MRI-guided coronary catheterization and PTCA: A feasibility study on a dog model

Quantifying myocardial perfusion during MR-guided interventions without exogenous contrast agents: intra-arterial spin labeling

PURPOSE

To test intra-arterial spin labeling (iASL) using active guiding catheters for myocardial perfusion measurements during magnetic resonance (MR)-guided interventions in a pig study.

METHODS

In this work, a single-loop radiofrequency (RF) coil at the tip of a 6F active coronary catheter was used as a transmit coil for local spin labeling. The transmit magnetic RF field (B1) of the coil and the labeling efficiency were determined, and iASL was tested in two pigs after the catheter was engaged in the aortic root, the ostium of the left coronary artery (LCA) under MR-guidance. The iASL effect was assessed by the signal difference between spin-labeling On and control (spin-labeling OFF) images, and in a cross-correlation between ON/Off states of spin-labeling a binary labeling paradigm. In addition, quantitative myocardial perfusion was calculated from the iASL experiments.

RESULTS

The maximum B1 in the vicinity of the catheter coil was 2.1 µT. A strong local labeling effect with a labeling efficiency of 0.45 was achieved with iASL both in vitro and in vivo. In both pigs, the proximal myocardial segments supplied by the LCA showed significant labelling effect up to distances of 60 mm from the aortic root with a relative signal difference of (3.14 ± 2.89)% in the first and (3.50 ± 1.25)% in the second animal. The mean correlation coefficients were R = 0.63 ± 0.22 and 0.42 ± 0.16, respectively. The corresponding computed myocardial perfusion values in this region of the myocardium were similar to those obtained with contrast perfusion methods ((1.2 ± 1.1) mL/min/g and (0.8 ± 0.6) mL/min/g).

CONCLUSION

The proposed iASL method demonstrates the feasibility of selective myocardial perfusion measurements during MR-guided coronary interventions, which with further technical improvements may provide an alternative to exogenous contrast-based perfusion. Due to the invasive nature of the iASL method, it can potentially be used in concert with MRI-guided coronary angioplasty.

Using Adaptive Imaging Parameters to Improve PEGylated Ultrasmall Iron Oxide Nanoparticles-Enhanced Magnetic Resonance Angiography

The PEGylated ultrasmall iron oxide nanoparticles (PUSIONPs) exhibit longer blood residence time and better biodegradability than conventional gadolinium-based contrast agents (GBCAs), enabling prolonged acquisitions in contrast-enhanced magnetic resonance angiography (CE-MRA) applications. The image quality of CE-MRA is dependent on the contrast agent concentration and the parameters of the pulse sequences. Here, a closed-form mathematical model is demonstrated and validated to automatically optimize the concentration, echo time (TE), repetition time (TR) and flip angle (FA). The pharmacokinetic studies are performed to estimate the dynamic intravascular concentrations within 12 h postinjection, and the adaptive concentration-dependent sequence parameters are determined to achieve optimal signal enhancement during a prolonged measurement window. The presented model is tested on phantom and in vivo rat images acquired from a 3T scanner. Imaging results demonstrate excellent agreement between experimental measurements and theoretical predictions, and the adaptive sequence parameters obtain better signal enhancement than the fixed ones. The low-dose PUSIONPs (0.03 mmol kg-1 and 0.05 mmol kg-1) give a comparable signal intensity to the high-dose one (0.10 mmol kg-1) within 2 h postinjection. The presented mathematical model provides guidance for the optimization of the concentration and sequence parameters in PUSIONPs-enhanced MRA, and has great potential for further clinical translation.

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.

MRI-guided endovascular intervention: current methods and future potential

INTRODUCTION

Image-guided endovascular interventions, performed using the insertion and navigation of catheters through the vasculature, have been increasing in number over the years, as minimally invasive procedures continue to replace invasive surgical procedures. Such endovascular interventions are almost exclusively performed under x-ray fluoroscopy, which has the best spatial and temporal resolution of all clinical imaging modalities. Magnetic resonance imaging (MRI) offers unique advantages and could be an attractive alternative to conventional x-ray guidance, but also brings with it distinctive challenges.

AREAS COVERED

In this review, the benefits and limitations of MRI-guided endovascular interventions are addressed, systems and devices for guiding such interventions are summarized, and clinical applications are discussed.

EXPERT OPINION

MRI-guided endovascular interventions are still relatively new to the interventional radiology field, since significant technical hurdles remain to justify significant costs and demonstrate safety, design, and robustness. Clinical applications of MRI-guided interventions are promising but their full potential may not be realized until proper tools designed to function in the MRI environment are available. Translational research and further preclinical studies are needed before MRI-guided interventions will be practical in a clinical interventional setting.

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.

