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Tampakis K, Pastromas S, Sykiotis A, Kampanarou S, Kourgiannidis G, Pyrpiri C, Bousoula M, Rozakis D, Andrikopoulos G. Real-time cardiovascular magnetic resonance-guided radiofrequency ablation: A comprehensive review. World J Cardiol 2023; 15:415-426. [PMID: 37900261 PMCID: PMC10600785 DOI: 10.4330/wjc.v15.i9.415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/10/2023] [Accepted: 08/31/2023] [Indexed: 09/21/2023] Open
Abstract
Cardiac magnetic resonance (CMR) imaging could enable major advantages when guiding in real-time cardiac electrophysiology procedures offering high-resolution anatomy, arrhythmia substrate, and ablation lesion visualization in the absence of ionizing radiation. Over the last decade, technologies and platforms for performing electrophysiology procedures in a CMR environment have been developed. However, performing procedures outside the conventional fluoroscopic laboratory posed technical, practical and safety concerns. The development of magnetic resonance imaging compatible ablation systems, the recording of high-quality electrograms despite significant electromagnetic interference and reliable methods for catheter visualization and lesion assessment are the main limiting factors. The first human reports, in order to establish a procedural workflow, have rationally focused on the relatively simple typical atrial flutter ablation and have shown that CMR-guided cavotricuspid isthmus ablation represents a valid alternative to conventional ablation. Potential expansion to other more complex arrhythmias, especially ventricular tachycardia and atrial fibrillation, would be of essential impact, taking into consideration the widespread use of substrate-based strategies. Importantly, all limitations need to be solved before application of CMR-guided ablation in a broad clinical setting.
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Affiliation(s)
- Konstantinos Tampakis
- Department of Pacing & Electrophysiology, Henry Dunant Hospital Center, Athens 11526, Greece.
| | - Sokratis Pastromas
- Department of Pacing & Electrophysiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | - Alexandros Sykiotis
- Department of Pacing & Electrophysiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | | | - Georgios Kourgiannidis
- Department of Pacing & Electrophysiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | - Chrysa Pyrpiri
- Department of Radiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | - Maria Bousoula
- Department of Anesthesiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | - Dimitrios Rozakis
- Department of Anesthesiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | - George Andrikopoulos
- Department of Pacing & Electrophysiology, Henry Dunant Hospital Center, Athens 11526, Greece
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Rogers T, Campbell-Washburn AE, Ramasawmy R, Yildirim DK, Bruce CG, Grant LP, Stine AM, Kolandaivelu A, Herzka DA, Ratnayaka K, Lederman RJ. Interventional cardiovascular magnetic resonance: state-of-the-art. J Cardiovasc Magn Reson 2023; 25:48. [PMID: 37574552 PMCID: PMC10424337 DOI: 10.1186/s12968-023-00956-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 07/25/2023] [Indexed: 08/15/2023] Open
Abstract
Transcatheter cardiovascular interventions increasingly rely on advanced imaging. X-ray fluoroscopy provides excellent visualization of catheters and devices, but poor visualization of anatomy. In contrast, magnetic resonance imaging (MRI) provides excellent visualization of anatomy and can generate real-time imaging with frame rates similar to X-ray fluoroscopy. Realization of MRI as a primary imaging modality for cardiovascular interventions has been slow, largely because existing guidewires, catheters and other devices create imaging artifacts and can heat dangerously. Nonetheless, numerous clinical centers have started interventional cardiovascular magnetic resonance (iCMR) programs for invasive hemodynamic studies or electrophysiology procedures to leverage the clear advantages of MRI tissue characterization, to quantify cardiac chamber function and flow, and to avoid ionizing radiation exposure. Clinical implementation of more complex cardiovascular interventions has been challenging because catheters and other tools require re-engineering for safety and conspicuity in the iCMR environment. However, recent innovations in scanner and interventional device technology, in particular availability of high performance low-field MRI scanners could be the inflection point, enabling a new generation of iCMR procedures. In this review we review these technical considerations, summarize contemporary clinical iCMR experience, and consider potential future applications.
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Affiliation(s)
- Toby Rogers
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA.
- Section of Interventional Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 4B01, Washington, DC, 20011, USA.
| | - Adrienne E Campbell-Washburn
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
| | - Rajiv Ramasawmy
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
| | - D Korel Yildirim
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
| | - Christopher G Bruce
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
| | - Laurie P Grant
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
| | - Annette M Stine
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
| | - Aravindan Kolandaivelu
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
- Johns Hopkins Hospital, Baltimore, MD, USA
| | - Daniel A Herzka
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
| | - Kanishka Ratnayaka
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA
- Rady Children's Hospital, San Diego, CA, USA
| | - Robert J Lederman
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10/Room 2C713, 9000 Rockville Pike, Bethesda, MD, 20892-1538, USA.
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Bennett TE, Rizzo J, Yang S, Rosfjord E. Assessing Reuse of Hypodermic Needles in Mice by means of Digital Imaging, Photomicrography, Bacterial Culture, Analysis of Nest Building, and Animal Vocalization. JOURNAL OF THE AMERICAN ASSOCIATION FOR LABORATORY ANIMAL SCIENCE : JAALAS 2023; 62:205-211. [PMID: 36990673 PMCID: PMC10230537 DOI: 10.30802/aalas-jaalas-22-000094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/02/2022] [Accepted: 01/23/2023] [Indexed: 03/31/2023]
Abstract
Hypodermic needles are sometimes reused in animal research settings to preserve the viability of and to conserve limited quantities of injected material. However, the reuse of needles is strongly discouraged in human medicine to prevent inju- ries and the spread of infectious disease. No official guidelines prohibit needle reuse in veterinary medicine, although the practice may be discouraged. We hypothesized that reused needles would be significantly more blunt than unused needles and that reuse for additional injections would cause more animal stress. To test these ideas, we evaluated mice that were injected subcutaneously in the flank or mammary fat pad to generate cell line xenograft and mouse allograft models. Needles were reused up to 20 times, based on an IACUC-approved protocol. A subset of reused needles was digitally imaged to determine needle dullness based on the area of deformation from the secondary bevel angle; this parameter was not different between new needles and needles that had been reused 20 times. In addition, the number of times a needle was reused was not significantly related to audible mouse vocalization during injection. Finally, nest building scores for mice that were injected with a needle used 0 through 5 times were similar to those of mice injected with a needle had been used 16 through 20 times. Among the 37 reused needles that were tested, 4 were positive for bacterial growth; the only organisms cultured were Staphylococcus spp. Contrary to our hypothesis, reusing needles for subcutaneous injections did not increase animal stress based on analysis of vocalization or nest building.
