Multifunctional interventional devices for MRI: a combined electrophysiology/MRI catheter

A Magnetic Particle Imaging Approach for Minimally Invasive Imaging and Sensing With Implantable Bioelectronic Circuits

Minimally-invasive and biocompatible implantable bioelectronic circuits are used for long-term monitoring of physiological processes in the body. However, there is a lack of methods that can cheaply and conveniently image the device within the body while simultaneously extracting sensor information. Magnetic Particle Imaging (MPI) with zero background signal, high contrast, and high sensitivity with quantitative images is ideal for this challenge because the magnetic signal is not absorbed with increasing tissue depth and incurs no radiation dose. We show how to easily modify common implantable devices to be imaged by MPI by encapsulating and magnetically-coupling magnetic nanoparticles (SPIOs) to the device circuit. These modified implantable devices not only provide spatial information via MPI, but also couple to our handheld MPI reader to transmit sensor information by modulating harmonic signals from magnetic nanoparticles via switching or frequency-shifting with resistive or capacitive sensors. This paper provides proof-of-concept of an optimized MPI imaging technique for implantable devices to extract spatial information as well as other information transmitted by the implanted circuit (such as biosensing) via encoding in the magnetic particle spectrum. The 4D images present 3D position and a changing color tone in response to a variable biometric. Biophysical sensing via bioelectronic circuits that take advantage of the unique imaging properties of MPI may enable a wide range of minimally invasive applications in biomedicine and diagnosis.

Interventional cardiovascular magnetic resonance: state-of-the-art

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.

RF-induced heating of interventional devices at 23.66 MHz

OBJECTIVE

Low-field MRI systems are expected to cause less RF heating in conventional interventional devices due to lower Larmor frequency. We systematically evaluate RF-induced heating of commonly used intravascular devices at the Larmor frequency of a 0.55 T system (23.66 MHz) with a focus on the effect of patient size, target organ, and device position on maximum temperature rise.

MATERIALS AND METHODS

To assess RF-induced heating, high-resolution measurements of the electric field, temperature, and transfer function were combined. Realistic device trajectories were derived from vascular models to evaluate the variation of the temperature increase as a function of the device trajectory. At a low-field RF test bench, the effects of patient size and positioning, target organ (liver and heart) and body coil type were measured for six commonly used interventional devices (two guidewires, two catheters, an applicator and a biopsy needle).

RESULTS

Electric field mapping shows that the hotspots are not necessarily localized at the device tip. Of all procedures, the liver catheterizations showed the lowest heating, and a modification of the transmit body coil could further reduce the temperature increase. For common commercial needles no significant heating was measured at the needle tip. Comparable local SAR values were found in the temperature measurements and the TF-based calculations.

CONCLUSION

At low fields, interventions with shorter insertion lengths such as hepatic catheterizations result in less RF-induced heating than coronary interventions. The maximum temperature increase depends on body coil design.

Role of Cardiovascular Magnetic Resonance in the Management of Atrial Fibrillation: A Review

Atrial fibrillation (AF) is the most common arrhythmia, and its prevalence is growing with time. Since the introduction of catheter ablation procedures for the treatment of AF, cardiovascular magnetic resonance (CMR) has had an increasingly important role for the treatment of this pathology both in clinical practice and as a research tool to provide insight into the arrhythmic substrate. The most common applications of CMR for AF catheter ablation are the angiographic study of the pulmonary veins, the sizing of the left atrium (LA), and the evaluation of the left atrial appendage (LAA) for stroke risk assessment. Moreover, CMR may provide useful information about esophageal anatomical relationship to LA to prevent thermal injuries during ablation procedures. The use of late gadolinium enhancement (LGE) imaging allows to evaluate the burden of atrial fibrosis before the ablation procedure and to assess procedural induced scarring. Recently, the possibility to assess atrial function, strain, and the burden of cardiac adipose tissue with CMR has provided more elements for risk stratification and clinical decision making in the setting of catheter ablation planning of AF. The purpose of this review is to provide a comprehensive overview of the potential applications of CMR in the workup of ablation procedures for atrial fibrillation.

[MRI-based catheter ablation : Current status and outlook]

Fluoroscopy-based catheter ablation has established itself as a standard procedure for the treatment of patients with cardiac arrhythmias. However, it is subject to certain limitations with regard to the visualization of arrhythmogenic substrate and ablation lesions and is associated with radiation exposure. Within the framework of studies, initial experience with MRI-based, radiation-free electrophysiological examinations and ablations could be gained. The integration of MRI technology into electrophysiological procedures promises numerous advantages. The ability to operate in a radiation-free environment during MRI-based catheter ablation is significant and promising. Furthermore, MRI provides important procedure-relevant information in terms of visualization of individual arrhythmogenic substrate. In order to further improve immediate and long-term ablation success, especially in the context of complex arrhythmias and structural heart disease, the direct and successful integration of MRI-generated findings into the ablation process is of utmost importance. The future of MRI-based catheter ablation could thus lie in particular in the treatment of more complex cardiac arrhythmias, which require personalized therapy paths. In this respect, however, the data situation is still extremely limited. Further technical developments and larger studies are indispensable in order to gain further important insights into the feasibility, safety and success rate of MRI-based invasive electrophysiological diagnostics and therapy in comparison to conventional ablation methods.