Magnetic resonance imaging for pathobiological assessment and interventional treatment of the coronary arteries

X-ray-based fluoroscopy is the standard tool for diagnostics and intervention in coronary artery disease. In recent years, computed tomography has emerged as a non-invasive alternative to coronary angiography offering detection of coronary calcification and imaging of the vessel lumen by the use of iodinated contrast agents. Even though currently available invasive or non-invasive techniques can show the degree of vessel stenosis, they are unable to provide information about biofunctional plaque properties, e.g. plaque inflammation. Furthermore, the use of radiation and the necessity of iodinated contrast agents remain unfavourable prerequisites. Magnetic resonance imaging (MRI) is a radiation-free alternative to X-ray which offers anatomical and functional imaging contrasts fostering the idea of non-invasive biofunctional assessment of the coronary vessel wall. In combination with molecular contrast agents that target-specific epitopes of the vessel wall, MRI might reveal unique plaque properties rendering it, for example, ‘vulnerable and prone to rupture’. Early detection of these lesions may allow for early or prophylactic treatment even before an adverse coronary event occurs. Besides diagnostic imaging, advances in real-time image acquisition and motion compensation now provide grounds for MRI-guided coronary interventions. In this article, we summarize our research on MRI-based molecular imaging in cardiovascular disease and feature our advances towards real-time MRI-based coronary interventions in a porcine model.

Real-time magnetic resonance imaging - guided coronary intervention in a porcine model

X-ray fluoroscopy is the gold standard for coronary diagnostics and intervention. Magnetic resonance imaging is a radiation-free alternative to x-ray with excellent soft tissue contrast in arbitrary slice orientation. Here, we assessed real-time MRI-guided coronary interventions from femoral access using newly designed MRI technologies. Six Goettingen minipigs were used to investigate coronary intervention using real-time MRI. Catheters were custom-designed and equipped with an active receive tip-coil to improve visibility and navigation capabilities. Using modified standard clinical 5 F catheters, intubation of the left coronary ostium was successful in all animals. For the purpose of MR-guided coronary interventions, a custom-designed 8 F catheter was used. In spite of the large catheter size, and therefore limited steerability, intubation of the left coronary ostium was successful in 3 of 6 animals within seconds. Thereafter, real-time guided implantation of a non-metallic vascular scaffold into coronary arteries was possible. This study demonstrates that real-time MRI-guided coronary catheterization and intervention via femoral access is possible without the use of any contrast agents or radiation, including placement of non-metallic vascular scaffolds into coronary arteries. Further development, especially in catheter and guidewire technology, will be required to drive forward routine MR-guided coronary interventions as an alternative to x-ray fluoroscopy.

MR-guided Cardiac Interventions

Diagnostic and interventional cardiac catheterization is routinely used in the diagnosis and treatment of congenital heart disease. There are well-established concerns regarding the risk of radiation exposure to patients and staff, particularly in children given the cumulative effects of repeat exposure. Magnetic resonance imaging (MRI) offers the advantage of being able to provide better soft tissue visualization, tissue characterization, and quantification of ventricular volumes and vascular flow. Initial work using MRI catheterization employed fusion of x-ray and MRI techniques, with x-ray fluoroscopy to guide catheter placement and subsequent MRI assessment for anatomical and hemodynamic assessment. Image overlay of 3D previously acquired MRI datasets with live fluoroscopic imaging has also been used to guide catheter procedures.Hybrid x-ray and MRI-guided catheterization paved the way for clinical application and validation of this technique in the assessment of pulmonary vascular resistance and pharmacological stress studies. Purely MRI-guided catheterization also proved possible with passive catheter tracking. First-in-man MRI-guided cardiac catheter interventions were possible due to the development of MRI-compatible guidewires, but halted due to guidewire limitations.More recent developments in passive and active catheter tracking have led to improved visualization of catheters for MRI-guided catheterization. Improvements in hardware and software have also increased image quality and scanning times with better interactive tools for the operator in the MRI catheter suite to navigate through the anatomy as required in real time. This has expanded to MRI-guided electrophysiology studies and radiofrequency ablation in humans. Animal studies show promise for the utility of MRI-guided interventional catheterization. Ongoing investment and development of MRI-compatible guidewires will pave the way for MRI-guided diagnostic and interventional catheterization coming into the mainstream.

Magnetic Resonance Imaging-Guided Cardiac Interventions

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

Ultrasonographic analysis versus histopathologic evaluation of carotid advanced atherosclerotic stenosis in an experimental rabbit model

Advanced carotid atherosclerosis with severe stenosis (>70%) is a major clinical risk factor for ischemic stroke. Our ability to test new protocols for the treatment of atherosclerotic stenosis in humans is limited for obvious ethical reasons; therefore, a suitable animal model is required. The aim of this study was to generate an easily reproducible and inexpensive experimental rabbit carotid model of advanced atherosclerosis with morphological similarities to the human disease and the subsequent assessment of the reliability of B-mode ultrasound technology in the study of lumen area stenosis in this model. Briefly, New Zealand white rabbits underwent primary perivascular cold injury at the right common carotid artery followed by a 1.5% cholesterol-rich diet injury for eight weeks. All of the rabbits' arteries were imaged by B-mode ultrasound weekly, after which the rabbits were sacrificed, and their vessels were processed for histopathology. Ultrasound longitudinal view images from three cardiac cycles were processed by a new computerized analyzing method based on dynamic programming and maximum gradient algorithm for measurement of instantaneous changes in arterial wall thickness and lumen diameter in sequential ultrasound images. Histopathology results showed progressive changes, from the lipid-laden cells and fibrous connective tissue proliferation in neointimal layer, up to the fibro-lipid plaque formation, resulting in vessel wall thickening, remodeling and lumen stenosis. The B-mode ultrasound images and the histologic measurements showed an increase in the mean wall thickness and the lumen area stenosis within eight weeks. Quantitative and morphometric analysis of the mean wall thickness and the lumen area stenosis percentage showed a significant correlation between the B-mode ultrasound and the histological measurements at each time point (R = 0.989 and R = 0.995, p < 0.05, respectively). In conclusion, we successfully produced advanced atherosclerosis in the rabbit carotid artery that is similar to the condition seen in patients. This condition in rabbits can be properly assessed by B-mode ultrasound image processing.

