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Meier C, Israel C, Eisenblätter M, Hoyer A, Stoye FV, Yilmaz A, Gielen S. Safety of magnetic resonance imaging in patients with cardiac implantable electronic devices and abandoned or epicardial leads: a systematic review and meta-analysis. Europace 2024; 26:euae165. [PMID: 38918179 PMCID: PMC11200101 DOI: 10.1093/europace/euae165] [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] [Received: 01/26/2024] [Accepted: 06/09/2024] [Indexed: 06/27/2024] Open
Abstract
AIMS Persistent reluctance to perform magnetic resonance imaging (MRI) in patients with abandoned and/or epicardial leads of cardiac implantable electronic devices is related to in vitro studies reporting tip heating. While there is a plethora of data on the safety of MRI in conditional and non-conditional implantable devices, there is a clear lack of safety data in patients with abandoned and/or epicardial leads. METHODS AND RESULTS Relevant literature was identified in Medline and CINAHL using the key terms 'magnetic resonance imaging' AND 'abandoned leads' OR 'epicardial leads'. Secondary literature and cross-references were supplemented. For reporting guidance, the Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 was used. International Prospective Register of Systematic Reviews (PROSPERO) registration number 465530. Twenty-one publications with a total of 656 patients with 854 abandoned and/or epicardial leads and 929 MRI scans of different anatomical regions were included. No scan-related major adverse cardiac event was documented, although the possibility of under-reporting of critical events in the literature should be considered. Furthermore, no severe device dysfunction or severe arrhythmia was reported. Mainly transient lead parameter changes were observed in 2.8% in the subgroup of patients with functional epicardial leads. As a possible correlate of myocardial affection, subjective sensations occurred mainly in the subgroup with abandoned epicardial leads (4.0%), but no change in myocardial biomarkers was observed. CONCLUSION Existing publications did not report any relevant adverse events for MRI in patients with abandoned and/or epicardial leads if performed according to strict safety guidelines. However, a more rigorous risk-benefit calculation should be made for patients with epicardial leads.
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Affiliation(s)
- Claudia Meier
- Campus Klinikum Lippe, Universitätsklinikum Ostwestfalen-Lippe, Universitätsklinik für Kardiologie, Angiologie und Internistische Intensivmedizin, Röntgenstraße 18, 32756 Detmold, Germany
- Medizinische Fakultät, Universität Bielefeld, Postfach 10 01 31, 33501 Bielefeld, Germany
| | - Carsten Israel
- Klinik für Innere Medizin, Kardiologie, Nephrologie und Diabetologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Michel Eisenblätter
- Medizinische Fakultät, Universität Bielefeld, Postfach 10 01 31, 33501 Bielefeld, Germany
- Campus Klinikum Lippe, Universitätsklinikum Ostwestfalen-Lippe, Universitätsinstitut für Diagnostische und Interventionelle Radiologie, Detmold, Germany
| | - Annika Hoyer
- Medizinische Fakultät, Universität Bielefeld, Postfach 10 01 31, 33501 Bielefeld, Germany
- Institut für Biostatistik und Medizinische Biometrie, Universität Bielefeld, Bielefeld, Germany
| | - Ferdinand Valentin Stoye
- Medizinische Fakultät, Universität Bielefeld, Postfach 10 01 31, 33501 Bielefeld, Germany
- Institut für Biostatistik und Medizinische Biometrie, Universität Bielefeld, Bielefeld, Germany
| | - Ali Yilmaz
- Herz-MRT-Zentrum, Universitätsklinikum Münster, Münster, Germany
| | - Stephan Gielen
- Campus Klinikum Lippe, Universitätsklinikum Ostwestfalen-Lippe, Universitätsklinik für Kardiologie, Angiologie und Internistische Intensivmedizin, Röntgenstraße 18, 32756 Detmold, Germany
- Medizinische Fakultät, Universität Bielefeld, Postfach 10 01 31, 33501 Bielefeld, Germany
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2
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Greenhill M, Rangan P, Su W, Weiss JP, Zawaneh M, Unzek S, Tamarappoo B, Indik J, Tung R, Morris MF. MRI in Patients with Cardiovascular Implantable Electronic Devices and Fractured or Abandoned Leads. Radiol Cardiothorac Imaging 2024; 6:e230303. [PMID: 38869431 PMCID: PMC11211945 DOI: 10.1148/ryct.230303] [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] [Received: 09/23/2023] [Revised: 04/04/2024] [Accepted: 05/02/2024] [Indexed: 06/14/2024]
Abstract
Purpose To examine the clinical effect of lead length and lead orientation in patients with cardiac implantable electronic devices (CIEDs) and lead fragments or abandoned leads undergoing 1.5-T MRI. Materials and Methods This Health Insurance Portability and Accountability Act-compliant retrospective study included patients with CIEDs and abandoned leads or lead fragments undergoing 1.5-T MRI from March 2014 through July 2020. CIED settings before and after MRI were reviewed, with clinically significant variations defined as a composite of the change in capture threshold of at least 50%, in sensing of at least 40%, or in lead impedance of at least 30% between before MRI and after MRI interrogation. Adverse clinical events were assessed at MRI and up to 30 days after. Univariable and multivariable analysis was performed. Results Eighty patients with 126 abandoned CIED leads or lead fragments underwent 107 1.5-T MRI examinations. Sixty-seven patients (median age, 74 years; IQR, 66-78 years; 44 male patients, 23 female patients) had abandoned leads, and 13 (median age, 66 years; IQR, 52-74 years; nine male patients, four female patients) had lead fragments. There were no reported deaths, clinically significant arrhythmias, or adverse clinical events within 30 days of MRI. Three patients with abandoned leads had a significant change in the composite of capture threshold, sensing, or lead impedance. In a multivariable generalized estimating equation analysis, lead orientation, lead length, MRI type, and MRI duration were not associated with a significant change in the composite outcome. Conclusion Use of 1.5-T MRI in patients with abandoned CIED leads or lead fragments of varying length and orientation was not associated with adverse clinical events. Keywords: Cardiac Assist Devices, MRI, Cardiac Implantable Electronic Device Supplemental material is available for this article. © RSNA, 2024.
