MRI AND CT IMAGING WITH

PACEMAKERS
- DIVYESH DADHANIA
• Basic physiology of conduction system

• Types of Cardiac implantable electronic devices(CIED)

• Indications

• Imaging in patients with CIED

MRI conditional devices
MRI Non conditional devices
HEART CONDUCTION SYSTEM- COMPONENTS
AND PHYSIOLOGY
Components:
1. SINO ATRIAL NODE- cells of SA node
has intrinsic automaticity and fastest
impulse generation, therefore acting
as pacemaker of heart.
2. INTERNODAL ATRIAL PATHWAY
3. ATRIOVENTRICULAR NODE
4. BUNDLE OF HIS
5. PURKINJE SYSTEM
Figure shows rhythmical discharge of
sinus node and comparison of action
potentials of sinus node with that of
ventricular muscle fibre.
 RATE OF IMPULSE GENERATION
TISSUE RATE OF IMPULSE GENERATION(PER
MINUTE)
SA NODE 70-80

AV NODE 40-60

BUNDLE OF HIS 40

PURKINJE FIBRES 24

• Each time the sinus node discharges, the impulse is conducted into
both the A-V node and the Purkinje fibres and also discharging their
excitable membranes. The sinus node discharges again before either
the A-V node or the Purkinje fibres can reach their own thresholds for
self-excitation thereby discharging both AV node and Purkinje fibres
before their self excitation. This way SA node maintains the
rhythmicity of heart and is known as the pacemaker of the heart.
STEPS OF IMPULSE CONDUCTION AND PROPAGATION
THROUGH HEART
Basics of Arrhythmias
• 1)Abnormal Pacemakers:AV nodal block-Complete /incomplete
• 2)Ectopic foci of excitation:Myocardial cells or purkinje system
• 3)Reentry
• 4)Accelerated AV conduction by accessory pathway-WPW
WHAT IS PACEMAKER?
• A small device capable of generating artificial pacing impulses and delivering them
to the heart to help control abnormal heart rhythms. Main purpose of a
pacemaker is to make sure the heart rate does not get too slow. It also can
monitor and record the rate and rhythm of the heart.

What is ICD?
• a small device which sends electrical pulses or shocks to the heart when it
senses any abnormalities in heartbeat. For example, if a patient with an ICD has
an irregular heartbeat or goes into sudden cardiac arrest, the device will send a
shock to the heart to restore normal heart rhythm.Those considered high risk for
a life-threatening ventricular arrhythmia and sudden cardiac death need an ICD.It
can act as pacemaker.
What is CRT?

