[Magnetic resonance imaging of the brain in patients with cardiac pacemakers. Experimental and clinical investigations at 1.5 Tesla]

Interference of cardiovascular implantable electronic devices by static electric and magnetic fields

Introduction: Electromagnetic interference (EMI) of cardiovascular implantable electronic devices (CIED) can lead to malfunctions and pose a danger for implant carriers. The increased use of DC technologies, e.g. in electric mobility, creates more static fields representing an increasing hazard for implant carriers.Areas covered: A combination of approaches was used to determine thresholds for EMI by static fields. A literature search was conducted to identify relevant EMI mechanisms and to extract possible thresholds. The literature search revealed four interference mechanisms caused by static magnetic fields and none for static electric fields. Due to the scarce information on motion-induced EMI, numerical simulations were performed to obtain a threshold. The simulation results were evaluated using medical product standards and benchmark tests on commercially available CIEDs. The results show that motion-induced interference should not occur below the activation of the magnetic safety switch (reed switch or Hall-effect sensor, MSS).Expert opinion: The determined threshold for motion-induced EMI at 24.8 mT shows that the MSS activation is still the most relevant mechanism that can occur at 0.8 mT. Limit values for the general population do not protect implant carriers from EMI.

MRI in patients with pacemakers: overview and procedural management

BACKGROUND

Magnetic resonance imaging (MRI) is generally contraindicated for patients with a pacemaker (PM) or implantable cardiac defibrillator (ICD), because of the risk of life-threatening interference with the device. Nevertheless, the question whether to perform MRI despite the presence of these devices can still arise when MRI is vitally indicated. In some hospitals, special precautionary measures are taken so that MRI can be performed in such cases.

METHODS

This review is based on the authors' experience in 42 patients who underwent MRI at our university hospital, on the pertinent literature, and on the recommendations of medical societies.

RESULTS

Because of its excellent image quality, MRI is often an indispensable diagnostic tool. Structured multidisciplinary management enables it to be performed safely even in patients with a PM or ICD. Pre- and post-MRI checks of the device are recommended, as well as extensive monitoring and the availability of the necessary personnel to deal with an emergency. In general, the pacing and defibrillator functions should be deactivated; for pacemaker-dependent patients, the asynchronous pacing mode should be activated. No serious incidents have occurred when these precautions have been observed, either among our own patients or in the literature. Newer PM systems have been approved for MRI scanning under certain conditions.

CONCLUSION

In patients with a PM or ICD, the benefit of MRI may far outweigh its risks if the indication has been established for the particular patient as an interdisciplinary decision and if the appropriate precautions are observed during scanning. Now that newer PM systems have been approved for MRI scanning, the problem seems close to being solved.

Magnetic resonance imaging in patients with cardiac pacemakers: era of "MR Conditional" designs

Advances in cardiac device technology have led to the first generation of magnetic resonance imaging (MRI) conditional devices, providing more diagnostic imaging options for patients with these devices, but also new controversies. Prior studies of pacemakers in patients undergoing MRI procedures have provided groundwork for design improvements. Factors related to magnetic field interactions and transfer of electromagnetic energy led to specific design changes. Ferromagnetic content was minimized. Reed switches were modified. Leads were redesigned to reduce induced currents/heating. Circuitry filters and shielding were implemented to impede or limit the transfer of certain unwanted electromagnetic effects. Prospective multicenter clinical trials to assess the safety and efficacy of the first generation of MR conditional cardiac pacemakers demonstrated no significant alterations in pacing parameters compared to controls. There were no reported complications through the one month visit including no arrhythmias, electrical reset, inhibition of generator output, or adverse sensations. The safe implementation of these new technologies requires an understanding of the well-defined patient and MR system conditions. Although scanning a patient with an MR conditional device following the strictly defined patient and MR system conditions appears straightforward, issues related to patients with pre-existing devices remain complex. Until MR conditional devices are the routine platform for all of these devices, there will still be challenging decisions regarding imaging patients with pre-existing devices where MRI is required to diagnose and manage a potentially life threatening or serious scenario. A range of other devices including ICDs, biventricular devices, and implantable physiologic monitors as well as guidance of medical procedures using MRI technology will require further biomedical device design changes and testing. The development and implementation of cardiac MR conditional devices will continue to require the expertise and collaboration of multiple disciplines and will need to prove safety, effectiveness, and cost effectiveness in patient care.

[Magnetic resonance imaging in orthopaedic medicine]

Magnetic resonance imaging (MRI) is an established diagnostic tool in orthopaedics. Superior soft tissue contrast, lack of ionised radiation and free slice orientation are the key points for optimal evaluation of joint structures, muscles and ligaments. Application of contrast agents improves the detection of inflammation and tumour tissue. However, measuring and interpretation of magnetic resonance imaging is a challenge both for orthopaedists and radiologists. Basic requirements for good diagnosis are clinical findings, plain radiographs and a clear indication. This report provides information about the method of magnetic resonance imaging, artefacts, indications, risks and drawbacks as well as limitations of this method that necessitate alternative imaging modalities.

Clinical utility and safety of a protocol for noncardiac and cardiac magnetic resonance imaging of patients with permanent pacemakers and implantable-cardioverter defibrillators at 1.5 tesla

BACKGROUND

Magnetic resonance imaging (MRI) is an important diagnostic modality currently unavailable for millions of patients because of the presence of implantable cardiac devices. We sought to evaluate the diagnostic utility and safety of noncardiac and cardiac MRI at 1.5T using a protocol that incorporates device selection and programming and limits the estimated specific absorption rate of MRI sequences.

METHODS AND RESULTS

Patients with no imaging alternative and with devices shown to be MRI safe by in vitro phantom and in vivo animal testing were enrolled. Of 55 patients who underwent 68 MRI studies, 31 had a pacemaker, and 24 had an implantable defibrillator. Pacing mode was changed to "asynchronous" for pacemaker-dependent patients and to "demand" for others. Magnet response and tachyarrhythmia functions were disabled. Blood pressure, ECG, oximetry, and symptoms were monitored. Efforts were made to limit the system-estimated whole-body average specific absorption rate to 2.0 W/kg (successful in >99% of sequences) while maintaining the diagnostic capability of MRI. No episodes of inappropriate inhibition or activation of pacing were observed. There were no significant differences between baseline and immediate or long-term (median 99 days after MRI) sensing amplitudes, lead impedances, or pacing thresholds. Diagnostic questions were answered in 100% of nonthoracic and 93% of thoracic studies. Clinical findings included diagnosis of vascular abnormalities (9 patients), diagnosis or staging of malignancy (9 patients), and assessment of cardiac viability (13 patients).

CONCLUSIONS

Given appropriate precautions, noncardiac and cardiac MRI can potentially be safely performed in patients with selected implantable pacemaker and defibrillator systems.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Strategy for Safe Performance of Magnetic Resonance Imaging on a Patient with Implantable Cardioverter Defibrillator

Clinically indicated magnetic resonance imaging (MRI) of the brain was safely performed at 1.5 T on a patient with an implantable cardioverter defibrillator (ICD). The ICD was reprogrammed to detection only, and imaging hardware and protocols were modified to minimize radiofrequency power deposition to the ICD system. The integrity of the ICD system was verified immediately post-MRI and after 6 weeks, including an ICD test with induction of ventricular fibrillation. This case demonstrates that in exceptional circumstances, in carefully selected patients, and using special precautions, an MRI exam of the brain may be possible in patients with ICDs.