MR imaging-guided cardiovascular interventions in young children

Diagnostic cardiac catheterization procedures in children have been largely replaced by magnetic resonance (MR) imaging studies. However, when invasive catheterization is required, MR imaging has a significant role to play, when combined with invasive pressure measurements. Beyond the established reduction to the radiation dose involved, solely MR image-guided or MR image-assisted catheterization procedures can accurately address clinical questions, such as estimation of pulmonary vascular resistance and cardiac output response to stress, without needing to perform laborious measurements that are prone to errors. This article describes MR image-guided or MR image-assisted cardiac catheterization procedures for diagnosis and intervention in children.

Interventional loopless antenna at 7 T

The loopless antenna magnetic resonance imaging detector is comprised of a tuned coaxial cable with an extended central conductor that can be fabricated at submillimeter diameters for interventional use in guidewires, catheters, or needles. Prior work up to 4.7 T suggests a near-quadratic gain in signal-to-noise ratio with field strength and safe operation at 3 T. Here, for the first time, the signal-to-noise ratio performance and radiofrequency safety of the loopless antenna are investigated both theoretically, using the electromagnetic method-of-moments, and experimentally in a standard 7 T human scanner. The results are compared with equivalent 3 T devices. An absolute signal-to-noise ratio gain of 5.7 ± 1.5-fold was realized at 7 T vs. 3 T: more than 20-fold higher than at 1.5 T. The effective field-of-view area also increased approximately 10-fold compared with 3 T. Testing in a saline gel phantom suggested that safe operation is possible with maximum local 1-g average specific absorption rates of <12 W kg(-1) and temperature increases of <1.9°C, normalized to a 4 W kg(-1) radiofrequency field exposure at 7 T. The antenna did not affect the power applied to the scanner's transmit coil. The signal-to-noise ratio gain enabled magnetic resonance imaging microscopy at 40-50 μm resolution in diseased human arterial specimens, offering the potential of high-resolution large-field-of-view or endoscopic magnetic resonance imaging for targeted intervention in focal disease.

Development of a 0.014-in., anti-solenoid loop MR imaging guidewire for intravascular 3.0-T MR imaging

PURPOSE

This study aimed to develop a 0.014-in., anti-solenoid loop (ASL) magnetic resonance imaging guidewire (MRIG) for intravascular 3.0-T MR imaging.

MATERIALS AND METHODS

We first designed the ASL MRIG, which was made of a coaxial cable with its extended inner conductor and outer conductor connected to two micro-anti-solenoids. We then evaluated in vitro the functionality of the ASL MRIG by imaging a "vessel" in a phantom and achieving signal-to-noise ratio (SNR) and SNR contour map of the new 0.014-in. ASL MRIG. Subsequently, we validated in vivo the feasibility of using the ASL MRIG to generate intravenous 3.0-T MR images of parallel iliofemoral arteries of near-human-sized living pigs.

RESULTS

In vitro evaluation showed that the 0.014-in. ASL MRIG functioned well as a receiver coil with the 3.0-T MR scanner, clearly displaying the vessel wall with even distribution of MR signals and SNR contours from the ASL MRIG. Of the in vivo studies, the new ASL MRIG enabled us to successfully generate intravenous 3.0-T MR imaging of the iliofemoral arteries.

CONCLUSION

This study confirms that it is possible to build such small-looped MRIG at 0.014 in. for intravascular 3.0-T MR imaging.

Magnetic Resonance–Guided Cardiac Interventions Using Magnetic Resonance–Compatible Devices

Background—

Percutaneous cardiac interventions are currently performed under x-ray guidance. Magnetic resonance imaging (MRI) has been used to guide intravascular interventions in the past, but mainly in animals. Translation of MR-guided interventions into humans has been limited by the lack of MR-compatible and safe equipment, such as MR guide wires with mechanical characteristics similar to standard guide wires. The aim of the present study was to evaluate the safety and efficacy of a newly developed MR-safe and compatible passive guide wire in aiding MR-guided cardiac interventions in a swine model and describe the 2 first-in-man solely MR-guided interventions.

