Chest radiography of contemporary trans-catheter cardiovascular devices: a pictorial essay

Abstract

There is a plethora of cardiovascular devices used for therapy and monitoring, and newer devices are being introduced constantly. As a result of advancement of medical technology and rapid development of such technology to address unmet needs across cardiovascular care, multiple conditions which were previously treated surgically or with medications now benefit from trans-catheter device-based evaluation and management. Moreover, innovation to existing technology has transformed the structural design of many traditional cardiovascular devices, making them safer and enabling easier deployment within the chest (catheter-based versus surgical). A post-procedure chest radiography (CXR) is often the first routine imaging test ordered in these patients. A CXR is a relatively inexpensive and noninvasive imaging tool, which can be obtained at the patient's bedside if needed. Commonly implanted cardiovascular devices can be quite easily checked for appropriate positioning on routine CXRs. Potential complications associated with malpositioning of such devices may be life-threatening. Such complications often manifest early on CXRs and may not be readily apparent on clinical examination. Prompt recognition of such abnormal radiographic appearances is critical for timely diagnosis and effective management. Clinicians need to be familiar with new devices in order to assess proper placement and identify complications related to mal-positioning. This pictorial essay aims to describe the radiologic appearances of contemporary cardiovascular devices, review indications for their usage and potential complications, and discuss magnetic resonance imaging (MRI) compatibility.

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“…Although less common, late embolism, defined as >24 hours post‐op, carries a 2‐fold higher risk of significant adverse events, as is the case of the previously described patient 7 . When rapid evaluation of a potentially dislodged device is necessary in the ED, a 2‐view chest x‐ray is likely to be the most efficient initial imaging modality for confirmation of continued proper placement 8 . On further review of the case, a 1‐view chest x‐ray had been obtained, but the left atrial appendage closure device was not visualized as it had embolized.…”

“…x-ray is likely to be the most efficient initial imaging modality for confirmation of continued proper placement. 8 On further review of the case, a 1-view chest x-ray had been obtained, but the left atrial appendage closure device was not visualized as it had embolized.…”

“… 7 When rapid evaluation of a potentially dislodged device is necessary in the ED, a 2‐view chest x‐ray is likely to be the most efficient initial imaging modality for confirmation of continued proper placement. 8 On further review of the case, a 1‐view chest x‐ray had been obtained, but the left atrial appendage closure device was not visualized as it had embolized. Point‐of‐care transthoracic echocardiogram may prove challenging to view the left atrial appendage closure device, given the positioning within the left atrium, and transesophageal echocardiogram may be necessary.…”

Pre-deployment assessment of an AI model to assist radiologists in chest X-ray detection and identification of lead-less implanted electronic devices for pre-MRI safety screening: realized implementation needs and proposed operational solutions

“…A chest X-ray (CXR) is a standard component of pre-MRI safety screening (for LLIEDs or other man-made objects in the chest). 20 – 27 Such CXR-based screening assumes even greater importance when there is inadequate EMR documentation from lack of a prior visit and/or internal misrecording. 26 – 28 Unfortunately, any LLIED could be overlooked on a CXR due to their mutually small sizes (subject to projection-related distortions), especially when accompanied by (1) Suboptimal radiographic technique (e.g., under-penetration); (2) Patient-related factors (e.g., motion-related blurring); (3) Obscuration by adjacent-internal or superimposed-external radio-opaque or electronic materials.…”

“…In addition, LLIED categories and/or types might be confused with each other by the interpreting radiologist because of (1) LLIEDs having remarkably similar appearances and positions on a frontal CXR (typically the only view acquired in emergency/trauma department or intensive care unit settings, without a lateral view, revealing LLIED intrathoracic location deep within the right ventricle for an LLP versus subcutaneous within the anterior chest wall for an LLR); (2) General lack of familiarity by a radiologist with LLIED-specific characteristics (especially retained legacy systems or recently introduced devices). 23 , 28 These fundamental issues are especially germane to the less familiar, infrequently used, much smaller, and more “stringently” MRI-conditional LLIEDs [e.g., pulmonary artery pressure monitor (PAPM) for heart failure 20 , 24 , 29 ] and MRI-“unsafe” LLIEDs [e.g., esophageal reflux capsule (ERC) for pH-monitoring 3 , 11 , 12 , 14 ], which can easily go unnoticed.…”