Transesophageal cardiac pacing during magnetic resonance imaging: feasibility and safety considerations

Safety and Feasibility of Transesophageal Pacing in a Dog

This study investigated the feasibility of using a modified transesophageal atrial pacing system for dogs requiring temporary ventricular pacing. Atrial pacing was readily achieved in the one dog studied, but it caused considerable diaphragmatic movement. Ventricular pacing could not be achieved at any lead configuration or energy stimulation. While transesophageal cardiac pacing was a safe procedure, the large variation in the chest anatomy of dogs requires further study to explore this model as a substitute for transvenous or transthoracic ventricular pacing.

MR in Patients with Pacemakers and ICDs: Defining the Issues

There has been great controversy related to performance of magnetic resonance imaging in patients with pacemakers and implantable cardiac defibrillators. Recent questions have been raised regarding whether contraindications are absolute or relative. Although there are theoretical as well as documented issues relating to device malfunction, data suggest that scanning patients with devices may be feasible when important clinical questions need to be addressed by following strict guidelines. Advanced knowledge and understanding of electrophysiologic as well as magnetic resonance imaging-related issues, and a multidisciplinary, collaborative approach is required to further define the role of MR in patients with pacemakers and implantable cardiac defibrillators.

Strategy for safe performance of extrathoracic magnetic resonance imaging at 1.5 tesla in the presence of cardiac pacemakers in non-pacemaker-dependent patients: a prospective study with 115 examinations

BACKGROUND

The purpose of the present study was to evaluate a strategy for safe performance of extrathoracic magnetic resonance imaging (MRI) in non-pacemaker-dependent patients with cardiac pacemakers.

METHODS AND RESULTS

Inclusion criteria were presence of a cardiac pacemaker and urgent clinical need for an MRI examination. Pacemaker-dependent patients and those requiring examinations of the thoracic region were excluded. The study group consisted of 82 pacemaker patients who underwent a total of 115 MRI examinations at 1.5T. To minimize radiofrequency-related lead heating, the specific absorption rate was limited to 1.5 W/kg. All pacemakers were reprogrammed before MRI: If heart rate was <60 bpm, the asynchronous mode was programmed to avoid magnetic resonance (MR)-induced inhibition; if heart rate was >60 bpm, sense-only mode was used to avoid MR-induced competitive pacing and potential proarrhythmia. Patients were monitored with ECG and pulse oximetry. All pacemakers were interrogated immediately before and after the MRI examination and after 3 months, including measurement of pacing capture threshold (PCT) and serum troponin I levels. All MR examinations were completed safely. Inhibition of pacemaker output or induction of arrhythmias was not observed. PCT increased significantly from pre- to post-MRI (P=0.017). In 2 of 195 leads, an increase in PCT was only detected at follow-up. In 4 of 114 examinations, troponin increased from a normal baseline value to above normal after MRI, and in 1 case (troponin pre-MRI 0.02 ng/mL, post-MRI 0.16 ng/mL), this increase was associated with a significant increase in PCT.

CONCLUSIONS

Extrathoracic MRI of non-pacemaker-dependent patients can be performed with an acceptable risk-benefit ratio under controlled conditions and by taking both MR- and pacemaker-related precautions.

Magnetic resonance imaging and cardiac pacemaker safety at 1.5-Tesla

OBJECTIVES

The study was done to determine whether patients with pacemakers could safely undergo magnetic resonance imaging (MRI) at 1.5-Tesla (T).

BACKGROUND

Because of theoretical risks, it is an absolute contraindication for a patient with a pacemaker to undergo MRI. However, there are times when an MRI is needed to provide valuable clinical information.

METHODS

Fifty-four patients underwent a total of 62 MRI examinations at 1.5-T. The type of MRI examination was not limited and included cardiac, vascular, and general MRI studies using various whole-body averaged specific absorption rate (SAR) of radiofrequency power. Restrictions were not placed on the type of pacemaker present in the patient. All pacemakers were interrogated immediately before and after MRI scanning, and patients were continuously monitored. Before and after MRI, interrogation was done, and pacing and sensing thresholds, as well as lead impedances, were all measured.