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Affiliation(s)
- Terese E Bennett
- Previously affiliated with Comparative Medicine, Worldwide Research, Development and Medical, Pfizer, Pearl River, New York
| | - Jason Rizzo
- Pharmaceutical Sciences Small Molecule Analytical Research and Development, Pfizer, Groton, Connecticut; and
| | - Sharon Yang
- Previously affiliated with Oncology Research and Development, Pfizer, Pearl River, New York
| | - Edward Rosfjord
- Previously affiliated with Oncology Research and Development, Pfizer, Pearl River, New York
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Oebel S, Jahnke C, Hindricks G, Paetsch I. Nutzen der kardialen Magnetresonanzdiagnostik für Patienten mit Herzrhythmusstörungen. Herz 2022; 47:110-117. [DOI: 10.1007/s00059-022-05105-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 11/28/2022]
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Rier SC, Vreemann S, Nijhof WH, van Driel VJHM, van der Bilt IAC. Interventional cardiac magnetic resonance imaging: current applications, technology readiness level, and future perspectives. Ther Adv Cardiovasc Dis 2022; 16:17539447221119624. [PMID: 36039865 PMCID: PMC9434707 DOI: 10.1177/17539447221119624] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cardiac magnetic resonance (CMR) provides excellent temporal and spatial resolution, tissue characterization, and flow measurements. This enables major advantages when guiding cardiac invasive procedures compared with X-ray fluoroscopy or ultrasound guidance. However, clinical implementation is limited due to limited availability of technological advancements in magnetic resonance imaging (MRI) compatible equipment. A systematic review of the available literature on past and present applications of interventional MR and its technology readiness level (TRL) was performed, also suggesting future applications. METHODS A structured literature search was performed using PubMed. Search terms were focused on interventional CMR, cardiac catheterization, and other cardiac invasive procedures. All search results were screened for relevance by language, title, and abstract. TRL was adjusted for use in this article, level 1 being in a hypothetical stage and level 9 being widespread clinical translation. The papers were categorized by the type of procedure and the TRL was estimated. RESULTS Of 466 papers, 117 papers met the inclusion criteria. TRL was most frequently estimated at level 5 meaning only applicable to in vivo animal studies. Diagnostic right heart catheterization and cavotricuspid isthmus ablation had the highest TRL of 8, meaning proven feasibility and efficacy in a series of humans. CONCLUSION This article shows that interventional CMR has a potential widespread application although clinical translation is at a modest level with TRL usually at 5. Future development should be directed toward availability of MR-compatible equipment and further improvement of the CMR techniques. This could lead to increased TRL of interventional CMR providing better treatment.
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Affiliation(s)
- Sophie C Rier
- Cardiology Division, Department of Cardiology, Haga Teaching Hospital, Els Borst-Eilersplein 275, Postbus 40551, The Hague 2504 LN, The Netherlands
| | - Suzan Vreemann
- Department of Cardiology, Haga Teaching Hospital, The Hague, The Netherlands Siemens Healthineers Nederland B.V., Den Haag, The Netherlands
| | - Wouter H Nijhof
- Siemens Healthineers Nederland B.V., Den Haag, The Netherlands
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Kogure T, Qureshi SA. The Future of Paediatric Heart Interventions: Where Will We Be in 2030? Curr Cardiol Rep 2020; 22:158. [PMID: 33037461 PMCID: PMC7546978 DOI: 10.1007/s11886-020-01404-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 11/30/2022]
Abstract
Purpose of Review Cardiac catheterization therapies to treat or palliate infants, children and adults with congenital heart disease have developed rapidly worldwide in both technical innovation and device development in the previous three decades. By reviewing of current status of novel or development of devices and techniques, we will discuss what is likely to happen in paediatric heart intervention in the next decade. Recent Findings Recently, biodegradable stents and devices, transcatheter pulmonary valve implantation for the native right ventricle outflow tract and MRI-guided interventions have been progressing rapidly with good immediate to early results. These are expected to be introduced and spread in the next decade although there are still challenges to overcome. Summary The future of paediatric heart intervention is very promising with rapid development of technological progress.
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Affiliation(s)
- Tomohito Kogure
- Department of Congenital Cardiology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK.,Department of Cardiology, Tokyo Women's Medical University, Tokyo, 162-0054, Japan
| | - Shakeel A Qureshi
- Department of Congenital Cardiology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK.
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Mukherjee RK, Whitaker J, Williams SE, Razavi R, O'Neill MD. Magnetic resonance imaging guidance for the optimization of ventricular tachycardia ablation. Europace 2019; 20:1721-1732. [PMID: 29584897 PMCID: PMC6212773 DOI: 10.1093/europace/euy040] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/19/2018] [Indexed: 01/02/2023] Open
Abstract
Catheter ablation has an important role in the management of patients with ventricular tachycardia (VT) but is limited by modest long-term success rates. Magnetic resonance imaging (MRI) can provide valuable anatomic and functional information as well as potentially improve identification of target sites for ablation. A major limitation of current MRI protocols is the spatial resolution required to identify the areas of tissue responsible for VT but recent developments have led to new strategies which may improve substrate assessment. Potential ways in which detailed information gained from MRI may be utilized during electrophysiology procedures include image integration or performing a procedure under real-time MRI guidance. Image integration allows pre-procedural magnetic resonance (MR) images to be registered with electroanatomical maps to help guide VT ablation and has shown promise in preliminary studies. However, multiple errors can arise during this process due to the registration technique used, changes in ventricular geometry between the time of MRI and the ablation procedure, respiratory and cardiac motion. As isthmus sites may only be a few millimetres wide, reducing these errors may be critical to improve outcomes in VT ablation. Real-time MR-guided intervention has emerged as an alternative solution to address the limitations of pre-acquired imaging to guide ablation. There is now a growing body of literature describing the feasibility, techniques, and potential applications of real-time MR-guided electrophysiology. We review whether real-time MR-guided intervention could be applied in the setting of VT ablation and the potential challenges that need to be overcome.
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Affiliation(s)
- Rahul K Mukherjee
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK
| | - Steven E Williams
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK.,Department of Cardiology, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK
| | - Mark D O'Neill
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK.,Department of Cardiology, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
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8
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Abstract
Diagnostic and interventional cardiac catheterization is routinely used in the diagnosis and treatment of congenital heart disease. There are well-established concerns regarding the risk of radiation exposure to patients and staff, particularly in children given the cumulative effects of repeat exposure. Magnetic resonance imaging (MRI) offers the advantage of being able to provide better soft tissue visualization, tissue characterization, and quantification of ventricular volumes and vascular flow. Initial work using MRI catheterization employed fusion of x-ray and MRI techniques, with x-ray fluoroscopy to guide catheter placement and subsequent MRI assessment for anatomical and hemodynamic assessment. Image overlay of 3D previously acquired MRI datasets with live fluoroscopic imaging has also been used to guide catheter procedures.Hybrid x-ray and MRI-guided catheterization paved the way for clinical application and validation of this technique in the assessment of pulmonary vascular resistance and pharmacological stress studies. Purely MRI-guided catheterization also proved possible with passive catheter tracking. First-in-man MRI-guided cardiac catheter interventions were possible due to the development of MRI-compatible guidewires, but halted due to guidewire limitations.More recent developments in passive and active catheter tracking have led to improved visualization of catheters for MRI-guided catheterization. Improvements in hardware and software have also increased image quality and scanning times with better interactive tools for the operator in the MRI catheter suite to navigate through the anatomy as required in real time. This has expanded to MRI-guided electrophysiology studies and radiofrequency ablation in humans. Animal studies show promise for the utility of MRI-guided interventional catheterization. Ongoing investment and development of MRI-compatible guidewires will pave the way for MRI-guided diagnostic and interventional catheterization coming into the mainstream.
