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MRI likely safe for patients with abandoned cardiac device leads

Journal
JAMA Cardiology
Reuters Health - 25/02/2021 - Patients with abandoned cardiac implantable electronic device (CIED) leads are at low risk from magnetic resonance imaging (MRI) and may safely undergo the procedure with appropriate monitoring, researchers say.

"Patients with abandoned leads are unable to undergo MRI scanning in most centers due to concern for significant lead tip heating," Dr. Robert Schaller of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia told Reuters Health by email. "We have performed more than 200 consecutive MRI scans of various anatomic regions in patients with abandoned leads. Our data have shown that it is clinically safe to the surrounding tissues and adjacent functioning leads."

"We hope that our report emboldens clinicians to consider MRI scanning in patients with abandoned leads within a program that includes appropriate safety monitoring," he said. "Collection of data to confirm our results will hopefully encourage medical societies, regulatory boards, and insurance providers to reconsider the indications and reimbursement of this procedure, once considered absolutely contraindicated."

As reported in JAMA Cardiology, 139 consecutive CIED recipients (mean age, 65.6; 79%, men) with at least one abandoned lead underwent 200 1.5 T MRIs of various anatomic regions including the thorax between 2013-2020. No patients were excluded.

CIEDs were reprogrammed based on patient-specific pacing needs. Electrocardiography telemetry and pulse oximetry were monitored continuously, and clinicians were in live visual and voice contact with the patient when possible. A CIED evaluation was done again after the MRI and programming was returned to baseline or to a clinically appropriate setting.

The main outcomes were variations of 50% or more the in pre- and post-MRI capture threshold; 40% or more in ventricular sensing; and 30% or more in lead impedance; and clinical sequelae such as pain and sustained tachyarrhythmia.

Repeat examinations were common, with a maximum of 16 examinations for one of the patients. Two hundred and forty-three leads were abandoned, with a mean of 1.22 per patient; the mean number of active leads was 2.04.

Sixty-four patients (46%) were pacemaker-dependent.

A transmit-receive radiofrequency coil was used in 41 patients (20.5%) who underwent brain MRI.

No abnormal vital signs, sustained tachyarrhythmias, changes in battery voltage, power-on reset events, or changes of pacing rate were noted.

CIED parameter changes - including decreased right atrial sensing in four patients and decreased left ventricular R-wave amplitude in one - were noted transiently. One patient with an abandoned subcutaneous array experienced sternal heating that subsided after the imaging study was stopped prematurely.

Two experts from the University of Pittsburgh Medical Center provided comments by email to Reuters Health.

Dr. Timothy Wong, Associate Director of the Cardiovascular Magnetic Resonance Center, Heart and Vascular Institute, said he is "cautiously in agreement with the findings." That said, he noted, "the numbers in this study are still fairly low, and many different types of MRI scans - brain, heart, spine, extremities, abdomen - were performed. Each type would have a differing potential impact on abandoned leads."

Nonetheless, he added, the study is "a step forward in accumulating the data needed to change practice. More studies from different institutions with larger numbers of patients are needed to obtain a more generalizable estimate of risk and best practices to mitigate risk."

Dr. Krishna Kancharla, a UPMC cardiac electrophysiologist, noted, "This is the second in this area and is now the largest published. The first study had similar safety with 80 patients." (https://bit.ly/37QLoNk)

"Abandoned lead type, implant location and lead capped status, type of MRI, and sequences may matter," he said. The heating risk is dependent on these factors, he added.

An individual risk benefit-assessment and a collaborative approach to the MRI could yield the best outcomes, he said. "CMS should consider supporting such cases with appropriate guidance in place," Dr. Kancharla concluded.

SOURCE: https://bit.ly/2Pcocma and https://bit.ly/2PcofhQ JAMA Cardiology, online February 17, 2021.

By Marilynn Larkin



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