Interventional cardiac magnetic resonance imaging: current applications, technology readiness level, and future perspectives

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.

MR safety watchdog for active catheters: Wireless impedance control with real-time feedback

PURPOSE

To dynamically minimize radiofrequency (RF)-induced heating of an active catheter through an automatic change of the termination impedance.

METHODS

A prototype wireless module was designed that modifies the input impedance of an active catheter to keep the temperature rise during MRI below a threshold, ΔT_max . The wireless module (MR safety watchdog; MRsWD) measures the local temperature at the catheter tip using either a built-in thermistor or external data from a fiber-optical thermometer. It automatically changes the catheter input impedance until the temperature rise during MRI is minimized. If ΔT_max is exceeded, RF transmission is blocked by a feedback system.

RESULTS

The thermistor and fiber-optical thermometer provided consistent temperature data in a phantom experiment. During MRI, the MRsWD was able to reduce the maximum temperature rise by 25% when operated in real-time feedback mode.

CONCLUSION

This study demonstrates the technical feasibility of an MRsWD as an alternative or complementary approach to reduce RF-induced heating of active interventional devices. The automatic MRsWD can reduce heating using direct temperature measurements at the tip of the catheter. Given that temperature measurements are intrinsically slow, for a clinical implementation, a faster feedback parameter would be required such as the RF currents along the catheter or scattered electric fields at the tip.

Acousto-Optic Catheter Tracking Sensor for Interventional MRI Procedures

OBJECTIVE

The objective of this paper is to introduce an acousto-optic optical fiber sensor for tracking catheter position during interventional magnetic resonance imaging (MRI) to overcome RF induced heating of active markers.

METHODS

The sensor uses a miniature coil coupled to a piezoelectric transducer, which is in turn mechanically connected to an optical fiber. The piezoelectric transducer converts the RF signal to acoustic waves in the optical fiber over a region including a fiber Bragg grating (FBG). The elastic waves in the fiber modulates the FBG geometry and hence the reflected light in the optical fiber. Since the coil is much smaller than the RF wavelength and the signal is transmitted on the dielectric optical fiber, the sensor effectively reduces RF induced heating risk. Proof of concept prototypes of the sensor are implemented using commercially available piezoelectric transducers and optical fibers with FBGs. The prototypes are characterized in a 1.5 T MRI system in comparison with an active tracking marker.

RESULTS

Acousto-optical sensor shows linear response with flip angle and it can be used to detect signals from multiple coils for potential orientation detection. It has been successfully used to detect the position of a tacking coil in phantom in an imaging experiment.

CONCLUSION

Acousto-optical sensing is demonstrated for tracking catheters during interventional MRI. Real-time operation of the sensor requires sensitivity improvements like using a narrow band FBG.

SIGNIFICANCE

Acousto-optics provides a compact solution to sense RF signals in MRI with dielectric transmission lines.

MRI use for atrial tissue characterization in arrhythmias and for EP procedure guidance

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.

Acquisition of electrocardiogram signals during magnetic resonance imaging

The recording of the electrocardiogram (ECG) during magnetic resonance imaging (MRI) acquisition is of great interest and importance. Firstly, MRI acquisition is a relatively slow process, which therefore complicates the imaging of moving organs. Cardiac MRI requires the development of strategies for acquiring high quality images, which is mainly achieved by synchronising the image acquisition with a specific time during the cardiac cycle. The ECG is used to monitor the heart's activity, and the detection of the largest and steepest peak in the cardiac cycle (the QRS complex) triggers the acquisition of slices of the k-space. Secondly, patients undergoing an MRI examination need to be monitored for safety during the procedure, and therefore ECG signals are used to track their cardiovascular state in real time. However, there are significant barriers to the accurate observation and processing of the ECG during MRI acquisition. In particular, the flow of charged blood particles through the large applied magnetic field leads to an extra current source, known as the magnetohdrodymanic (MHD) effect. This review article discusses these barriers and state-of-the-art solutions. An overview of the relevant technology including hardware and applications are described. The development of new software tools for the processing of the ECG signals acquired during MRI is also detailed. These developments include the design of specific QRS detection algorithms, which are able to distinguish QRS complexes from the MHD effect but also the gradient artefacts. Different techniques for the suppression of the gradient artefacts are also presented as well as the most challenging problem to-date-the problem of separating the MHD effect from the ECG. The article concludes by summarising the advantages of using ECG signals during MRI, but also presents the current limitations of modern analysis techniques in this domain. The most promising avenues of research are also discussed and suggestions for new methodological analyses for the development of this field are given.

