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Wan EY, Rogers AJ, Lavelle M, Marcus M, Stone SA, Ottoboni L, Srivatsa U, Leal MA, Russo AM, Jackson LR, Crossley GH. Periprocedural Management and Multidisciplinary Care Pathways for Patients With Cardiac Implantable Electronic Devices: A Scientific Statement From the American Heart Association. Circulation 2024; 150:e183-e196. [PMID: 38984417 DOI: 10.1161/cir.0000000000001264] [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] [Indexed: 07/11/2024]
Abstract
The rapid technological advancements in cardiac implantable electronic devices such as pacemakers, implantable cardioverter defibrillators, and loop recorders, coupled with a rise in the number of patients with these devices, necessitate an updated clinical framework for periprocedural management. The introduction of leadless pacemakers, subcutaneous and extravascular defibrillators, and novel device communication protocols underscores the imperative for clinical updates. This scientific statement provides an inclusive framework for the periprocedural management of patients with these devices, encompassing the planning phase, procedure, and subsequent care coordinated with the primary device managing clinic. Expert contributions from anesthesiologists, cardiac electrophysiologists, and cardiac nurses are consolidated to appraise current evidence, offer patient and health system management strategies, and highlight key areas for future research. The statement, pertinent to a wide range of health care professionals, underscores the importance of quality care pathways for patient safety, optimal device function, and minimization of hemodynamic disturbances or arrhythmias during procedures. Our primary objective is to deliver quality care to the expanding patient cohort with cardiac implanted electronic devices, offering direction in the era of evolving technologies and laying a foundation for sustained education and practice enhancement.
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Pieri C, Bhuva A, Moralee R, Abiodun A, Gopalan D, Roditi GH, Moon JC, Manisty C. Access to MRI for patients with cardiac pacemakers and implantable cardioverter defibrillators. Open Heart 2021; 8:e001598. [PMID: 34031214 PMCID: PMC8149430 DOI: 10.1136/openhrt-2021-001598] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine provision of MRI for patients with cardiac implantable electronic devices (CIEDs; pacemakers and defibrillators) in England, to understand regional variation and assess the impact of guideline changes. METHODS Retrospective data related to MRI scans performed in patients with CIED over the preceding 12 months was collected using a structured survey tool distributed to every National Health Service Trust MRI unit in England. Data were compared with similar data from 2014/2015 and with demand (estimated from local CIED implantation rates and regional population data by sustainability and transformation partnerships (STPs)). RESULTS Responses were received from 212 of 223 (95%) hospitals in England. 112 (53%) MRI units' scan patients with MR-conditional CIEDs (10% also scan non-MR conditional devices), compared with 46% of sites in 2014/2015. Total annual scan volume increased over fourfold between 2014 and 2019 (1090 to 4896 scans). There was widespread geographical variation, with five STPs (total population >3·5 million representing approximately 25 000 patients with CIED) with no local provision. There was no correlation between local demand (CIED implantation rates) and MRI provision (scan volume). Complication rates were extremely low with three events nationally in 12 months (0·06% CIED-MRI scans). CONCLUSIONS Provision of MRI for patients with CIEDs in England increased over fourfold in 4 years, but an estimated 10-fold care gap remains. Almost half of hospitals and 1 in 10 STPs have no service, with no relationship between local supply and demand. Availability of MRI for patients with non-MR conditional devices, although demonstrably safe, remains limited.
