Elsevier

Heart Rhythm

Volume 14, Issue 7, July 2017, Pages e97-e153
Heart Rhythm

News From the Heart Rhythm Society
2017 HRS expert consensus statement on magnetic resonance imaging and radiation exposure in patients with cardiovascular implantable electronic devices

https://doi.org/10.1016/j.hrthm.2017.04.025Get rights and content

Section snippets

TABLE OF CONTENTS

Section I: Introduction and Methodology ...............e95

Section II: Definitions of CIED Systems in Relation to MRI ..................................................e97

Section III: MRI Technology and Relationship to Risk ............................................e97

Section IV: MR Conditional CIED Technology ....e100

Section V: Management of Patients with a CIED Referred for MRI ........................................e102

Section VI: Management of Patients with a CIED Undergoing CT Imaging

Section I: Introduction and Methodology

This document is intended to help cardiologists, radiologists, radiation oncologists, and other health care professionals involved in the care of adult and pediatric patients with cardiac implantable electronic devices (CIEDs) who are to undergo magnetic resonance imaging (MRI), computed tomography (CT), and/or radiation treatment. We also address the safety of employees with CIEDs who might come into an MRI environment. Our objective is to delineate practical recommendations in appropriate

a. Definition of MR Conditional Systems

The term MR conditional refers to any device for which a specified MRI environment with specified conditions of use does not pose a known hazard. Field conditions that define the MRI environment can include the region of imaging, static magnetic field strength, spatial gradient, time-varying magnetic field (dB/dt), radiofrequency (RF) fields, and specific absorption rate (SAR). Additional conditions might be required, including the use of specific leads and generator combinations, as well as

a. MRI Physics

MRI is the clinical application of the science of nuclear magnetic resonance (NMR) spectroscopy. NMR is based on the physical properties of specific atomic nuclei absorbing and emitting RF energy when placed in an external magnetic field. In clinical MRI, hydrogen nuclei are most often used to generate the images of the anatomy of interest. Hydrogen nuclei exist naturally in the human body in abundance, especially in water and fat; thus, MRI scans essentially map the location of water and fat

Section IV: MR Conditional CIED Technology

As described in Section III, during MRI, three types of fields are present that can, alone or in combination, adversely affect the CIED, the patient, or both: a static magnetic field, gradient magnetic fields, and RF fields. These forces, in varying combinations, lead to the potential for device movement, excess heating, electric current induction, EMI, abnormal reed switch behavior, power-on reset activity, and battery depletion.

Rendering a CIED system MR conditional entails modifying features

a. Identification of Patient and CIED Characteristics

The decision to perform MRI on a patient with a CIED is similar to any other medical decision: There are potential benefits and risks. Factors that influence these risks and benefits should be identified.

Patient characteristics that could increase the risk of bradyarrhythmias or tachyarrhythmias should be understood, such as knowledge of the underlying (intrinsic) rhythm, which will determine the appropriate pacing programming for the MR scan. It must be determined whether the CIED system meets

a. Evidence Review and FDA Advisory

Since its introduction for clinical diagnostic imaging in the 1970s, CT has traditionally been considered safe for patients with CIEDs, including ICDs and permanent PMs. A summary of the evidence is available in Table B3 in Appendix B.

However, potential temporary interactions between CT and CIEDs are possible due to the emission of electromagnetic ionizing radiation during CT imaging (electromagnetic energy of very short wavelengths) resulting in electromagnetic interference. Exposure of the

i. RT Overview

The use of ionizing radiation in the treatment of malignancies and other proliferative disorders spans over a century. The unit of measurement for absorbed radiation dose (i.e., energy deposited) is the Gray (Gy). In general, the total dose to be delivered during the course of radiotherapy is split into daily increments, or fractions, to allow for interval recovery of the surrounding normal tissues. A radiation course can range from a single fraction to 8–9 weeks of daily treatment, depending

Section VIII: Future Directions

The importance of MRI for patient evaluation cannot be overstated, and the presence of a CIED should not preclude the performance of MR scanning when clinically indicated. The growing range of devices now labeled MR conditional is welcome, and further development of MR conditional devices is encouraged. Nevertheless, improvements could be made, particularly in the area of lessening the service burden to the patient and clinical team before, during, and after the performance of MRI. First and

References (143)

  • W.M. Bailey et al.

    Clinical safety of the ProMRI pacemaker system in patients subjected to thoracic spine and cardiac 1.5-T magnetic resonance imaging scanning conditions

    Heart Rhythm

    (2016)
  • K. Awad et al.

    Clinical safety of the Iforia implantable cardioverter-defibrillator system in patients subjected to thoracic spine and cardiac 1.5-T magnetic resonance imaging scanning conditions

    Heart Rhythm

    (2015)
  • H. Tandri et al.