Methods and Results—

In the preclinical trial, the new MR-compatible wire aided the performance of 20 interventions in 5 swine. These consisted of balloon dilation of nondiseased pulmonary and aortic valves, aortic arch, and branch pulmonary arteries. After ethics and regulatory authority approval, the 2 first-in-man MR-guided interventions were performed in a child and an adult, both with elements of valvar pulmonary stenosis. Catheter manipulations were monitored with real-time MRI sequence with interactive modification of imaging plane and slice position. Temporal resolution was 11 to 12 frames/s. Catheterization procedure times were 110 and 80 minutes, respectively. Both patients had successful relief of the valvar stenosis and no procedural complications.

Conclusions—

The described preclinical study and case reports are encouraging that with the availability of the new MR-compatible and safe guide wire, certain percutaneous cardiac interventions will become feasible to perform solely under MR guidance in the future. A clinical trial is underway in our institution.

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.

The performance of interventional loopless MRI antennae at higher magnetic field strengths

Interventional, "loopless antenna" MRI detectors are currently limited to 1.5 T. This study investigates whether loopless antennae offer signal-to-noise ratio (SNR) and field-of-view (FOV) advantages at higher fields, and whether device heating can be controlled within safe limits. The absolute SNR performance of loopless antennae from 0.5 to 5 T is investigated both analytically, using electromagnetic (EM) dipole antenna theory, and numerically with the EM method of moments, and found to vary almost quadratically with field strength depending on the medium's electrical properties, the noise being dominated by direct sample conduction losses. The prediction is confirmed by measurements of the absolute SNR of low-loss loopless antennae fabricated for 1.5, 3, and 4.7 T, immersed in physiologically comparable saline. Gains of 3.8 +/- 0.2- and 9.7 +/- 0.3-fold in SNR, and approximately 10- and 50-fold gains in the useful FOV area are observed at 3 and 4.7 T, respectively, compared to 1.5 T. Heat testing of a 3 T biocompatible nitinol-antenna fabricated with a redesigned decoupling circuit shows maximum heating of approximately 1 degrees C for MRI operating at high MRI exposure levels. Experiments in the rabbit aorta confirm the SNR and FOV advantages of the 3 T antenna versus an equivalent commercial 1.5 T device in vivo. This work is the first to study the performance of experimental internal MRI detectors above 1.5 T. The large SNR and FOV gains realized present a major opportunity for high-resolution imaging of vascular pathology and MRI-guided intervention.

Intravascular magnetic resonance imaging

The purpose of this article is to review the current state of the art with respect to intravascular magnetic resonance imaging, including intravascular coils, their implementation for plaque identification and characterization, and strategies for future approaches to coronary imaging and other cardiovascular applications.

MR-guided endovascular interventions: a comprehensive review on techniques and applications

The magnetic resonance (MR) guidance of endovascular interventions is probably one of the greatest challenges of clinical MR research. MR angiography is not only an imaging tool for the vasculature but can also simultaneously depict high tissue contrast, including the differentiation of the vascular wall and perivascular tissues, as well as vascular function. Several hurdles had to be overcome to allow MR guidance for endovascular interventions. MR hardware and sequence design had to be developed to achieve acceptable patient access and to allow real-time or near real-time imaging. The development of interventional devices, both applicable and safe for MR imaging (MRI), was also mandatory. The subject of this review is to summarize the latest developments in real-time MRI hardware, MRI, visualization tools, interventional devices, endovascular tracking techniques, actual applications and safety issues.

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.

Effect of bolus length of intraarterial injections on contrast-enhanced MR-angiography in patients

PURPOSE

To perform MR-guided interventions, repetitive injections of contrast agent in the arterial system are necessary. By reducing the intraarterial bolus length during image acquisition and consecutively reducing the gadolinium-chelate-based contrast agent dose, we focus on a comparable vascular depiction. The tradeoff in reducing bolus length is vascular depiction.

MATERIALS AND METHODS

Intraarterial gadolinium-chelate injection was performed to depict the femoropopliteal artery and infrapopliteal arteries in six patients. Six measurements with a bolus length of 20% to 100% of the total acquisition time were performed (three-dimensional [3D] Turbo-fast low-angle shot (FLASH) sequence, 1.5 T). Contrast-to-noise ratio (CNR) was determined and a consensus reading of vascular depiction was performed.

RESULTS

CNR values comparable 100% of bolus length were obtained for the femoropopliteal artery at >or=40% and for the infrapopliteal arteries at >or=60%. Qualitative analysis demonstrated that a bolus length of >or=60% is necessary to reveal a good diagnostic vascular depiction.

CONCLUSION

Quantitatively, a reduction of intraarterial gadolinium-chelate dosage in patients is possible down to 40% in the femoropopliteal artery and to 60% in the infrapopliteal arteries to acquire a CNR comparable to 100% of bolus length. Qualitatively, however, the bolus length can only be reduced down to 60% for both level to produce a good diagnostic vascular depiction and is, for diagnostic purposes, the limiting factor.

Dynamic imaging of contrast-enhanced coronary vessels with a magnetization prepared rotated stripe keyhole acquisition

PURPOSE

To evaluate dynamic coronary imaging based on a magnetization prepared contrast-enhanced (CE) rotated stripe keyhole acquisition scheme.

