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Grant EK, Kanter JP, Olivieri LJ, Cross RR, Campbell-Washburn A, Faranesh AZ, Cronin I, Hamann KS, O’Byrne ML, Slack MC, Lederman RJ, Ratnayaka K. X-ray fused with MRI guidance of pre-selected transcatheter congenital heart disease interventions. Catheter Cardiovasc Interv 2019; 94:399-408. [PMID: 31062506 PMCID: PMC6823111 DOI: 10.1002/ccd.28324] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/15/2019] [Accepted: 04/14/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To determine whether X-ray fused with MRI (XFM) is beneficial for select transcatheter congenital heart disease interventions. BACKGROUND Complex transcatheter interventions often require three-dimensional (3D) soft tissue imaging guidance. Fusion imaging with live X-ray fluoroscopy can potentially improve and simplify procedures. METHODS Patients referred for select congenital heart disease interventions were prospectively enrolled. Cardiac MRI data was overlaid on live fluoroscopy for procedural guidance. Likert scale operator assessments of value were recorded. Fluoroscopy time, radiation exposure, contrast dose, and procedure time were compared to matched cases from our institutional experience. RESULTS Forty-six patients were enrolled. Pre-catheterization, same day cardiac MRI findings indicated intervention should be deferred in nine patients. XFM-guided cardiac catheterization was performed in 37 (median age 8.7 years [0.5-63 years]; median weight 28 kg [5.6-110 kg]) with the following prespecified indications: pulmonary artery (PA) stenosis (n = 13), aortic coarctation (n = 12), conduit stenosis/insufficiency (n = 9), and ventricular septal defect (n = 3). Diagnostic catheterization showed intervention was not indicated in 12 additional cases. XFM-guided intervention was performed in the remaining 25. Fluoroscopy time was shorter for XFM-guided intervention cases compared to matched controls. There was no significant difference in radiation dose area product, contrast volume, or procedure time. Operator Likert scores indicated XFM provided useful soft tissue guidance in all cases and was never misleading. CONCLUSIONS XFM provides operators with meaningful three-dimensional soft tissue data and reduces fluoroscopy time in select congenital heart disease interventions.
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Affiliation(s)
- Elena K. Grant
- Department of Cardiology, Children’s National Medical Center, Washington, District of Columbia
- Division of Intramural Research, Cardiovascular Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Joshua P. Kanter
- Department of Cardiology, Children’s National Medical Center, Washington, District of Columbia
| | - Laura J. Olivieri
- Department of Cardiology, Children’s National Medical Center, Washington, District of Columbia
| | - Russell R. Cross
- Department of Cardiology, Children’s National Medical Center, Washington, District of Columbia
| | - Adrienne Campbell-Washburn
- Division of Intramural Research, Cardiovascular Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Anthony Z. Faranesh
- Division of Intramural Research, Cardiovascular Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Ileen Cronin
- Department of Cardiology, Children’s National Medical Center, Washington, District of Columbia
| | - Karin S. Hamann
- Department of Cardiology, Children’s National Medical Center, Washington, District of Columbia
| | - Michael L. O’Byrne
- Divison of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael C. Slack
- Children’s Heart Program, University of Maryland Children’s Heart Program, Baltimore, Maryland
| | - Robert J. Lederman
- Division of Intramural Research, Cardiovascular Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Kanishka Ratnayaka
- Division of Intramural Research, Cardiovascular Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
- Department of Cardiology, Rady Children’s Hospital, San Diego, California
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Ratnayaka K, Kanter JP, Faranesh AZ, Grant EK, Olivieri LJ, Cross RR, Cronin IF, Hamann KS, Campbell-Washburn AE, O’Brien KJ, Rogers T, Hansen MS, Lederman RJ. Radiation-free CMR diagnostic heart catheterization in children. J Cardiovasc Magn Reson 2017; 19:65. [PMID: 28874164 PMCID: PMC5585983 DOI: 10.1186/s12968-017-0374-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 07/17/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Children with heart disease may require repeated X-Ray cardiac catheterization procedures, are more radiosensitive, and more likely to survive to experience oncologic risks of medical radiation. Cardiovascular magnetic resonance (CMR) is radiation-free and offers information about structure, function, and perfusion but not hemodynamics. We intend to perform complete radiation-free diagnostic right heart catheterization entirely using CMR fluoroscopy guidance in an unselected cohort of pediatric patients; we report the feasibility and safety. METHODS We performed 50 CMR fluoroscopy guided comprehensive transfemoral right heart catheterizations in 39 pediatric (12.7 ± 4.7 years) subjects referred for clinically indicated cardiac catheterization. CMR guided catheterizations were assessed by completion (success/failure), procedure time, and safety events (catheterization, anesthesia). Pre and post CMR body temperature was recorded. Concurrent invasive hemodynamic and diagnostic CMR data were collected. RESULTS During a twenty-two month period (3/2015 - 12/2016), enrolled subjects had the following clinical indications: post-heart