2017 HRS expert consensus statement on magnetic resonance imaging and radiation exposure in patients with cardiovascular implantable electronic devices

The Burden of Cardiac Implantable Electronic Device Checks in the Peri-MRI Setting: The CHECK-MRI Study

BACKGROUND

Most modern cardiac implantable electronic device (CIED) systems are now compatible with magnetic resonance imaging (MRI) scans. The requirement for both pre- and post-MRI CIED checks imposes significant workload to the cardiac electrophysiology service. Here, we sought to determine the burden of CIED checks associated with MRI scans.

METHODS

We identified all CIED checks performed peri-MRI scans at our institution over a 3-year period between 1 July 2017 to 30 June 2020, comprising three separate financial years (FY). Device check reports, MRI scan reports and clinical summaries were collated. The workload burden was determined by assessing the occasions and duration of service. Analysis was performed to determine cost burden/projections for this service and identify factors contributing to the workload.

RESULTS

A total of 739 CIED checks were performed in the peri-MRI scan setting (370 pre- and 369 post-MRI scan), including 5% (n=39) that were performed outside of routine hours (weekday <8 am or >5 pm, and weekends). MRIs were performed for 295 patients (75±13 years old, 64% male) with a CIED (88% permanent pacemaker, and 12% high voltage device), including 49 who had more than one MRI scan. The proportion of total MRI scans for patients with a CIED in-situ increased each FY (from 0.5% of all MRIs in FY1, to 0.9% in FY2, to 1.0% in FY3). The weekly workload increased (R²=0.2, p<0.001), but with week-to-week variability due to ad hoc scheduling (209 days with only one MRI vs 78 days with ≥2 MRIs for CIED patients). The projected annual cost of this service will increase to AUD$161,695 in 10 years for an estimated annual 546 MRI scans for CIED patients.

CONCLUSIONS

There is an increasing workload burden and expense associated with CIED checks in the peri-MRI setting. Appropriate budgeting, staff allocation and standardisation of automated CIED pre-programming features among manufacturers are urgently needed.

An algorithm for pacing and cardioverting electronic devices undergoing magnetic resonance imaging: The PACED-MRI protocol

OBJECTIVE

Cardiac implantable electronic devices (CIEDs) have traditionally been a contraindication for magnetic resonance imaging (MRI). However, there is an increasing amount of literature to suggest that MRI can be safely performed in select patients with pacemakers and implantable cardioverter defibrillators by following a standardized protocol. We created an institutional protocol, made accessible as an online form, that is primarily technologist-driven and does not require direct electrophysiologist supervision. The purpose of this study was to evaluate the PACEDMRI protocol for screening and completing MRI in patients with MR conditional CIEDs.

SUBJECTS AND METHODS

After the implementation of our standardized PACED-MRI protocol, patients with MR conditional CIEDs who were referred for MRI were included in the study. On the day of the MRI, the device company representative utilized our protocol accessed through PACEDMRI.com. If all parameters and criteria within the protocol were met, the examination proceeded. The device representative programed the CIED to the appropriate mode for MRI as instructed by the PACED-MRI protocol. CIED interrogation was performed immediately before and after MRI. The on-call electrophysiology nurse practitioner was notified only if the protocol instructed the team to not proceed with MRI. CIED programming changes, malfunctions, and intraprocedural events were documented. Additionally, any adverse outcomes were recorded including peri-MRI symptom onset, arrhythmia, and death.

RESULTS

One hundred thirty-eight MRI examinations were performed on patients with MR conditional CIEDs (100 pacemakers: 38 implantable cardiac defibrillators). There was no incidence of symptom onset requiring early termination of the MRI, death, or arrhythmic events during or after MRI. No significant changes in lead parameters, including sensing amplitudes, lead thresholds, or lead impedances were noted on post-MRI device interrogation. Out of the 138 completed MRIs, the on-call electrophysiology provider was notified on one, non-urgent occasion.

CONCLUSION

The implementation of the standardized, technologists-driven PACED-MRI protocol allowed for a multidisciplinary approach to MRI for patients with MR conditional CIEDs. This study demonstrates that the PACED-MRI protocol can be used for patients with MR conditional CIEDs undergoing MRI without the need for direct electrophysiologist supervision.

Radiotherapy-induced malfunctions of cardiac implantable electronic devices: A meta-analysis

BACKGROUND

Radiation therapy (RT) may pose acute and long-term risks for patients with cardiac implantable electronic devices (CIEDs), including pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs).

OBJECTIVE

We conducted a systematic review and meta-analysis to examine the association between RT and PM/ICD malfunctions in patients with cancer.

METHODS

We searched the literature using the PubMed, the Cochrane Library the Web of Science, and Embase for relative publications until April 2022. Of the 550 initially identified studies, 17 retrospective observational studies including 2454 patients were finally analyzed.

RESULTS

The meta-analysis showed that RT was associated with an increased risk of ICD malfunctions (odds ratio [OR] 2.75; 95% confidence interval [CI] 1.74-4.33). Five studies were included in the subgroup analysis regarding photon beam energy, showing that radiation-induced CIED failure was more likely to occur in ICDs when beam energy was ≥10 MV (OR 5.28; 95% CI 2.14-13.03). Neutron-generating RT significantly increased the risk of CIED malfunctions (OR 3.97; 95% CI 1.70-9.26), especially the risk of reset (OR 5.79; 95% CI 2.37-14.12; P = .0001). We did not find significant differences in the risk of CIED failure between chest RT and other RT sites (OR 1.09; 95% CI 0.63-1.88).