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Affiliation(s)
- Mark Greenhill
- From the Department of Radiology (M.G.) and Division of Cardiology
(J.I.), Banner University Medical Center Tucson, Tucson, Ariz; Division of
Clinical Data Analytics, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (P.R.); and Department of Radiology (S.U., B.T., M.F.M.) and
Division of Cardiology (W.S., J.P.W., M.Z., S.U., B.T., R.T., M.F.M.), Banner
University Medical Center Phoenix, 1111 E McDowell Rd, Phoenix, AZ 85006
| | - Pooja Rangan
- From the Department of Radiology (M.G.) and Division of Cardiology
(J.I.), Banner University Medical Center Tucson, Tucson, Ariz; Division of
Clinical Data Analytics, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (P.R.); and Department of Radiology (S.U., B.T., M.F.M.) and
Division of Cardiology (W.S., J.P.W., M.Z., S.U., B.T., R.T., M.F.M.), Banner
University Medical Center Phoenix, 1111 E McDowell Rd, Phoenix, AZ 85006
| | - Wilber Su
- From the Department of Radiology (M.G.) and Division of Cardiology
(J.I.), Banner University Medical Center Tucson, Tucson, Ariz; Division of
Clinical Data Analytics, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (P.R.); and Department of Radiology (S.U., B.T., M.F.M.) and
Division of Cardiology (W.S., J.P.W., M.Z., S.U., B.T., R.T., M.F.M.), Banner
University Medical Center Phoenix, 1111 E McDowell Rd, Phoenix, AZ 85006
| | - J. Peter Weiss
- From the Department of Radiology (M.G.) and Division of Cardiology
(J.I.), Banner University Medical Center Tucson, Tucson, Ariz; Division of
Clinical Data Analytics, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (P.R.); and Department of Radiology (S.U., B.T., M.F.M.) and
Division of Cardiology (W.S., J.P.W., M.Z., S.U., B.T., R.T., M.F.M.), Banner
University Medical Center Phoenix, 1111 E McDowell Rd, Phoenix, AZ 85006
| | - Michael Zawaneh
- From the Department of Radiology (M.G.) and Division of Cardiology
(J.I.), Banner University Medical Center Tucson, Tucson, Ariz; Division of
Clinical Data Analytics, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (P.R.); and Department of Radiology (S.U., B.T., M.F.M.) and
Division of Cardiology (W.S., J.P.W., M.Z., S.U., B.T., R.T., M.F.M.), Banner
University Medical Center Phoenix, 1111 E McDowell Rd, Phoenix, AZ 85006
| | - Samuel Unzek
- From the Department of Radiology (M.G.) and Division of Cardiology
(J.I.), Banner University Medical Center Tucson, Tucson, Ariz; Division of
Clinical Data Analytics, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (P.R.); and Department of Radiology (S.U., B.T., M.F.M.) and
Division of Cardiology (W.S., J.P.W., M.Z., S.U., B.T., R.T., M.F.M.), Banner
University Medical Center Phoenix, 1111 E McDowell Rd, Phoenix, AZ 85006
| | - Balaji Tamarappoo
- From the Department of Radiology (M.G.) and Division of Cardiology
(J.I.), Banner University Medical Center Tucson, Tucson, Ariz; Division of
Clinical Data Analytics, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (P.R.); and Department of Radiology (S.U., B.T., M.F.M.) and
Division of Cardiology (W.S., J.P.W., M.Z., S.U., B.T., R.T., M.F.M.), Banner
University Medical Center Phoenix, 1111 E McDowell Rd, Phoenix, AZ 85006
| | - Julia Indik
- From the Department of Radiology (M.G.) and Division of Cardiology
(J.I.), Banner University Medical Center Tucson, Tucson, Ariz; Division of
Clinical Data Analytics, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (P.R.); and Department of Radiology (S.U., B.T., M.F.M.) and
Division of Cardiology (W.S., J.P.W., M.Z., S.U., B.T., R.T., M.F.M.), Banner
University Medical Center Phoenix, 1111 E McDowell Rd, Phoenix, AZ 85006
| | - Roderick Tung
- From the Department of Radiology (M.G.) and Division of Cardiology
(J.I.), Banner University Medical Center Tucson, Tucson, Ariz; Division of
Clinical Data Analytics, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (P.R.); and Department of Radiology (S.U., B.T., M.F.M.) and
Division of Cardiology (W.S., J.P.W., M.Z., S.U., B.T., R.T., M.F.M.), Banner
University Medical Center Phoenix, 1111 E McDowell Rd, Phoenix, AZ 85006
| | - Michael F. Morris
- From the Department of Radiology (M.G.) and Division of Cardiology
(J.I.), Banner University Medical Center Tucson, Tucson, Ariz; Division of
Clinical Data Analytics, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (P.R.); and Department of Radiology (S.U., B.T., M.F.M.) and
Division of Cardiology (W.S., J.P.W., M.Z., S.U., B.T., R.T., M.F.M.), Banner
University Medical Center Phoenix, 1111 E McDowell Rd, Phoenix, AZ 85006
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3
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Kim D, Collins JD, White JA, Hanneman K, Lee DC, Patel AR, Hu P, Litt H, Weinsaft JW, Davids R, Mukai K, Ng MY, Luetkens JA, Roguin A, Rochitte CE, Woodard PK, Manisty C, Zareba KM, Mont L, Bogun F, Ennis DB, Nazarian S, Webster G, Stojanovska J. SCMR expert consensus statement for cardiovascular magnetic resonance of patients with a cardiac implantable electronic device. J Cardiovasc Magn Reson 2024; 26:100995. [PMID: 38219955 PMCID: PMC11211236 DOI: 10.1016/j.jocmr.2024.100995] [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: 12/13/2023] [Accepted: 01/09/2024] [Indexed: 01/16/2024] Open