MATERIALS AND METHODS

Background suppression of long T(1) tissue was used so that the k-space would be selectively dominated by the contribution of the CE vessel. The phase-encoding axis was then adjusted parallel to the long axis of the vessel to sample the significant power spectrum of the vessel. The performance of this approach was evaluated by means of computer simulations and experimental studies on phantoms and a pig model instrumented with an intracoronary catheter for infusion of contrast media.

RESULTS

Computer simulations and phantom studies demonstrated that by rotating the gradient axes to match the k-space pattern of the frequency spectrum, one can reduce the keyhole band to 20% of the full k-space while preserving the structure's lumen width and sharpness. In vivo studies validated those findings, and dynamic angiograms of the CE coronary arteries were obtained as rapidly as 140 msec per image, with an in-plane spatial resolution of 1.5 mm.

CONCLUSION

With efficient background suppression, a rotated stripes keyhole acquisition can efficiently acquire the significant k-space of a CE vessel, and provide improved vessel definition with a reduced acquisition matrices scheme.

MR coronary angiography in pigs with intraarterial injections of a hyperpolarized 13C substance

A new diagnostic application of a water-soluble contrast medium (CM) based on the hyperpolarization of a 13C substance is introduced. The degree of polarization achieved is >30%, which is about a factor of 10(5) higher than the thermal equilibrium polarization level at 1.5 T. Imaging of hyperpolarized (HP) CM during a cardiac interventional MRI procedure was studied. Catheters were positioned in the left and right coronary arteries of pigs. A coil tuned to 13C was used for nonproton imaging. The HP-13C CM ( approximately 5 ml, 0.5 M, approximately 30% polarization) was injected during projection imaging using a fully balanced steady-state free precession (SSFP) pulse sequence with and without cardiac gating. The contrast agent-filled catheter was clearly visible during the procedure. The coronary arteries were well depicted and the signal-to-noise ratios (SNRs) were in the range of 10-40. The use of HP-13C CM may provide a new diagnostic procedure for interventional MRI.

Advances in interventional cardiovascular MRI

Because of its superior soft tissue imaging, MRI has become a valuable diagnostic tool in cardiovascular disease. These strengths make MRI attractive to guide therapeutic catheter-based procedures, both conventional and novel. We review how to configure an interventional MRI suite, how MRI catheter devices differ from conventional radiographic catheters, and finally developments in preclinical and investigational clinical applications.

Real-time MRI guided atrial septal puncture and balloon septostomy in swine

Cardiac perforation during atrial septal puncture (ASP) might be avoided by improved image guidance. X-ray fluoroscopy (XRF), which guides ASP, visualizes tissue poorly and does not convey depth information. Ultrasound is limited by device shadows and constrained imaging windows. Alternatively, real-time MRI (rtMRI) provides excellent tissue contrast in any orientation and may enable ASP and balloon atrial septostomy (BAS) in swine. Custom MRI catheters incorporated "active" (receiver antenna) and "passive" (iron or gadolinium) elements. Wholly rtMRI-guided transfemoral ASP and BAS were performed in 10 swine in a 1.5T interventional suite. Hemodynamic results were measured with catheters and velocity encoded MRI. Successful ASP was performed in all 10 animals. Necropsy confirmed septostomy confined within the fossa ovalis in all. BAS was successful in 9/10 animals. Antenna failure in a re-used needle led to inadvertent vena cava tear prior to BAS in 1 animal. ASP in the same animal was easily performed using a new needle. rtMRI illustrated clear device-tissue-lumen relationships in multiple orientations, and facilitated simple ASP and BAS. The mean procedure time was 19 +/- 10 minutes. Septostomy achieved a mean left to right shunt ratio of 1.3:1 in these healthy animals. Interactive rtMRI permits rapid transcatheter ASP and BAS in swine. Further technical development may enable novel applications.

The future of real-time cardiac magnetic resonance imaging

Dynamic changes in cardiac structure and function are usually examined by real-time imaging techniques such as angiography or echocardiography. MRI has many advantages compared with these established cardiac imaging modalities. However, system hardware and software limitations have limited cardiac MRI to gated acquisitions that are lengthy and often result in failed acquisitions and examinations. Recently, MRI has evolved into a technique capable of imaging dynamic processes in real time. Improvements in hardware, pulse sequences, and image reconstruction algorithms have enabled real-time cardiac MRI with high spatial resolution, high temporal resolution, and various types of image contrast without requiring cardiac gating or breath-holding. This article provides an overview of current capability and highlights key technical and clinical advances. The future prospects of real-time cardiac MRI will depend on 1) the development of techniques that further improve signal to noise ratio, contrast, spatial resolution, and temporal resolution, without introducing artifacts; 2) the development of software infrastructure that facilitates rapid interactive examination; and 3) the development and validation of several new clinical assessments.

Fast magnetization-driven preparation for imaging of contrast-enhanced coronary arteries during intra-arterial injection of contrast agent

PURPOSE

To implement a short-duration magnetization preparation sequence, which consists of a saturation followed by multiple inversion pulses, for imaging of short-T1 species and suppression of long-T1 species.

