Interventional MRI using multiple 3D angiography roadmaps with real-time imaging

Optimised passive marker device visibility and automatic marker detection for 3-T MRI-guided endovascular interventions: a pulsatile flow phantom study

BACKGROUND

Passive paramagnetic markers on magnetic resonance imaging (MRI)-compatible endovascular devices induce susceptibility artifacts, enabling MRI-visibility and real-time MRI-guidance. Optimised visibility is crucial for automatic detection and device tracking but depends on MRI technical parameters and marker characteristics. We assessed marker visibility and automatic detection robustness for varying MRI parameters and marker characteristics in a pulsatile flow phantom.

METHODS

Guidewires with varying iron(II,III) oxide nanoparticle (IONP) concentration markers were imaged using gradient-echo (GRE) and balanced steady-state free precession (bSSFP) sequences at 3 T. Furthermore, echo time (TE), slice thickness (ST) and phase encoding direction (PED) were varied. Artifact width was measured and contrast-to-noise ratios were calculated. Marker visibility and image quality were scored by two MRI interventional radiologists. Additionally, a deep learning model for automatic marker detection was trained and the effects of the parameters on detection performance were evaluated. Two-tailed Wilcoxon signed-rank tests were used (significance level, p < 0.05).

RESULTS

Medan artifact width (IQR) was larger in bSSFP compared to GRE images (12.7 mm (11.0-15.2) versus 8.4 mm (6.5-11.0)) (p < 0.001) and showed a positive relation with TE and IONP concentration. Switching PED and doubling ST had limited effect on artifact width. Image quality assessment scores were higher for GRE compared to bSSFP images. The deep learning model automatically detected the markers. However, the model performance was reduced after adjusting PED, TE, and IONP concentration.

CONCLUSION

Marker visibility was sufficient and a large range of artifact sizes was generated by adjusting TE and IONP concentration. Deep learning-based marker detection was feasible but performance decreased for altered MR parameters. These factors should be considered to optimise device visibility and ensure reliable automatic marker detectability in MRI-guided endovascular interventions.

Real-time MRI guidance of cardiac interventions

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.

Magnetic Resonance Imaging-Guided Cardiac Interventions

Performing intraoperative cardiovascular procedures inside an MR imaging scanner can potentially provide substantial advantage in clinical outcomes by reducing the risk and increasing the success rate relative to the way such procedures are performed today, in which the primary surgical guidance is provided by X-ray fluoroscopy, by electromagnetically tracked intraoperative devices, and by ultrasound. Both noninvasive and invasive cardiologists are becoming increasingly familiar with the capabilities of MR imaging for providing anatomic and physiologic information that is unequaled by other modalities. As a result, researchers began performing animal (preclinical) interventions in the cardiovascular system in the early 1990s.

Voltage-based device tracking in a 1.5 Tesla MRI during imaging: initial validation in swine models

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.

Emerging technologies for image guidance and device navigation in interventional radiology

Recent developments in image-guidance and device navigation, along with emerging robotic technologies, are rapidly transforming the landscape of interventional radiology (IR). Future state-of-the-art IR procedures may include real-time three-dimensional imaging that is capable of visualizing the target organ, interventional tools, and surrounding anatomy with high spatial and temporal resolution. Remote device actuation is becoming a reality with the introduction of novel magnetic-field enabled instruments and remote robotic steering systems. Robots offer several degrees of freedom and unprecedented accuracy, stability, and dexterity during device navigation, propulsion, and actuation. Optimization of tracking and navigation of interventional tools inside the human body will be critical in converting IR suites into the minimally invasive operating theaters of the future with increased safety and unsurpassed therapeutic efficacy. In the not too distant future, individual image guidance modalities and device tracking methods could merge into autonomous, multimodality, multiparametric platforms that offer real-time data of anatomy, morphology, function, and metabolism along with on-the-fly computational modeling and remote robotic actuation. The authors provide a concise overview of the latest developments in image guidance and device navigation, while critically envisioning what the future might hold for 2020 IR procedures.

MR fluoroscopy in vascular and cardiac interventions (review)

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.

Imaging in interventional oncology

Medical imaging in interventional oncology is used differently than in diagnostic radiology and prioritizes different imaging features. Whereas diagnostic imaging prioritizes the highest-quality imaging, interventional imaging prioritizes real-time imaging with lower radiation dose in addition to high-quality imaging. In general, medical imaging plays five key roles in image-guided therapy, and interventional oncology, in particular. These roles are (a) preprocedure planning, (b) intraprocedural targeting, (c) intraprocedural monitoring, (d) intraprocedural control, and (e) postprocedure assessment. Although many of these roles are still relatively basic in interventional oncology, as research and development in medical imaging focuses on interventional needs, it is likely that the role of medical imaging in intervention will become even more integral and more widely applied. In this review, the current status of medical imaging for intervention in oncology will be described and directions for future development will be examined.

Nanoparticles for cell labeling

Cell based therapeutics are emerging as powerful regimens. To better understand the migration and proliferation mechanisms of implanted cells, a means to track cells in living subjects is essential, and to achieve that, a number of cell labeling techniques have been developed. Nanoparticles, with their superior physical properties, have become the materials of choice in many investigations along this line. Owing to inherent magnetic, optical or acoustic attributes, these nanoparticles can be detected by corresponding imaging modalities in living subjects at a high spatial and temporal resolution. These features allow implanted cells to be separated from host cells; and have advantages over traditional histological methods, as they permit non-invasive, real-time tracking in vivo. This review attempts to give a summary of progress in using nanotechnology to monitor cell trafficking. We will focus on direct cell labeling techniques, in which cells ingest nanoparticles that bear traceable signals, such as iron oxide or quantum dots. Ferritin and MagA reporter genes that can package endogenous iron or iron supplement into iron oxide nanoparticles will also be discussed.