Abstract
Cardiovascular magnetic resonance (CMR) is a proven imaging modality for informing diagnosis and prognosis, guiding therapeutic decisions, and risk stratifying surgical intervention. Patients with a cardiac implantable electronic device (CIED) would be expected to derive particular benefit from CMR given high prevalence of cardiomyopathy and arrhythmia. While several guidelines have been published over the last 16 years, it is important to recognize that both the CIED and CMR technologies, as well as our knowledge in MR safety, have evolved rapidly during that period. Given increasing utilization of CIED over the past decades, there is an unmet need to establish a consensus statement that integrates latest evidence concerning MR safety and CIED and CMR technologies. While experienced centers currently perform CMR in CIED patients, broad availability of CMR in this population is lacking, partially due to limited availability of resources for programming devices and appropriate monitoring, but also related to knowledge gaps regarding the risk-benefit ratio of CMR in this growing population. To address the knowledge gaps, this SCMR Expert Consensus Statement integrates consensus guidelines, primary data, and opinions from experts across disparate fields towards the shared goal of informing evidenced-based decision-making regarding the risk-benefit ratio of CMR for patients with CIEDs.
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Affiliation(s)
- Daniel Kim
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | | | - James A White
- Departments of Cardiac Sciences and Diagnostic Imaging, Cummings School of Medicine, University of Calgary, Calgary, Canada
| | - Kate Hanneman
- Department of Medical Imaging, University Medical Imaging Toronto, Toronto General Hospital and Peter Munk Cardiac Centre, University of Toronto, Toronto, Canada
| | - Daniel C Lee
- Department of Medicine (Division of Cardiology), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Amit R Patel
- Cardiovascular Division, University of Virginia, Charlottesville, VA, USA
| | - Peng Hu
- School of Biomedical Engineering, ShanghaiTech University, Shanghai, China
| | - Harold Litt
- Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan W Weinsaft
- Department of Medicine (Division of Cardiology), Weill Cornell Medicine, New York, NY, USA
| | - Rachel Davids
- SHS AM NAM USA DI MR COLLAB ADV-APPS, Siemens Medical Solutions USA, Inc., Chicago, Il, USA
| | - Kanae Mukai
- Salinas Valley Memorial Healthcare System, Ryan Ranch Center for Advanced Diagnostic Imaging, Monterey, CA, USA
| | - Ming-Yen Ng
- Department of Diagnostic Radiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, the Hong Kong Special Administrative Region of China
| | - Julian A Luetkens
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Ariel Roguin
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera and Faculty of Medicine. Technion - Israel Institute of Technology, Israel
| | - Carlos E Rochitte
- Heart Institute, InCor, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Pamela K Woodard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Charlotte Manisty
- Institute of Cardiovascular Science, University College London, London, UK
| | - Karolina M Zareba
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - Lluis Mont
- Cardiovascular Institute, Hospital Clínic, University of Barcelona, Catalonia, Spain
| | - Frank Bogun
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Daniel B Ennis
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Saman Nazarian
- Section of Cardiac Electrophysiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory Webster
- Department of Pediatrics (Cardiology), Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Jadranka Stojanovska
- Department of Radiology, Grossman School of Medicine, New York University, New York, NY, USA
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4
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Stankovic I, Voigt JU, Burri H, Muraru D, Sade LE, Haugaa KH, Lumens J, Biffi M, Dacher JN, Marsan NA, Bakelants E, Manisty C, Dweck MR, Smiseth OA, Donal E. Imaging in patients with cardiovascular implantable electronic devices: part 2-imaging after device implantation. A clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI) and the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J Cardiovasc Imaging 2023; 25:e33-e54. [PMID: 37861420 DOI: 10.1093/ehjci/jead273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 10/15/2023] [Accepted: 10/15/2023] [Indexed: 10/21/2023] Open
Abstract