MATERIALS AND METHODS

Computer optimizations were performed to derive preparation schemes that 1) suppress long-T1 background species with T1>or=250 msec, 2) maximize the MZ of contrast-enhanced (CE) structures with T1<or=50 msec, and 3) have a preparation duration in the range of 200 msec. The optimized sequences were tested on a phantom and a pig model instrumented with an intracoronary catheter for infusion of contrast media.

RESULTS

Computer simulations generated preparation schemes with durations of 165-225 msec depending on the number of preparation pulses used, which generated saturation of over 98% for T1>250 msec, and about a 30% reduction for 20 msec<T1<50 msec. The phantom studies validated the performance of the optimized sequences. Coronary artery angiograms (380 msec for preparation and image acquisition) demonstrated signal-to-noise ratios (SNRs) in the range of 13-15.5 and contrast-to-noise ratios (CNRs) in the range of 6.3-7.1 in the CE coronary vessels.

CONCLUSION

This work demonstrates that fast magnetization-driven preparation schemes can be implemented for fast imaging of CE coronary vessels with efficient saturation of background species.

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.

MR-guided endovascular interventions: device visualization, tracking, navigation, clinical applications, and safety aspects

Reliable visualization and tracking are essential for guiding endovascular devices within blood vessels. The most commonly used methods are susceptibility artifact-based tracking that relies on the artifact created within the image by the device and microcoil- or antenna-based tracking that uses the high signal generated by small MR endovascular receive coils when the transmit coil emits a nonselective radiofrequency pulse. To date, the use of endovascular MR guidance techniques has primarily been confined to animal experiments. There are only a few reports on MR-guided endovascular applications in patients. Therefore, access to the patient within the scanner, dedicated devices, and safety issues remain major challenges. To face these challenges, attention from all radiologists, especially interventional radiologists, is required to make MR-guided endovascular procedures a clinical reality.

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-guided stenting of aortic coarctation with commercially available catheter devices in Swine

BACKGROUND

Real-time MR imaging (rtMRI) is now technically capable of guiding catheter-based cardiovascular interventions. Compared with x-ray, rtMRI offers superior tissue imaging in any orientation without ionizing radiation. Translation to clinical trials has awaited the availability of clinical-grade catheter devices that are both MRI visible and safe. We report a preclinical safety and feasibility study of rtMRI-guided stenting in a porcine model of aortic coarctation using only commercially available catheter devices.

METHOD AND RESULTS

Coarctation stenting was performed wholly under rtMRI guidance in 13 swine. rtMRI permitted procedure planning, device tracking, and accurate stent deployment. "Active" guidewires, incorporating MRI antennas, improved device visualization compared with unmodified "passive" nitinol guidewires and shortened procedure time (26+/-11 versus 106+/-42 minutes; P=0.008). Follow-up catheterization and necropsy showed accurate stent deployment, durable gradient reduction, and appropriate neointimal formation. MRI immediately identified aortic rupture when oversized devices were tested.

CONCLUSIONS

This experience demonstrates preclinical safety and feasibility of rtMRI-guided aortic coarctation stenting using commercially available catheter devices. Patients may benefit from rtMRI in the future because of combined device and tissue imaging, freedom from ionizing radiation, and the ability to identify serious complications promptly.

Radiofrequency-enhanced vascular gene transduction and expression for intravascular MR imaging-guided therapy: feasibility study in pigs

PURPOSE

To evaluate the feasibility of radiofrequency (RF)-enhanced vascular gene transduction and expression by using a magnetic resonance (MR) imaging-heating guidewire as an intravascular heating vehicle during MR imaging-guided therapy.

MATERIALS AND METHODS

The institutional committee for animal care and use approved the experimental protocol. The study included in vitro evaluation of the use of RF energy to enhance gene transduction and expression in vascular cells, as well as in vivo validation of the feasibility of intravascular MR imaging-guided RF-enhanced vascular gene transduction and expression in pig arteries. For in vitro experiments, approximately 10(4) vascular smooth muscle cells were seeded in each of four chambers of a cell culture plate. Next, 1 mL of a green fluorescent protein gene (gfp)-bearing lentivirus was added to each chamber. Chamber 4 was heated at approximately 41 degrees C for 15 minutes by using an MR imaging-heating guidewire connected to a custom RF generator. At day 6 after transduction, the four chambers were examined and compared at confocal microscopy to determine the efficiency of gfp transduction and expression. For the in vivo experiments, a lentivirus vector bearing a therapeutic gene, vascular endothelial growth factor 165 (VEGF-165), was transferred by using a gene delivery balloon catheter in 18 femoral-iliac arteries (nine artery pairs) in domestic pigs and Yucatan pigs with atherosclerosis. During gene infusion, one femoral-iliac artery in each pig was heated to approximately 41 degrees C with RF energy transferred via the intravascular MR imaging-heating guidewire, while the contralateral artery was not heated (control condition). At day 6, the 18 arteries were harvested for quantitative Western blot analysis to compare VEGF-165 transduction and expression efficiency between RF-heated and nonheated arterial groups.

