Magnetic Resonance Imaging and Radiation Exposure in Patients with Cardiovascular Implantable Electronic Devices
Key Points
Key Points
- MRI generates static and gradient magnetic fields as well as RF energy. The potential interactions between CIEDs and electromagnetic interference from MRI include the following:
- Magnetic field-induced force and torque due to ferromagnetic materials: CIED generator movement is extremely unlikely due to confinement in the subcutaneous tissues.
- Leads do not contain any significant ferromagnetic materials to cause movement in a magnetic field.
- Gradient magnetic field-induced electrical current: Gradient magnetic fields can induce current in conductive wires within the field that could lead to myocardial capture and potentially lead to atrial or ventricular arrhythmias.
- Heating and tissue damage: RF fields can lead to nonconditional CIED component heating and subsequent thermal damage to the surrounding tissue (functional ablation). Changes in sensing or capture thresholds can occur as a result of tissue damage near lead electrodes.
- Effects on reed switch activity: The reed switch is a feature that permits programming of the device by placement of a magnet. Magnetic fields might therefore affect the reed switch activity of a nonconditional CIED, leading to asynchronous pacing and inhibition of tachycardia therapies.
- Electrical reset: High-energy electromagnetic interference (EMI) can lead to electrical or power-on-reset, a backup demand mode, wherein pacing might be inhibited and tachyarrhythmia therapy activated.
- Power-on-reset parameters vary by vendor and type of CIED (See Tables 1 and 2), and can include reset of pacing polarity to unipolar.
- Inhibition of pacing function due to oversensing of MRI-generated signals or pacing at an output below threshold (bipolar or unipolar) in a pacemaker (PM)-dependent patient might occur in the setting of power-on-reset and must be recognized to prevent catastrophic consequences.
- Additionally, battery status can be affected, particularly for CIEDs that are near an elective replacement interval (ERI), which could result in unreliable function.
- Inappropriate function and therapies: EMI from RF energy pulses or rapidly changing magnetic field gradients might cause oversensing that can lead to inappropriate inhibition of demand pacing and possibly asystole in a pacing-dependent patient, or induction of therapies such as inappropriate shocks in a patient with an implantable cardioverter defibrillator (ICD). Other inappropriate tracking or programming changes can occur.
- Magnetic field-induced force and torque due to ferromagnetic materials: CIED generator movement is extremely unlikely due to confinement in the subcutaneous tissues.
- These effects are influenced by various factors, including magnet field strength, RF power, position of the patient and the CIED within the MRI bore, CIED characteristics, and the size of the patient.
Table 1. Programmed Parameters for PMs During Power-On Reset Mode
| Manufacturer | Pacing mode | Pacing output | Pacing polarity | Sensitivity | Magnet1 response |
|---|---|---|---|---|---|
| BIOTRONIK | VVI 70 bpm | 4.8 V @ 1.0 ms | Unipolar | 2.5 mV | Yes |
| Boston Scientific2 | VVI 65 bpm | 5.0 V @1.0 ms | Bipolar | 1.5 mV | No |
| Medtronic | VVI 65 bpm | 5.0 V @ 0.4 ms | Bipolar | 2.8 mV | Yes |
| St. Jude Medical | VVI 67.5 bpm | 4.0 V @ 0.6 ms3 | Unipolar | 2.0 mV | No |
| ELA-Sorin | VVI 70 bpm | 5.0 V @ 0.5 ms | Unipolar | 2.2 mV | No |
2 Boston Scientific CRT-P devices differ in pacing output (5 V @ 0.5 ms) and pacing polarity (right ventricle lead is unipolar and left ventricle lead paces from left ventricle to pulse generator).