transplant 33%, shunt 28%, pulmonary hypertension 18%, cardiomyopathy 15%, valvular heart disease 3%, and other 3%. Radiation-free CMR guided right heart catheterization attempts were all successful using passive catheters. In two subjects with septal defects, right and left heart catheterization were performed. There were no complications. One subject had six such procedures. Most subjects (51%) had undergone multiple (5.5 ± 5) previous X-Ray cardiac catheterizations. Retained thoracic surgical or transcatheter implants (36%) did not preclude successful CMR fluoroscopy heart catheterization. During the procedure, two subjects were receiving vasopressor infusions at baseline because of poor cardiac function, and in ten procedures, multiple hemodynamic conditions were tested. CONCLUSIONS Comprehensive CMR fluoroscopy guided right heart catheterization was feasible and safe in this small cohort of pediatric subjects. This includes subjects with previous metallic implants, those requiring continuous vasopressor medication infusions, and those requiring pharmacologic provocation. Children requiring multiple, serial X-Ray cardiac catheterizations may benefit most from radiation sparing. This is a step toward wholly CMR guided diagnostic (right and left heart) cardiac catheterization and future CMR guided cardiac intervention. TRIAL REGISTRATION ClinicalTrials.gov NCT02739087 registered February 17, 2016.
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Affiliation(s)
- Kanishka Ratnayaka
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2c713, MSC 1538, Bethesda, MD 20892-1538 USA
- Division of Cardiology, Rady Children’s Hospital, 3020 Children’s Way, San Diego, CA 92123 USA
| | - Joshua P. Kanter
- Division of Cardiology, Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010 USA
| | - Anthony Z. Faranesh
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2c713, MSC 1538, Bethesda, MD 20892-1538 USA
| | - Elena K. Grant
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2c713, MSC 1538, Bethesda, MD 20892-1538 USA
- Division of Cardiology, Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010 USA
| | - Laura J. Olivieri
- Division of Cardiology, Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010 USA
| | - Russell R. Cross
- Division of Cardiology, Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010 USA
| | - Ileen F. Cronin
- Division of Cardiology, Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010 USA
| | - Karin S. Hamann
- Division of Cardiology, Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010 USA
| | - Adrienne E. Campbell-Washburn
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2c713, MSC 1538, Bethesda, MD 20892-1538 USA
| | - Kendall J. O’Brien
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2c713, MSC 1538, Bethesda, MD 20892-1538 USA
- Division of Cardiology, Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010 USA
| | - Toby Rogers
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2c713, MSC 1538, Bethesda, MD 20892-1538 USA
| | - Michael S. Hansen
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2c713, MSC 1538, Bethesda, MD 20892-1538 USA
| | - Robert J. Lederman
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2c713, MSC 1538, Bethesda, MD 20892-1538 USA
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Grant EK, Berul CI, Cross RR, Moak JP, Hamann KS, Sumihara K, Cronin I, O'Brien KJ, Ratnayaka K, Hansen MS, Kellman P, Olivieri LJ. Acute Cardiac MRI Assessment of Radiofrequency Ablation Lesions for Pediatric Ventricular Arrhythmia: Feasibility and Clinical Correlation. J Cardiovasc Electrophysiol 2017; 28:517-522. [PMID: 28245348 DOI: 10.1111/jce.13197] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 12/28/2016] [Accepted: 01/18/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Arrhythmia ablation with current techniques is not universally successful. Inadequate ablation lesion formation may be responsible for some arrhythmia recurrences. Periprocedural visualization of ablation lesions may identify inadequate lesions and gaps to guide further ablation and reduce risk of arrhythmia recurrence. METHODS This feasibility study assessed acute postprocedure ablation lesions by MRI, and correlated these findings with clinical outcomes. Ten pediatric patients who underwent ventricular tachycardia ablation were transferred immediately postablation to a 1.5T MRI scanner and late gadolinium enhancement (LGE) imaging was performed to characterize ablation lesions. Immediate and mid-term arrhythmia recurrences were assessed. RESULTS Patient characteristics include median age 14 years (1-18 years), median weight 52 kg (11-81 kg), normal cardiac anatomy (n = 6), d-transposition of great arteries post arterial switch repair (n = 2), anomalous coronary artery origin post repair (n = 1), and cardiac rhabdomyoma (n = 1). All patients underwent radiofrequency catheter ablation of ventricular arrhythmia with acute procedural success. LGE was identified at the reported ablation site in 9/10 patients, all arrhythmia-free at median 7 months follow-up. LGE was not visible in 1 patient who had recurrence of frequent premature ventricular contractions within 2 hours, confirmed on Holter at 1 and 21 months post procedure. CONCLUSIONS Ventricular ablation lesion visibility by MRI in the acute post procedure setting is feasible. Lesions identifiable with MRI may correlate with clinical outcomes. Acute MRI identification of gaps or inadequate lesions may provide the unique temporal opportunity for additional ablation therapy to decrease arrhythmia recurrence.
