent.
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Sandeep N, Uchida Y, Ratnayaka K, McCarter R, Hanumanthaiah S, Bangoura A, Zhao Z, Oliver-Danna J, Leatherbury L, Kanter J, Mukouyama YS. Characterizing the angiogenic activity of patients with single ventricle physiology and aortopulmonary collateral vessels. J Thorac Cardiovasc Surg 2015; 151:1126-35.e2. [PMID: 26611747 DOI: 10.1016/j.jtcvs.2015.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/11/2015] [Accepted: 10/01/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Patients with single ventricle congenital heart disease often form aortopulmonary collateral vessels via an unclear mechanism. To gain insights into the pathogenesis of aortopulmonary collateral vessels, we correlated angiogenic factor levels with in vitro activity and angiographic aortopulmonary collateral assessment and examined whether patients with single ventricle physiology have increased angiogenic factors that can stimulate endothelial cell sprouting in vitro. METHODS In patients with single ventricle physiology (n = 27) and biventricular acyanotic control patients (n = 21), hypoxia-inducible angiogenic factor levels were measured in femoral venous and arterial plasma at cardiac catheterization. To assess plasma angiogenic activity, we used a 3-dimensional in vitro cell sprouting assay that recapitulates angiogenic sprouting. Aortopulmonary collateral angiograms were graded using a 4-point scale. RESULTS Compared with controls, patients with single ventricle physiology had increased vascular endothelial growth factor (artery: 58.7 ± 1.2 pg/mL vs 35.3 ± 1.1 pg/mL, P < .01; vein: 34.8 ± 1.1 pg/mL vs 21 ± 1.2 pg/mL, P < .03), stromal-derived factor 1-alpha (artery: 1901.6 ± 1.1 pg/mL vs 1542.6 ± 1.1 pg/mL, P < .03; vein: 2092.8 pg/mL ± 1.1 vs 1752.9 ± 1.1 pg/mL, P < .02), and increased arterial soluble fms-like tyrosine kinase-1, a regulatory vascular endothelial growth factor receptor (612.3 ± 1.2 pg/mL vs 243.1 ± 1.2 pg/mL, P < .003). Plasma factors and sprout formation correlated poorly with aortopulmonary collateral severity. CONCLUSIONS We are the first to correlate plasma angiogenic factor levels with angiography and in vitro angiogenic activity in patients with single ventricle disease with aortopulmonary collaterals. Patients with single ventricle disease have increased stromal-derived factor 1-alpha and soluble fms-like tyrosine kinase-1, and their roles in aortopulmonary collateral formation require further investigation. Plasma factors and angiogenic activity correlate poorly with aortopulmonary collateral severity in patients with single ventricles, suggesting complex mechanisms of angiogenesis.
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Rogers T, Ratnayaka K, Schenke WH, Sonmez M, Kocaturk O, Mazal JR, Chen MY, Faranesh AZ, Lederman RJ. TCT-158 Fully Percutaneous Transthoracic Left Atrial Entry and Closure to Deliver Large Caliber Transcatheter Mitral Valve Implants. J Am Coll Cardiol 2015. [DOI: 10.1016/j.jacc.2015.08.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Olivieri LJ, Cross RR, O'Brien KE, Ratnayaka K, Hansen MS. Optimized protocols for cardiac magnetic resonance imaging in patients with thoracic metallic implants. Pediatr Radiol 2015; 45:1455-64. [PMID: 26040508 PMCID: PMC7610221 DOI: 10.1007/s00247-015-3366-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 03/31/2015] [Accepted: 04/15/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cardiac magnetic resonance (MR) imaging is a valuable tool in congenital heart disease; however patients frequently have metal devices in the chest from the treatment of their disease that complicate imaging. Methods are needed to improve imaging around metal implants near the heart. Basic sequence parameter manipulations have the potential to minimize artifact while limiting effects on image resolution and quality. OBJECTIVE Our objective was to design cine and static cardiac imaging sequences to minimize metal artifact while maintaining image quality. MATERIALS AND METHODS Using systematic variation of standard imaging parameters on a fluid-filled phantom containing commonly used metal cardiac devices, we developed optimized sequences for steady-state free precession (SSFP), gradient recalled echo (GRE) cine imaging, and turbo spin-echo (TSE) black-blood imaging. We imaged 17 consecutive patients undergoing routine cardiac MR with 25 metal implants of various origins using both standard and optimized imaging protocols for a given slice position. We rated images for quality and metal artifact size by measuring metal artifact in two orthogonal planes within the image. RESULTS All metal artifacts were reduced with optimized imaging. The average metal artifact reduction for the optimized SSFP cine was 1.5+/-1.8 mm, and for the optimized GRE cine the reduction was 4.6+/-4.5 mm (P < 0.05). Quality ratings favored the optimized GRE cine. Similarly, the average metal artifact reduction for the optimized TSE images was 1.6+/-1.7 mm (P < 0.05), and quality ratings favored the optimized TSE imaging. CONCLUSION Imaging sequences tailored to minimize metal artifact are easily created by modifying basic sequence parameters, and images are superior to standard imaging sequences in both quality and artifact size. Specifically, for optimized cine imaging a GRE sequence should be used with settings that favor short echo time, i.e. flow compensation off, weak asymmetrical echo and a relatively high receiver bandwidth. For static black-blood imaging, a TSE sequence should be used with fat saturation turned off and high receiver bandwidth.