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9
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Experimental validation of robot-assisted cardiovascular catheterization: model-based versus model-free control. Int J Comput Assist Radiol Surg 2018; 13:797-804. [PMID: 29611096 DOI: 10.1007/s11548-018-1757-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 03/26/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE In cardiac electrophysiology, a long and flexible catheter is delivered to a cardiac chamber for the treatment of arrhythmias. Although several robot-assisted platforms have been commercialized, the disorientation in tele-operation is still not well solved. We propose a validation platform for robot-assisted cardiac EP catheterization, integrating a customized MR Safe robot, a standard clinically used EP catheter, and a human-robot interface. Both model-based and model-free control methods are implemented in the platform for quantitative evaluation and comparison. METHODS The model-based and model-free control methods were validated by subject test (ten participants), in which the subjects have to perform a simulated radiofrequency ablation task using both methods. A virtual endoscopic view of the catheter is also provided to enhance hand-to-eye coordination. Assessment indices for targeting accuracy and efficiency were acquired for the evaluation. RESULTS (1) Accuracy: The average distance measured from catheter tip to the closest lesion target during ablation of model-free method was 19.1% shorter than that of model-based control. (2) Efficiency: The model-free control reduced the total missed targets by 35.8% and the maximum continuously missed targets by 46.2%, both indices corresponded to a low p value ([Formula: see text]). CONCLUSION The model-free method performed better in terms of both accuracy and efficiency, indicating the model-free control could adapt to soft interaction with environment, as compared with the model-based control that does not consider contacts.
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10
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Hołda MK, Hołda J, Koziej M, Piątek K, Klimek-Piotrowska W. Porcine heart interatrial septum anatomy. Ann Anat 2018; 217:24-28. [PMID: 29458135 DOI: 10.1016/j.aanat.2018.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 01/24/2018] [Accepted: 01/25/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND The left-sided atrial septal pouch (SP), a recently re-discovered anatomical structure within the human interatrial septum, has emerged as a possible source of thrombi formation and a trigger for atrial fibrillation, thereby potentially increasing the risk for ischemic stroke. In many studies, the swine interatrial septum has been used as model of the human heart. Also, possible new strategies and devices for management of the SPs may first be tested in this pig model. Therefore, in this study, we aimed to evaluate swine interatrial septum morphology and to compare it with the human analog, especially in the light of SP occurrence. METHODS A total of 75 swine (Sus scrofa f. domestica) hearts were examined. The interatrial septum morphology was assessed, and SPs were measured. RESULTS The most common variant of the interatrial septum was smooth septum (26.6%) followed by the patent foramen ovale channel and right SP (both 22.7%). No left or double SPs were observed. In 28.0% of all cases the fold of tissue (left septal ridge) was observed on the left side of the interatrial septum in the location where the left-sided SP should be expected. The mean length of the patent foramen ovale channel was 7.1±1.5mm. The mean right SP depth was 6.3±2.2mm, and its ostium width and height were 5.8±1.2 and 5.3±1.6mm, respectively. CONCLUSIONS There are significant differences between human and porcine interatrial septum morphology that should be taken into account during experimental studies. The absence of the left SP in swine results in the inability to use porcine heart as an experimental model for left-sided SP management.
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Affiliation(s)
- Mateusz K Hołda
- HEART - Heart Embryology and Anatomy Research Team, Jagiellonian University Medical College, Cracow, Poland.
| | - Jakub Hołda
- HEART - Heart Embryology and Anatomy Research Team, Jagiellonian University Medical College, Cracow, Poland
| | - Mateusz Koziej
- HEART - Heart Embryology and Anatomy Research Team, Jagiellonian University Medical College, Cracow, Poland
| | - Katarzyna Piątek
- HEART - Heart Embryology and Anatomy Research Team, Jagiellonian University Medical College, Cracow, Poland
| | - Wiesława Klimek-Piotrowska
- HEART - Heart Embryology and Anatomy Research Team, Jagiellonian University Medical College, Cracow, Poland
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Schmidt EJ, Halperin HR. MRI use for atrial tissue characterization in arrhythmias and for EP procedure guidance. Int J Cardiovasc Imaging 2018; 34:81-95. [PMID: 28593399 PMCID: PMC5889521 DOI: 10.1007/s10554-017-1179-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 05/24/2017] [Indexed: 12/19/2022]
Abstract
We review the utilization of magnetic resonance imaging methods for classifying atrial tissue properties that act as a substrate for common cardiac arrhythmias, such as atrial fibrillation. We then review state-of-the-art methods for mapping this substrate as a predicate for treatment, as well as methods used to ablate the electrical pathways that cause arrhythmia and restore patients to sinus rhythm.
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Affiliation(s)
- Ehud J Schmidt
- Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA.
| | - Henry R Halperin
- Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
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Campbell-Washburn AE, Tavallaei MA, Pop M, Grant EK, Chubb H, Rhode K, Wright GA. Real-time MRI guidance of cardiac interventions. J Magn Reson Imaging 2017; 46:935-950. [PMID: 28493526 PMCID: PMC5675556 DOI: 10.1002/jmri.25749] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 03/29/2017] [Indexed: 11/09/2022] Open
Abstract
Cardiac magnetic resonance imaging (MRI) is appealing to guide complex cardiac procedures because it is ionizing radiation-free and offers flexible soft-tissue contrast. Interventional cardiac MR promises to improve existing procedures and enable new ones for complex arrhythmias, as well as congenital and structural heart disease. Guiding invasive procedures demands faster image acquisition, reconstruction and analysis, as well as intuitive intraprocedural display of imaging data. Standard cardiac MR techniques such as 3D anatomical imaging, cardiac function and flow, parameter mapping, and late-gadolinium enhancement can be used to gather valuable clinical data at various procedural stages. Rapid intraprocedural image analysis can extract and highlight critical information about interventional targets and outcomes. In some cases, real-time interactive imaging is used to provide a continuous stream of images displayed to interventionalists for dynamic device navigation. Alternatively, devices are navigated relative to a roadmap of major cardiac structures generated through fast segmentation and registration. Interventional devices can be visualized and tracked throughout a procedure with specialized imaging methods. In a clinical setting, advanced imaging must be integrated with other clinical tools and patient data. In order to perform these complex procedures, interventional cardiac MR relies on customized equipment, such as interactive imaging environments, in-room image display, audio communication, hemodynamic monitoring and recording systems, and electroanatomical mapping and ablation systems. Operating in this sophisticated environment requires coordination and planning. This review provides an overview of the imaging technology used in MRI-guided cardiac interventions. Specifically, this review outlines clinical targets, standard image acquisition and analysis tools, and the integration of these tools into clinical workflow. LEVEL OF EVIDENCE 1 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2017;46:935-950.