CONCLUSION

Our meta-analysis suggests that ICDs are more likely to be affected by RT than PMs. These adverse events, especially reset, in patients with cancer were associated with neutron-generating RT and beam energy ≥10 MV. Given the increasing requirement for RT in several patients with cancer as well as the increasing implantation rates of CIEDs, a better risk stratification is needed in this setting.

Predictors for adverse events during cardiac lead extraction - Experience from a large single centre

BACKGROUND

As the use of cardiac implantable electronic devices (CIED) has increased in recent years, the need for transvenous lead extraction (TLE) has also steadily increased. However, the TLE procedure could lead to serious complications and even death. Clinical decision-making tools are necessary for predicting these adverse events, but the appropriate tools have not yet been developed.

OBJECTIVE

To explore the possible predictors and develop a clinical model to predict TLE related adverse events.

METHODS

All the patients who were admitted to our cardiac center for TLE from January 2014 to January 2021 were included in this study. The patient information, device baseline characteristics, procedure-related information, complications and outcomes were recorded. Independent predictors of TLE related adverse events were identified by univariate, LASSO and multivariate analysis. A nomogram for predicting these adverse events was developed based on these independent predictors. Calibration and decision curve analysis were conducted to evaluate the nomogram.

RESULTS

One thousand and one hundred patients were included in this study, 778 (70.7%) were male and the median age was 68 years old. A total of 2,208 leads were extracted and 2.01±0.74 leads were extracted per procedure. Fifty-five patients (5%) developed adverse events including minor complications (2.4%), major complications (2.3%) and death (0.27%). Seven independent predictors for TLE related adverse events were identified and selected to establish the nomogram including BMI, female gender, hypoalbuminemia, number of extracted leads>3, longest dwell time of the extracted leads and manual traction. The area under the receiver operating characteristic (ROC) curve (AUC) for the prediction model was 0.774. Calibration curve and decision curve analysis showed that the nomogram had good prediction performance.

CONCLUSION

TLE related adverse events are some of the key issues that concern clinicians. We have identified seven independent factors and established a predictive model that may help clinicians identify at-risk patients and create better plans for lead extraction.

A systematic review and meta-analysis on oncological radiotherapy in patients with a cardiac implantable electronic device: Prevalence and predictors of device malfunction in 3121 patients

BACKGROUND

The number of patients with cardiac implantable electronic devices (CIEDs) undergoing radiotherapy (RT) for cancer treatment is growing. At present, prevalence and predictors of RT-induced CIEDs malfunctions are not defined.

METHODS

Systematic review and meta-analysis conducted following the PRISMA recommendations. PubMed, Scopus and Google Scholar were searched from inception to 31/01/2022 for studies reporting RT-induced malfunctions in CIEDs patients. Aim was to assess the prevalence of RT-induced CIEDs malfunctions and identify potential predictors.

RESULTS

Thirty-two out of 3962 records matched the inclusion criteria and were included in the meta-analysis. A total of 135 CIEDs malfunctions were detected among 3121 patients (6.6%, 95% confidence interval [CI]: 5.1%-8.4%). The pooled prevalence increased moving from pacemaker (PM) to implantable cardioverter defibrillator (ICD), and cardiac resynchronization therapy and defibrillator (CRT-D) groups (4.1%, 95% CI: 2.9-5.8; 8.2% 95% CI: 5.9-11.3; and 19.8%, 95% CI: 11.4-32.2 respectively). A higher risk ratio (RR) of malfunctions was found when neutron-producing energies were used as compared to non-neutron-producing energies (RR 9.98, 95% CI: 5.09-19.60) and in patients with ICD/CRT-D as compared to patients with PM/CRT-P (RR 2.07, 95% CI: 1.40-3.06). On the contrary, no association was found between maximal radiation dose at CIED >2 Gy and CIEDs malfunctions (RR 0.93; 95% CI: 0.31-2.76).

CONCLUSIONS

Radiotherapy related CIEDs malfunction had a prevalence ranging from 4% to 20%. The use of neutron-producing energies and more complex devices (ICD/CRT-D) were associated with higher risk of device malfunction, while the radiation dose at CIED did not significantly impact on the risk unless higher doses (>10 Gy) were used.

Right ventricular failure: Current strategies and future development

Right heart failure can be defined as a clinical syndrome consisting of signs and symptoms of heart failure resulting from right ventricular dysfunction. Function is normally altered due to three mechanisms: (1) pressure overload (2) volume overload, or (3) a decrease in contractility due to ischaemia, cardiomyopathy or arrythmias. Diagnosis is based upon a combination of clinical assessment plus echocardiographic, laboratory and haemodynamic parameters, and clinical risk assessment. Treatment includes medical management, mechanical assist devices and transplantation if recovery is not observed. Distinct attention to special circumstances such as left ventricular assist device implantation should be sought. The future is moving towards new therapies, both pharmacological and device centered. Immediate diagnosis and management of RV failure, including mechanical circulatory support where needed, alongside a protocolized approach to weaning is important in successfully managing right ventricular failure.