Monitoring local heating around an interventional MRI antenna with RF radiometry

PURPOSE

Radiofrequency (RF) radiometry uses thermal noise detected by an antenna to measure the temperature of objects independent of medical imaging technologies such as magnetic resonance imaging (MRI). Here, an active interventional MRI antenna can be deployed as a RF radiometer to measure local heating, as a possible new method of monitoring device safety and thermal therapy.

METHODS

A 128 MHz radiometer receiver was fabricated to measure the RF noise voltage from an interventional 3 T MRI loopless antenna and calibrated for temperature in a uniformly heated bioanalogous gel phantom. Local heating (ΔT) was induced using the antenna for RF transmission and measured by RF radiometry, fiber-optic thermal sensors, and MRI thermometry. The spatial thermal sensitivity of the antenna radiometer was numerically computed using a method-of-moment electric field analyses. The gel's thermal conductivity was measured by MRI thermometry, and the localized time-dependent ΔT distribution computed from the bioheat transfer equation and compared with radiometry measurements. A "H-factor" relating the 1 g-averaged ΔT to the radiometric temperature was introduced to estimate peak temperature rise in the antenna's sensitive region.

RESULTS

The loopless antenna radiometer linearly tracked temperature inside a thermally equilibrated phantom up to 73 °C to within ±0.3 °C at a 2 Hz sample rate. Computed and MRI thermometric measures of peak ΔT agreed within 13%. The peak 1 g-average temperature was H = 1.36 ± 0.02 times higher than the radiometric temperature for any media with a thermal conductivity of 0.15-0.50 (W/m)/K, indicating that the radiometer can measure peak 1 g-averaged ΔT in physiologically relevant tissue within ±0.4 °C.

CONCLUSIONS

Active internal MRI detectors can serve as RF radiometers at the MRI frequency to provide accurate independent measures of local and peak temperature without the artifacts that can accompany MRI thermometry or the extra space needed to accommodate alternative thermal transducers. A RF radiometer could be integrated in a MRI scanner to permit "self-monitoring" for assuring device safety and/or monitoring delivery of thermal therapy.

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.

Modeling of electrodes and implantable pulse generator cases for the analysis of implant tip heating under MR imaging

PURPOSE

The authors' purpose is to model the case of an implantable pulse generator (IPG) and the electrode of an active implantable medical device using lumped circuit elements in order to analyze their effect on radio frequency induced tissue heating problem during a magnetic resonance imaging (MRI) examination.

METHODS

In this study, IPG case and electrode are modeled with a voltage source and impedance. Values of these parameters are found using the modified transmission line method (MoTLiM) and the method of moments (MoM) simulations. Once the parameter values of an electrode/IPG case model are determined, they can be connected to any lead, and tip heating can be analyzed. To validate these models, both MoM simulations and MR experiments were used. The induced currents on the leads with the IPG case or electrode connections were solved using the proposed models and the MoTLiM. These results were compared with the MoM simulations. In addition, an electrode was connected to a lead via an inductor. The dissipated power on the electrode was calculated using the MoTLiM by changing the inductance and the results were compared with the specific absorption rate results that were obtained using MoM. Then, MRI experiments were conducted to test the IPG case and the electrode models. To test the IPG case, a bare lead was connected to the case and placed inside a uniform phantom. During a MRI scan, the temperature rise at the lead was measured by changing the lead length. The power at the lead tip for the same scenario was also calculated using the IPG case model and MoTLiM. Then, an electrode was connected to a lead via an inductor and placed inside a uniform phantom. During a MRI scan, the temperature rise at the electrode was measured by changing the inductance and compared with the dissipated power on the electrode resistance.

RESULTS

The induced currents on leads with the IPG case or electrode connection were solved for using the combination of the MoTLiM and the proposed lumped circuit models. These results were compared with those from the MoM simulations. The mean square error was less than 9%. During the MRI experiments, when the IPG case was introduced, the resonance lengths were calculated to have an error less than 13%. Also the change in tip temperature rise at resonance lengths was predicted with less than 4% error. For the electrode experiments, the value of the matching impedance was predicted with an error less than 1%.

CONCLUSIONS

Electrical models for the IPG case and electrode are suggested, and the method is proposed to determine the parameter values. The concept of matching of the electrode to the lead is clarified using the defined electrode impedance and the lead Thevenin impedance. The effect of the IPG case and electrode on tip heating can be predicted using the proposed theory. With these models, understanding the tissue heating due to the implants becomes easier. Also, these models are beneficial for implant safety testers and designers. Using these models, worst case conditions can be determined and the corresponding implant test experiments can be planned.

Three-dimensional Rotational Angiography as a Periprocedural Imaging Tool in Atrial Fibrillation Ablation

Atrial fibrillation (AF) ablation relies increasingly on three-dimensional (3D) visualisation tools to help guide an operator in performing a procedure safely and successfully. Current generation non-fluoroscopic navigation systems can be used as stand-alone tools, but also offer the capability to integrate information from additional imaging studies in order to enhance 3D model accuracy. Between available imaging modalities, 3D rotational angiography offers a set of interesting features such as near realtime availability, applicability in high-volume workflows, integration with other imaging systems (fluoroscopic or non-fluoroscopic) and very low incremental cost per procedure. Applicability of this imaging approach in AF ablation, as a complement or substitute to other imaging/navigation tools, is reviewed.