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Affiliation(s)
- Adrienne E Campbell-Washburn
- Laboratory of Imaging Technology, Biochemistry and Biophysics Center, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Mohammad A Tavallaei
- Physical Sciences Platform and Schulich Heart Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Mihaela Pop
- Physical Sciences Platform and Schulich Heart Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Elena K Grant
- Laboratory of Imaging Technology, Biochemistry and Biophysics Center, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
- Department of Cardiology, Children's National Medical Center, Washington, DC, USA
| | - Henry Chubb
- Division of Imaging Sciences and Biomedical Engineering, King's College London, UK
| | - Kawal Rhode
- Division of Imaging Sciences and Biomedical Engineering, King's College London, UK
| | - Graham A Wright
- Physical Sciences Platform and Schulich Heart Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
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Velasco Forte MN, Pushparajah K, Schaeffter T, Valverde Perez I, Rhode K, Ruijsink B, Alhrishy M, Byrne N, Chiribiri A, Ismail T, Hussain T, Razavi R, Roujol S. Improved passive catheter tracking with positive contrast for CMR-guided cardiac catheterization using partial saturation (pSAT). J Cardiovasc Magn Reson 2017; 19:60. [PMID: 28806996 PMCID: PMC5556659 DOI: 10.1186/s12968-017-0368-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 06/29/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Cardiac catheterization is a common procedure in patients with congenital heart disease (CHD). Although cardiovascular magnetic resonance imaging (CMR) represents a promising alternative approach to fluoroscopy guidance, simultaneous high contrast visualization of catheter, soft tissue and the blood pool remains challenging. In this study, a novel passive tracking technique is proposed for enhanced positive contrast visualization of gadolinium-filled balloon catheters using partial saturation (pSAT) magnetization preparation. METHODS The proposed pSAT sequence uses a single shot acquisition with balanced steady-state free precession (bSSFP) readout preceded by a partial saturation pre-pulse. This technique was initially evaluated in five healthy subjects. The pSAT sequence was compared to conventional bSSFP images acquired with (SAT) and without (Non-SAT) saturation pre-pulse. Signal-to-noise ratio (SNR) of the catheter balloon, blood and myocardium and the corresponding contrast-to-noise ratio (CNR) are reported. Subjective assessment of image suitability for CMR-guidance and ideal pSAT angle was performed by three cardiologists. The feasibility of the pSAT sequence is demonstrated in two adult patients undergoing CMR-guided cardiac catheterization. RESULTS The proposed pSAT approach provided better catheter balloon/blood contrast and catheter balloon/myocardium contrast than conventional Non-SAT sequences. It also resulted in better blood and myocardium SNR than SAT sequences. When averaged over all volunteers, images acquired with a pSAT angle of 20° to 40° enabled simultaneous visualization of the catheter balloon and the cardiovascular anatomy (blood and myocardium) and were found suitable for CMR-guidance in >93% of cases. The pSAT sequence was successfully used in two patients undergoing CMR-guided diagnostic cardiac catheterization. CONCLUSIONS The proposed pSAT sequence offers real-time, simultaneous, enhanced contrast visualization of the catheter balloon, soft tissues and blood. This technique provides improved passive tracking capabilities during CMR-guided catheterization in patients.
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Affiliation(s)
- Mari Nieves Velasco Forte
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, St Thomas’ Hospital, 3rd Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH UK
- Department of Congenital Heart Disease, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Cardiovascular Pathology Unit, Institute of Biomedicine of Seville, IBIS, Virgen del Rocio University Hospital/CSIC/University of Seville, Seville, Spain
| | - Kuberan Pushparajah
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, St Thomas’ Hospital, 3rd Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH UK
- Department of Congenital Heart Disease, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Tobias Schaeffter
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, St Thomas’ Hospital, 3rd Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH UK
- Department of Medical Physics, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Israel Valverde Perez
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, St Thomas’ Hospital, 3rd Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH UK
- Department of Congenital Heart Disease, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Cardiovascular Pathology Unit, Institute of Biomedicine of Seville, IBIS, Virgen del Rocio University Hospital/CSIC/University of Seville, Seville, Spain
| | - Kawal Rhode
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, St Thomas’ Hospital, 3rd Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH UK
| | - Bram Ruijsink
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, St Thomas’ Hospital, 3rd Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH UK
| | - Mazen Alhrishy
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, St Thomas’ Hospital, 3rd Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH UK
| | - Nicholas Byrne
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, St Thomas’ Hospital, 3rd Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH UK
| | - Amedeo Chiribiri
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, St Thomas’ Hospital, 3rd Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH UK
| | - Tevfik Ismail
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, St Thomas’ Hospital, 3rd Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH UK
| | - Tarique Hussain
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, St Thomas’ Hospital, 3rd Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH UK
- Dept. of Pediatrics, University of Texas Southwestern Medical Center, 1935 Medical District Drive, Dallas, USA
| | - Reza Razavi
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, St Thomas’ Hospital, 3rd Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH UK
- Department of Congenital Heart Disease, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Sébastien Roujol
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, St Thomas’ Hospital, 3rd Floor Lambeth Wing, Westminster Bridge Road, London, SE1 7EH UK
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14
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Thin film based semi-active resonant marker design for low profile interventional cardiovascular MRI devices. MAGNETIC RESONANCE MATERIALS IN PHYSICS BIOLOGY AND MEDICINE 2016; 30:93-101. [PMID: 27605033 DOI: 10.1007/s10334-016-0586-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 08/05/2016] [Accepted: 08/16/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES A new microfabrication method to produce low profile radio frequency (RF) resonant markers on catheter shafts was developed. A semi-active RF resonant marker incorporating a solenoid and a plate capacitor was constructed on the distal shaft of a 5 Fr guiding catheter. The resulting device can be used for interventional cardiovascular MRI procedures. MATERIALS AND METHODS Unlike current semi-active device visualization techniques that require rigid and bulky analog circuit components (capacitor and solenoid), we fabricated a low profile RF resonant marker directly on guiding the catheter surface by thin film metal deposition and electroplating processes using a modified physical vapor deposition system. RESULTS The increase of the overall device profile thickness caused by the semi-active RF resonant marker (130 µm thick) was lowered by a factor of 4.6 compared with using the thinnest commercial non-magnetic and rigid circuit components (600 µm thick). Moreover, adequate visibility performance of the RF resonant marker in different orientations and overall RF safety were confirmed through in vitro experiments under MRI successfully. CONCLUSION The developed RF resonant marker on a clinical grade 5 Fr guiding catheter will enable several interventional congenital heart disease treatment procedures under MRI.
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15
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Abstract
Interventional cardiovascular magnetic resonance (iCMR) promises to enable radiation-free catheterization procedures and to enhance contemporary image guidance for structural heart and electrophysiological interventions. However, clinical translation of exciting pre-clinical interventions has been limited by availability of devices that are safe to use in the magnetic resonance (MR) environment. We discuss challenges and solutions for clinical translation, including MR-conditional and MR-safe device design, and how to configure an interventional suite. We review the recent advances that have already enabled diagnostic MR right heart catheterization and simple electrophysiologic ablation to be performed in humans and explore future clinical applications.
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16
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Schmidt EJ, Tse ZTH, Reichlin TR, Michaud GF, Watkins RD, Butts-Pauly K, Kwong RY, Stevenson W, Schweitzer J, Byrd I, Dumoulin CL. Voltage-based device tracking in a 1.5 Tesla MRI during imaging: initial validation in swine models. Magn Reson Med 2015; 71:1197-209. [PMID: 23580479 DOI: 10.1002/mrm.24742] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
PURPOSE Voltage-based device-tracking (VDT) systems are commonly used for tracking invasive devices in electrophysiological cardiac-arrhythmia therapy. During electrophysiological procedures, electro-anatomic mapping workstations provide guidance by integrating VDT location and intracardiac electrocardiogram information with X-ray, computerized tomography, ultrasound, and MR images. MR assists navigation, mapping, and radiofrequency ablation. Multimodality interventions require multiple patient transfers between an MRI and the X-ray/ultrasound electrophysiological suite, increasing the likelihood of patient-motion and image misregistration. An MRI-compatible VDT system may increase efficiency, as there is currently no single method to track devices both inside and outside the MRI scanner. METHODS An MRI-compatible VDT system was constructed by modifying a commercial system. Hardware was added to reduce MRI gradient-ramp and radiofrequency unblanking pulse interference. VDT patches and cables were modified to reduce heating. Five swine cardiac VDT electro-anatomic mapping interventions were performed, navigating inside and thereafter outside the MRI. RESULTS Three-catheter VDT interventions were performed at >12 frames per second both inside and outside the MRI scanner with <3 mm error. Catheters were followed on VDT- and MRI-derived maps. Simultaneous VDT and imaging was possible in repetition time >32 ms sequences with <0.5 mm errors, and <5% MRI signal-to-noise ratio (SNR) loss. At shorter repetition times, only intracardiac electrocardiogram was reliable. Radiofrequency heating was <1.5°C. CONCLUSION An MRI-compatible VDT system is feasible.
