Magnetic Resonance Imaging and Radiation Exposure in Patients with Cardiovascular Implantable Electronic Devices
Publication Date: May 11, 2017
Last Updated: December 16, 2022
Device Parameters
Table 5. Recommendations and Protocol for the Management of Patients with an MR Conditional Device Undergoing MRI
MR conditional devices should be considered MR conditional only when the product labeling is adhered to, which includes programming the appropriate "MR mode" and scanning with the prerequisites specified for the device. (I, A)
573
MR imaging in a patient with an MR conditional system should always be performed in the context of a rigorously applied standardized institutional workflow, following the appropriate conditions of use. (I, B-R)
573
It is recommended for patients with an MR conditional system that personnel with the skill to perform advanced cardiac life support, including expertise in the performance of CPR, arrhythmia recognition, defibrillation, and transcutaneous pacing, be in attendance with the patient for the duration of time the patient’s device is reprogrammed, until assessed and declared stable to return to unmonitored status. (I, B-R)
573
It is recommended for patients with an MR conditional system that ECG and pulse oximetry monitoring be continued until baseline, or until other clinically appropriate CIED settings are restored. (I, A)
573
All resuscitative efforts and emergency treatments that involve the use of a defibrillator/monitor, device programming system, or any other MRI-unsafe equipment should be performed after moving the patient outside of Zone 4. (I, C-EO)
573
It is recommended for patients with an MR conditional system that personnel with the skill to program the CIED be available as defined by the institutional protocol. (I, C-EO)
573
It is reasonable to perform an MR scan on a patient with an MR conditional system implanted more recently than the exempt period for conditionality of the system, based on assessment of risk and benefit for that patient. (IIa, C-EO)
573
Management of Patients with a CIED Referred for MRI
Table 6. Recommendations for the Decision to Perform an MRI on Patients with an MR Nonconditional CIED
It is reasonable for patients with an MR nonconditional CIED system to undergo MR imaging if there are no fractured, epicardial, or abandoned leads; the MRI is the best test for the condition; and there is an institutional protocol and a designated MR-responsible physician and CIED physician. (IIa, B-NR)
573
It is reasonable to perform an MR scan immediately after implantation of a lead or generator of an MR nonconditional CIED system if clinically warranted. (IIa, B-NR)
573
For patients with an MR nonconditional CIED, it is reasonable to perform repeat MRI when required, without restriction regarding the minimum interval between imaging studies or the maximum number of studies performed. (IIa, C-LD)
573
Table 7. Recommendations for the Management of Patients with an MR Nonconditional CIED Who Are to Have an MRI Scan
It is recommended for the patient with an MR nonconditional CIED that device evaluation be performed immediately pre and post-MRI with documentation of pacing threshold(s), P and R-wave amplitude, and lead impedance using a standardized protocol. (I, B-NR)
573
A defibrillator/monitor (with external pacing function) and a manufacturer-specific device programming system should be immediately available in the holding area adjacent to the MR scanner room while an MR nonconditional CIED is reprogrammed for imaging. (I, B-NR)
573
It is recommended that continuous MR conditional ECG and pulse oximetry monitoring be used while an MR nonconditional CIED is reprogrammed for imaging. (I, B-NR)
573
It is recommended that personnel with the skill to perform advanced cardiac life support, including expertise in the performance of CPR, arrhythmia recognition, defibrillation, and transcutaneous pacing, accompany the patient with an MR nonconditional CIED for the duration of time the patient’s device is reprogrammed, until assessed and declared stable to return to unmonitored status. (I, B-NR)
573
For patients with an MR nonconditional CIED who are pacing-dependent (PM or ICD), it is recommended that:
- Personnel with the skill to program the CIED be in attendance during MR scanning.
- A physician with the ability to establish temporary transvenous pacing be immediately available on the premises of the imaging facility.
- A physician with the ability to direct CIED programming be immediately available on the premises of the imaging facility.