In vitro study to simulate the intracardiac magnetohydrodynamic effect

PURPOSE

Blood flow causes induced voltages via the magnetohydrodynamic (MHD) effect distorting electrograms (EGMs) made during magnetic resonance imaging. To investigate the MHD effect in this context MHD voltages occurring inside the human heart were simulated in an in vitro model system inside a 1.5 T MR system.

METHODS

The model was developed to produce MHD signals similar to those produced by intracardiac flow and to acquire them using standard clinical equipment. Additionally, a new approach to estimate MHD distortions on intracardiac electrograms is proposed based on the analytical calculation of the MHD signal from MR phase contrast data.

RESULTS

The recorded MHD signals were similar in magnitude to intracardiac signals that would be measured by an electrogram of the left ventricle. The dependency of MHD signals on magnetic field strength and electrode separation was well reflected by an analytical model. MHD signals reconstructed from MR flow data were in excellent agreement with the MHD signal measured by clinical equipment.

CONCLUSION

The in vitro model allows investigation of MHD effects on intracardiac electrograms. A phase contrast MR scan was successfully applied to characterize and estimate the MHD distortion on intracardiac signals allowing correction of these effects.

Comparison of three artificial models of the magnetohydrodynamic effect on the electrocardiogram

The electrocardiogram (ECG) is often acquired during magnetic resonance imaging (MRI), but its analysis is restricted by the presence of a strong artefact, called magnetohydrodynamic (MHD) effect. MHD effect is induced by the flow of electrically charged particles in the blood perpendicular to the static magnetic field, which creates a potential of the order of magnitude of the ECG and temporally coincident with the repolarisation period. In this study, a new MHD model is proposed by using MRI-based 4D blood flow measurements made across the aortic arch. The model is extended to several cardiac cycles to allow the simulation of a realistic ECG acquisition during MRI examination and the quality assessment of MHD suppression techniques. A comparison of two existing models, based, respectively, on an analytical solution and on a numerical method-based solution of the fluids dynamics problem, is made with the proposed model and with an estimate of the MHD voltage observed during a real MRI scan. Results indicate a moderate agreement between the proposed model and the estimated MHD model for most leads, with an average correlation factor of 0.47. However, the results demonstrate that the proposed model provides a closer approximation to the observed MHD effects and a better depiction of the complexity of the MHD effect compared with the previously published models, with an improved correlation (+5%), coefficient of determination (+22%) and fraction of energy (+1%) compared with the best previous model. The source code will be made freely available under an open source licence to facilitate collaboration and allow more rapid development of more accurate models of the MHD effect.

[Use of cardiac MRI in the field of electrophysiology. Present status and future aspects]

In recent years, ablation therapy has become the first-line treatment of modern electrophysiology in patients with cardiac arrhythmias. Today, cardiac magnetic resonance imaging (cMRI) is an important supportive imaging technique in the implementation of complex electrophysiological investigations and ablation therapy. In clinical routine, cMRI is used not only to generate accurate three-dimensional (3D) models of cavities of the heart but also for visualization of complex anatomical structures. The development of cMRI makes it possible to detect the underlying substrate of complex arrhythmias such as myocardial scar in patients with ventricular tachycardia or the structural remodeling of the left atrium in patients with atrial fibrillation. The opportunity of fusion of the different imaging modalities (e.g., fluoroscopy, cMRI) has become essential for the planning and the implementation of a safe ablation therapy. The possibility of direct visualization of induced lesions using cMRI after and in the long term after ablation can predict the success of therapy and detects potential complications. The continuous research in the field of cMRI and the development of MRI-compatible pacing and ablation catheters provided the basics for performing electrophysiological treatment in humans directly inside the MRI. The implementation of ablation using exact visualization of the anatomical substrate, precise catheter navigation and real-time visualization of lesions in cMRI promises to improve success rates and the safety of complex ablation treatment and may revolutionize electrophysiology in the future.

[Interventional electrophysiology in cardiac MRI : what is the current status?]

The ablation of simple and complex cardiac arrhythmias has become a first-line therapy in interventional cardiology and is mainly guided by conventional fluoroscopy. Cardiac magnetic resonance imaging (cMRI) allows exact three-dimensional (3D) visualization of complex anatomical structures and serves in the planning and implementation of ablation procedures. Post-procedural lesion visualization using cMRI can assess the success of ablation therapy and may distinguish potential complications. Performing ablation directly in the MRI scanner, with the option of anatomical substrate imagining, exact catheter navigation and real-time lesion visualization, holds the promise of improving success rates and safety in the interventional therapy of simple and complex arrhythmias.