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Affiliation(s)
- Ehud J Schmidt
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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17
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Al Maluli H, DeStephan CM, Alvarez RJ, Sandoval J. Atrial Septostomy: A Contemporary Review. Clin Cardiol 2015; 38:395-400. [PMID: 25733325 DOI: 10.1002/clc.22398] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 01/20/2015] [Accepted: 01/28/2015] [Indexed: 11/10/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease, but it boasts significant morbidity and mortality. Although remarkable achievements have been made in the medical treatment of PAH, there is a role for invasive or surgical procedures in patients with progressive disease despite optimal medical therapy or with no access to such therapy. Atrial septostomy creates a right-to-left intracardiac shunt to decompress the overloaded right ventricle. Despite significant advances to validate and improve this palliative procedure, as well as recent reports of improved outcomes, it is only slowly being adopted. This article aims to detail the history, indications, contraindications, procedural techniques, and outcomes of atrial septostomy. We will also shed light on some of the newer interventions, inspired by the same physiological concept, that are being evaluated as potential palliative modalities in patients with PAH.
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Affiliation(s)
- Hayan Al Maluli
- Department of Internal Medicine, Cardiology Division, Temple University Hospital, Philadelphia, Pennsylvania
| | - Christine M DeStephan
- Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania
| | - René J Alvarez
- Department of Internal Medicine, Cardiology Division, Temple University Hospital, Philadelphia, Pennsylvania
| | - Julio Sandoval
- Cardiopulmonary Department, National Cardiology Institute Ignacio Chávez, Mexico City, Mexico
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18
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Abstract
Diagnosis and prognostication in patients with complex cardiopulmonary disease can be a clinical challenge. A new procedure, MRI catheterization, involves invasive right-sided heart catheterization performed inside the MRI scanner using MRI instead of traditional radiographic fluoroscopic guidance. MRI catheterization combines simultaneous invasive hemodynamic and MRI functional assessment in a single radiation-free procedure. By combining both modalities, the many individual limitations of invasive catheterization and noninvasive imaging can be overcome, and additional clinical questions can be addressed. Today, MRI catheterization is a clinical reality in specialist centers in the United States and Europe. Advances in medical device design for the MRI environment will enable not only diagnostic but also interventional MRI procedures to be performed within the next few years.
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Affiliation(s)
- Toby Rogers
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Kanishka Ratnayaka
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD; Department of Cardiology, Children's National Medical Center, Washington, DC
| | - Robert J Lederman
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD.
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19
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McGill LA, Pennell DJ. Emerging roles for cardiovascular magnetic resonance. Clin Med (Lond) 2013; 13 Suppl 6:s3-8. [PMID: 24298179 DOI: 10.7861/clinmedicine.13-6-s3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Cardiovascular magnetic resonance (CMR) is a noninvasive imaging tool with high spatial resolution in the absence of ionising radiation. CMR imaging is routine in the functional assessment of coronary lesions and is widely held as the gold standard in myocardial viability imaging. Its unique tissue characterisation capabilities have revolutionised the assessment of the cardiomyopathies and it is the investigation of choice for cardiovascular surveillance imaging. To date its greatest success has been in the management of thalassaemia major, where the ability to detect myocardial iron loading has significantly improved patient survival. In the near future, CMR fibrosis imaging may serve as a risk stratification tool for the cardiomyopathies; and the ability to assess interstitial fibrosis may advance this role into other disease processes. Novel methods of tissue characterisation and emerging technical advances present new avenues for this modality, securing its place as the noninvasive imaging tool of the future.
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Affiliation(s)
- Laura-Ann McGill
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
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20
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Tzifa A, Schaeffter T, Razavi R. MR imaging-guided cardiovascular interventions in young children. Magn Reson Imaging Clin N Am 2012; 20:117-28. [PMID: 22118596 DOI: 10.1016/j.mric.2011.08.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Diagnostic cardiac catheterization procedures in children have been largely replaced by magnetic resonance (MR) imaging studies. However, when invasive catheterization is required, MR imaging has a significant role to play, when combined with invasive pressure measurements. Beyond the established reduction to the radiation dose involved, solely MR image-guided or MR image-assisted catheterization procedures can accurately address clinical questions, such as estimation of pulmonary vascular resistance and cardiac output response to stress, without needing to perform laborious measurements that are prone to errors. This article describes MR image-guided or MR image-assisted cardiac catheterization procedures for diagnosis and intervention in children.
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Affiliation(s)
- Aphrodite Tzifa
- Division of Imaging Sciences, King's College London BHF Centre, NIHR Biomedical Research Centre at Guy's & St Thomas' Hospital NHS Foundation Trust, UK.
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21
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Saeed M, Hetts SW, English J, Wilson M. MR fluoroscopy in vascular and cardiac interventions (review). Int J Cardiovasc Imaging 2012; 28:117-37. [PMID: 21359519 PMCID: PMC3275732 DOI: 10.1007/s10554-010-9774-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 12/13/2010] [Indexed: 12/22/2022]
Abstract
Vascular and cardiac disease remains a leading cause of morbidity and mortality in developed and emerging countries. Vascular and cardiac interventions require extensive fluoroscopic guidance to navigate endovascular catheters. X-ray fluoroscopy is considered the current modality for real time imaging. It provides excellent spatial and temporal resolution, but is limited by exposure of patients and staff to ionizing radiation, poor soft tissue characterization and lack of quantitative physiologic information. MR fluoroscopy has been introduced with substantial progress during the last decade. Clinical and experimental studies performed under MR fluoroscopy have indicated the suitability of this modality for: delivery of ASD closure, aortic valves, and endovascular stents (aortic, carotid, iliac, renal arteries, inferior vena cava). It aids in performing ablation, creation of hepatic shunts and local delivery of therapies. Development of more MR compatible equipment and devices will widen the applications of MR-guided procedures. At post-intervention, MR imaging aids in assessing the efficacy of therapies, success of interventions. It also provides information on vascular flow and cardiac morphology, function, perfusion and viability. MR fluoroscopy has the potential to form the basis for minimally invasive image-guided surgeries that offer improved patient management and cost effectiveness.
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Affiliation(s)
- Maythem Saeed
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA 94107-1701, USA.