    Determinants of gradient field-induced current in a pacemaker lead system in a magnetic resonance imaging environment

    Heart Rhythm

    (2008)
  • W.M. Bailey et al.

    Clinical safety of the ProMRI pacemaker system in patients subjected to head and lower lumbar 1.5-T magnetic resonance imaging scanning conditions

    Heart Rhythm

    (2015)
  • E.M. Cronin et al.

    Magnetic resonance imaging conditional pacemakers: rationale, development and future directions

    Indian Pacing Electrophysiol J

    (2012)
  • O. Klein-Wiele et al.

    Feasibility and safety of adenosine cardiovascular magnetic resonance in patients with MR conditional pacemaker systems at 1.5 Tesla

    J Cardiovasc Magn Reson

    (2015)
  • C.G. Wollmann et al.

    Monocenter feasibility study of the MRI compatibility of the Evia pacemaker in combination with Safio S pacemaker lead

    J Cardiovasc Magn Reson

    (2012)
  • J.V. Higgins et al.

    “Power-on resets” in cardiac implantable electronic devices during magnetic resonance imaging

    Heart Rhythm

    (2015)
  • S. Inbar et al.

    Case report: nuclear magnetic resonance imaging in a patient with a pacemaker

    Am J Med Sci

    (1993)
  • F. Buendia et al.

    Nuclear magnetic resonance imaging in patients with cardiac pacing devices

    Rev Esp Cardiol

    (2010)
  • E.T. Martin et al.

    Magnetic resonance imaging and cardiac pacemaker safety at 1.5-Tesla

    J Am Coll Cardiol

    (2004)
  • C.P. Naehle et al.

    Magnetic resonance imaging at 1.5-T in patients with implantable cardioverter-defibrillators

    J Am Coll Cardiol

    (2009)
  • J.D. Cohen et al.

    Determining the risks of magnetic resonance imaging at 1.5 tesla for patients with pacemakers and implantable cardioverter defibrillators

    Am J Cardiol

    (2012)
  • O.M. Muehling et al.

    Immediate and 12 months follow up of function and lead integrity after cranial MRI in 356 patients with conventional cardiac pacemakers

    J Cardiovasc Magn Reson

    (2014)
  • R.J. Russo

    Determining the risks of clinically indicated nonthoracic magnetic resonance imaging at 1.5 T for patients with pacemakers and implantable cardioverter-defibrillators: rationale and design of the MagnaSafe Registry

    Am Heart J

    (2013)
  • S. Maffe et al.

    Pseudo “end of life” indication after electromagnetic field exposure: an unusual effect of magnetic resonance imaging on implanted cardioverter defibrillator

    Int J Cardiol

    (2012)
  • K.G. Haeusler et al.

    Safety and reliability of the insertable Reveal XT recorder in patients undergoing 3 Tesla brain magnetic resonance imaging

    Heart Rhythm

    (2011)
  • A.N. Solan et al.

    Treatment of patients with cardiac pacemakers and implantable cardioverter-defibrillators during radiotherapy

    Int J Radiat Oncol Biol Phys

    (2004)
  • R. Donnino et al.

    Effect of computed tomography imaging on rhythm devices in real-world practice

    J Am Coll Cardiol

    (2014)
  • E. Kanal et al.

    ACR guidance document on MR safe practices: 2013

    J Magn Reson Imaging

    (2013)
  • R. Luechinger et al.

    Force and torque effects of a 1.5-Tesla MRI scanner on cardiac pacemakers and ICDs

    Pacing Clin Electrophysiol

    (2001)
  • A. Babouri et al.

    In vitro investigation of eddy current effect on pacemaker operation generated by low frequency magnetic field

    Conf Proc IEEE Eng Med Biol Soc

    (2007)
  • P. Nordbeck et al.

    Measuring RF-induced currents inside implants: impact of device configuration on MRI safety of cardiac pacemaker leads

    Magn Reson Med

    (2009)
  • C.J. Yeung et al.

    Minimizing RF heating of conducting wires in MRI

    Magn Reson Med

    (2007)
  • J. Fetter et al.

    The effects of nuclear magnetic resonance imagers on external and implantable pulse generators

    Pacing Clin Electrophysiol

    (1984)
  • R. Luechinger et al.

    In vivo heating of pacemaker leads during magnetic resonance imaging

    Eur Heart J

    (2005)
  • S. Nazarian et al.

    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

    Circulation

    (2006)
  • R. Luechinger et al.

    Pacemaker reed switch behavior in 0.5, 1.5, and 3.0 Tesla magnetic resonance imaging units: are reed switches always closed in strong magnetic fields?

    Pacing Clin Electrophysiol

    (2002)
  • J.R. Gimbel

    Unexpected asystole during 3T magnetic resonance imaging of a pacemaker-dependent patient with a ‘modern’ pacemaker

    Europace

    (2009)
  • S. Nazarian et al.

