Real-Time MRI Guided Intervention
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Real-Time MRI Guided Intervention Henry R. Halperin, M.D., M.A., F.A.H.A. Johns Hopkins University School of Medicine Departments of Medicine, Radiology, Biomedical Engineering Baltimore, MD USA. Presenter Disclosure Information. Henry R Halperin, MD, MA.

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Real-Time MRI Guided Intervention Henry R. Halperin, M.D., M.A., F.A.H.A.Johns Hopkins University School of MedicineDepartments of Medicine, Radiology, Biomedical EngineeringBaltimore, MD USA


Presenter Disclosure Information

Henry R Halperin, MD, MA

Disclosure Information...The following relationships exist related to this presentation:

Equity Interest: Lexmed, Significant

Equity Interest: Surgivision, Modest

Grant Support: RO1 HL64795, K24 HL04194, Significant Consulting Fees: Boston Scientific, Modest

Off label use: Catheters in MRI, Gadolinium for cardiac studies


3d image integration

3D Image Integration

Current State of the Art


Pulmonary vein isolation atrial fibrillation ablation
Pulmonary Vein Isolation: Atrial Fibrillation Ablation


Can achieve 100 pv isolation

Can Achieve ~100% PV Isolation

But:

20-50% recurrence rate


Underestimation of gaps lesions cannot be visualized directly
Underestimation of Gaps:Lesions cannot be visualized directly

Dong, Halperin, et al: Circulation. 2006;113:186-194.

Gaps can have reversible conduction block !


Underestimation of lesion presence
Underestimation of Lesion Presence

  • Conventional PVI using X-rays and Navx

  • Pt moved to MRI scanner via transport system

  • Viability imaging with MRI

  • 40% of Navx marked ablation sites did not have lesions

Rhode K, Knowles B, Razavi R: SCMR 2009


Real time mr guided intervention

Real-Time MR Guided Intervention

The Future and/or Now?


Rationale for Using MRI

  • Accurate anatomy

  • Visualize different kinds of soft tissue (ablated)

  • Real-time 3-D imaging

  • No ionizing radiation

  • Similar cost as bi-plane x-ray system



Mri compatible clinical catheters

500

~

~

<

MRI Compatible Clinical Catheters

  • Irvine Biomedical Inc

  • IDE and IRB Approved

  • Limited imaging power (SAR)

Nazarian et al: Circulation. 2008 Jul 15;118(3):223-9


500

~

~

SAR Amplification Factor

<

  • Improved torque transmission (non-magnetic wire braid)

  • Improved heating suppression

Improved MRI Compatible Catheters

Susil et al: Mag Res Med, 47(3):584-600, 2002


IEGM Recording During MR Imaging

MRI compatible catheter in RV apex.

GE 1.5T CV/I

Fiesta (SSFP)

TR/TE 3.2/1.1

FA 45o

FOV 48x12cm

ST 2cm

128x32

BW 128 kHz

10 frames/sec

IEGM


Intracardiac electrograms with multiple catheters
Intracardiac Electrograms(with multiple catheters)

HRA

HBE

RVA

Outside Scanner Inside Scanner During Imaging

Nazarian et al: Circulation. 2008 Jul 15;118(3):223-9


Catheter manipulation using real time imaging
Catheter ManipulationUsing Real Time Imaging




Mr guided studies

MR Guided Studies

What does it give us?



Imaging Ablated Ventricular Tissue

Pre Ablation Post Ablation

Lardo et al, Circ 2000;

102(6):698-705


Gadolinium lesion enhancement
Gadolinium Lesion Enhancement

Dickfeld et al, JACC, 2006;47:370-8


Accuracy of lesion size estimates
Accuracy of Lesion Size Estimates

Contrast-Void

Delayed Enhancement

Dickfeld et al, JACC, 2006;47:370-8


Mri thermography proton precession rate phase is temperature sensitive
MRI Thermography (Proton precession rate (phase) is temperature sensitive)

DEMRI

Path

Temperature Evolution



LA Imaging Compared with Histology

MR Image

MRI

Histopathology

Histology

R = 0.89, p < 0.001, n=20

Lardo et al, Circ 2000;102(6):698-705


Imaging la ablation chronically
Imaging LA Ablation Chronically

Wylie J, Peters D, Josephson M, Manning W, et al: Heart Rhythm 2008;5:656–662


Imaging la ablation chronically after second procedure completion of isolation
Imaging LA Ablation Chronically(after second procedure - completion of isolation)

McGann C, Marrouche N, et al: J Am Coll Cardiol 2008;52:1263–71


Closing the gaps in linear lesions

Closing the Gaps in Linear Lesions

Prediction of Conduction Block


Filling in gaps and conduction block

Pace

20 ms

Sense

40 ms

Gap Closed

Pace

Pace

Sense

Sense

Conduction Block

Filling In Gaps and Conduction Block

Gap Open

Pace

Sense



Mr guided ep study setup
MR Guided EP Study Setup

  • Conscious Sedation

  • Monitoring

    • O2 Sat

    • NIBP

    • ECG

Nazarian et al: Circulation. 2008 Jul 15;118(3):223-9


Real time mri guided ep study
Real-Time MRI Guided EP Study

Nazarian et al: Circulation.

2008 Jul 15;118(3):223-9


Summary
Summary

  • MR can be used to guide catheter navigation in real time

  • MR images can be obtained in real time during electrogram acquisition and during ablation

  • Ablated tissue and true anatomy can be visualized

  • Imaging characteristics may be able to predict the presence of conduction block

  • This approach may improve safety and efficacy of many ablations

  • Ablations in patients to start end of summer


Investigators

Hiroshi Ashikaga

Ergin Atalar

Ronald Berger

David Bluemke

Paul Bottomley

Hugh Calkins

Timm Dickfeld

Jun Dong

Yoav Dori

Rob Evers

Owen Faris

Ahmet Genc

Michael Guttman

Rozann Hansford

Ritsushi Kato

Lars Lickfett

Investigators

  • Aravindin Kolandeavelu

  • Jennifer LaCorte

  • Albert Lardo

  • Joao Lima

  • Elliot McVeigh

  • Glenn Meininger

  • Frank Miller

  • Saman Nazarian

  • Erez Nevo

  • Nael Osman

  • Ravi Ranjan

  • Ariel Roguin

  • Meiyappan Solaiyappan

  • Robert Susil

  • Menekhem Zviman


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