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22
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Barbash IM, Saikus CE, Faranesh AZ, Ratnayaka K, Kocaturk O, Chen MY, Bell JA, Virmani R, Schenke WH, Hansen MS, Slack MC, Lederman RJ. Direct percutaneous left ventricular access and port closure: pre-clinical feasibility. JACC Cardiovasc Interv 2011; 4:1318-25. [PMID: 22192372 PMCID: PMC3404602 DOI: 10.1016/j.jcin.2011.07.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 07/21/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVES This study sought to evaluate feasibility of nonsurgical transthoracic catheter-based left ventricular (LV) access and closure. BACKGROUND Implanting large devices, such as mitral or aortic valve prostheses, into the heart requires surgical exposure and repair. Reliable percutaneous direct transthoracic LV access and closure would allow new nonsurgical therapeutic procedures. METHODS Percutaneous direct LV access was performed in 19 swine using real-time magnetic resonance imaging (MRI) and an "active" MRI needle antenna to deliver an 18-F introducer sheath. The LV access ports were closed percutaneously using a commercial ventricular septal defect occluder and an "active" MRI delivery cable for enhanced visibility. We used "permissive pericardial tamponade" (temporary fluid instillation to separate the 2 pericardial layers) to avoid pericardial entrapment by the epicardial disk. Techniques were developed in 8 animals, and 11 more were followed up to 3 months by MRI and histopathology. RESULTS Imaging guidance allowed 18-F sheath access and closure with appropriate positioning of the occluder inside the transmyocardial tunnel. Of the survival cohort, immediate hemostasis was achieved in 8 of 11 patients. Failure modes included pericardial entrapment by the epicardial occluder disk (n = 2) and a true-apex entry site that prevented hemostatic apposition of the endocardial disk (n = 1). Reactive pericardial effusion (192 ± 118 ml) accumulated 5 ± 1 days after the procedure, requiring 1-time drainage. At 3 months, LV function was preserved, and the device was endothelialized. CONCLUSIONS Direct percutaneous LV access and closure is feasible using real-time MRI. A commercial occluder achieved hemostasis without evident deleterious effects on the LV. Having established the concept, further clinical development of this approach appears realistic.
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Affiliation(s)
- Israel M. Barbash
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, the National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Christina E. Saikus
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, the National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Anthony Z. Faranesh
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, the National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Kanishka Ratnayaka
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, the National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
- Children’s National Medical Center, Washington, DC
| | - Ozgur Kocaturk
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, the National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Marcus Y. Chen
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, the National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Jamie A. Bell
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, the National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | - William H. Schenke
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, the National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Michael S. Hansen
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, the National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Robert J. Lederman
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, the National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
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23
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Tzifa A, Krombach GA, Krämer N, Krüger S, Schütte A, von Walter M, Schaeffter T, Qureshi S, Krasemann T, Rosenthal E, Schwartz CA, Varma G, Buhl A, Kohlmeier A, Bücker A, Günther RW, Razavi R. Magnetic Resonance–Guided Cardiac Interventions Using Magnetic Resonance–Compatible Devices. Circ Cardiovasc Interv 2010; 3:585-92. [DOI: 10.1161/circinterventions.110.957209] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Percutaneous cardiac interventions are currently performed under x-ray guidance. Magnetic resonance imaging (MRI) has been used to guide intravascular interventions in the past, but mainly in animals. Translation of MR-guided interventions into humans has been limited by the lack of MR-compatible and safe equipment, such as MR guide wires with mechanical characteristics similar to standard guide wires. The aim of the present study was to evaluate the safety and efficacy of a newly developed MR-safe and compatible passive guide wire in aiding MR-guided cardiac interventions in a swine model and describe the 2 first-in-man solely MR-guided interventions.
Methods and Results—
In the preclinical trial, the new MR-compatible wire aided the performance of 20 interventions in 5 swine. These consisted of balloon dilation of nondiseased pulmonary and aortic valves, aortic arch, and branch pulmonary arteries. After ethics and regulatory authority approval, the 2 first-in-man MR-guided interventions were performed in a child and an adult, both with elements of valvar pulmonary stenosis. Catheter manipulations were monitored with real-time MRI sequence with interactive modification of imaging plane and slice position. Temporal resolution was 11 to 12 frames/s. Catheterization procedure times were 110 and 80 minutes, respectively. Both patients had successful relief of the valvar stenosis and no procedural complications.
Conclusions—
The described preclinical study and case reports are encouraging that with the availability of the new MR-compatible and safe guide wire, certain percutaneous cardiac interventions will become feasible to perform solely under MR guidance in the future. A clinical trial is underway in our institution.
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Affiliation(s)
- Aphrodite Tzifa
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
| | - Gabriele A. Krombach
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
| | - Nils Krämer
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
| | - Sascha Krüger
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
| | - Adrian Schütte
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
| | - Matthias von Walter
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
| | - Tobias Schaeffter
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
| | - Shakeel Qureshi
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
| | - Thomas Krasemann
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
| | - Eric Rosenthal
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
| | - Claudia A. Schwartz
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
| | - Gopal Varma
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
| | - Alexandra Buhl
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
| | - Antonia Kohlmeier
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
| | - Arno Bücker
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
| | - Rolf W. Günther
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
| | - Reza Razavi
- From King's College London BHF Centre (A.T., T.S., S.Q., G.V., R.R.), Division of Imaging Sciences, NIHR Biomedical, Research Centre at Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; the Pediatric Cardiology Department (A.T., S.Q., T.K., E.R., R.R.), Evelina Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; the Department of Diagnostic Radiology (G.A.K., N.K., C.A.S., A.K., A.B., R.W.G.), University Hospital Aachen, Aachen, Germany; Philips Research
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Abstract
Catheter ablation is a first-line treatment for many cardiac arrhythmias and is generally performed under X-ray fluoroscopy guidance. However, current techniques for ablating complex arrhythmias such as atrial fibrillation and ventricular tachycardia are associated with sub-optimal success rates and prolonged radiation exposure. Pre-procedure 3-D magnetic resonance imaging (MRI) has improved understanding of the anatomic basis of complex arrhythmias and is being used for planning and guidance of ablation procedures. A particular strength of MRI compared to other imaging modalities is the ability to visualize ablation lesions. Post-procedure MRI is now being applied to assess ablation lesion location and permanence with the goal of identifying factors leading to procedure success and failure. In the future, intra-procedure real-time MRI, together with the ability to image complex 3-D arrhythmogenic anatomy and target additional ablation to regions of incomplete lesion formation, may allow for more successful treatment of even complex arrhythmias without exposure to ionizing radiation. Development of clinical grade MRI-compatible electrophysiology devices is required to transition intra-procedure MRI from preclinical studies to more routine use in patients.
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25
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O'Donnell M, McVeigh ER, Strauss HW, Tanaka A, Bouma BE, Tearney GJ, Guttman MA, Garcia EV. Multimodality cardiovascular molecular imaging technology. J Nucl Med 2010; 51 Suppl 1:38S-50S. [PMID: 20457794 DOI: 10.2967/jnumed.109.068155] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Cardiovascular molecular imaging is a new discipline that integrates scientific advances in both functional imaging and molecular probes to improve our understanding of the molecular basis of the cardiovascular system. These advances are driven by in vivo imaging of molecular processes in animals, usually small animals, and are rapidly moving toward clinical applications. Molecular imaging has the potential to revolutionize the diagnosis and treatment of cardiovascular disease. The 2 key components of all molecular imaging systems are the molecular contrast agents and the imaging system providing spatial and temporal localization of these agents within the body. They must deliver images with the appropriate sensitivity and specificity to drive clinical applications. As work in molecular contrast agents matures and highly sensitive and specific probes are developed, these systems will provide the imaging technologies required for translation into clinical tools. This is the promise of molecular medicine.
