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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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  1. 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

  2. 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

  3. 3D Image Integration Current State of the Art

  4. Pulmonary Vein Isolation: Atrial Fibrillation Ablation

  5. Can Achieve ~100% PV Isolation But: 20-50% recurrence rate

  6. Underestimation of Gaps:Lesions cannot be visualized directly Dong, Halperin, et al: Circulation. 2006;113:186-194. Gaps can have reversible conduction block !

  7. 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

  8. Real-Time MR Guided Intervention The Future and/or Now?

  9. 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

  10. Real-Time MR Guided Studies The technology

  11. 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

  12. 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

  13. 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

  14. 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

  15. Catheter ManipulationUsing Real Time Imaging

  16. Catheter Manipulation

  17. Dynamic Heart with Real-Time Plane

  18. MR Guided Studies What does it give us?

  19. Lesion Visualization

  20. Imaging Ablated Ventricular Tissue Pre Ablation Post Ablation Lardo et al, Circ 2000; 102(6):698-705

  21. Gadolinium Lesion Enhancement Dickfeld et al, JACC, 2006;47:370-8

  22. Accuracy of Lesion Size Estimates Contrast-Void Delayed Enhancement Dickfeld et al, JACC, 2006;47:370-8

  23. MRI Thermography (Proton precession rate (phase) is temperature sensitive) DEMRI Path Temperature Evolution

  24. One Lesion Placed under MRI Guidance

  25. 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

  26. Imaging LA Ablation Chronically Wylie J, Peters D, Josephson M, Manning W, et al: Heart Rhythm 2008;5:656–662

  27. Imaging LA Ablation Chronically(after second procedure - completion of isolation) McGann C, Marrouche N, et al: J Am Coll Cardiol 2008;52:1263–71

  28. Closing the Gaps in Linear Lesions Prediction of Conduction Block

  29. Pace 20 ms Sense 40 ms Gap Closed Pace Pace Sense Sense Conduction Block Filling In Gaps and Conduction Block Gap Open Pace Sense

  30. Real-Time MRI Guided Study in Patients IDE and IRB Approved

  31. MR Guided EP Study Setup • Conscious Sedation • Monitoring • O2 Sat • NIBP • ECG Nazarian et al: Circulation. 2008 Jul 15;118(3):223-9

  32. Real-Time MRI Guided EP Study Nazarian et al: Circulation. 2008 Jul 15;118(3):223-9

  33. 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

  34. 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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