RESULTS

Confocal microscopy showed gfp expression in chamber 4 that was 293% the level of expression in chamber 1 (49.6% +/- 25.8 vs 16.8% +/- 8.0). Results of Western blot analysis showed VEGF-165 expression for normal arteries in the RF-heated group that was 300% the level of expression in the nonheated group (70.4 arbitrary units [au] +/- 107.1 vs 23.5 au +/- 29.8), and, for atherosclerotic arteries in the RF-heated group, 986% the level in the nonheated group (129.2 au +/- 100.3 vs 13.1 au +/- 4.9).

CONCLUSION

Simultaneous monitoring and enhancement of vascular gene delivery and expression is feasible with the MR imaging-heating guidewire.

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.

Feasibility of Stent Placement in Carotid Arteries with Real-time MR Imaging Guidance in Pigs

All examinations were performed with approval from the institutional animal care and use committee of Columbia University. To assess the feasibility of real-time magnetic resonance (MR) imaging-guided neurovascular intervention in a swine model, the authors placed stents in the carotid arteries of five domestic pigs. Seven-French vascular sheaths were placed in the target carotid arteries via femoral access by using active MR tracking. Ten nitinol stents (8-10 x 20-40 mm) were successfully deployed in the target segments of carotid arteries bilaterally. MR imaging and necropsy findings confirmed stent position. Necropsy revealed no gross vascular injury. Study results demonstrated the feasibility of performing real-time MR imaging-guided neurovascular intervention by using an active-tracking technique in an animal model.

Development of a 0.014-inch magnetic resonance imaging guidewire

The purpose of this study was to develop a standard 0.014-inch intravascular magnetic resonance imaging guidewire (MRIG), a coaxial cable with an extension of the inner conductor, specifically designed for use in the small vessels. After a theoretical analysis, the 0.014-inch MRIG was built by plating/cladding highly electrically conductive materials, silver or gold, over the inside and outside of the coaxial conductors. The conductors were made of superelastic, nonmagnetic, biocompatible materials, Nitinol or MP35N. Then, in comparison with a previously designed 0.032-inch MRIG, the performance of the new 0.014-inch MRIG in vitro and in vivo was successfully evaluated. This study represents the initial work to confirm the critical role of highly conductive and superelastic materials in building such small-size MRIGs, which are expected to generate high-resolution MR imaging of vessel walls/plaques and guide endovascular interventional procedures in the small vessels, such as the coronary arteries.

Registration of two-dimensional cardiac images to preprocedural three-dimensional images for interventional applications

PURPOSE

To evaluate the accuracy and efficiency of rigid-body registration of two-dimensional fast cine and real-time cardiac images to high-resolution and SNR three-dimensional preprocedural reference volumes for application during MRI-guided interventional procedures.

MATERIALS AND METHODS

Mutual information (MI) and correlation ratio (CR) similarity measures were evaluated. The dependence of registration accuracy and efficiency on different resolution and SNR parameters, and also on cardiac-phase differences was evaluated in a porcine model. Two-dimensional images were initially misoriented at distances (d) of 2-10 mm, and rotations of +/-5 degrees about all axes. Registration error and computation time were evaluated, and performance was also assessed visually.

RESULTS

The maximum registration error using MI (<2.7 mm and <3.6 degrees ) occurred for d = 10 mm, misrotation of +/-5 degrees , and relative SNR = 1. The computation time was 15 seconds for MI and 10 seconds for CR.

CONCLUSION

Registration accuracy was not highly dependent on the relative timing, within the cycle, between the two-dimensional and three-dimensional images. Registration using CR was faster than that using MI, although accuracy was marginally higher with MI. J.

Transfemoral catheterization of carotid arteries with real-time MR imaging guidance in pigs

All procedures and protocols were approved by the institutional animal care and use committee of Columbia University. To determine whether transfemoral catheterization of the carotid arteries can be performed entirely with real-time magnetic resonance (MR) imaging guidance, the authors catheterized the carotid arteries in six domestic pigs by using active-tracking catheters and guidewires and MR tracking software created for neurovascular procedures. The carotid arteries were successfully catheterized 24 times, on average within 5 minutes after insertion of the catheter into the femoral artery. Results demonstrated the feasibility of performing transfemoral catheterization of the carotid arteries with active MR tracking devices in a conventional MR imaging unit.

Magnetic resonance imaging in myocardial ischemia

PURPOSE OF REVIEW

MRI is a novel strategy to assess myocardial ischemia. It provides information on myocardial perfusion, viability, and potentially the extent of coronary artery disease. This technology may replace many of the current noninvasive and, perhaps, invasive techniques in the diagnosis and management of patients with coronary artery disease. This review aims to cover the major advances in cardiac MRI related to both diagnosis and therapy of myocardial ischemia.

RECENT FINDINGS

Although improved image acquisition techniques have made it possible to obtain excellent image quality in most patients, powerful processing software has permitted the quantification of accurate and reproducible functional information regarding perfusion, wall motion, and viability. Stem cell delivery and gene therapy to the myocardium using cardiac MRI has been shown to be feasible. The use of 3-T systems for cardiac imaging and the imaging of atherosclerosis with MRI are currently being studied.