Cardiac implantable electronic devices (CIEDs) improve quality of life and prolong survival, but there are additional considerations for cardiovascular imaging after implantation-both for standard indications and for diagnosing and guiding management of device-related complications. This clinical consensus statement (part 2) from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists, cardiac imagers, and pacing specialists regarding the use of imaging in patients after implantation of conventional pacemakers, cardioverter defibrillators, and cardiac resynchronization therapy (CRT) devices. The document summarizes the existing evidence regarding the role and optimal use of various cardiac imaging modalities in patients with suspected CIED-related complications and also discusses CRT optimization, the safety of magnetic resonance imaging in CIED carriers, and describes the role of chest radiography in assessing CIED type, position, and complications. The role of imaging before and during CIED implantation is discussed in a companion document (part 1).
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Affiliation(s)
- Ivan Stankovic
- Clinical Hospital Centre Zemun, Department of Cardiology, Faculty of Medicine, University of Belgrade, Vukova 9, 11080 Belgrade, Serbia
| | - Jens-Uwe Voigt
- Department of Cardiovascular Diseases, University Hospitals Leuven/Department of Cardiovascular Sciences, Catholic University of Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Denisa Muraru
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Leyla Elif Sade
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, PA, USA
- University of Baskent, Department of Cardiology, Ankara, Turkey
| | - Kristina Hermann Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway
- Faculty of Medicine, Karolinska Institutet and Cardiovascular Division, Karolinska University Hospital, Stockholm, Sweden
| | - Joost Lumens
- Cardiovascular Research Center Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Mauro Biffi
- Department of Cardiology, IRCCS, Azienda Ospedaliero Universitaria Di Bologna, Policlinico Di S.Orsola, Bologna, Italy
| | - Jean-Nicolas Dacher
- Department of Radiology, Normandie University, UNIROUEN, INSERM U1096-Rouen University Hospital, F 76000 Rouen, France
| | - Nina Ajmone Marsan
- Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, The Netherlands
| | - Elise Bakelants
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Charlotte Manisty
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Little France Crescent, Edinburgh EH16 4SB, UK
| | - Otto A Smiseth
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Rennes, France
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5
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Gakenheimer-Smith L, Ou Z, Kuang J, Moore JP, Burrows A, Kovach J, Dechert B, Beach CM, Ayers M, Tan RB, Mostafavifar M, Mah DY, Conner TM, Turpin S, Avasarala K, Shah MJ, Webster G, Posey J, Etheridge SP, Binka E, Niu M, Asaki SY, Lambert LM, Pilcher TA. Multicenter retrospective evaluation of magnetic resonance imaging in pediatric and congenital heart disease patients with cardiac implantable electronic devices. Heart Rhythm 2023; 20:1752-1758. [PMID: 37648183 DOI: 10.1016/j.hrthm.2023.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 08/04/2023] [Accepted: 08/23/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Guidelines addressing magnetic resonance imaging (MRI) in patients with cardiac implantable electronic devices (CIEDs) provide algorithms for imaging pediatric and congenital heart disease (CHD) patients. Guideline acceptance varies by institution. Guidelines also do not support routine MRI scans in patients with epicardial or abandoned leads, common in pediatric and CHD patients. OBJECTIVE The purpose of this study was to determine the incidence of MRI-related complications in pediatric and CHD patients with CIEDs, including epicardial and/or abandoned leads. METHODS A multicenter retrospective review included patients with CIEDs who underwent any MRI between 2007 and 2022 at congenital cardiac centers. The primary outcome was any patient adverse event or clinically significant CIED change after MRI, defined as pacing lead capture threshold increase >0.5 V with output change, P- or R- wave amplitude decrease >50% with sensitivity change, or impedance change >50%. RESULTS Across 14 institutions, 314 patients (median age 18.8 [1.3; 31.4] years) underwent 389 MRIs. There were 288 pacemakers (74%) and 87 implantable cardioverter-defibrillators (22%); 52% contained epicardial leads, and 14 (4%) were abandoned leads only. Symptoms or CIED changes occurred in 4.9% of MRI scans (6.1% of patients). On 9 occasions (2%), warmth or pain occurred. Pacing capture threshold or lead impedance changes occurred in 1.4% and 2.0% of CIEDs post-MRI and at follow-up. CONCLUSION Our data provide evidence that MRIs can be performed in pediatric and CHD patients with CIEDs, including non-MRI-conditional CIEDs and epicardial and/or abandoned leads, with rare minor symptoms or CIED changes but no other complications.
