Feasibility of adenosine stress cardiovascular magnetic resonance perfusion imaging in patients with MR-conditional transvenous permanent pacemakers and defibrillators

Abstract

Background The use of stress perfusion-cardiovascular magnetic resonance (CMR) imaging remains limited in patients with implantable devices. The primary goal of the study was to assess the safety, image quality, and the diagnostic value of stress perfusion-CMR in patients with MR-conditional transvenous permanent pacemakers (PPM) or implantable cardioverter-defibrillators (ICD). Methods Consecutive patients with a transvenous PPM or ICD referred for adenosine stress-CMR were enrolled in this single-center longitudinal study. The CMR protocol was performed using a 1.5 T system according to current guidelines while all devices were put in MR-mode. Quality of cine, late-gadolinium-enhancement (LGE), and stress perfusion sequences were assessed. An ischemia burden of ≥ 1.5 segments was considered significant. We assessed the safety, image quality and the occurrence of interference of the magnetic field with the implantable device. In case of ischemia, we also assessed the correlation with the presence of significant coronary lesions on coronary angiography. Results Among 3743 perfusion-CMR examinations, 66 patients had implantable devices (1.7%). Image quality proved diagnostic in 98% of cases. No device damage or malfunction was reported immediately and at 1 year. Fifty patients were continuously paced during CMR. Heart rate and systolic blood pressure remained unchanged during adenosine stress, while diastolic blood pressure decreased (p = 0.007). Six patients (9%) had an ischemia-positive stress CMR and significant coronary stenoses were confirmed by coronary angiography in all cases. Conclusion Stress perfusion-CMR is safe, allows reliable ischemia detection, and provides good diagnostic value.

Hemodynamic response and safety of vasodilator stress cardiovascular magnetic resonance in patients with permanent pacemakers or implantable cardioverter‐defibrillators

“…To this end, Pavon et al recently described a more universal approach of asynchronous pacing in all individuals with >1% pacing on device interrogation, set to 10 bpm above the resting heart rate. 5 The group reported safety of this approach with good image quality in CMRconditional devices and high correlation with subsequent coronary angiography in cases of perfusion defects identified. They further reported no changes in heart rate or systolic blood pressure and a significant decrease in diastolic blood pressure.…”

“…A more universal device reprogramming protocol would have appeal in streamlining tests for this patient population. To this end, Pavon et al recently described a more universal approach of asynchronous pacing in all individuals with >1% pacing on device interrogation, set to 10 bpm above the resting heart rate 5 . The group reported safety of this approach with good image quality in CMR‐conditional devices and high correlation with subsequent coronary angiography in cases of perfusion defects identified.…”

“…One downside to a high rate of asynchronous pacing includes a limitation on assessment of hyperemic response, which can be overcome with assessing the splenic “switch off” sign only if the patients receive adenosine 7 . Diastolic blood pressure decrease might be another manner in which hyperemic response is assessed given our experience as well as that of Pavon et al 5 Some of the factors to consider when choosing between stress SPECT versus CMR are summarized in Table 4.…”

“…Vasodilator stress CMR studies in these individuals have the unique requirement of device reprogramming and patient monitoring to ensure a safe test of adequate diagnostic quality. Limited data exist on the use of vasodilator stress CMR in this cohort, with reports of its performance only in CMR conditional devices and only on 1.5 Tesla systems 3–5 . We sought to expand the understanding of the hemodynamic response of patients with PPMs or ICDs by examining the nuclear vasodilator stress testing environment (where device reprogramming is not required), as well as report on our institutional experience in using vasodilator stress CMR in these individuals.…”

Considerations for stress perfusion cardiac magnetic resonance imaging in patients with cardiac implantable electronic devices

“…Adequacy of vasodilator stressor response is conventionally tracked by using rise of heart rate ≥10 bpm or fall of systolic blood pressure (SBP) > 10 mmHg as hemodynamic markers of adequacy 5 . However, as confirmed by Miller et al 2 in this issue of the Journal , in keeping with a prior study, 6 such thresholds for change in heart rate and SBP are not reliably observed in CIED patients who have been programmed to asynchronous pacing at 10 bpm above usual heart rate for the duration of CMR imaging with adenosine 2,6 or regadenoson 2 . These conventional hemodynamic markers of adequacy of vasodilator stressor challenge therefore cannot be applied in this clinical scenario, of CIED patients programmed to asynchronous pacing at 10 bpm above usual heart rate for the duration of CMR imaging with adenosine or regadenoson.…”