Improving Outcomes in Ventricular Tachycardia Ablation Using Imaging to Identify Arrhythmic Substrates

Ventricular tachycardia (VT) ablation is limited by modest acute and long-term success rates, in part due to the challenges in accurately identifying the arrhythmogenic substrate. The combination of multimodality imaging along with information from electroanatomic mapping allows for a more comprehensive assessment of the arrhythmogenic substrate which facilitates VT ablation, and the use of preprocedural imaging has been shown to improve long-term ablation outcomes. Beyond regional recognition of the arrhythmogenic substrate, advanced imaging techniques can be used to create tailored ablation strategies preprocedurally. This review will focus on how imaging can be used to guide ablation planning and execution with a focus on clinical applications aimed at improving the outcome of VT ablation procedures.

Incidence and Predictors of Cardiac Implantable Electronic Devices Malfunction with Radiotherapy Treatment

Aims: To investigate the incidence of cardiac implantable electronic devices (CIED) malfunction with radiotherapy (RT) treatment and assess predictors of CIED malfunction. Methods: A 6-year retrospective analysis of patients who underwent RT with CIED identified through the radiation oncology electronic database. Clinical, RT (cumulative dose, dose per fraction, beam energy, beam energy dose, and anatomical area of RT) and CIED details (type, manufacturer, and device malfunction) were collected from electronic medical records. Results: We identified 441 patients with CIED who underwent RT. CIED encountered a permanent pacemaker (PPM) (78%), cardiac resynchronization therapy—pacing (CRT-P) (2%), an implantable cardioverter defibrillator (ICD) (10%), and a CRT-defibrillator (CRT-D) (10%). The mean cumulative dose of RT was 36 gray (Gy) (IQR 1.8–80 Gy) and the most common beam energy used was photon ≥10 megavolt (MV) with a median dose of 7 MV (IQR 5–18 MV). We further identified 17 patients who had CIED malfunction with RT. This group had a higher cumulative RT dose of 42.5 Gy (20–77 Gy) and a photon dose of 14 MV (12–18 MV). None of the malfunctions resulted in clinical symptoms. Using logistic regression, the predictors of CIED malfunction were photon beam energy use ≥10 MV (OR 5.73; 95% CI, 1.58–10.76), anatomical location of RT above the diaphragm (OR 5.2, 95% CI, 1.82–15.2), and having a CIED from the ICD group (OR 4.6, 95% CI, 0.75–10.2). Conclusion: Clinicians should be aware of predictors of CIED malfunction with RT to ensure the safety of patients.

Trends in Utilization of Magnetic Resonance Imaging for Stroke Patients With Cardiac Rhythm Devices

Background and Purpose

Magnetic resonance imaging (MRI) is safe for most patients with cardiovascular implantable electronic devices (CIEDs). However, patients presenting with acute ischemic stroke or transient ischemic attack (AIS/TIA) who have CIEDs may undergo MRI less frequently than patients without devices. We assessed contemporary use of MRI for patients with AIS/TIA and the effect of a recent coverage revision by the Center for Medicare and Medicaid Services (CMS) on MRI utilization.

Methods

Using Optum® claims data from January 2012 to June 2019, we performed an interrupted time series analysis of MRI utilization during AIS/TIA hospitalizations with the April 2018 CMS coverage revision serving as the intervention. For patients treated after the coverage revision, we used multivariable logistic regression to determine the association between lack of CIED and MRI utilization for AIS/TIA.

Results

We identified 417,899 patient hospitalizations for AIS/TIA, of which 30,425 (7%) had a CIED present (CIED vs non-CIED patients: age 77.6 ± 9.8 vs 72.7 ± 12.3 years; 45.5% vs 54.3% female). From 2012 to 2019, annual MRI utilization increased from 3% to 20% for CIED patients and 58% to 66% for non-CIED patients. The CMS coverage revision was associated with a 4.2% absolute additional increase in MRI utilization for CIED patients. Non-CIED patients treated after the CMS coverage revision were substantially more likely than CIED patients to undergo MRI (adjusted OR 6.7, 95% CI: 6.3-7.1, P<.001).

Conclusions

MRI utilization has increased for stroke patients with CIEDs but remains far lower than in similar patients without devices.

Contemporary approach to catheter ablation of ventricular tachycardia in nonischemic cardiomyopathy

Nonischemic cardiomyopathy (NICM) comprises a heterogenous group of disorders with myocardial dysfunction unrelated to significant coronary disease. As the use of implantable defibrillators has increased in this patient population, catheter ablation is being utilized more frequently to treat NICM patients with ventricular tachycardia (VT). Progress has been made in identifying multiple subtypes of NICM with variable scar patterns. The distribution of scar is often mid-myocardial and subepicardial, and identifying and ablating this substrate can be challenging. Here, we will review the current understanding of NICM subtypes and the outcomes of VT ablation in this population. We will discuss the use of cardiac imaging, electrocardiography, and electroanatomic mapping to define the VT substrate and the ablation techniques required to successfully prevent VT recurrence.