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Affiliation(s)
- Christopher Pieri
- Institute of Health Sciences, Queen Mary University of London Barts and The London School of Medicine and Dentistry, London, UK
| | - Anish Bhuva
- Department of Cardiology, Barts Health NHS Trust, London, UK
- Department of Radiology, Imperial College London, London, UK
| | - Russell Moralee
- Department of Radiology, Imperial College London, London, UK
| | - Aderonke Abiodun
- Department of Cardiology, Barts Health NHS Trust, London, UK
- Department of Radiology, Imperial College London, London, UK
| | - Deepa Gopalan
- Department of Radiology, University of Glasgow, Glasgow, UK
| | - Giles H Roditi
- Department of Cardiovascular Imaging, Barts Heart Centre, London, Greater London, UK
| | - James C Moon
- Department of Cardiology, Barts Health NHS Trust, London, UK
- Department of Radiology, Imperial College London, London, UK
| | - Charlotte Manisty
- Department of Cardiology, Barts Health NHS Trust, London, UK
- Department of Radiology, Imperial College London, London, UK
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Ryan JW, Murray AS, Gilligan PJ, Bisset JM, Nolan C, Doyle A, Emerson B, Galvin JM, Murray JG. MRI safety management in patients with cardiac implantable electronic devices: Utilizing failure mode and effects analysis for risk optimization. Int J Qual Health Care 2020; 32:431-437. [PMID: 32578847 DOI: 10.1093/intqhc/mzaa067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 06/13/2020] [Accepted: 06/20/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Cardiac implantable electronic devices (CIEDs) are increasing in prevalence. Exposing patients with CIEDs to magnetic resonance imaging (MRI) can lead to adverse outcomes. This has led certain radiology departments to not accept MRI referrals related to patients with CIEDs. Patients with MR-conditional CIEDs can be safely scanned under specific conditions. Our institution has accepted such referrals since 2014. The aim of this study was to systematically identify and reduce risk in our CIED-MRI protocol using failure mode and effects analysis (FMEA). METHODS A multidisciplinary FMEA team was assembled and included senior stakeholders from the CIED-MRI protocol. A process map was constructed followed by risk analysis and scoring. Targeted interventions were formulated and implemented; high-risk failure modes were prioritized. A new process map and protocol were drafted and repeat risk analysis was performed. Monitoring and re-evaluation of the CIED-MRI pathway were instigated at departmental quality assurance (QA) meetings. RESULTS Interventions included direct CIED characterization using wireless technology pre-MRI, CIED programming and reprogramming in the MRI suite before and immediately after MRI reducing device downtime and continuous patient monitoring during MRI by a cardiac physiologist. The cumulative risk priority number (RPN) decreased from 1190 pre-FMEA to 492 post-FMEA. DISCUSSION Despite the risk of exposing CIEDs to the MR environment, patients with MR-conditional CIEDs can be safely scanned with an appropriate multidisciplinary support. We found FMEA an indispensable tool in identifying and minimizing risk with no adverse events recorded since FMEA recommendations were implemented.
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Affiliation(s)
- James W Ryan
- Mater Private Hospital, Eccles Street, Dublin, Ireland
| | | | | | | | - Chris Nolan
- Mater Private Hospital, Eccles Street, Dublin, Ireland
| | - Audrey Doyle
- Mater Private Hospital, Eccles Street, Dublin, Ireland
| | - Barry Emerson
- Mater Private Hospital, Eccles Street, Dublin, Ireland
| | | | - John G Murray
- Mater Private Hospital, Eccles Street, Dublin, Ireland
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Abstract
OBJECTIVE. Patients with cardiac implantable electronic devices (CIEDs) require cardiac MRI (CMRI) for a variety of reasons. The purpose of this study is to review and evaluate the value and safety of CMRI for patients with in situ CIEDs. CONCLUSION. Late gadolinium enhancement CMRI is the reference standard for assessing myocardial viability in patients with ventricular tachycardia before ablation of arrhythmogenic substrates. The use of late gadolinium enhancement CMRI for patients with CIEDs is safe as long as an imaging protocol is in place and precaution measures are taken.
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Bauer WR, Lau DH, Wollmann C, McGavigan A, Mansourati J, Reiter T, Frömer S, Ladd ME, Quick HH. Clinical safety of ProMRI implantable cardioverter-defibrillator systems during head and lower lumbar magnetic resonance imaging at 1.5 Tesla. Sci Rep 2019; 9:18243. [PMID: 31796767 PMCID: PMC6890633 DOI: 10.1038/s41598-019-54342-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 11/05/2019] [Indexed: 11/21/2022] Open
Abstract
Magnetic resonance imaging (MRI) has long been contraindicated in patients with implanted pacemakers, defibrillators, and cardiac resynchronisation therapy (CRT) devices due to the risk of adverse effects through electromagnetic interference. Since many recipients of these devices will have a lifetime indication for an MRI scan, the implantable systems should be developed as ‘MRI-conditional’ (be safe for the MRI environment under predefined conditions). We evaluated the clinical safety of several Biotronik ProMRI (‘MRI-conditional’) defibrillator and CRT systems during head and lower lumbar MRI scans at 1.5 Tesla. The study enrolled 194 patients at 22 sites in Australia, Canada, and Europe. At ≥9 weeks after device implantation, predefined, non-diagnostic, specific absorption rate (SAR)-intensive head and lower lumbar MRI scans (total ≈30 minutes per patient) were performed in 146 patients that fulfilled pre-procedure criteria. Three primary endpoints were evaluated: freedom from serious adverse device effects (SADEs) related to MRI and defibrillator/CRT (leading to death, hospitalisation, life-threatening condition, or potentially requiring implanted system revision or replacement), pacing threshold increase, and sensing amplitude decrease, all at the 1-month post-MRI clinical visit. No MRI-related SADE occurred. Lead values remained stable, measured in clinic and monitored daily by the manufacturer home monitoring technology.