    A prospective evaluation of a protocol for magnetic resonance imaging of patients with implanted cardiac devices

    Ann Intern Med

    (2011)
  • M. Ainslie et al.

    Cardiac MRI of patients with implanted electrical cardiac devices

    Heart

    (2014)
  • G.N. Levine et al.

    Safety of magnetic resonance imaging in patients with cardiovascular devices: an American Heart Association scientific statement from the Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology, and the Council on Cardiovascular Radiology and Intervention: endorsed by the American College of Cardiology Foundation, the North American Society for Cardiac Imaging, and the Society for Cardiovascular Magnetic Resonance

    Circulation

    (2007)
  • Shellock, F. Chapter 16: MRI Issues for Implants and devices, in MRI Bioeffects, safety, and patient management by...
  • A. Gill et al.

    Assessment of MRI issues at 3-Tesla for metallic surgical implants: findings applied to 61 additional skin closure staples and vessel ligation clips

    J Cardiovasc Magn Reson

    (2012)
  • E. Kanal et al.

    MR imaging of patients with intracranial aneurysm clips

    Radiology

    (1993)
  • P.F. New et al.

    Potential hazards and artifacts of ferromagnetic and nonferromagnetic surgical and dental materials and devices in nuclear magnetic resonance imaging

    Radiology

    (1983)
  • F.G. Shellock et al.

    Drug eluting coronary stent: in vitro evaluation of magnet resonance safety at 3 Tesla

    J Cardiovasc Magn Reson

    (2005)
  • M. Nogueira et al.

    Otological bioimplants: Ex vivo assessment of ferromagnetism and artifacts at 1.5 Tesla

    AJR Am J Roentgenol

    (1995)
  • S. Rashid et al.

    Modified wideband three-dimensional late gadolinium enhancement MRI for patients with implantable cardiac devices

    Magn Reson Med

    (2016)
  • S. Rashid et al.

    Improved late gadolinium enhancement MR imaging for patients with implanted cardiac devices

    Radiology

    (2014)
  • Cited by (291)

    View all citing articles on Scopus

    Document Reviewers: Luis Aguinaga, MD; Timothy S.E. Albert, MD, FACC; Peter F. Aziz, MD, FHRS; Alec Block, MD; Peter Brady, MB, ChB, MD; Mina Chung, MD, FACC; Michael Dominello, DO; Andrew E. Epstein, MD, FACC; Susan P. Etheridge, MD, FHRS; Paul A. Friedman, MD; Thomas C. Gerber, MD, PhD, FAHA; Robert H. Helm, MD; Ricardo Kuniyoshi, MD, PhD; Martin J. LaPage, MD, MS, FHRS; C.P. Lau, MD; Harold Litt, MD; Lluis Mont, MD; Takashi Nitta, MD; Jack Rickard, MD, MPH; Frank Rybicki, MD, PhD; Wenyin Shi, MD, PhD; Christian Sticherling, MD; Andrew Taylor, MD; Mark Trombetta, MD, FACR; Paul J. Wang, MD, FHRS; L. Samuel Wann, MD, MACC; Ying Xiao, PhD

    Developed in collaboration with and endorsed by the American College of Cardiology (ACC), American College of Radiology (ACR), American Heart Association (AHA), American Society for Radiation Oncology (ASTRO), Asia Pacific Heart Rhythm Society (APHRS), European Heart Rhythm Association (EHRA), Japanese Heart Rhythm Society (JHRS), Pediatric and Congenital Electrophysiology Society (PACES), Brazilian Society of Cardiac Arrhythmias (SOBRAC), and Latin American Society of Cardiac Stimulation and Electrophysiology (SOLAECE) and in collaboration with the Council of Affiliated Regional Radiation Oncology Societies (CARROS).

    Address reprint requests and correspondence: Heart Rhythm Society, 1325 G Street NW, Suite 400, Washington, DC 20005. E-mail address: [email protected].

    Deceased. See In Memoriam at the end of this document

    Representative of the Japanese Heart Rhythm Society (JHRS)

    Representative of the Brazilian Society of Cardiac Arrhythmias (SOBRAC)

    §

    Representative of the Council of Affiliated Regional Radiation Oncology Societies (CARROS)

    Representative of the American College of Radiology (ACR)

    #

    Representative of the American Society for Radiation Oncology (ASTRO)

    ∗∗

    Representative of the European Heart Rhythm Association (EHRA)

    ‡‡

    Representative of the Pediatric and Congenital Electrophysiology Society (PACES)

    §§

    Representative of the American College of Cardiology (ACC)

    ¶¶

    Representative of the Asia Pacific Heart Rhythm Society (APHRS)

    ##

    Representative of the Latin American Society of Cardiac Stimulation and Electrophysiology (SOLAECE)

    ∗∗∗

    Representative of the American Heart Association (AHA)

    View full text