The impact of particle radiotherapy on the functioning of cardiac implantable electronic devices: a systematic review of in vitro and in vivo studies according to PICO criteria

The number of oncological patients who may benefit from proton beam radiotherapy (PBT) or carbon ion radiotherapy (CIRT), overall referred to as particle radiotherapy (RT), is expected to strongly increase in the next future, as well as the number of cardiological patients requiring cardiac implantable electronic devices (CIEDs). The management of patients with a CIED requiring particle RT deserves peculiar attention compared to those undergoing conventional photon beam RT, mostly due to the potential generation of secondary neutrons by particle beams interactions. Current consensus documents recommend managing these patients as being at intermediate/high risk of RT-induced device malfunctioning regardless of the dose on the CIED and the beam delivery method used, despite the last one significantly affects secondary neutrons generation (very limited neutrons production with active scanning as opposed to the passive scattering technique). The key issues for the current review were expressed in four questions according to the Population, Intervention, Control, Outcome criteria. Three in vitro and five in vivo studies were included. Based on the available data, PBT and CIRT with active scanning have a limited potential to interfere with CIED that has only emerged from in vitro study so far, while a significant potential for neutron-related, not severe, CIED malfunctions (resets) was consistently reported in both clinical and in vitro studies with passive scattering.

Pre-deployment assessment of an AI model to assist radiologists in chest X-ray detection and identification of lead-less implanted electronic devices for pre-MRI safety screening: realized implementation needs and proposed operational solutions

Purpose

Chest X-ray (CXR) use in pre-MRI safety screening, such as for lead-less implanted electronic device (LLIED) recognition, is common. To assist CXR interpretation, we "pre-deployed" an artificial intelligence (AI) model to assess (1) accuracies in LLIED-type (and consequently safety-level) identification, (2) safety implications of LLIED nondetections or misidentifications, (3) infrastructural or workflow requirements, and (4) demands related to model adaptation to real-world conditions.

Approach

A two-tier cascading methodology for LLIED detection/localization and identification on a frontal CXR was applied to evaluate the performance of the original nine-class AI model. With the unexpected early appearance of LLIED types during simulated real-world trialing, retraining of a newer 12-class version preceded retrialing. A zero footprint (ZF) graphical user interface (GUI)/viewer with DICOM-based output was developed for inference-result display and adjudication, supporting end-user engagement and model continuous learning and/or modernization.

Results

During model testing or trialing using both the nine-class and 12-class models, robust detection/localization was consistently 100%, with mAP 0.99 from fivefold cross-validation. Safety-level categorization was high during both testing ( AUC ≥ 0.98 and ≥ 0.99 , respectively) and trialing (accuracy 98% and 97%, respectively). LLIED-type identifications by the two models during testing (1) were 98.9% and 99.5% overall correct and (2) consistently showed AUC ≥ 0.92 (1.00 for 8/9 and 9/12 LLIED-types, respectively). Pre-deployment trialing of both models demonstrated overall type-identification accuracies of 94.5% and 95%, respectively. Of the small number of misidentifications, none involved MRI-stringently conditional or MRI-unsafe types of LLIEDs. Optimized ZF GUI/viewer operations led to greater user-friendliness for radiologist engagement.

Conclusions

Our LLIED-related AI methodology supports (1) 100% detection sensitivity, (2) high identification (including MRI-safety) accuracy, and (3) future model deployment with facilitated inference-result display and adjudication for ongoing model adaptation to future real-world experiences.

[Magnetic resonance imaging in cardiological patients : Basic principles for application]

Magnetic resonance imaging (MRI) can be safely performed in patients with cardiac implants such as pacemakers and cardioverter defibrillators (ICD). Prerequisites for safe use are knowledge of the physical conditions as well as professional indication and cardiological monitoring by an experienced cardiologist.

Considerations for Stress Perfusion Cardiac Magnetic Resonance Imaging in Patients with Cardiac Implantable Electronic Devices

With increasing collective experience with cardiac magnetic resonance (CMR) imaging in patients with cardiac implantable electronic devices (CIEDs), guided by published safety data and professional society scientific documents,¹ there has been growing interest in extending the application of CMR imaging in patients with CIEDs This article is protected by copyright. All rights reserved.

Compact pediatric cardiac magnetic resonance imaging protocols

Cardiac MRI is in many respects an ideal modality for pediatric cardiovascular imaging, enabling a complete noninvasive assessment of anatomy, morphology, function and flow in one radiation-free and potentially non-contrast exam. Nonetheless, traditionally lengthy and complex imaging acquisition strategies have often limited its broader use beyond specialized centers. In this review, the author presents practical cardiac MRI imaging protocols to facilitate the performance of succinct yet successful exams that provide the most salient clinical data for the majority of congenital and acquired pediatric cardiac disease. In addition, the author reviews newer and evolving techniques that permit more rapid but similarly diagnostic MRI, including compressed sensing and artificial intelligence/machine learning reconstruction, four-dimensional flow acquisition and blood pool contrast agents. With the modern armamentarium of cardiac MRI methods, the goal of compact yet comprehensive exams in children can now be realized.

A comparative study of MRI-induced RF heating in pediatric and adult populations with epicardial and endocardial implantable electronic devices

Patients with congenital heart defects, inherited arrhythmia syndromes, and congenital disorders of cardiac conduction often receive a cardiac implantable electronic device (CIED). At least 75% of patients with CIEDs will need magnetic resonance imaging (MRI) during their lifetime. In 2011, the US Food and Drug Administration approved the first MR-conditional CIEDs for patients with endocardial systems, in which leads are passed through the vein and affixed to the endocardium. The majority of children, however, receive an epicardial CIED, where leads are directly sewn to the epicardium. Unfortunately, an epicardial CIED is a relative contraindication to MRI due to the unknown risk of RF heating. In this work, we performed anthropomorphic phantom experiments to investigate differences in RF heating between endocardial and epicardial leads in both pediatric and adult-sized phantoms, where adult endocardial CIED was the control. Clinical Relevance-This work provides a quantitative comparison of MRI RF heating of epicardial and endocardial leads in pediatric and adult populations.