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Affiliation(s)
- Elena K Grant
- Department of Cardiology, Children's National Health System, Washington, District of Columbia, USA.,Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Charles I Berul
- Department of Cardiology, Children's National Health System, Washington, District of Columbia, USA
| | - Russell R Cross
- Department of Cardiology, Children's National Health System, Washington, District of Columbia, USA
| | - Jeffrey P Moak
- Department of Cardiology, Children's National Health System, Washington, District of Columbia, USA
| | - Karin S Hamann
- Department of Cardiology, Children's National Health System, Washington, District of Columbia, USA
| | - Kohei Sumihara
- Department of Cardiology, Children's National Health System, Washington, District of Columbia, USA
| | - Ileen Cronin
- Department of Cardiology, Children's National Health System, Washington, District of Columbia, USA
| | - Kendall J O'Brien
- Department of Cardiology, Children's National Health System, Washington, District of Columbia, USA
| | - Kanishka Ratnayaka
- Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.,Department of Cardiology, Rady Children's Hospital, San Diego, California, USA
| | - Michael S Hansen
- Department of Cardiology, Children's National Health System, Washington, District of Columbia, USA.,Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Peter Kellman
- Department of Cardiology, Children's National Health System, Washington, District of Columbia, USA.,Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Laura J Olivieri
- Department of Cardiology, Children's National Health System, Washington, District of Columbia, USA
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Grant EK, Faranesh AZ, Cross RR, Olivieri LJ, Hamann KS, O'Brien KJ, Hansen MS, Donofrio MT, Lederman RJ, Ratnayaka K, Slack MC. Image Fusion Guided Device Closure of Left Ventricle to Right Atrium Shunt. Circulation 2016; 132:1366-7. [PMID: 26438770 DOI: 10.1161/circulationaha.115.013724] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Elena K Grant
- From Department of Cardiology, Children's National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children's Heart Program, Baltimore, MD (M.C.S.).
| | - Anthony Z Faranesh
- From Department of Cardiology, Children's National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children's Heart Program, Baltimore, MD (M.C.S.)
| | - Russell R Cross
- From Department of Cardiology, Children's National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children's Heart Program, Baltimore, MD (M.C.S.)
| | - Laura J Olivieri
- From Department of Cardiology, Children's National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children's Heart Program, Baltimore, MD (M.C.S.)
| | - Karin S Hamann
- From Department of Cardiology, Children's National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children's Heart Program, Baltimore, MD (M.C.S.)
| | - Kendall J O'Brien
- From Department of Cardiology, Children's National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children's Heart Program, Baltimore, MD (M.C.S.)
| | - Michael S Hansen
- From Department of Cardiology, Children's National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children's Heart Program, Baltimore, MD (M.C.S.)
| | - Mary T Donofrio
- From Department of Cardiology, Children's National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children's Heart Program, Baltimore, MD (M.C.S.)
| | - Robert J Lederman
- From Department of Cardiology, Children's National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children's Heart Program, Baltimore, MD (M.C.S.)
| | - Kanishka Ratnayaka
- From Department of Cardiology, Children's National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children's Heart Program, Baltimore, MD (M.C.S.)
| | - Michael C Slack
- From Department of Cardiology, Children's National Medical Center, Washington, DC (E.K.G., A.Z.F., R.R.C., L.J.O., K.S.H., K.J.O., M.S.H., M.T.D., R.J.L., K.R.); Division of Intramural Research, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (E.K.G., A.Z.F., M.S.H., R.J.L., K.R.); and University of Maryland Children's Heart Program, Baltimore, MD (M.C.S.)
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