• Cardiac resynchronization therapy (CRT) is a recent addition to

therapy for symptomatic heart failure.CRT has consistently been
shown to improve symptoms and exercise capacity in several
randomized clinical trials.
• CRT-P:Therapy delivered with Pacemaker
• CRT-D:therapy delivered with Defibrilator
CIED DESIGN
Consists of two components:
• Electronic pulse generator: contain the circuitry and batteries.
Encased in titanium housing
• Electrodes ( leads): which carry the impulse created by the
generator to the heart. 1. Endocardial leads. 2. Epicardial Leads.They
are secured to the myocardium either “actively” by means of a small
screw, or “passively” by means of small tines near the lead tip.
• Pacemaker leads consist of conducting wires, a silicone or
polyurethane insulation coating, and platinum electrodes used for
pacing. Defibrillation leads have one or two additional wire coils
capable of delivering high-voltage impulses for defibrillation
PACEMAKER TYPES
• Pacemakers are of two types: permanent and
temporary.
• Permanent Pacemaker: all systems are implanted into
the body, including power source.
1. Asynchronous(fixed rate)/ synchronous(demand)
2. Single/dual chamber/multisite biventricular
Single-Chamber System : Either atrium /Ventricle
Depending on the chamber to be paced and sensed
Dual-Chamber Systems(MC) :In right atrium and
ventricle.
Multisite biventricular(CRT-P):It involves
simultaneous pacing of the right ventricle and the left
ventricle by putting coronary sinus lead.
3. Programmable/nonprogrammable
CLASS I INDICATION FOR PACEMAKER(Should be performed)
• Sinus node dysfunction
• Acquired atrioventricular block in adults
• Chronic bifascicular block
• After acute myocardial infarction
• Hypersensitive carotid sinus syndrome and neurocardiogenic syncope
• After cardiac transplantation
• Pacing to prevent tachycardia
• Patients with congenital heart disease
CLASS I INDICATION FOR ICD
• Structural heart disease, sustained VT
• Syncope of undetermined origin, inducible VT or VF at
electrophysiologic study (EPS)
• Left ventricular ejection fraction (LVEF) ≤35% due to prior MI, at least
40 days post-MI, NYHA class II or III
• LVEF ≤35%, NYHA class II or III
• LVEF ≤30% due to prior MI, at least 40 days post-MI
• LVEF ≤40% due to prior MI, inducible VT or VF at EPS
CLASS IIA Indication for ICD
• Unexplained syncope, significant LV dysfunction, nonischemic cardiomyopathy
• Sustained VT, normal or near-normal ventricular function
• Hypertrophic cardiomyopathy with 1 or more major risk factors
• Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) with 1 or
more risk factors for sudden cardiac death (SCD)
• Long QT syndrome, syncope or VT while receiving beta-blockers
• Nonhospitalized patients awaiting heart transplant
• Brugada syndrome, syncope or VT
• Catecholaminergic polymorphic VT, syncope or VT while receiving beta-blockers
• Cardiac sarcoidosis, giant cell myocarditis, or Chagas disease
INDICATION FOR CRT
• Sinus rhythm, EF less than or equal to 35%, NYHA functional class III/IV
and QRS duration of 120 ms or greater: IA recommendation in the
German guideline only with QRS greater than 150 ms and left bundle
branch block (LBBB);
• Frequent right ventricular stimulation, EF less than or equal to 35%, and
NYHA functional status III/IV: IIa C recommendation; in the German
guideline IIb C;
• Atrial fibrillation, EF less than or equal to 35%, and NYHA functional status
III/IV IIa B recommendation; in the German guideline IIa C;
• NYHA functional class II, Sinus rhythm, EF less than or equal to 35%: IIb C
recommendation (without any QRS criterion but frequent RV stimulation);
in the German guideline with QRS duration >150 ms and LBBB: IIb B.
CIED and imaging
• Chest x ray
• CT scan
• MRI
Imaging of choice for CIED integrity is chest radiography.
•.
CT Scan in patients with CIED
• Metallic Streak artefacts due to beam hardening and object
blooming.
• Lack of insulation of the tip and its much larger active surface can
influence on image quality, and hence artifacts seem to originate
mostly from the tip rather than the body of the lead.
• During ECG gating in Unipolar leads,reconstruction is affected by
inappropriate gating due to double counting of the high voltage
unipolar pacemaker ‘spikes’. Leads with bipolar pacing do not pose
such issues.
• No effects on the devices during Cardiac/Chest CT scan.
• Can be used to detect perforation if ECHO is equivocal.
 MRI in Patients with CIED
• No CIED is MR Safe. Denial of MRI services is particularly consequential as 50%–75% of
patients with a CIED are estimated to require an MRI during their lifetime.

• MR conditional denotes an item that poses no hazards in a specified MRI environment

with specified conditions of use. The first MR conditional CIED system was approved
by the FDA in 2011.
• MR nonconditional is a term used in the 2017 Heart Rhythm Society guidelines, which
refers to objects that have not been declared MR conditional or safe.

• MRI in patients with non-MRI-conditional devices should be considered only if the

patient is not pacemaker dependent. MRI in pacemaker-dependent patients is allowed
with the provision of temporary pacing facilities and a CIED-trained physician in place.
• MRI should not be performed if there is evidence of generator or lead malfunction.