Cardiac Society of Australia and New Zealand (CSANZ) Position Statement on the Follow-Up of Cardiovascular Implantable Electronic Devices 2022

Recognising the need for a national approach for the recommended best practice for the follow-up of implanted cardiac rhythm devices to ensure patient safety, this document has been produced by the Cardiac Society of Australia and New Zealand (CSANZ). It draws on accepted practice standards and guidelines of international electrophysiology bodies. It lays out methodology, frequency, and content of follow-up, including remote monitoring; personnel, including physician, allied health, nursing and industry; paediatric and adult congenital heart patients; and special considerations including magnetic resonance imaging scanning, perioperative management, and hazard alerts.

Nachsorge und MRT-Untersuchungen bei Patienten mit implantierten kardialen Aggregaten

In den 2021 publizierten ESC-Leitlinien wird im Rahmen des Kapitels über die Aggregatnachsorge insbesondere die Bedeutung der Telemetrie hervorgehoben. Durch eine telemetrische Nachsorge sind wesentlich seltener Präsenznachsorgen notwendig bei gleichwertiger oder sogar verbesserter Sicherheit. Eine telemetrische Überwachung sollte daher bei allen Patienten mit CIED erwogen werden.

Die Leitlinien beschreiben detailliert die Möglichkeiten und Einschränkungen von MRT-Untersuchungen bei Patienten mit CIED. Programmierempfehlungen für die verschiedenen Hersteller werden dargestellt. Unter Einhaltung entsprechender Sicherheitsstandards kann eine MRT auch ohne größeres Risiko bei Patienten mit nicht MRT-kompatiblen Systemen erfolgen.

Ablation Lesion Assessment with MRI

Late gadolinium enhancement (LGE) MRI is capable of detecting not only native cardiac fibrosis, but also ablation-induced scarring. Thus, it offers the unique opportunity to assess ablation lesions non-invasively. In the atrium, LGE-MRI has been shown to accurately detect and localise gaps in ablation lines. With a negative predictive value close to 100% it can reliably rule out pulmonary vein reconnection non-invasively and thus may avoid unnecessary invasive repeat procedures where a pulmonary vein isolation only approach is pursued. Even LGE-MRI-guided repeat pulmonary vein isolation has been demonstrated to be feasible as a standalone approach. LGE-MRI-based lesion assessment may also be of value to evaluate the efficacy of ventricular ablation. In this respect, the elimination of LGE-MRI-detected arrhythmogenic substrate may serve as a potential endpoint, but validation in clinical studies is lacking. Despite holding great promise, the widespread use of LGE-MRI is still limited by the absence of standardised protocols for image acquisition and post-processing. In particular, reproducibility across different centres is impeded by inconsistent thresholds and internal references to define fibrosis. Thus, uniform methodological and analytical standards are warranted to foster a broader implementation in clinical practice.

Cardiac Implantable Electronic Device Dysfunctions in Patients Undergoing Radiotherapy A Prospective Cohort Study

BACKGROUND

Increasing numbers of patients with cardiac implantable electronic devices (CIEDs) are undergoing radiotherapy for cancer. The aim of the study was to prospectively evaluate the incidence, characteristics, and associated factors of CIED dysfunctions related to radiotherapy.

METHODS

Between April 2013 and March 2020, all patients with a CIED who underwent ≥1 radiotherapy session were enrolled. Patients were monitored according to a systematic protocol, including device interrogation before the 1^st and after each radiotherapy session. The primary endpoint was CIED dysfunction, defined as oversensing, total or partial deprogramming, and/or unrecoverable reset.

RESULTS

We included a total of 92 CIED radiotherapy courses: 77 (83.7%) in patients with a pacemaker and 15 (16.3%) in those with an implantable cardioverter defibrillator. Overall, 13 dysfunctions (14.1%) were observed during 92 courses (1509 sessions), giving an incidence of 0.9 per 100 sessions. These included nine deprogramming (three total resets to back-up pacing mode and six partial deprogramming that were all successfully reprogrammed), three transient oversensing, and one unrecoverable oversensing requiring CIED and leads replacement. There were no adverse clinical events related to device dysfunction. In multivariable analysis, neutron-producing irradiation (odds ratio [OR], 5.59; 95% confidence interval [CI], 1.09-28.65; P=0.039) and cumulative tumor dose (OR, 1.05; 95% CI, 1.01-1.10; P=0.007) remained significantly associated with CIED dysfunction.

CONCLUSIONS

In this prospective study, transient or permanent subclinical CIED dysfunction occurred in 14.1% of radiotherapy courses. Our findings emphasize the importance of high-energy beams and neutron-producing irradiation in risk assessment. This article is protected by copyright. All rights reserved.

Remote Programming of Cardiac Implantable Electronic Devices for MRI: Are We Ready to Change the Channel?

Magnetic resonance imaging (MRI) has become an indispensable diagnostic tool across many fields of clinical medicine. Although reprogramming of cardiac implantable electronic devices (CIEDs) for MRI is now routine at most institutions, early experiences were notable for potential adverse effects such as device-related heating, device or lead movement, and device malfunction. This article is protected by copyright. All rights reserved.

