Clinical impact of cardiovascular magnetic resonance with optimized myocardial scar detection in patients with cardiac implantable devices

Abstract

Background: Myocardial scar assessment using late gadolinium enhancement Cardiovascular Magnetic Resonance (LGE CMR) is commonly indicated for patients with cardiac implantable electronic devices (CIEDs), however metal artifact can degrade images. We evaluated the clinical impact of LGE CMR incorporating a device-dependent metal artifact reduction strategy in patients with CIEDs. Methods: 136 CMR studies were performed in 133 consecutive patients (age 56±19 years, 69% male) with CIEDs (22% implantable loop recorders [ILRs], 40% permanent pacemakers [PPMs], 38% implantable cardioverter defibrillators [ICDs]; 42% non-MRI conditional) over 2 years, without complication. LGE imaging was tailored to the CIED, using a wideband sequence for left-sided PPMs and ICDs and conventional sequences for ILRs and right-sided PPMs, scoring segmental artifact. Diagnostic utility and impact on clinical management were scored by consensus of experts. Results: CMR provided unexpected diagnoses in 22 (16%) and changed management in 113 (83%) patients. Myocardial scar was present in 92 (68%), with other abnormalities detected in another 13%. Using conventional LGE, 43 (32%) studies were non-diagnostic (79% of defibrillators) compared to 0% using wideband LGE imaging. Wideband LGE results changed clinical management in an additional 39 (75%) defibrillator patients and 10 (19%) pacemaker patients when compared to imaging with conventional LGE sequences. Conclusion: The clinical yield from CMR using optimized LGE sequences in patients with CIEDs is high with no demonstrated clinical risk. A device-dependent LGE imaging strategy using wideband LGE is needed to achieve clinical utility especially in ICD recipients.

Clinical experience regarding safety and diagnostic value of cardiovascular magnetic resonance in patients with a subcutaneous implanted cardioverter/defibrillator (S-ICD) at 1.5 T

“…It has been shown recently that a cardiac device in 5-10 cm distance to the heart usually results in a magnetic resonance frequency offset of 2-6 kHz in the myocardium at 1.5-T [15]. As recently shown in patients with conventional cardiac devices [13,[15][16][17][18][19][20][21][22][23], we have used an adiabatic wide-band inversionrecovery pulse with an adjustable frequency offset to improve the myocardial nulling even in the presence of offresonance effects. In the majority of our LGE-images (56%), the respective images showed sufficient quality for a meaningful diagnostic assessment.…”

Making MRI available for patients with cardiac implantable electronic devices: growing need and barriers to change

“…Artifact is related to the type and proximity of the device, being more prominent in ICDs than PPMs due to the greater off-resonance induced by the battery and high-voltage transformer. Strategies to reduce artifact generally yield interpretable results and so ensure clinical yield is high, which is particularly important for patients with ICDs [33]. These strategies include using spoiled gradient echo cines, shorter echo times, or wideband inversion recovery pulses for late gadolinium enhancement [34,35].…”

“…When MRI scans are provided for CIED patients, about a third are for acute indications and another third yield a positive cancer diagnosis [36]. The impact on decision-making is remarkably high [33,37], but is limited to the experience of a few centers [26]. The consequences of not performing these scans can be devastating, particularly for cancer, half of transient ischemic attacks or spinal cord compression-where delayed diagnosis and travelling great distances for an MRI scan are particularly unwarranted [29].…”

The Added Value of Cardiac Magnetic Resonance in Muscular Dystrophies

“…Regarding devices such as pacemaker and defibrillator, currently there are magnetic resonance imaging (MRI) conditional devices and patients can be safely scanned at 1.5T field strength, if followed specific recommendations from the device company [22,23].…”