• "The American College of Radiology recognizes that MRI in patients with pacemakers
is never routine and should be conducted only when the case is properly triaged and
deemed medically necessary and when alternative radiologic methods have not been
diagnostic,"
INTERACTIONS WITH CIED
• The MR imager produces three electromagnetic fields, which can
interfere with CIED:
• 1)The static magnetic field (measured in tesla),
• 2)The radiofrequency field (measured by specific absorption rate
[SAR] in watts per kilogram)
• 3)The pulsed gradient field (measured in tesla per meter per second).
• The gradient magnetic and radiofrequency fields can
electromagnetically couple with leads to induce electric currents
through the “antenna effect.”
• This can alter the recorded ECG, stimulate dangerous arrhythmias,
and permanently interfere with ICD function. Induced currents can
result in inhibition of pacing due to the device perceiving an intrinsic
underlying rhythm on the electrogram. Furthermore, the induced
artifactual current can be interpreted as ventricular arrhythmia with
subsequent attempts to initiate antitachyarrhythmia therapy in
ICDs.
• So Most protocols call for the disabling of antitachyarrhythmia
sensing
Mechanical Displacement
• Ferromagnetic components are present in the batteries and reed
switches (a magnetically activated switch that places the device in “magnet
mode”) of CIEDs.
• Concern regarding displacement has proven unjustified for PPMs made
after 1995, because the ferromagnetic content is so low that they only
experience forces within the range of gravity.
• ICDs have a higher ferromagnetic content and consequently generate
forces that are marginally higher than gravity, yet, these are still unlikely to
be clinically significant.
• It is important to note that CIED lead tips are unaffected by static
magnetic fields as they have no ferromagnetic materials. This negates the
possibility of the lead becoming dislodged and failing to capture.
 Device Reprogramming
• MRI can reprogram CIEDs in two main ways.
• 1)The static magnetic field can activate reed switch. The reed switch used
to reset the pacemaker into an asynchronous pacing mode and disable
antitachyarrhythmia function in response to a magnet being placed on the
patient’s skin (magnet mode). Activation of the reed switch prevents
interference with CIED function during electrocautery surgery.
• 2)pacemakers can undergo power-on reset (POR). PORs are electrical
resets designed for safety in the event of battery depletion or circuit
malfunction. PORs typically reset the device to inhibited pacing (pacing
mode VVI).
• POR and reed switch activation detected by interrogating the pacemaker
after the MRI and/or noticing changes in the patient’s vital signs during
imaging.
Reed Switch Closure
• Reed switch “closes” in a magnetic field causing current to flow through it.
• PPMs contain reed switches that, when closed, set the pacemaker to a
preprogrammed function. This is typically asynchronous (pacing mode
VOO) pacing. In asynchronous pacing, the device paces the ventricle at a
preprogrammed rate continuously. In addition, the reed switch suspends
antitachyarrhythmia therapies for ICDs. So. devices will not detect a
ventricular arrhythmia, spontaneous or MRI induced, and will not treat the
arrhythmia.
• A theoretical danger of competitive pacing between the heart’s intrinsic
rhythm and the preprogrammed asynchronous pacing. Lead to
proarrhythmia due to R-on-T phenomena in patients who have a high heart
rate.
• Unpredictable in the static field strengths produced by clinical MRI, with
half of them initially closing and then reopening later during the imaging.
For this reason, most protocols disable the magnet response when
reprogramming the CIED prior to MRI so that the static field does not
activate the reed switch.
 Power On Reset
• A POR programme reverts the device to factory default settings when battery
voltage falls below a critical level or damage to the circuits is detected. This is
a failsafe feature.
• The settings to which the device reverts vary by manufacturer. Many devices
reset to inhibition pacing, with antitachyarrhythmiatherapy on, where the
device will initiate therapies for life-threatening arrhythmias. This is
problematic when electrical induction in the leads causes inappropriate
sensing of induction as intrinsic cardiac activity and results in inhibition of
required pacing.
• In patients needing high intrinsic heart rates (such as children),it may not
provide the required cardiac output. However, devices are usually easy to
reprogram after the MRI following a POR event.
Heating Effect
• Consequence of the radiofrequency field is deposition of heat energy,
particularly at the lead tips, which can result in myocardial tissue
damage. At an SAR of 4.0 W/ kg–below most clinical scans, tissue
heating in the absence of foreign materials (such as CIEDs) does not
exceed 0.7°C . However, energy absorption changes in the presence
of conducting materials. This makes temperatures difficult to predict.
MR NON CONDITIONAL DEVICES SAFETY STUDIES
Pacemakers:
• The MagnaSafe registry of 1500 MRI examinations and the Nazarian et al
cohort of 2103 MRI examinations in patients with CIED constitute the
largest studies to date with MR nonconditional devices.
• MagnaSafe demonstrated a remarkable lack of adverse events in its 1000
PPM MRI examinations, with no deaths, generator failures, lead failures, or
loss of myocardial capture.
• The only complications seen in the pacemaker cohort were low rates of
minor lead parameter changes (ranging from 0.8% to 16.4% depending on
the parameter), spontaneously reverting atrial fibrillation, and
PORs.MagnaSafe registry excluded thoracic MRI examinations, where
energy absorption by the CIED is thought to be the greatest.
• Reed switch activation is a largely accepted fact of MRI in devices that are
not fitted with newer magnetic field–resistant Hall sensors.
ICD:
• Regarding ICD displacement, there have been no major lead or
implant complications in ICD studies to date. Minor symptoms over
the implant site have been reported at a rate similar to that of PPMs.
• Burke et al found that nine of 14 patients with ICDs undergoing MRI
recorded electromagnetic noise as fast ventricular tachycardia or
ventricular fibrillation.
• Battery depletion has also proved to be a low-risk event.
CONTRAINDICATIONS FOR STUDIES
Recent Implants:
• Recent implantation of a CIED ranges from 6 weeks to 3 months .The
purpose of a waiting period after implantation was to allow the lead
tips to establish a fibrous sheath in the myocardium, thereby reducing
the likelihood of lead dislodgement.

• Friedman et al prospectively observed no major complications or

troponin increase in any of the patients , nor any difference in lead
parameters at 104 days follow-up. He examined eight examinations
of early pacemaker implants (, 6 weeks; range, 7–36 days) versus 211
examinations of older implants (mean, 1150 days).
Epicardial and Abandoned Leads:Traditionally excluded from
studies due to preclinical research demonstrating unpredictable
heating in vivo.
• There is limited experience and literature regarding permanent
surgical epicardial leads and thus, it is not possible to determine their
safety.