Remote Programming of Cardiac Implantable Electronic Devices: A Novel Approach to Program Cardiac Devices for Magnetic Resonance Imaging

BACKGROUND

Magnetic Resonance imaging (MRI) in patients with MRI-conditional cardiovascular implantable electronic devices (CIED) remain a logistical issue for device programming during the scan. In current practice, a trained person needs to be present on-site to program CIED for MRI scan. This can cause delay in patient care, rescheduling of tests and increase healthcare costs. A novel remote programming (RP) strategy can be utilized to reprogram the CIED remotely. We sought to explore the feasibility and safety of RP of CIEDs in patients undergoing MRI scan.

METHODS

We implemented the Medtronic CIED RP software at our institution after ensuring HIPAA compliance. The MRI technician started the session by contacting an off-site remote operator and placing a programmer wand from the 2090 Medtronic programmer over the CIED. The remote operator logged into a remote access software and provided a unique access code to the MRI technician. After entering the access code into the programmer, the remote operator was able to program the device as needed. We conducted a periodic audit of the first 209 patients who underwent RP of CIEDs for MRI. Outcomes analyzed were successful completion of RP sessions and time saved per scan.

RESULTS

Of the 209 MRI scans, 51 scans were performed urgently. There were no connectivity and programming problems or need for MRI rescheduling. In-person reprogramming was not required for any patient. All scans were completed safely in a timely manner, and there were no reports of CIED malfunction. Time saved per scan was estimated to be 28 +/-10 minutes.

CONCLUSIONS

Remote programming of CIEDs for MRI scans is a safe and effective strategy. This article is protected by copyright. All rights reserved.

New Insights into MR Safety for Implantable Medical Devices

Over the last two decades, the status of MR safety has dramatically changed. In particular, ever since the MR-conditional cardiac device was approved by the Food and Drug Administration (FDA) in 2008 and by the Pharmaceuticals and Medical Devices Agency (PMDA) in 2012, the safety of patients with an implantable medical device (IMD) has been one of the most important issues in terms of MR use. In conjunction with the regulatory approvals for various IMDs, standards, technical specifications, and guidelines have also been rapidly created and developed. Many invaluable papers investigating and reviewing the history and status of MR use in the presence of IMDs already exist. As such, this review paper seeks to bridge the gap between clinical practice and the information that is obtained by standard-based tests and provided by an IMD's package insert or instructions for use. Interpretation of the gradient of the magnetic flux density intensity of the static magnetic field with respect to the magnetic displacement force is discussed, along with the physical background of RF field. The relationship between specific absorption rate (SAR) and B1+RMS, and their effects on image quality are described. In addition, insofar as providing new directions for future research and practice, the feasibility of safety test methods for RF-induced heating of IMDs using MR thermometry, evaluation of tissue heat damage, and challenges in cardiac IMDs will be discussed.

Should they stay, or should they go: do we need to remove the old cardiac implantable electronic device if a new system is required on the contralateral side?

Background

Ipsilateral approach in patients requiring cardiac implantable electronic device (CIED) revision or upgrade may not be feasible, primarily due to vascular occlusion. If a new CIED is implanted on the contralateral side, a common practice is to explant the old CIED to avoid device interaction.

Objective

The purpose of this study was to assess a conservative approach of abandoning the old CIED after implanting a new contralateral device.

Methods

We used an artificial intelligence algorithm to analyze postimplant chest radiographs to identify those with multiple CIEDs. Outcomes of interest included device interaction, abandoned CIED elective replacement indicator (ERI) behavior, subsequent programming changes, and explant of abandoned CIED. Theoretical risk of infection with removal of abandoned CIED was estimated using a validated scoring system.

Results

Among 12,045 patients, we identified 40 patients with multiple CIEDs. Occluded veins were the most common indication for contralateral implantation (n = 27 [67.5%]). Fifteen abandoned CIEDs reached ERI, with 4 reverting to VVI 65. One patient underwent explant due to device interaction, and 2 required device reprogramming. Of 32 patients with an implantable cardioverter-defibrillator, 8 (25%) had treated ventricular arrhythmia. There were no failed or inappropriate therapies due to interaction. Eighteen patients (45%) had hypothetical >1% annual risk of hospitalization for device infection if the abandoned CIED had been explanted.

Conclusion

In patients requiring new CIED implant on the contralateral side, abandoning the old device is feasible. This approach may reduce the risk of infection and concerns regarding abandoned leads and magnetic resonance imaging scans. Knowledge of ERI behavior is essential to avoid device interactions.

In-vitro investigation of cardiac implantable electronic device malfunction during and after direct photon exposure: A three-centres experience

PURPOSE

Radiotherapy may cause malfunction of implantable cardioverter-defibrillators (ICDs) and pacemakers (PMs). We carried-out a multicentre randomized in-vitro study on 65 ICDs and 145 PMs to evaluate malfunctions during and after direct irradiation to doses up to 10 Gy.

METHODS

Three centres equipped with different linear accelerator and treatment-planning systems participated in the study. Computed Tomography (CT) acquisitions were performed to build the treatment plans. All devices were exposed to dose of 2, 5, or 10 Gy (6 MV). All devices underwent a baseline examination and 64 wireless real-time telemetry-transmissions (47 ICDs and 17 PMs) were monitored during photon exposures. All devices were interrogated after exposure and once monthly for six subsequent months.