SUMMARY

MRI is a highly accurate method of characterizing both reversible and irreversible myocardial injury and of obtaining information on myocardial viability. It has the ability to prognostic patients by evaluating ejection fraction and contractility. Robust and uncomplicated methodologies for coronary MR angiography are almost on the horizon. Quantification of several parameters used to diagnose, prognosticate, and follow patients with ischemic heart disease should be much easier in the future. It may, with the recent advances in imaging such as 3-T systems, provide major noninvasive diagnostic capability. Cardiac MRI, with its improved imaging, and its ability to treat and monitor various forms of invasive and noninvasive therapy, may attain its potential as a "one-stop shop" in the near future.

Evaluation of internal MRI coils using ultimate intrinsic SNR

The upper bounds of the signal-to-noise ratio (also known as the "ultimate intrinsic signal-to-noise ratio" (UISNR)) for internal and external coils were calculated. In the calculation, the body was modeled as a dielectric cylinder with a small coaxial cylindrical cavity in which internal coils could be placed. The calculated UISNR values can be used as reference solutions to evaluate the performance of internal MRI coils. As examples, we evaluated the performance of a loopless antenna and an endourethral coil design by comparing their ISNR with the UISNR.

The Catheter-Driven MRI Scanner: A New Approach to Intravascular Catheter Tracking and Imaging-Parameter Adjustment for Interventional MRI

OBJECTIVE

Our aim was to test the feasibility of a hands-free approach to MRI that allows the interventionalist to track an angiographic catheter in real time throughout the procedure and to automatically change imaging parameters by catheter manipulation.

MATERIALS AND METHODS

A tracking method that is based on an active device localization was implemented on a 1.5-T MRI scanner. The system determines the current position and orientation of a catheter in 3D space in an endless feedback loop. Automatic scanning plane-adjustment procedures written in the software of the MRI system ensure image acquisition at the location of the catheter tip. The system calculates the device velocity to automatically adjust parameters such as field of view (FOV) and resolution. To evaluate the feasibility and performance in vivo and ex vivo, we performed experiments in two vessel phantoms and on six pigs.

RESULTS

The system collected the tracking data within 40 msec; an additional 10-20 msec was then required to perform the localization and velocity calculations and to update the image parameters. The system could localize a motionless catheter in the aorta in 100% and a moving catheter in 98% of measured attempts. The system responded in real time to changes in device velocity by dynamically adjusting spatial resolution and FOV in both phantom and porcine trials. Using this technique, we successfully catheterized the renal artery in two pigs.

CONCLUSION

Active tracking, combined with automatic scanning plane and imaging parameter adjustment, provides an intuitive MRI scanner interface for the guidance of the vascular procedure.

Magnetic resonance imaging-guided coronary interventions

Magnetic resonance imaging (MRI) guidance for coronary interventions offers potential advantages over conventional x-ray angiography. Advantages include the use of nonionizing radiation, combined assessment of anatomy and function, and three-dimensional assessment of the coronary arteries leading to the myocardium. These advantages have prompted a series of recent studies in this field. Real-time coronary MR angiography, with low-dose catheter-directed intraarterial (IA) infusion of contrast media, has achieved in-plane spatial resolution as low as 0.8 x 0.8 mm2 and temporal resolution as short as 130 msec per image. Catheter-based IA injection of contrast agent has proven useful in the collection of multislice and three-dimensional images, not only for coronary intervention guidance, but also in the assessment of regional myocardial perfusion fed by the affected vessel. Actively visible guidewires and guiding catheters, based on the loopless antenna concept, have been effectively used to negotiate tortuous coronary vessels during catheterization, permitting placement of coronary angioplasty balloon catheters. Passive tracking approaches have been used to image contrast agent-filled coronary catheters and to place susceptibility-based endovascular stents. Although the field is in its infancy, these early results demonstrate the feasibility for performing MRI-guided coronary interventions. Although further methodological and technical developments are required before these methods become clinically applicable, we anticipate that MRI someday will be included in the armamentarium of techniques used to diagnose and treat coronary artery disease.

The effect of hyperoxygenation on T1 relaxation time in vitro

RATIONALE AND OBJECTIVES

Ventilation with high oxygen (O2) concentrations has been shown to decrease T1 in blood and tissues of patients. This study aims to assess the effect of hyperoxygenation on the T1 relaxation time of blood and other physiologic solutions.

MATERIALS AND METHODS

Varied gaseous mixtures of O2 and air between 21% and 100% O2 were created using an experimental circuit at room temperature, and used to saturate human blood, plasma, or normal saline. The samples were studied using an 8.45-Tesla magnetic resonance (MR) system and a 1.5-Tesla clinical MR scanner.

RESULTS

MR spectroscopy at 8.45 Tesla showed that the percentage of O2 chosen for saturation correlated negatively with T1 (R2 = 1.00 for blood, 0.99 for plasma, and 1.00 for normal saline). The reduction in T1 between solutions saturated with 21% and 100% O2 was 487 milliseconds (22% of the baseline T1 value) for blood, 391 milliseconds (15%) for plasma and 622 milliseconds (19%) for saline. Similarly, MR measurements at 1.5 Tesla showed T1 reduction with increasing O2 concentration. Conclusion. The decreasing T1 in blood depends strongly on the fraction of dissolved O2 in solution and is largely independent of the hemoglobin content.