3 St. Jude Medical Accent/Anthem and Frontier II models deliver 5 V @ 0.6 ms.
Table 2. Programmed Parameters for ICDs During Power-On Reset Mode
| Manufacturer | Rate cutoff | Detection criteria | Sensitivity | Energy | Pacing mode | Pacing output |
|---|---|---|---|---|---|---|
| BIOTRONIK | 150 bpm | 8/12 | 0.8 mV | 40 J × 8 | VVI 70 bpm | 7.5 V @ 1.5 ms1 |
| Boston Scientific | 165 bpm | 8/10 | 0.25 mV | 41 J × 5 | VVI 72.5 bpm | 5.0 V @ 1.0 ms |
| Medtronic | 188 bpm | 18/24 | 0.3 mV | 35 J × 6 | VVI 65 bpm | 6.0 V @ 1.5 ms |
| St. Jude Medical2 | 146 bpm | 12 | 0.3 mV | 36 J × 63 | VVI 60 bpm | 5.0 V @ 0.5 ms |
| ELA-Sorin | 190 bpm | 6/8 | 0.4 mV | 42 J × 44 | VVI 60 bpm | 5.0 V @ 0.35 ms |
| All devices will respond to magnet application by temporarily disabling tachyarrhythmia detection. Pacing polarity for all devices is bipolar with the exception of Boston Scientific, which paces in a unipolar configuration. Energy values listed for Medtronic and St. Jude Medical represent energy delivered. The remaining represent energy charged. | ||||||
2 The St. Jude Medical Current and Promote family of devices revert to an autosense sensitivity setting, pace at VVI 67.5 beats per minute (bpm) with pacing outputs of 5.0 V @ 0.6 ms.
3 The St. Jude Medical Epic and Epic II family of devices delivers 30 J × 6.
4 ELA-Sorin LivaNova Ovatio family of devices: 34 J × 4.
Device Parameters
...vice Parameters...
...U.S. Food and Drug Administration (FDA)-Approved...
...efinitions of CIED Systems in Relation to MRIHavin...
...mmendations and Protocol for the Mana...
...evices should be considered MR conditional...
...in a patient with an MR conditional s...
...nded for patients with an MR conditional system t...
...ded for patients with an MR conditional sys...
...citative efforts and emergency treatments that inv...
...nded for patients with an MR condition...
...reasonable to perform an MR scan on a patient wi...
Management of Patients with a CIED Referred for MRI
...of Patients with a CIED Referred for M...
...e 6. Recommendations for the Decision...
...e for patients with an MR nonconditional C...
...to perform an MR scan immediately after implan...
...with an MR nonconditional CIED, it is reasonable...
...commendations for the Management of Patient...
...recommended for the patient with an...
...llator/monitor (with external pacing functio...
...ended that continuous MR conditional ECG and pulse...
...mmended that personnel with the skill to perform a...
...th an MR nonconditional CIED who are pa...
...with an MR nonconditional CIED who are n...
It is recommended that for the patient...
...yarrhythmia detections for patients...
...ible physician who is accountable for over...
...mended that ECG and pulse oximetry monitori...
...ll resuscitative efforts and emerge...
...ith an MR nonconditional CIED who...
...asonable to program patients with a...
.... Management Algorit...
...e 2. Checklist for MRI Safety in the Setting of...
.... Implantable Loop Recorder...
...mended that prior to MRI scanning patien...
...anning of MR conditional ILRs should be p...
...9. Employee Safety...
It is recommended that the MR suite...
...ecommendations for the Management of Patient...
...ended that patients with a CIED undergo c...
...sonable to exclude the device from...
...easonable to monitor patients who have an ICD...
Management of Patients with a CIED Undergoing CT Imaging
...agement of Patients with a CIED Under...
...11. Secondary Neutron-Producing Radiatio...
Table 12. Recommendations and Protocol...
...the initiation of radiation treatment, a c...
...roducing treatment is preferred ove...
...omplete CIED evaluations for patient...
A complete CIED evaluation should be p...
...visual and voice contact is recommended during...
...on is recommended if its current location...
...might be reasonable to perform a complete...
...IED relocation is NOT recommended for devices...
Management of Patients with a CIED Undergoing Radiation Therapy
...nagement of Patients with a CIED Undergoing Rad...
...gure 3. Checklist for Performance of Ra...
...ure 4. CIED Management for Radiation Thera...