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Rogers T, Ratnayaka K, Schenke WH, Faranesh AZ, Mazal JR, O’Neill WW, Greenbaum AB, Lederman RJ. Intentional right atrial exit for microcatheter infusion of pericardial carbon dioxide or iodinated contrast to facilitate sub-xiphoid access. Catheter Cardiovasc Interv 2015; 86:E111-8. [PMID: 25315516 PMCID: PMC4537524 DOI: 10.1002/ccd.25698] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 10/11/2014] [Indexed: 01/08/2023]
Abstract
OBJECTIVES We test the safety of transatrial pericardial access using small catheters, infusion of carbon dioxide (CO2 ) or iodinated contrast to facilitate sub-xiphoid access, and catheter withdrawal under full anticoagulation. BACKGROUND Sub-xiphoid pericardial access is required for electrophysiological and structural heart interventions. If present, an effusion protects the heart from needle injury by separating the myocardium from the pericardium. However, if the pericardium is 'dry' then there is a significant risk of right ventricle or coronary artery laceration caused by the heart beating against the needle tip. Intentional right atrial exit is an alternative pericardial access route, through which contrast media could be infused to separate pericardial layers. METHODS Transatrial pericardial access was obtained in a total of 30 Yorkshire swine using 4Fr or 2.8Fr catheters. In 16 animals, transatrial catheters were withdrawn under anticoagulation and MRI was performed to monitor for pericardial hemorrhage. In 14 animals, iodinated contrast or CO2 was infused before sub-xiphoid access was obtained. RESULTS Small effusions (mean 18.5 ml) were observed after 4Fr (1.3 mm outer-diameter) but not after 2.8Fr (0.9 mm outer-diameter) transatrial catheter withdrawal despite full anticoagulation (mean activated clotting time 383 sec), with no hemodynamic compromise. Pericardial CO2 resorbed spontaneously within 15 min. CONCLUSIONS Intentional transatrial exit into the pericardium using small catheters is safe and permits infusion of CO2 or iodinated contrast to separate pericardial layers and facilitate sub-xiphoid access. This reduces the risk of right ventricular or coronary artery laceration. 2.8Fr transatrial catheter withdrawal does not cause any pericardial hemorrhage, even under full anticoagulation.
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Rogers T, Ratnayaka K, Schenke WH, Sonmez M, Kocaturk O, Mazal JR, Chen MY, Flugelman MY, Troendle JF, Faranesh AZ, Lederman RJ. Fully percutaneous transthoracic left atrial entry and closure as a potential access route for transcatheter mitral valve interventions. Circ Cardiovasc Interv 2015; 8:e002538. [PMID: 26022536 DOI: 10.1161/circinterventions.114.002538] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percutaneous access for mitral interventions is currently limited to transapical and transseptal routes, both of which have shortcomings. We hypothesized that the left atrium could be accessed directly through the posterior chest wall under imaging guidance. METHODS AND RESULTS We tested percutaneous transthoracic left atrial access in 12 animals (10 pigs and 2 sheep) under real-time magnetic resonance imaging or x-ray fluoroscopy plus C-arm computed tomographic guidance. The pleural space was insufflated with CO2 to displace the lung, an 18F sheath was delivered to the left atrium, and the left atrial port was closed using an off-the-shelf nitinol cardiac occluder. Animals were survived for a minimum of 7 days. The left atrial was accessed, and the port was closed successfully in 12/12 animals. There was no procedural mortality and only 1 hemodynamically insignificant pericardial effusion was observed at follow-up. We also successfully performed the procedure on 3 human cadavers. A simulated trajectory to the left atrium was present in all of 10 human cardiac computed tomographic angiograms analyzed. CONCLUSIONS Percutaneous transthoracic left atrial access is feasible without instrumenting the left ventricular myocardium. In our experience, magnetic resonance imaging offers superb visualization of anatomic structures with the ability to monitor and address complications in real-time, although x-ray guidance seems feasible. Clinical translation seems realistic based on human cardiac computed tomographic analysis and cadaver testing. This technique could provide a direct nonsurgical access route for future transcatheter mitral implantation.
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