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Schmidt EJ, Mallozzi RP, Thiagalingam A, Holmvang G, d'Avila A, Guhde R, Darrow R, Slavin GS, Fung MM, Dando J, Foley L, Dumoulin CL, Reddy VY. Electroanatomic mapping and radiofrequency ablation of porcine left atria and atrioventricular nodes using magnetic resonance catheter tracking. Circ Arrhythm Electrophysiol 2010; 2:695-704. [PMID: 19841033 DOI: 10.1161/circep.109.882472] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The MRI-compatible electrophysiology system previously used for MR-guided left ventricular electroanatomic mapping was enhanced with improved MR tracking, an MR-compatible radiofrequency ablation system and higher-resolution imaging sequences to enable mapping, ablation, and ablation monitoring in smaller cardiac structures. MR-tracked navigation was performed to the left atrium (LA) and atrioventricular (AV) node, followed by LA electroanatomic mapping and radiofrequency ablation of the pulmonary veins (PVs) and AV node. METHODS AND RESULTS One ventricular ablation, 7 PV ablations, 3 LA mappings, and 3 AV node ablations were conducted. Three MRI-compatible devices (ablation/mapping catheter, torqueable sheath, stimulation/pacing catheter) were used, each with 4 to 5 tracking microcoils. Transseptal puncture was performed under x-ray, with all other procedural steps performed in the MRI. Preacquired MRI roadmaps served for real-time catheter navigation. Simultaneous tracking of 3 devices was performed at 13 frames per second. LA mapping and PV radiofrequency ablation were performed using tracked ablation catheters and sheaths. Ablation points were registered and verified after ablation using 3D myocardial delayed enhancement and postmortem gross tissue examination. Complete LA electroanatomic mapping was achieved in 3 of 3 pigs, Right inferior PV circumferential ablation was achieved in 3 of 7 pigs, with incomplete isolation caused by limited catheter deflection. During AV node ablation, ventricular pacing was performed, 3 devices were simultaneously tracked, and intracardiac ECGs were displayed. 3D myocardial delayed enhancement visualized node injury 2 minutes after ablation. AV node block succeeded in 2 of 3 pigs, with 1 temporary block. CONCLUSIONS LA mapping, PV radiofrequency ablation, and AV node ablation were demonstrated under MRI guidance. Intraprocedural 3D myocardial delayed enhancement assessed lesion positional accuracy and dimensions.
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Affiliation(s)
- Ehud J Schmidt
- Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115, USA.
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27
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Linte CA, White J, Eagleson R, Guiraudon GM, Peters TM. Virtual and Augmented Medical Imaging Environments: Enabling Technology for Minimally Invasive Cardiac Interventional Guidance. IEEE Rev Biomed Eng 2010; 3:25-47. [DOI: 10.1109/rbme.2010.2082522] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Ratnayaka K, Lederman RJ. Interventional cardiovascular MR—The next stage in pediatric cardiology. PROGRESS IN PEDIATRIC CARDIOLOGY 2010. [DOI: 10.1016/j.ppedcard.2009.10.008] [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: 10/20/2022]
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Saikus CE, Lederman RJ. Interventional cardiovascular magnetic resonance imaging: a new opportunity for image-guided interventions. JACC Cardiovasc Imaging 2009; 2:1321-31. [PMID: 19909937 PMCID: PMC2843404 DOI: 10.1016/j.jcmg.2009.09.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2009] [Revised: 09/10/2009] [Accepted: 09/11/2009] [Indexed: 01/12/2023]
Abstract
Cardiovascular magnetic resonance (CMR) combines excellent soft-tissue contrast, multiplanar views, and dynamic imaging of cardiac function without ionizing radiation exposure. Interventional cardiovascular magnetic resonance (iCMR) leverages these features to enhance conventional interventional procedures or to enable novel ones. Although still awaiting clinical deployment, this young field has tremendous potential. We survey promising clinical applications for iCMR. Next, we discuss the technologies that allow CMR-guided interventions and, finally, what still needs to be done to bring them to the clinic.
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Affiliation(s)
- Christina E Saikus
- Translational Medicine Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD 20892-1538, USA
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Kolandaivelu A, Lardo AC, Halperin HR. Cardiovascular magnetic resonance guided electrophysiology studies. J Cardiovasc Magn Reson 2009; 11:21. [PMID: 19580654 PMCID: PMC2719626 DOI: 10.1186/1532-429x-11-21] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Accepted: 07/06/2009] [Indexed: 11/10/2022] Open
Abstract
Catheter ablation is a first line treatment for many cardiac arrhythmias and is generally performed under x-ray fluoroscopy guidance. However, current techniques for ablating complex arrhythmias such as atrial fibrillation and ventricular tachycardia are associated with suboptimal success rates and prolonged radiation exposure. Pre-procedure 3D CMR has improved understanding of the anatomic basis of complex arrhythmias and is being used for planning and guidance of ablation procedures. A particular strength of CMR compared to other imaging modalities is the ability to visualize ablation lesions. Post-procedure CMR is now being applied to assess ablation lesion location and permanence with the goal of indentifying factors leading to procedure success and failure. In the future, intra-procedure real-time CMR, together with the ability to image complex 3-D arrhythmogenic anatomy and target additional ablation to regions of incomplete lesion formation, may allow for more successful treatment of even complex arrhythmias without exposure to ionizing radiation. Development of clinical grade CMR compatible electrophysiology devices is required to transition intra-procedure CMR from pre-clinical studies to more routine use in patients.
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Affiliation(s)
| | - Albert C Lardo
- Johns Hopkins Hospital, Division of Cardiology, Baltimore, MD 21205, USA
| | - Henry R Halperin
- Johns Hopkins Hospital, Division of Cardiology, Baltimore, MD 21205, USA
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Kolandaivelu A, Halperin H. MRI for electrophysiology. CURRENT CARDIOVASCULAR IMAGING REPORTS 2009. [DOI: 10.1007/s12410-009-0014-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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33
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Real-time MR imaging-guided laser atrial septal puncture in swine. J Vasc Interv Radiol 2008; 19:1347-53. [PMID: 18725098 DOI: 10.1016/j.jvir.2008.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2007] [Revised: 05/05/2008] [Accepted: 05/12/2008] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The authors performed this study to report their initial preclinical experience with real-time magnetic resonance (MR) imaging-guided atrial septal puncture by using a MR imaging-conspicuous blunt laser catheter that perforates only when energized. MATERIALS AND METHODS The authors customized a 0.9-mm clinical excimer laser catheter with a receiver coil to impart MR imaging visibility at 1.5 T. Seven swine underwent laser transseptal puncture under real-time MR imaging. MR imaging signal-to-noise ratio profiles of the device were obtained in vitro. Tissue traversal force was tested with a calibrated meter. Position was corroborated with pressure measurements, oximetry, angiography, and necropsy. Intentional non-target perforation simulated serious complication. RESULTS Embedded MR imaging antennae accurately reflected the position of the laser catheter tip and profile in vitro and in vivo. Despite having an increased profile from the microcoil, the 0.9-mm laser catheter traversed in vitro targets with similar force (0.22 N +/- 0.03) compared with the unmodified laser. Laser puncture of the atrial septum was successful and accurate in all animals. The laser was activated an average of 3.8 seconds +/- 0.4 before traversal. There were no sequelae after 6 hours of observation. Necropsy revealed 0.9-mm holes in the fossa ovalis in all animals. Intentional perforation of the aorta and atrial free wall was evident immediately. CONCLUSIONS MR imaging-guided laser puncture of the interatrial septum is feasible in swine and offers controlled delivery of perforation energy by using an otherwise blunt catheter. Instantaneous soft tissue imaging provides immediate feedback on safety.