Designing passive MRI-safe implantable conducting leads with electrodes

PURPOSE

The presence of implanted electronic devices with conducting leads and electrodes are contraindicated for magnetic resonance imaging (MRI), denying many patients its potential benefits. The prime concern is MRI's radio frequency (RF) fields, which can cause elevated local specific absorption rates (SARs) and potential heat injury. The purpose of this article is to develop and compare a range of passive implantable "MRI-safe" lead designs.

METHODS

Conducting leads incorporating different lengths (3-75 cm), insulation thicknesses (0-105 microm), resistances (100-3000 omega), coiled conductors (inner diameter < or = 1.2 mm), high-impedance (135-2700 omega) RF traps, and single-coiled and triple-coiled coaxial-wound "billabong" leads with reversed coil sections that oppose and reduce the induced current, are investigated both experimentally using local temperature measurements, and by numerical full-wave electromagnetic field analysis of the local SAR, in three different-sized bioanalogous model saline-gel phantoms at 1.5 T MRI and 4 W/kg exposure.

RESULTS

In all designs, the maximum computed 1 g average SAR and experimental temperature rise occur at the bare electrodes. Electrode heating increases with lead insulation thickness and peaks for uncoiled leads 25-50 cm long. A reasonable match between computed SAR and the point SAR estimated from thermal sensors obtained by approximating the computation volume to that of the thermal probes. Factors that maximize the impedance of leads with resistive, coiled, RF trap and billabong elements can effectively limit heating below 1-2 degrees, but folded lead configurations can be a concern. The RF trap and billabong designs can both support multiple conductors and electrodes, with billabong prototype leads also heating <1 degrees C when tested for 3 T MRI.

CONCLUSIONS

Lead insulation and length strongly affect implanted lead safety to RF exposure during MRI. Lead designs employing impedance and reversed winding sections offer hope for the development of passive, MRI-safe, implantable conducting leads for future human use.

Navigation within the heart and vessels in clinical practice

The field of interventional cardiology has developed at an unprecedented pace on account of the visual and imaging power provided by constantly improving biomedical technologies. Transcatheter-based technology is now routinely used for coronary revascularization and noncoronary interventions using balloon angioplasty, stents, and many other devices. In the early days of interventional practice, the operating physician had to manually navigate catheters and devices under fluoroscopic imaging and was exposed to radiation, with its comcomitant necessity for wearing heavy lead aprons for protection. Until recently, very little has changed in the way procedures have been carried out in the catheterization laboratory. The technological capacity to remotely manipulate devices, using robotic arms and computational tools, has been developed for surgery and other medical procedures. This has brought to practice the powerful combination of the abilities afforded by imaging, navigational tools, and remote control manipulation. This review covers recent developments in navigational tools for catheter positioning, electromagnetic mapping, magnetic resonance imaging (MRI)-based cardiac electrophysiological interventions, and navigation tools through coronary arteries.

Interactive real-time mapping and catheter ablation of the cavotricuspid isthmus guided by magnetic resonance imaging in a porcine model

Aims

We investigated the feasibility of real-time magnetic resonance imaging (RTMRI) guided ablation of the cavotricuspid isthmus (CTI) by using a MRI-compatible ablation catheter.

Methods and results

Cavotricuspid isthmus ablation was performed in an interventional RTMRI suite by using a novel 7 French, steerable, non-ferromagnetic ablation catheter in a porcine in vivo model (n = 20). The catheter was introduced and navigated by RTMRI visualization only. Catheter position and movement during manipulation were continuously visualized during the entire intervention. Two porcine prematurely died due to VT/VF. Anatomical completion of the CTI ablation line could be achieved after a mean of 6.3±3 RF pulses (RF energy: 1807±1016.4 Ws/RF pulse, temperature: 55.9±5.9°C) in n = 18 animals. In 15 of 18 procedures (83.3%) a complete CTI block was proven by conventional mapping in the electrophysiological (EP) lab.

Conclusion

Completely non-fluoroscopic ablation guided by RTMRI using a steerable and non-ferromagnetic catheter is a promising novel technology in interventional electrophysiology.

Interventional cardiovascular magnetic resonance imaging: a new opportunity for image-guided interventions

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.

Interventional cardiovascular magnetic resonance: still tantalizing

The often touted advantages of MR guidance remain largely unrealized for cardiovascular interventional procedures in patients. Many procedures have been simulated in animal models. We argue these opportunities for clinical interventional MR will be met in the near future. This paper reviews technical and clinical considerations and offers advice on how to implement a clinical-grade interventional cardiovascular MR (iCMR) laboratory. We caution that this reflects our personal view of the "state of the art."

Electroanatomic mapping of the left ventricle in a porcine model of chronic myocardial infarction with magnetic resonance-based catheter tracking

BACKGROUND

X-ray fluoroscopy constitutes the fundamental imaging modality for catheter visualization during interventional electrophysiology procedures. The minimal tissue discriminative capability of fluoroscopy is mitigated in part by the use of electroanatomic mapping systems and enhanced by the integration of preacquired 3-dimensional imaging of the heart with computed tomographic or magnetic resonance (MR) imaging. A more ideal paradigm might be to use intraprocedural MR imaging to directly image and guide catheter mapping procedures.