SAR: At present, many studies continue to impose SAR limits, usually

to less than 2.0 W/kg, to limit heating and electromagnetic induction .
How ever, the recently published Nazarian et al cohort removed SAR
restrictions during recruitment owing to a lack of evidence for harm
beyond normal SAR limits in non-CIED patients
Serial MRI Examinations: Assumption that cumulative minor
effects could become clinically significant.
• Naehle et al performed a retrospective review of 47 patients with
PPM who had undergone at least two examinations (including horacic
examinations) at 1.5 T . The study included three patients who
underwent more than 10 examinations. They found that changes in
capture thresholds, impedance, and battery voltage were not
clinically significant even after 10-plus examinations.

Pacemaker Dependancy: Pacemaker dependency comes with a

higher risk during MRI due to potential inappropriate inhibition of
pacemaker activity with resultant asystole.
• Careful monitoring is mandated during MRI to avoid potential
catastrophe in the form of inappropriately inhibited pacing after a
POR.
Thoracic And Cradiac MRI:Most studies including thoracic and
cardiac MRI examinations have had a safety profile equivalent to that
of extrathoracic MRI.
• Main issue with thoracic and cardiac imaging is the MRI artifact over
the area of interest.
MR CONDITIONAL DEVICES
• Typical MRI examination conditions in clude static field strength, SAR,
and imaging field of view.
• Information can be found on the individual manufacturer’s website
and varies depending on the model of CIED being imaged.

• CIEDs undergo multiple alterations to be MR conditional devices.

These include lead modification to reduce lead tip heating, circuitry
shielding to prevent POR, reduction of ferromagnetic materials,
changing the reed switch to a “Hall sensor” (which has predictable
behavior in a magnetic field), and updated software. Newer software
aids re programming and, in some instances, automatically changes to
MRI mode when a strong magnetic field is detected.
IMAGE QUALITY
• The most important factor that affects image quality is the anatomic region
being imaged.
• ICDs show larger areas of MRI artifact than do PPMs due to their bulkier
design and greater use of ferromagnetic components.
• Right ventricular studies are of higher quality than those of the left
ventricle.
• For cardiac and thoracic MRI, balanced steady-state free precession images
exhibit more artifact than do gradient-echo sequences.
• Overall,about 90% of thoracic and cardiac MRI examinations are described
as diagnostic.Under worst-case conditions (left-sided ICD and balanced
steady-state free precession acquisition) about 50% of studies are reported
to have acceptable image quality.
Latest developments
• Leadless PPM-less artefacts,smaller size
• Requirement of monitoring during Scan.
• Most Data available is from 1.5 T
MRI Artefacts in Leadless Cardiac Pacemaker
in 1.5T and 3T Magnets
• Only one prospective study
• 15 patients,7 in 1.5 T and 7 in 3T magnets
• LCP(Micra) implanted more than 6 weeks before the CMR
• bSSFP cine images(Short axis,4- and 2-chamber view of
LV),LVOT,RVOT,FLASH GRE in 4C viewand T1- & T2-weighted TSE
sequences were obtained of the 4-chamber view and in the short
axis.
• Reviewed by 4 observers
• Grade 1: excellent image quality, no artefacts affecting myocardial
segments or cardiac structures

• Grade 2: good image quality with artefact adjacent to the myocardial

segments or cardiac structures, delineation of myocardial borders may be
limited, no impact on diagnostic value

• Grade 3: artefact moderately affecting cardiac structures, less than half of

the myocardial segment is superimposed by the artefact

• Grade 4: poor image quality with significant artefact affecting more than
half of the myocardial segment, non-diagnostic image
Conclusion
• Overall image quality was excellent or good in the majority of CMR
images (myocardial segments of the LV affected by grade 1: 70.5%,
grade 2: 12.1%, grade 3: 7.6%, grade 4: 9.8%).
• 3 Tesla CMR imaging led to a significantly higher artefact burden ratio
per patient compared to 1.5 Tesla CMR imaging.
• No significant change of pacing thresholds and a marginal, but
statistically significant increase of sensing amplitude and impedances.
• Allowed a comprehensive evaluation of the cardiac structures and
function,wall motion abnormalities and tissue characterization.
However, mid anteroseptal, inferoseptal and apical septal myocardial
segments of the LV were affected by artefacts due to the LCP which
may impair or even exclude diagnostic evaluation of these segments.

• Assessment of LV function and aortic, mitral and tricuspid valve as

well as tissue characterization with T1 and T2 weighted imaging were
feasible with 1.5 Tesla and 3 Tesla.