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Affiliation(s)
- Lindsey Gakenheimer-Smith
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah.
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jinqiu Kuang
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Jeremy P Moore
- Division of Cardiology, Department of Pediatrics, UCLA Medical Center, Los Angeles, California
| | - Austin Burrows
- Division of Cardiology, Department of Pediatrics, UCLA Medical Center, Los Angeles, California
| | - Joshua Kovach
- Department of Pediatrics, Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Brynn Dechert
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | | | - Mark Ayers
- Division of Pediatric Cardiology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Reina Bianca Tan
- Division of Pediatric Cardiology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | | | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tracy Marrs Conner
- Division of Pediatric Cardiology, Washington University in St. Louis, St. Louis, Missouri
| | - Susan Turpin
- UCSF Benioff Children's Hospital, Oakland, California
| | | | - Maully J Shah
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory Webster
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Jessica Posey
- Children's Healthcare of Atlanta Cardiology, Atlanta, Georgia
| | - Susan P Etheridge
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Edem Binka
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Mary Niu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - S Yukiko Asaki
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Linda M Lambert
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Thomas A Pilcher
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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6
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Barison A, Ricci F, Pavon AG, Muscogiuri G, Bisaccia G, Camastra G, De Lazzari M, Lanzillo C, Raguso M, Monti L, Vargiu S, Pedrotti P, Piacenti M, Todiere G, Pontone G, Indolfi C, Dellegrottaglie S, Lombardi M, Schwitter J, Aquaro GD. Cardiovascular Magnetic Resonance in Patients with Cardiac Electronic Devices: Evidence from a Multicenter Study. J Clin Med 2023; 12:6673. [PMID: 37892813 PMCID: PMC10607654 DOI: 10.3390/jcm12206673] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/11/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Most recent cardiac implantable electronic devices (CIEDs) can safely undergo a cardiovascular magnetic resonance (CMR) scan under certain conditions, but metal artifacts may degrade image quality. The aim of this study was to assess the overall diagnostic yield of CMR and the extent of metal artifacts in a multicenter, multivendor study on CIED patients referred for CMR. METHODS We analyzed 309 CMR scans from 292 patients (age 57 ± 16 years, 219 male) with an MR-conditional pacemaker (n = 122), defibrillator (n = 149), or loop recorder (n = 38); CMR scans were performed in 10 centers from 2012 to 2020; MR-unsafe implants were excluded. Clinical and device parameters were recorded before and after the CMR scan. A visual analysis of metal artifacts was performed for each sequence on a segmental basis, based on a 5-point artifact score. RESULTS The vast majority of CMR scans (n = 255, 83%) were completely performed, while only 32 (10%) were interrupted soon after the first sequences and 22 (7%) were only partly acquired; CMR quality was non-diagnostic in 34 (11%) scans, poor (<1/3 sequences were diagnostic) in 25 (8%), or acceptable (1/3 to 2/3 sequences were diagnostic) in 40 (13%), while most scans (n = 201, 68%) were of overall good quality. No adverse event or device malfunctioning occurred, and only nonsignificant changes in device parameters were recorded. The most affected sequences were SSFP (median score 0.32 [interquartile range 0.07-0.91]), followed by GRE (0.18 [0.02-0.59]) and LGE (0.14 [0.02-0.55]). ICDs induced more artifacts (median score in SSFP images 0.87 [0.50-1.46]) than PMs (0.11 [0.03-0.28]) or ILRs (0.11 [0.00-0.56]). Moreover, most artifacts were located in the anterior, anteroseptal, anterolateral, and apical segments of the LV and in the outflow tract of the RV. CONCLUSIONS CMR is a versatile imaging technique, with a high safety profile and overall good image quality even in patients with MR-conditional CIEDs. Several strategies are now available to optimize image quality, substantially enhancing overall diagnostic yield.