RESULTS

Fifty-four of the 64 wireless-enabled CIEDs (84.4%) recorded noise-related interferences during exposure. In detail, 40/47 ICDs (85.1%) reported interference, of which 16 ICDs (34%) reported potentially clinically relevant pacing inhibition and inappropriate detections. Following exposure, a soft reset occurred in 1/145 PM (0.7%) while 7/145 PMs (4.8%) reported battery issues. During the six-month follow-up, 1/145 PM (0.7%) reported a soft reset, while 12/145 more PMs (8.3%) and 1/64 ICD (1.5%) showed abnormal battery depletion. All reported issues occurred independently of exposure dose. Finally, irreversible effects on software and battery life occurred in only non-MRI-compatible devices.

CONCLUSION

ICDs mostly featured real-time transient sensing issues, while PMs mostly experienced long-term battery or software issues that were observed immediately following radiation exposure and during follow-up. Irreversible effects on battery life and software occurred in only non-MRI-compatible devices.

Multimodality Imaging in Arrhythmogenic Right Ventricular Cardiomyopathy

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare, heritable myocardial disease associated with the development of ventricular arrhythmias, heart failure, and sudden cardiac death in early adulthood. Multimodality imaging is a central component in the diagnosis and evaluation of ARVC. Diagnostic criteria established by an international task force in 2010 include noninvasive parameters from echocardiography and cardiac magnetic resonance imaging. These criteria identify right ventricular structural abnormalities, chamber and outflow tract dilation, and reduced right ventricular function as features of ARVC. Echocardiography is a widely available and cost-effective technique, and it is often selected for initial evaluation. Beyond fulfillment of diagnostic criteria, features such as abnormal tricuspid annular plane excursion, increased right ventricular basal diameter, and abnormal strain patterns have been described. 3-dimensional echocardiography may also expand opportunities for structural and functional assessment of ARVC. Cardiac magnetic resonance has the ability to assess morphological and functional cardiac features of ARVC and is also a core modality in evaluation, however, tissue characterization of the right ventricle is limited by spatial resolution and low specificity for detection of pathological changes. Nonetheless, the ability of cardiac magnetic resonance to identify left ventricular involvement, offer high negative predictive value, and provide a reproducible structural evaluation of the right ventricle enhance the ability and scope of the modality. In this review, the prognostic significance of multimodality imaging is outlined, including the supplemental value of multidetector computed tomography and nuclear imaging. Strengths and weaknesses of imaging techniques, as well as future direction of multimodality assessment, are also described.

Safety of magnetic resonance imaging in patients with cardiac implantable electronic devices with generator and lead(s) brand mismatch

Magnetic resonance imaging (MRI) is a valuable imaging modality for the assessment of both cardiac and non‐cardiac structures. With a growing population of patients with cardiovascular implantable electronic devices (CIEDs), 50%–75% of these patients will need an MRI. MRI‐conditional CIEDs have demonstrated safety of MRI scanning with such devices, yet non‐conditional devices such as hybrid CIEDs which have generator and lead brand mismatch may pose a safety risk. In this retrospective study, we examined the outcomes of patients with hybrid CIEDs undergoing MRI compared to those patients with non‐hybrid CIEDs. A total of 349 patients were included, of which 24 patients (7%) had hybrid CIEDs. The primary endpoint was the safety of MRI for patients with hybrid CIEDs as compared to those with non‐hybrid devices, measured by the rate of adverse events, including death, lead or generator failure needing immediate replacement, loss of capture, new onset arrhythmia, or power‐on reset. Secondary endpoints consisted of pre‐ and post‐MRI changes of decreased P‐wave or R‐wave sensing by ≥50%, changes in pacing lead impedance by ≥50 ohms, increase in pacing thresholds by ≥ 0.5 V at 0.4 ms, and decreasing battery voltage of ≥ 0.04 V. The primary endpoint of any adverse reaction was present in 1 (4.2%) patient with a hybrid device, and consistent of atrial tachyarrhythmia, and in 10 (3.1%) patients with a non‐hybrid device, and consisted of self‐limited atrial and non‐sustained ventricular arrhythmias; this was not statistically significant. No significant differences were found in the secondary endpoints. This study demonstrates that MRI in patients with hybrid CIEDs does not result in increased patient risk or significant device changes when compared to those patients who underwent MRI with non‐hybrid CIEDs.

Safety verification of carbon-ion radiotherapy for patients with cardiac implantable electronic devices (CIEDs)

According to guidelines, carbon-ion beam therapy is considered to carry a high safety risk for patients with cardiac implantable electronic devices (CIEDs), although the actual impacts remain unclear. In this study, we investigated the safety of carbon-ion beam therapy in patients with CIEDs. Patients with CIEDs who underwent carbon-ion therapy at Gunma University Heavy Ion Medical Center between June 2010 and December 2019 were identified and investigated for abnormalities in the operation of their CIEDs, such as oversensing and resetting during irradiation, and abnormalities in operation after treatment. In addition, the risk of irradiation from carbon-ion beam therapy was evaluated by model simulations. Twenty patients (22 sites) with CIEDs were identified, 19 with pacemakers and one with an implantable cardioverter-defibrillator (ICD). Treatments were completed without any problems, except for one case in which the treatment was discontinued because of worsening of the primary disease. Monte Carlo simulation indicated that the carbon beam irradiation produced neutrons at a constant and high level in the irradiation field. Nevertheless, with the distances between the CIEDs and the irradiation fields in the analyzed cases, the quantity of neutrons at the CIEDs was lower than that within the irradiation. Although carbon-ion beam therapy can be safely administered to patients with CIEDs, it is advisable to perform the therapy with sufficient preparation and backup devices because of the risks involved.