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Guttman MA, Ozturk C, Raval AN, Raman VK, Dick AJ, DeSilva R, Karmarkar P, Lederman RJ, McVeigh ER. Interventional cardiovascular procedures guided by real-time MR imaging: an interactive interface using multiple slices, adaptive projection modes and live 3D renderings. J Magn Reson Imaging 2008; 26:1429-35. [PMID: 17968897 DOI: 10.1002/jmri.21199] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To develop and test a novel interactive real-time MRI environment that facilitates image-guided cardiovascular interventions. MATERIALS AND METHODS Color highlighting of device-mounted receiver coils, accelerated imaging of multiple slices, adaptive projection modes, live three-dimensional (3D) renderings and other interactive features were utilized to enhance navigation of devices and targeting of tissue. RESULTS Images are shown from several catheter-based interventional procedures performed in swine that benefit from this custom interventional MRI interface. These include endograft repair of aortic aneurysm, balloon septostomy of the cardiac interatrial septum, angioplasty and stenting, and endomyocardial cell injection, all using active catheters containing MRI receiver coils. CONCLUSION Interactive features not available on standard clinical scanners enhance real-time MRI for guiding cardiovascular interventional procedures.
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Affiliation(s)
- Michael A Guttman
- Laboratory of Cardiac Energetics, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892-1061, USA.
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Bastarrika Alemañ G, Domínguez Echávarri PD, Azcárate Agüero PM, Castaño Rodríguez S, Fernández Jarne ME, Gavira Gómez JJ. [Quantification of ventricular mass and function using real-time free-breathing SSFP sequences]. RADIOLOGIA 2008; 50:67-74. [PMID: 18275792 DOI: 10.1016/s0033-8338(08)71931-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To compare real-time free-breathing steady-state free precession (SSFP) sequences with conventional breath-hold segmented SSFP sequences on the quantification of ventricular mass and function. MATERIAL AND METHODS Cardiac function and mass were assessed in 15 consecutive patients with cardiopathies who underwent MRI for diverse indications. Sequences were planned in the short axis to include the area from the base to the apex of the ventricle. Two sequences were used: 1) a conventional breath-hold segmented SSFP sequence with 7-mm-thick slices and 3-mm gap between slices and 2) a real-time free-breathing SSFP sequence with 10-mm-thick slices. The systolic and diastolic volumes (VTD, VTS) and ejection fraction (EF) of both ventricles were evaluated and the mass of the left ventricle (LVM) was measured. The correlation between the different sequences was studied for each variable. RESULTS An excellent correlation was observed between the two sequences on the quantification of cardiac parameters in both ventricles (0.9; p < 0.01). The mean differences for EF, VTD, VTS, and stroke volume (VTD-VTS) were 2.5% (2.1), 5.6 ml (14.2), -0.8 ml (6.4), 6.4 ml (9.4), respectively, for the left ventricle and 1.7% (3.1), 1.8 ml (18.7), -1.9 ml (9.8), 3.7 ml (10.8), respectively, for the right ventricle. The mean difference between the LVM was 4.8 g (6.3). CONCLUSIONS The real-time free-breathing SSFP sequence is useful for the quantification of ventricular mass and function. The correlation with conventional SSFP is excellent. Both sequences allow the cardiac parameters to be precisely quantified and the results are reproducible.
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Affiliation(s)
- G Bastarrika Alemañ
- Servicio de Radiología. Clínica Universitaria. Universidad de Navarra. Pamplona. España.
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Raval AN, Karmarkar PV, Guttman MA, Ozturk C, Sampath S, DeSilva R, Aviles RJ, Xu M, Wright VJ, Schenke WH, Kocaturk O, Dick AJ, Raman VK, Atalar E, McVeigh ER, Lederman RJ. Real-time magnetic resonance imaging-guided endovascular recanalization of chronic total arterial occlusion in a swine model. Circulation 2006; 113:1101-7. [PMID: 16490819 PMCID: PMC1428785 DOI: 10.1161/circulationaha.105.586727] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Endovascular recanalization (guidewire traversal) of peripheral artery chronic total occlusion (CTO) can be challenging. X-ray angiography resolves CTO poorly. Virtually "blind" device advancement during x-ray-guided interventions can lead to procedure failure, perforation, and hemorrhage. Alternatively, MRI may delineate the artery within the occluded segment to enhance procedural safety and success. We hypothesized that real-time MRI (rtMRI)-guided CTO recanalization can be accomplished in an animal model. METHODS AND RESULTS Carotid artery CTO was created by balloon injury in 19 lipid-overfed swine. After 6 to 8 weeks, 2 underwent direct necropsy analysis for histology, 3 underwent primary x-ray-guided CTO recanalization attempts, and the remaining 14 underwent rtMRI-guided recanalization attempts in a 1.5-T interventional MRI system. Real-time MRI intervention used custom CTO catheters and guidewires that incorporated MRI receiver antennae to enhance device visibility. The mean length of the occluded segments was 13.3+/-1.6 cm. The rtMRI-guided CTO recanalization was successful in 11 of 14 swine and in only 1 of 3 swine with the use of x-ray alone. After unsuccessful rtMRI (n=3), x-ray-guided attempts were also unsuccessful. CONCLUSIONS Recanalization of long CTO is entirely feasible with the use of rtMRI guidance. Low-profile clinical-grade devices will be required to translate this experience to humans.
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Affiliation(s)
- Amish N Raval
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1538, USA
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Abstract
Magnetic resonance imaging (MRI), which provides superior soft-tissue imaging and no known harmful effects, has the potential as an alternative modality to guide various medical interventions. This review will focus on MR-guided endovascular interventions and present its current state and future outlook. In the first technical part, enabling technologies such as developments in fast imaging, catheter devices, and visualization techniques are examined. This is followed by a clinical survey that includes proof-of-concept procedures in animals and initial experience in human subjects. In preclinical experiments, MRI has already proven to be valuable. For example, MRI has been used to guide and track targeted cell delivery into or around myocardial infarctions, to guide atrial septal puncture, and to guide the connection of portal and systemic venous circulations. Several investigational MR-guided procedures have already been reported in patients, such as MR-guided cardiac catheterization, invasive imaging of peripheral artery atheromata, selective intraarterial MR angiography, and preliminary angioplasty and stent placement. In addition, MR-assisted transjugular intrahepatic portosystemic shunt procedures in patients have been shown in a novel hybrid double-doughnut x-ray/MRI system. Numerous additional investigational human MR-guided endovascular procedures are now underway in several medical centers around the world. There are also significant hurdles: availability of clinical-grade devices, device-related safety issues, challenges to patient monitoring, and acoustic noise during imaging. The potential of endovascular interventional MRI is great because as a single modality, it combines 3-dimensional anatomic imaging, device localization, hemodynamics, tissue composition, and function.
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Affiliation(s)
- Cengizhan Ozturk
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
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