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Affiliation(s)
- Andrea Barison
- Fondazione Toscana Gabriele Monasterio, 56127 Pisa, Italy
- Life Science Institute, Scuola Superiore Sant’Anna, 56127 Pisa, Italy
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy
| | - Anna Giulia Pavon
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
| | - Giuseppe Muscogiuri
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
| | - Giandomenico Bisaccia
- Department of Neuroscience, Imaging and Clinical Sciences, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy
| | | | - Manuel De Lazzari
- Department of Cardiac Thoracic and Vascular Sciences and Public Health, University of Padua, 35122 Padova, Italy
| | | | - Mario Raguso
- Ospedale Policlinico Casilino, 00169 Roma, Italy
| | - Lorenzo Monti
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Sara Vargiu
- Cardiologia 3, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Patrizia Pedrotti
- Cardiac Magnetic Resonance Laboratory, Cardiologia 4, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | | | | | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20122 Milan, Italy
| | - Ciro Indolfi
- Division of Cardiology, Magna Graecia University, 88100 Catanzaro, Italy
- Center for Cardiovascular Research, Magna Graecia University, 88100 Catanzaro, Italy
- Mediterranea Cardiocentro, 80122 Naples, Italy
| | - Santo Dellegrottaglie
- Advanced Cardiovascular Imaging Unit, Ospedale Medico-Chirurgico Accreditato Villa dei Fiori, 80011 Acerra, Italy
| | - Massimo Lombardi
- Multimodality Cardiac Imaging Section, IRCCS Policlinico San Donato, 20097 Milan, Italy
| | - Juerg Schwitter
- Division of Cardiology, Cardiovascular Department, University Hospital Lausanne—CHUV, 1011 Lausanne, Switzerland
- CMR Center, University Hospital Lausanne—CHUV, 1011 Lausanne, Switzerland
- Faculty of Biology & Medicine, University of Lausanne—UniL, 1015 Lausanne, Switzerland
| | - Giovanni Donato Aquaro
- Academic Radiology Unit, Department of Surgical Medical and Molecular Pathology and Critical Area, University of Pisa, 56126 Pisa, Italy
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Jiang F, Henry KR, Bhusal B, Sanpitak P, Webster G, Popescu A, Laternser C, Kim D, Golestanirad L. Age Matters: A Comparative Study of RF Heating of Epicardial and Endocardial Electronic Devices in Pediatric and Adult Phantoms during Cardiothoracic MRI. Diagnostics (Basel) 2023; 13:2847. [PMID: 37685385 PMCID: PMC10486594 DOI: 10.3390/diagnostics13172847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 06/29/2023] [Accepted: 08/04/2023] [Indexed: 09/10/2023] Open
Abstract
This study focused on the potential risks of radiofrequency-induced heating of cardiac implantable electronic devices (CIEDs) in children and adults with epicardial and endocardial leads of varying lengths during cardiothoracic MRI scans. Infants and young children are the primary recipients of epicardial CIEDs, though the devices have not been approved as MR conditional by the FDA due to limited data, leading to pediatric hospitals either refusing the MRI service to most pediatric CIED patients or adopting a scan-all strategy based on results from adult studies. The study argues that risk-benefit decisions should be made on an individual basis. We used 120 clinically relevant epicardial and endocardial device configurations in adult and pediatric anthropomorphic phantoms to determine the temperature rise during RF exposure at 1.5 T. The results showed that there was significantly higher RF heating of epicardial leads than endocardial leads in the pediatric phantom, but not in the adult phantom. Additionally, body size and lead length significantly affected RF heating, with RF heating up to 12 °C observed in models based on younger children with short epicardial leads. The study provides evidence-based knowledge on RF-induced heating of CIEDs and highlights the importance of making individual risk-benefit decisions when assessing the potential risks of MRI scans in pediatric CIED patients.
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Affiliation(s)
- Fuchang Jiang
- Department of Biomedical Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Kaylee R. Henry
- Department of Biomedical Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Bhumi Bhusal
- Department of Radiology, Northwestern University, Chicago, IL 60611, USA
| | - Pia Sanpitak
- Department of Radiology, Northwestern University, Chicago, IL 60611, USA
| | - Gregory Webster
- Division of Cardiology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, IL 60611, USA
| | - Andrada Popescu
- Division of Medical Imaging, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, IL 60611, USA
| | - Christina Laternser
- Division of Cardiology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, IL 60611, USA
| | - Daniel Kim
- Department of Radiology, Northwestern University, Chicago, IL 60611, USA
| | - Laleh Golestanirad
- Department of Biomedical Engineering, Northwestern University, Evanston, IL 60208, USA
- Department of Radiology, Northwestern University, Chicago, IL 60611, USA
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8
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Jiang F, Henry KR, Bhusal B, Webster G, Bonmassar G, Kim D, Golestanirad L. RF-induced heating of capped and uncapped abandoned epicardial leads during MRI at 1.5 T and 3 T. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-5. [PMID: 38082570 PMCID: PMC10838566 DOI: 10.1109/embc40787.2023.10340533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
There is a paucity of data regarding the safety of magnetic resonance imaging (MRI) in patients with abandoned epicardial leads. Few studies have reported temperature rises up to 76 °C during MRI at 1.5 T in gel phantoms implanted with epicardial leads; however, lead trajectories used in these experiments were not clinically relevant. This work reports patient-specific RF heating of both capped and uncapped abandoned epicardial lead configurations during MRI at both 1.5 T and 3 T field strengths. We found that leads routed along realistic, patient-derived trajectories generated substantially lower RF heating than the previously reported worst-case phantom experiments. We also found that MRI at the head imaging landmark leads to substantially lower RF heating compared to MRI at the chest or abdomen landmarks at both 1.5 T and 3 T. Our results suggest that patients with abandoned epicardial leads may safely undergo MRI for head imaging, but caution is warranted during chest and abdominal imaging.Clinical Relevance- Patients with abandoned epicardial leads may safely undergo MRI for head imaging, but caution is warranted during chest and abdominal imaging.