Feasibility of adenosine stress cardiovascular magnetic resonance perfusion imaging in patients with MR-conditional transvenous permanent pacemakers and defibrillators

BACKGROUND

The use of stress perfusion-cardiovascular magnetic resonance (CMR) imaging remains limited in patients with implantable devices. The primary goal of the study was to assess the safety, image quality, and the diagnostic value of stress perfusion-CMR in patients with MR-conditional transvenous permanent pacemakers (PPM) or implantable cardioverter-defibrillators (ICD).

METHODS

Consecutive patients with a transvenous PPM or ICD referred for adenosine stress-CMR were enrolled in this single-center longitudinal study. The CMR protocol was performed using a 1.5 T system according to current guidelines while all devices were put in MR-mode. Quality of cine, late-gadolinium-enhancement (LGE), and stress perfusion sequences were assessed. An ischemia burden of ≥ 1.5 segments was considered significant. We assessed the safety, image quality and the occurrence of interference of the magnetic field with the implantable device. In case of ischemia, we also assessed the correlation with the presence of significant coronary lesions on coronary angiography.

RESULTS

Among 3743 perfusion-CMR examinations, 66 patients had implantable devices (1.7%). Image quality proved diagnostic in 98% of cases. No device damage or malfunction was reported immediately and at 1 year. Fifty patients were continuously paced during CMR. Heart rate and systolic blood pressure remained unchanged during adenosine stress, while diastolic blood pressure decreased (p = 0.007). Six patients (9%) had an ischemia-positive stress CMR and significant coronary stenoses were confirmed by coronary angiography in all cases.

CONCLUSION

Stress perfusion-CMR is safe, allows reliable ischemia detection, and provides good diagnostic value.

Magnetic resonance imaging safety in patients with abandoned or functioning epicardial pacing leads

OBJECTIVES

The European Society of Cardiology Guidelines on cardiac pacing from 2021 allow magnetic resonance imaging (MRI) in patients with cardiac implantable electronic devices (CIEDs) but do not recommend MRI in patients with epicardial pacing leads. The clinical dilemma remains whether performing an MRI in patients with CIED and epicardial leads is safe. We aimed to evaluate the safety of performing an MRI in patients with CIED and abandoned or functioning epicardial pacing leads.

METHODS

We included all adult patients who underwent clinically indicated MRIs with CIED and functioning or abandoned epicardial leads in a single tertiary hospital between November 2011 and October 2019. The data were retrospectively collected.

RESULTS

Twenty-six MRIs were performed on 17 patients with functioning or abandoned epicardial pacing leads. Sixty-nine percent of the MRI scans (18/26) were conducted on patients with functioning epicardial pacing leads. A definite adverse event occurred in one MRI scan. This was a transient elevation of the pacing threshold in a patient with a functioning epicardial ventricular pacing lead implanted 29 years previously. An irreversible atrial pacing lead impedance elevation was detected 6 months after the MRI in another patient; the association with the previous MRI remained unclear. No adverse events were detected in MRIs performed on patients with modern (implanted in 2000 or later) functioning epicardial leads.

CONCLUSIONS

MRIs in patients with CIED and modern functioning epicardial pacing leads were performed without detectable adverse events. Further large-scale studies are necessary to confirm MRI safety in patients with epicardial pacing leads.

KEY POINTS

• Currently, MRI in patients with cardiac implantable electronic devices (CIEDs) and functioning or abandoned epicardial pacing leads is not recommended. • MRIs in patients with CIED and modern functioning epicardial leads (implanted in 2000 or later) were performed without detectable adverse events in our patient cohort. • Allowing MRI in patients with epicardial pacing leads may significantly improve the diagnostic work-up, especially in specific patient groups, such as patients with congenital heart disease.

Radiotherapy for patient with cardiac implantable electronic device, consensus from French radiation oncology society

Radiotherapy in patients with cardiac implantable electronic device such as pacemakers or defibrillators, is a clinical situation that is becoming increasingly common. There is a risk of interaction between the magnetic field induced by accelerators and the cardiac implantable electronic device, but also a risk of device dysfunction due to direct and/or indirect irradiation if the cardiac implantable electronic device is in the field of treatment. The risk can be dose-dependent, but it is most often independent of the total dose and occurs randomly in case of neutron production (stochastic effect). The presence of this type of device is therefore described as a contraindication for radiotherapy by the French national agency for the safety of medicines and health products (Agence nationale de sécurité du médicament et des produits de santé, ANSM). Nevertheless, since radiotherapy is often possible, it is advisable to respect the recommendations of good practice, in particular the eligibility criteria, the monitoring modalities before, during and after irradiation according to the type of treatment, the dose and the characteristics of the cardiac implantable electronic device. It is sometimes necessary to discuss repositioning the device and/or modifying the treatment plan to minimize the risk of cardiac implantable electronic device dysfunction. We present the update of the recommendations of the French society of oncological radiotherapy on in patients with cardiac implantable electronic device.