RESULTS

A total of 107 leads and 61 pulse generators were evaluated. No adverse events occurred. Forty (37%) of the leads underwent changes, whereas 10 (9.4%) leads underwent a significant change. Only 2 of the 107 (1.9%) leads required a change in programmed output. Threshold changes were unrelated to cardiac chamber, anatomical location, peak SAR, and time from lead implant to the MRI examination. Electrocardiographic changes and patient symptoms were minor and did not require cessation of MRI.

CONCLUSIONS

Safety was demonstrated in this series of patients with pacemakers at 1.5-T.

Hazardous situation in the MR bore: induction in ECG leads causes fire

There is a potential hazard during examinations of patients with attached or implanted long conductors, e.g. ECG leads: an MR exam of the lumbar spine of a patient was performed in a 1.5-T scanner under ECG monitoring using equipment marked as MR compatible. Standard cabling of 370-cm length was guided without loops from the electrodes through the caudal opening of the magnet bore. During a sagittal T1-weighted turbo-spin-echo scan suddenly a flame of approximately 3 cm arose from the patient's shirt, close to the position of the electrodes. The supervising anaesthesiologist extinguished the flames with his hands. A subsequent physical examination revealed second- to third-degree burns. The analysis of the incident revealed that high voltages can be induced in straight conductors without loops as ECG cables by coupling with the electric component of the HF field. Local heating or sparking can cause an open flame at the position of the electrodes. This danger exists even with ECG equipment that is specifically marked as MR compatible.

Magnetic resonance safety update 2002: implants and devices

The preservation of a safe magnetic resonance (MR) environment requires constant vigilance by MR healthcare professionals, particularly with regard to the management of patients with metallic biomedical implants or devices. The variety and complexity of implants and devices constantly changes, requiring continuous attention and diligence with regard to obtaining the most current and accurate information about these objects relative to the MR environment. This review article discusses MR safety and MR compatibility issues and presents important information for a variety of implants and devices, with an emphasis on those objects that have recently undergone evaluation or that require additional consideration because of existing controversy or confusion.

Magnetic resonance safety testing of a newly-developed fiber-optic cardiac pacing lead

PURPOSE

To assess magnetic resonance (MR) safety for a newly developed, fiber-optic cardiac pacing lead.

MATERIALS AND METHODS

MR safety was assessed for the fiber-optic cardiac pacing lead by evaluating magnetic field interactions and heating. Translational attraction and torque were evaluated using a 1.5-Tesla MR system and previously described, standardized techniques. MR imaging-related heating was assessed using a 1.5-Tesla MR system and a transmit/receive, body radiofrequency (RF) coil with the fiber-optic lead positioned to simulate an in vivo condition in a saline-filled phantom. The phantom had dimensions similar to a human subject's torso and head. A fluoroptic thermometry system was used to record temperatures on and near the electrodes of the fiber-optic pacing lead at five-second intervals immediately before and during 20 minutes of MR imaging performed at a whole-body-averaged specific absorption rate (SAR) of 1.5 W/kg. Temperatures were also recorded from a reference site during this experiment.

RESULTS

Magnetic field interactions for the fiber-optic lead were minimal (deflection angle, 23 degrees; torque, +2). The highest temperature change recorded for the fiber-optic cardiac pacing lead and reference site was +0.8 degrees C.

CONCLUSION

The minor magnetic field interactions and relative lack of heating for the fiber-optic pacing lead indicate that it should be safe for patients with this device to undergo MR imaging procedures using MR systems operating at 1.5-T or less and at a whole-body-averaged SARs up to 1.5 W/kg.