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Ma YD, Watson RE, Olson NE, Birgersdotter-Green U, Patel K, Mulpuru SK, Madhavan M, Deshmukh AJ, Killu AM, Friedman PA, Cha YM. Safety of Magnetic Resonance Imaging in Patients with Surgically Implanted Permanent Epicardial Leads. Heart Rhythm 2023:S1547-5271(23)02102-1. [PMID: 37075957 DOI: 10.1016/j.hrthm.2023.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 03/28/2023] [Accepted: 04/09/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) safety in patients with an epicardial cardiac implantable electronic device (CIED) is uncertain. OBJECTIVE To assess the safety and adverse effects of MRI in patients who had surgically implanted epicardial CIED. METHODS Patients with surgically implanted CIEDs who underwent MRI with an appropriate Cardiology-Radiology collaborative protocol between January 2008 and January 2021 were prospectively studied in two clinical centers. All patients underwent close cardiac monitoring through MRI procedures. Outcomes were compared between the epicardial CIED group and matched the non-MRI-conditional transvenous CIED group. RESULTS Twenty-nine consecutive patients with epicardial CIED (male 41.4%, mean age of 43 years) underwent 52 MRIs in the 57 anatomic regions. Sixteen patients had pacemakers, 9 had cardiac defibrillators or cardiac resynchronization therapy defibrillators, and 4 had no device generators. There were no significant adverse events in epicardial or transvenous CIED groups. The battery life, pacing, sensing thresholds, lead impedance and cardiac biomarkers were not significantly changed, except one patient had a transient decrease in atrial lead sensing function. CONCLUSION MRI of CIEDs with epicardially implanted leads does not represent a greater risk than the transvenous CIEDs when performed with a multidisciplinary collaborative protocol centered on patient safety.
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Affiliation(s)
- Yue-Dong Ma
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, China
| | | | - Nora E Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ulrika Birgersdotter-Green
- Department of Cardiovascular Medicine, University of California, San Diego Health System, 200 West Arbor Drive, San Diego, California
| | - Kavisha Patel
- Department of Cardiovascular Medicine, University of California, San Diego Health System, 200 West Arbor Drive, San Diego, California
| | - Siva K Mulpuru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Malini Madhavan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Paul A Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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Vuorinen AM, Lehmonen L, Karvonen J, Holmström M, Kivistö S, Kaasalainen T. Reducing cardiac implantable electronic device-induced artefacts in cardiac magnetic resonance imaging. Eur Radiol 2023; 33:1229-1242. [PMID: 36029346 PMCID: PMC9889467 DOI: 10.1007/s00330-022-09059-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/17/2022] [Accepted: 07/24/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Cardiac implantable electronic device (CIED)-induced metal artefacts possibly significantly diminish the diagnostic value of magnetic resonance imaging (MRI), particularly cardiac MR (CMR). Right-sided generator implantation, wideband late-gadolinium enhancement (LGE) technique and raising the ipsilateral arm to the generator during CMR scanning may reduce the CIED-induced image artefacts. We assessed the impact of generator location and the arm-raised imaging position on the CIED-induced artefacts in CMR. METHODS We included all clinically indicated CMRs performed on patients with normal cardiac anatomy and a permanent CIED with endocardial pacing leads between November 2011 and October 2019 in our institution (n = 171). We analysed cine and LGE sequences using the American Heart Association 17-segment model for the presence of artefacts. RESULTS Right-sided generator implantation and arm-raised imaging associated with a significantly increased number of artefact-free segments. In patients with a right-sided pacemaker, the median percentage of artefact-free segments in short-axis balanced steady-state free precession LGE was 93.8% (IQR 9.4%, n = 53) compared with 78.1% (IQR 20.3%, n = 58) for left-sided pacemaker (p < 0.001). In patients with a left-sided implantable cardioverter-defibrillator, the median percentage of artefact-free segments reached 87.5% (IQR 6.3%, n = 9) using arm-raised imaging, which fell to 62.5% (IQR 34.4%, n = 9) using arm-down imaging in spoiled gradient echo short-axis cine (p = 0.02). CONCLUSIONS Arm-raised imaging represents a straightforward method to reduce CMR artefacts in patients with left-sided generators and can be used alongside other image quality improvement methods. Right-sided generator implantation could be considered in CIED patients requiring subsequent CMR imaging to ensure sufficient image quality. KEY POINTS • Cardiac implantable electronic device (CIED)-induced metal artefacts may significantly diminish the diagnostic value of an MRI, particularly in cardiac MRIs. • Raising the ipsilateral arm relative to the CIED generator is a cost-free, straightforward method to significantly reduce CIED-induced artefacts on cardiac MRIs in patients with a left-sided generator. • Right-sided generator implantation reduces artefacts compared with left-sided implantation and could be considered in CIED patients requiring subsequent cardiac MRIs to ensure adequate image quality in the future.