METHODS AND RESULTS

An MR imaging-based electroanatomic mapping system was designed to assess the feasibility of navigating catheters to the left ventricle in vivo using MR tracking of microcoils incorporated into the catheters, measuring intracardiac ventricular electrograms, and integrating this information with 3-dimensional MR angiography and myocardial delayed enhancement images to allow ventricular substrate mapping. In all animals (4 normal, and 10 chronically infarcted swine), after transseptal puncture under fluoroscopic guidance, catheters were successfully navigated to the left ventricle with MR tracking (13 to 15 frames per second) by both transseptal and retrograde aortic approaches. Electrogram artifacts related to the MR imaging gradient pulses were successfully removed with analog and digital signal processing. In all animals, it was possible to map the entire left ventricle and to project electrogram voltage amplitude maps to identify the scarred myocardium.

CONCLUSIONS

It is possible to use MR tracking to navigate catheters to the left ventricle, to measure electrogram activity, and to render accurate 3-dimensional voltage maps in a porcine model of chronic myocardial infarction, completely in the MR imaging environment. Myocardial delayed enhancement guidance provided dense sampling of the proximity of the infarct and accurate localization of complex infarcts.

Feasibility of real-time magnetic resonance imaging for catheter guidance in electrophysiology studies

BACKGROUND

Compared with fluoroscopy, the current imaging standard of care for guidance of electrophysiology procedures, magnetic resonance imaging (MRI) provides improved soft-tissue resolution and eliminates radiation exposure. However, because of inherent magnetic forces and electromagnetic interference, the MRI environment poses challenges for electrophysiology procedures. In this study, we sought to test the feasibility of performing electrophysiology studies with real-time MRI guidance.

METHODS AND RESULTS

An MRI-compatible electrophysiology system was developed. Catheters were targeted to the right atrium, His bundle, and right ventricle of 10 mongrel dogs (23 to 32 kg) via a 1.5-T MRI system using rapidly acquired fast gradient-echo images (approximately 5 frames per second). Catheters were successfully positioned at the right atrial, His bundle, and right ventricular target sites of all animals. Comprehensive electrophysiology studies with recording of intracardiac electrograms and atrial and ventricular pacing were performed. Postprocedural pathological evaluation revealed no evidence of thermal injury to the myocardium. After proof of safety in animal studies, limited real-time MRI-guided catheter mapping studies were performed in 2 patients. Adequate target catheter localization was confirmed via recording of intracardiac electrograms in both patients.

CONCLUSIONS

To the best of our knowledge, this is the first study to report the feasibility of real-time MRI-guided electrophysiology procedures. This technique may eliminate patient and staff radiation exposure and improve real-time soft tissue resolution for procedural guidance.

Interventional cardiovascular magnetic resonance imaging

Magnetic resonance imaging provides structural and functional cardiovascular information with excellent soft tissue contrast. Real-time magnetic resonance imaging can guide transcatheter cardiovascular interventions in large animal models and may prove superior to x-ray and adjunct modalities for peripheral vascular, structural heart, and cardiac electrophysiology applications. We describe technical considerations, preclinical work, and early clinical studies in this emerging field.

Magnetic resonance imaging and radiofrequency ablations

Cardiac MRI has evolved one of the major imaging technologies in cardiology. Increasingly MRI has also been used for electrophysiological applications. Anatomically based procedures such as the circumferential pulmonary vein ablation emphasized the importance of including the individual's cardiac anatomy in a tailored ablation approach. Today, many centers routinely perform pre-ablation imaging to identify left atrial anatomy. Three-dimensional reconstructions based on MRI are frequently integrated in clinical mapping systems to provide cardiac anatomy during the ablation procedure. Similarly, MRI is a clinically very valuable tool in assessing potential ablation complications such as pulmonary vein stenosis. New innovative use of MRI is likely to occur in three areas over the next several years. During ventricular tachycardia ablations volume rendering/fusion imaging will enable a detailed three-dimensional substrate evaluation and provide supplementary scar characterization using a combination of different imaging approaches. With the ongoing technical improvements real-time MRI will likely emerge as a stand-alone clinical modality to directly guide catheter ablation procedures. The advent of stronger field strength MRI, faster imaging protocols, and improved gating techniques will allow accurate peri- and post-procedural visualization of ablation lesions. These developments should result in shorter procedure times and decreased complications rates. Ultimately, they will enable the development of novel ablation strategies and expand the current indications for electrophysiological ablations.

MRI-guided congenital cardiac catheterization and intervention: the future?