Thermal injuries associated with MRI

Most physicians are aware of the absolute contraindications to magnetic resonance imaging (MRI). However, less familiar is the potential for an MRI-induced thermal or electrical burn associated with electrical monitoring devices. Although detailed studies concerning the burn hazard in MRI have not been reported, it is widely believed that direct electromagnetic induction in looped cables associated with the patient is responsible for the excessive heating and it is on this theory that present guidelines are based. Recent reports have however indicated that other mechanisms may cause the heating of metal, either in or on the patient. This document reviews numerous reported burn injuries sustained during MRI and addresses the underlying heating mechanisms possibly causing these events.

MR imaging and cardiac pacemakers: in-vitro evaluation and in-vivo studies in 51 patients at 0.5 T

PURPOSE

To evaluate the safety and feasibility of magnetic resonance (MR) imaging at 0.5 T in patients with implanted cardiac pacemakers.

MATERIALS AND METHODS

Twenty-one models of pacemakers and 44 pacemaker electrodes were exposed to in vitro MR imaging with continuous registration of pacemaker output and temperature at the lead tip. Prior to MR imaging examination, pacemakers were programmed to an asynchronous mode (A00, V00, or D00). Pacemakers were examined before and after MR imaging. Forty-four patients with implanted pacemakers underwent 51 MR imaging examinations under cardiologic surveillance, continuous electrocardiography, pulse oximetry, and capnographic monitoring.

RESULTS

MR imaging was safely performed in all patients. None of the pacemakers displayed a pacing dysfunction at MR imaging. No changes occurred in the programmed parameters in any device tested in vivo or in vitro. Maximum increases in the temperature at the lead tips were 8.90 degrees C at a specific absorption rate (SAR) of 0.6 W/kg and 23.50 degrees C under a worst-case radio-frequency (RF) heating condition with an SAR of 1.3 W/kg.

CONCLUSION

MR imaging at 0.5 T can be safely performed in patients with implanted pacemakers in carefully selected clinical circumstances when appropriate strategies (programming to an asynchronous mode, adequate monitoring techniques, limited RF exposure) are used.

The AAPM/RSNA physics tutorial for residents. MR imaging safety considerations. Radiological Society of North America

Experience and research over the past decade have demonstrated that diagnostic magnetic resonance (MR) imaging is a biologically safe imaging modality. Specifically, there is currently no convincing evidence that there is any long-term or irreversible biologic effects associated with the radiation and magnetic fields used in MR imaging, specifically radio-frequency (RF) radiation, static magnetic fields, and time-varying gradient fields. However, numerous hazards of MR imaging do exist that can cause severe injuries or even death. These hazards are primarily the result of (a) strong magnetic fields and the strong force that they exert on ferromagnetic objects brought into their influence, including interference with electronic devices such as pacemakers and other implanted electronic devices, and (b) RF burns resulting from inadvertently induced currents in conductive loops placed on the patient's skin surface (eg, electrocardiographic leads and other monitoring devices). Other potential concerns are peripheral nerve stimulation resulting from rapidly switched gradients and auditory noise levels. Establishing a complete and coordinated educational program for all MR imaging facility personnel and conducting effective screening and preparation of patients scheduled for MR imaging procedures are essential to avoid accidents and RF burns and to maintain a safe MR imaging facility.

Recording of EEG during fMRI experiments: patient safety

The acquisition of electroencephalograms (EEG) during functional magnetic resonance imaging (fMRI) experiments raises important practical issues of patient safety. The presence of electrical wires connected to the patient in rapidly changing magnetic fields results in currents flowing through the patient due to induced electromotive forces (EMF), by three possible mechanisms: fixed loop in rapidly changing gradient fields; fixed loop in a RF electromagnetic field; moving loop in the static magnetic field. RF-induced EMFs were identified as the most important potential hazard. We calculated the minimum value of current-limiting resistance to be fitted in each EEG electrode lead for a representative worst case loop, and measured RF magnetic field intensity and heating in a specific type of current-limiting resistors. The results show that electrode resistance should be > or = 13 k(omega) for our setup. The methodology presented is general and can be useful for other centers.