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Affiliation(s)
- Wolfgang Rudolf Bauer
- Department of Internal Medicine I, Universitätsklinikum Würzburg, Würzburg, Germany.
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Christian Wollmann
- Department of Internal Medicine III, Universitätsklinikum St. Pölten, St. Pölten, Austria.,Institute of Cardiovascular Research, Karl-Landsteiner Society, St. Pölten, Austria
| | | | - Jacques Mansourati
- Hôpital de la Cavale Blanche, University Hospital of Brest and University of Western Brittany, Brest, France
| | - Theresa Reiter
- Department of Internal Medicine I, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Simone Frömer
- Centre for Clinical Research, BIOTRONIK SE & Co. KG, Berlin, Germany
| | - Mark E Ladd
- Medical Physics in Radiology, German Cancer Research Center, Heidelberg, Germany.,Faculty of Physics and Astronomy and Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
| | - Harald H Quick
- High-Field and Hybrid MR Imaging, University Hospital Essen, Essen, Germany.,Erwin L. Hahn Institute for MR Imaging, University Duisburg-Essen, Essen, Germany
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Bhuva AN, Moralee R, Moon JC, Manisty CH. Making MRI available for patients with cardiac implantable electronic devices: growing need and barriers to change. Eur Radiol 2019; 30:1378-1384. [PMID: 31776746 PMCID: PMC7033076 DOI: 10.1007/s00330-019-06449-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/02/2019] [Accepted: 09/12/2019] [Indexed: 11/22/2022]
Abstract
Abstract More than half of us will need a magnetic resonance imaging (MRI) scan in our lifetimes. MRI is an unmatched diagnostic test for an expanding range of indications including neurological and musculoskeletal disorders, cancer diagnosis, and treatment planning. Unfortunately, patients with cardiac pacemakers or defibrillators have historically been prevented from having MRI because of safety concerns. This results in delayed diagnoses, more invasive investigations, and increased cost. Major developments have addressed this—newer devices are designed to be safe in MRI machines under specific conditions, and older legacy devices can be scanned provided strict protocols are followed. This service however remains difficult to deliver sustainably worldwide: MRI provision remains grossly inadequate because patients are less likely to be referred, and face difficulties accessing services even when referred. Barriers still exist but are no longer technical. These include logistical hurdles (poor cardiology and radiology interaction at physician and technician levels), financial incentives (re-imbursement is either absent or fails to acknowledge the complexity), and education (physicians self-censor MRI requests). This article therefore highlights the recent changes in the clinical, logistical, and regulatory landscape. The aim of the article is to enable and encourage healthcare providers and local champions to build MRI services urgently for cardiac device patients, so that they may benefit from the same access to MRI as everyone else. Key Points • There is now considerable evidence that MRI can be provided safely to patients with cardiac implantable electronic devices (CIEDs). However, the volume of MRI scans delivered to patients with CIEDs is fifty times lower than that of the estimated need, and patients are approximately fifty times less likely to be referred. • Because scans for this patient group are frequently for cancer diagnosis and treatment planning, MRI services need to develop rapidly, but the barriers are no longer technical. • New services face logistical, educational, and financial hurdles which can be addressed effectively to establish a sustainable service at scale.
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Affiliation(s)
- A N Bhuva
- Department of Cardiac Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK. .,Institute for Cardiovascular Science, University College London, London, UK.
| | - R Moralee
- Department of Cardiac Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - J C Moon
- Department of Cardiac Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Institute for Cardiovascular Science, University College London, London, UK
| | - C H Manisty
- Department of Cardiac Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Institute for Cardiovascular Science, University College London, London, UK
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