Over the last 10 years, a number of technological advances have allowed real-time magnetic resonance imaging to guide cardiac catheterization, including improved image quality, faster scanning times, and open magnets allowing access to the patient. Potential advantages include better soft tissue imaging to improve catheter manipulation and additional functional information to assist with interventional decision-making, all without exposure to ionizing radiation. MRI-guided diagnostic catheterization, balloon dilation, stent placement, valvar replacement, atrial septal defect closure, and radiofrequency ablation all have been shown feasible in animal models. MRI-guided catheterization has the potential to replace the current X-ray-based diagnostic and interventional procedures for children with congenital heart disease, avoiding all radiation exposure while improving soft tissue imaging.

High-resolution real-time spiral MRI for guiding vascular interventions in a rabbit model at 1.5T

PURPOSE

To study the feasibility of a combined high spatial and temporal resolution real-time spiral MRI sequence for guiding coronary-sized vascular interventions.

MATERIALS AND METHODS

Eight New Zealand White rabbits (four normal and four with a surgically-created stenosis in the abdominal aorta) were studied. A real-time interactive spiral MRI sequence combining 1.1 x 1.1 mm(2) in-plane resolution and 189-msec total image acquisition time was used to image all phases of an interventional procedure (i.e., guidewire placement, balloon angioplasty, and stenting) in the rabbit aorta using coronary-sized devices on a 1.5 T MRI system.

RESULTS

Real-time spiral MRI identified all rabbit aortic stenoses and provided high-temporal-resolution visualization of guide-wires crossing the stenoses in all animals. Angioplasty balloon dilatation and deployment of coronary-sized copper stents in the rabbit aorta were also successfully imaged by real-time spiral MRI.

CONCLUSION

Combining high spatial and temporal resolution with spiral MRI allows real-time MR-guided vascular intervention using coronary-sized devices in a rabbit model. This is a promising approach for guiding coronary interventions.

Magnetic resonance imaging-guided vascular interventions

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.

Real-time magnetic resonance imaging to guide pediatric endovascular procedures

Although x-ray fluoroscopy (XRF) has guided diagnostic and therapeutic transcatheter procedures for decades, certain limitations still exist. XRF still visualizes tissue poorly and relies on projection of shadows that do not convey depth information. Adjunctive echocardiography overcomes some of these limitations but still suffers suboptimal or unreliable imaging windows. Furthermore, ionizing radiation exposure in children imparts a cancer risk. An interventional platform using real-time magnetic resonance imaging (MRI) may offer superior image guidance without radiation. Although there are many remaining challenges, but real-time MRI has the potential to revolutionize transcatheter therapeutics.

Active device tracking and high-resolution intravascular MRI using a novel catheter-based, opposed-solenoid phased array coil

A novel two-element, catheter-based phased array coil was designed and built for both active MR device tracking and high-resolution vessel wall imaging. The device consists of two independent solenoid coils that are wound in opposite directions, connected to separate receive channels, and mounted collinearly on an angiographic catheter. The elements were used independently or together for tracking or imaging applications, respectively. The array's dual functionality was tested on a clinical 1.5 T MRI scanner in vitro, in vivo, and in situ. During real-time catheter tracking, each element gave rise to a high-amplitude peak in the respective projection data, which enabled reliable and robust device tracking as well as automated slice positioning. In vivo microimaging with 240 microm in-plane resolution was achieved in 9 s using the device and TrueFISP imaging. Therefore, a single device was successfully implemented that met the combined requirements of intravascular device tracking and imaging.

Renal Embolization: Feasibility of Magnetic Resonance-Guidance Using Active Catheter Tracking and Intraarterial Magnetic Resonance Angiography

RATIONALE AND OBJECTIVES

Magnetic resonance (MR)-guidance of endovascular interventions offers various advantages, including the absence of ionizing radiation, excellent soft tissue contrast, and multiplanar and functional imaging capabilities. The objective of this study was to assess the feasibility of MR-guided renal embolization using active catheter tracking with automatic slice positioning and intraarterial contrast-enhanced MR angiography (MRA).

MATERIALS AND METHODS

MR-guided embolization of 16 kidneys was attempted in 15 pigs using real-time tracking of active 5-Fr. catheters. Embolization was monitored by selective intraarterial projection MRA. Intraarterial three-dimensional (3D) MRA was used for the assessment of embolization results. Additional pathologic correlation was available in 2 animals. The image quality of intraarterial 3D contrast-enhanced-MRA was rated by an independent radiologist who was not involved in the animal experiments.

RESULTS

Active catheter tracking with automatic slice positioning allowed reliable catheter guidance and catheterization of the renal artery in all animals. Embolization was successful in all kidneys (11 left, 5 right), as verified by intraarterial 3D contrast-enhanced MRA (ce-MRA) and/or pathology. The image quality of intraarterial 3D ce-MRA was rated excellent in 10 animals, moderate in 4 animals, and poor in 1 animal.

CONCLUSION

Renal embolization using active catheter tracking and intraarterial ce-MRA is feasible. Selective intraarterial ce-MRA allows the assessment of blood supply and organ perfusion before, during, and after therapeutic interventions, thereby complementing MR-guided endovascular interventions.