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Affiliation(s)
- Aino-Maija Vuorinen
- Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, P.O. Box 340, HUS, 00029 Helsinki, Finland
| | - Lauri Lehmonen
- Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, P.O. Box 340, HUS, 00029 Helsinki, Finland
| | - Jarkko Karvonen
- Heart and Lung Center, University of Helsinki and Helsinki University Hospital, P.O. Box 340, HUS, 00029 Helsinki, Finland
| | - Miia Holmström
- Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, P.O. Box 340, HUS, 00029 Helsinki, Finland
| | - Sari Kivistö
- Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, P.O. Box 340, HUS, 00029 Helsinki, Finland
| | - Touko Kaasalainen
- Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, P.O. Box 340, HUS, 00029 Helsinki, Finland
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Occupational Exposure Assessment of the Static Magnetic Field Generated by Nuclear Magnetic Resonance Spectroscopy: A Case Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19137674. [PMID: 35805332 PMCID: PMC9265854 DOI: 10.3390/ijerph19137674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/09/2022] [Accepted: 06/21/2022] [Indexed: 01/27/2023]
Abstract
Magnetic resonance (MR) systems are used in academic research laboratories and industrial research fields, besides representing one of the most important imaging modalities in clinical radiology. This technology does not use ionizing radiation, but it cannot be considered without risks. These risks are associated with the working principle of the technique, which mainly involves static magnetic fields that continuously increase—namely, the radiofrequency (RF) field and spatial magnetic field gradient. To prevent electromagnetic hazards, the EU and ICNIRP have defined workers’ exposure limits. Several studies that assess health risks for workers and patients of diagnostic MR are reported in the literature, but data on workers’ risk evaluation using nuclear MR (NMR) spectroscopy are very poor. Therefore, the aim of this research is the risk assessment of an NMR environment, paying particular attention to workers with active implantable medical devices (AIMDs). Our perspective study consisted of the measurement of the static magnetic field around a 300 MHz (7 T) NMR research spectrometer and the computation of the electric field induced by the movements of an operator. None of the calculated exposure parameters exceeded the threshold limits imposed by legislation for protection against short-term effects of acute occupational exposure, but our results revealed that the level of exposure exceeded the action level threshold limit for workers with AIMD during the execution of tasks requiring the closest proximity to the spectrometer. Moreover, the strong dependence of the induced electric field results from the walking speed models is shown. This case study represents a snapshot of the NMR risk assessment with the specific goal to increase the interest in the safety of NMR environments.
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Mondésert B, Moore JP, Khairy P. Cardiac Implantable Electronic Devices in the Fontan Patient. Can J Cardiol 2022; 38:1048-1058. [PMID: 35588949 DOI: 10.1016/j.cjca.2022.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 12/22/2022] Open
Abstract
As a result of remarkable progress in operative techniques and cardiology care during childhood, Fontan patients continue to age and require team-based multidisciplinary expertise to manage complications encountered in adulthood. They face particular challenges in terms of altered hemodynamic stressors, cardiac and hepatic failure, and arrhythmias. Arrhythmias in Fontan patients are highly prevalent and associated with underlying anatomy, surgical technique, and postoperative sequelae. Diagnostic tools, treatments, and device strategies for arrhythmias in Fontan patients should be adapted to the specific anatomy, type of surgical repair, and clinical status. Great strides in our understanding of arrhythmia mechanisms, options and techniques to obtain access to relevant cardiac structures, and application of both old and new technologies have contributed to improving cardiac implantable electronic device (CIED) therapies for this unique population. In this state-of-the-art review, we discuss the various arrhythmias encountered in Fontan patients, their diagnosis, and options for treatment and prevention, with a focus on CIEDs. Throughout, access challenges particular to the Fontan circulation are considered. Recently developed technologies, such as the sub-cutaneous implantable cardioverter defibrillator carry the potential to be transformative but require awareness of Fontan-specific issues. Moreover, new leadless pacing technology represents a promising strategy that may soon become applicable to Fontan patients with sinus node dysfunction. CIEDs are essential tools in managing Fontan patients but the complex clinical scenarios that arise in this patient population are among the most challenging for the congenital electrophysiologist.
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Affiliation(s)
- Blandine Mondésert
- Adult Congenital Heart Disease Center, Montreal Heart Institute, Medicine Department, Université de Montréal, Montreal, Canada.
| | - Jeremy P Moore
- Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, CA; UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, CA; Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, CA
| | - Paul Khairy
- Adult Congenital Heart Disease Center, Montreal Heart Institute, Medicine Department, Université de Montréal, Montreal, Canada
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