573
For patients with an MR nonconditional CIED who are not pacing-dependent, it is recommended that:
- Personnel with the skill to program the CIED be available on the premises of the imaging facility
- A physician with the ability to direct CIED programming be available on the premises of the imaging facility
573
It is recommended that for the patient with an MR nonconditional CIED who is pacing-dependent to program their device to an asynchronous pacing mode with deactivation of advanced or adaptive features during the MRI examination, and the pacing rate should be selected to avoid competitive pacing. (I, B-NR)
573
All tachyarrhythmia detections for patients with an ICD should be disabled prior to MRI. (I, B-NR)
573
The MR-responsible physician who is accountable for overseeing the safety of the MRI environment, including the administration of any medication and/or contrast agents (if applicable) should be made aware of the presence of a patient with an MR nonconditional CIED. (I, C-EO)
573
It is recommended that ECG and pulse oximetry monitoring be continued until baseline or until other clinically appropriate CIED settings are restored for patients with an MR nonconditional CIED. (I, C-EO)
573
All resuscitative efforts and emergency treatments that involve the use of a defibrillator/monitor, device programming system, or any other MRI-unsafe equipment should be performed after moving the patient outside of Zone 4. (I, C-EO)
573
For a patient with an MR nonconditional CIED who is not pacing-dependent, it is reasonable to program their device to either a nonpacing mode (OVO/ODO) or to an inhibited mode (DDI/VVI), with deactivation of advanced or adaptive features during the MRI examination. (IIa, B-NR)
573
It is reasonable to program patients with an MR nonconditional CRT device who are not pacing-dependent to an asynchronous pacing mode (VOO/DOO) with deactivation of advanced or adaptive features during the MRI examination, and with a pacing rate that avoids competitive pacing. (IIa, C-EO)
573
Table 8. Implantable Loop Recorder
It is recommended that prior to MRI scanning patients with an implantable loop recorder (ILR) that the ILR be evaluated and that any desired recorded information be removed/downloaded from the system and cleared after the MRI. (I, B-NR)
573
MR scanning of MR conditional ILRs should be performed within labeled scanning prerequisites specific to each device manufacturer. (I, C-LD)
573
Table 9. Employee Safety
It is recommended that the MR suite has a clearly delineated 5 gauss boundary and visible signs to advise individuals who have an implantable cardiac device, regardless of MR conditional labeling, to stay outside of the 5 gauss boundary at all times. (I, C-EO)
573
Table 10. Recommendations for the Management of Patients with a CIED Undergoing CT Imaging
It is recommended that patients with a CIED undergo clinical diagnostic CT without any additional device interrogation, programming, or monitoring. (I, B-NR)
573
It is reasonable to exclude the device from the field of view of 4D CT and cone-beam CT scans if the images are not compromised. (IIa, C-EO)
573
It might be reasonable to monitor patients who have an ICD or who are pacing-dependent by ECG or pulse oximetry if the CIED will undergo prolonged, uninterrupted exposure by CT. (IIb, C-EO)
573
Management of Patients with a CIED Undergoing CT Imaging
Table 12. Recommendations and Protocol for the Management of Patients with a CIED Undergoing Radiation Therapy
Prior to the initiation of radiation treatment, a complete CIED evaluation should be performed and the treatment team should be informed of:
- Whether the device is a PM or ICD
- Whether the patient is pacing-dependent
- The minimum programmed pacing rate
- The maximum programmed tracking and sensor rates.
573
Non-neutron-producing treatment is preferred over neutron-producing treatment in patients with a CIED to minimize the risk of device reset. (I, B-NR)
573
Perform weekly complete CIED evaluations for patients undergoing neutron-producing treatment. (I, B-NR)
573
A complete CIED evaluation should be performed at the conclusion of the course of radiation therapies. (I, B-NR)
573
Continuous visual and voice contact is recommended during each treatment fraction. (I, C-EO)
573
CIED relocation is recommended if its current location will interfere with adequate tumor treatment. (I, C-EO)
573
It might be reasonable to perform a complete CIED evaluation weekly for patients who are pacing-dependent and undergoing non-neutron-producing treatment. (IIb, B-NR)
573
CIED relocation is NOT recommended for devices receiving a maximum cumulative incident dose of <5 GY. (III - Harm, B-NR)
573
Recommendation Grading
Overview
Title
Magnetic Resonance Imaging and Radiation Exposure in Patients with Cardiovascular Implantable Electronic Devices
Authoring Organization
Heart Rhythm Society
Publication Month/Year
May 11, 2017
Last Updated Month/Year
March 20, 2024
Supplemental Implementation Tools
Document Type
Consensus
External Publication Status
Published
Country of Publication
US
Document Objectives
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 to- mography (CT), and/or radiation treatment.
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Emergency care, Hospital, Outpatient, Radiology services
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Management
Diseases/Conditions (MeSH)
D017147 - Defibrillators, Implantable, D010138 - Pacemaker, Artificial
Keywords
magnetic resonance imaging (MRI), radiation therapy, cardiovascular implantable electronic device (CIED), pacemaker, computed tomographic imaging (CT), CIED
Source Citation
Indik JH, Gimbel JR, Abe H, Alkmim-Teixeira R, Birgersdotter-Green U, Clarke GD, et al. 2017 HRS expert consensus statement on magnetic resonance imaging and radiation exposure in patients with cardiovascular implantable electronic devices. Hear Rhythm [Internet]. 2017;14(7):e97–153. Available from: http://dx.doi.org/10.1016/j.hrthm.2017.04.025