MR-trackable intramyocardial injection catheter

There is growing interest in delivering cellular agents to infarcted myocardium to prevent postinfarction left ventricular remodeling. MRI can be effectively used to differentiate infarcted from healthy myocardium. MR-guided delivery of cellular agents/therapeutics is appealing because the therapeutics can be precisely targeted to the desired location within the infarct. In this study, a steerable intramyocardial injection catheter that can be actively tracked under MRI was developed and tested. The components of the catheter were arranged to form a loopless RF antenna receiver coil that enabled active tracking. Feasibility studies were performed in canine and porcine myocardial infarction models. Myocardial delayed-enhancement (MDE) imaging identified the infarcted myocardium, and real-time MRI was used to guide left ventricular catheterization from a carotid artery approach. The distal 35 cm of the catheter was seen under MRI with a bright signal at the distal tip of the catheter. The catheter was steered into position, the distal tip was apposed against the infarct, the needle was advanced, and a bolus of MR contrast agent and tissue marker dye was injected intramyocardially, as confirmed by imaging and postmortem histology. A pilot study involving intramyocardial delivery of magnetically labeled stem cells demonstrated the utility of the active injection catheter system.

Real-time accelerated interactive MRI with adaptive TSENSE and UNFOLD

Reduced field-of-view (FOV) acceleration using time-adaptive sensitivity encoding (TSENSE) or unaliasing by Fourier encoding the overlaps using the temporal dimension (UNFOLD) can improve the depiction of motion in real-time MRI. However, increased computational resources are required to maintain a high frame rate and low latency in image reconstruction and display. A high-performance software system has been implemented to perform TSENSE and UNFOLD reconstructions for real-time MRI with interactive, on-line display. Images were displayed in the scanner room to investigate image-guided procedures. Examples are shown for normal volunteers and cardiac interventional experiments in animals using a steady-state free precession (SSFP) sequence. In order to maintain adequate image quality for interventional procedures, the imaging rate was limited to seven frames per second after an acceleration factor of 2 with a voxel size of 1.8 x 3.5 x 8 mm. Initial experiences suggest that TSENSE and UNFOLD can each improve the compromise between spatial and temporal resolution in real-time imaging, and can function well in interactive imaging. UNFOLD places no additional constraints on receiver coils, and is therefore more flexible than SENSE methods; however, the temporal image filtering can blur motion and reduce the effective acceleration. Methods are proposed to overcome the challenges presented by the use of TSENSE in interactive imaging. TSENSE may be temporarily disabled after changing the imaging plane to avoid transient artifacts as the sensitivity coefficients adapt. For imaging with a combination of surface and interventional coils, a hybrid reconstruction approach is proposed whereby UNFOLD is used for the interventional coils, and TSENSE with or without UNFOLD is used for the surface coils.

Endovascular interventional magnetic resonance imaging

Minimally invasive interventional radiological procedures, such as balloon angioplasty, stent placement or coiling of aneurysms, play an increasingly important role in the treatment of patients suffering from vascular disease. The non-destructive nature of magnetic resonance imaging (MRI), its ability to combine the acquisition of high quality anatomical images and functional information, such as blood flow velocities, perfusion and diffusion, together with its inherent three dimensionality and tomographic imaging capacities, have been advocated as advantages of using the MRI technique for guidance of endovascular radiological interventions. Within this light, endovascular interventional MRI has emerged as an interesting and promising new branch of interventional radiology. In this review article, the authors will give an overview of the most important issues related to this field. In this context, we will focus on the prerequisites for endovascular interventional MRI to come to maturity. In particular, the various approaches for device tracking that were proposed will be discussed and categorized. Furthermore, dedicated MRI systems, safety and compatibility issues and promising applications that could become clinical practice in the future will be discussed.

Novel technique for cardiac electromechanical mapping with magnetic resonance imaging tagging and an epicardial electrode sock

Near-simultaneous measurements of electrical and mechanical activation over the entire ventricular surface are now possible using magnetic resonance imaging tagging and a multielectrode epicardial sock. This new electromechanical mapping technique is demonstrated in the ventricularly paced canine heart. A 128-electrode epicardial sock and pacing electrodes were placed on the hearts of four anesthetized dogs. In the magnetic resonance scanner, tagged cine images (8-15 ms/frame) and sock electrode recordings (1000 Hz) were acquired under right-ventricular pacing and temporally referenced to the pacing stimulus. Electrical recordings were obtained during intermittent breaks in image acquisition, so that both data sets represented the same physiologic state. Since the electrodes were not visible in the images, electrode recordings and cine images were spatially registered with Gd-DTPA markers attached to the sock. Circumferential strain was calculated at locations corresponding to electrodes. For each electrode location, electrical and mechanical activation times were calculated and relationships between the two activation patterns were demonstrated. This method holds promise for improving understanding of the relationships between the patterns of electrical activation and contraction in the heart.