Real-time MR imaging-guided laser atrial septal puncture in swine

Abdalla A Elagha, Ozgur Kocaturk, Michael A Guttman, Cengizhan Ozturk, Ann H Kim, George W Burton, June H Kim, Venkatesh K Raman, Amish N Raval, Victor J Wright, William H Schenke, Elliot R McVeigh, Robert J Lederman, Abdalla A Elagha, Ozgur Kocaturk, Michael A Guttman, Cengizhan Ozturk, Ann H Kim, George W Burton, June H Kim, Venkatesh K Raman, Amish N Raval, Victor J Wright, William H Schenke, Elliot R McVeigh, Robert J Lederman

Abstract

Purpose: The authors performed this study to report their initial preclinical experience with real-time magnetic resonance (MR) imaging-guided atrial septal puncture by using a MR imaging-conspicuous blunt laser catheter that perforates only when energized.

Materials and methods: The authors customized a 0.9-mm clinical excimer laser catheter with a receiver coil to impart MR imaging visibility at 1.5 T. Seven swine underwent laser transseptal puncture under real-time MR imaging. MR imaging signal-to-noise ratio profiles of the device were obtained in vitro. Tissue traversal force was tested with a calibrated meter. Position was corroborated with pressure measurements, oximetry, angiography, and necropsy. Intentional non-target perforation simulated serious complication.

Results: Embedded MR imaging antennae accurately reflected the position of the laser catheter tip and profile in vitro and in vivo. Despite having an increased profile from the microcoil, the 0.9-mm laser catheter traversed in vitro targets with similar force (0.22 N +/- 0.03) compared with the unmodified laser. Laser puncture of the atrial septum was successful and accurate in all animals. The laser was activated an average of 3.8 seconds +/- 0.4 before traversal. There were no sequelae after 6 hours of observation. Necropsy revealed 0.9-mm holes in the fossa ovalis in all animals. Intentional perforation of the aorta and atrial free wall was evident immediately.

Conclusions: MR imaging-guided laser puncture of the interatrial septum is feasible in swine and offers controlled delivery of perforation energy by using an otherwise blunt catheter. Instantaneous soft tissue imaging provides immediate feedback on safety.

Conflict of interest statement

Conflicts of Interest

Spectranetics customized laser catheters under a Collaborative Research and Development Agreement with NHLBI. George Burton is an employee of Spectranetics.

No other authors have a conflict of interest.

Figures

Figure 1
Figure 1
The commercial 0.9mm excimer laser catheter is modified with a microcoil at the distal tip connected via a microcoaxial cable that serves as a dipole antenna. The fiberoptic shaft is lengthened 8 meters in order to connect to a laser console positioned outside the shielded MRI lab. The resulting “active” catheter antenna connects to the MRI system to impart visibility during imaging.
Figure 2
Figure 2
Signal-to-noise (SNR) profile of the active laser catheter. The calibration mark = 5mm. (A) An insulated copper microcoil is evident at the tip of the modified laser catheter. (B) MRI of the active laser catheter in a calibrated geometry phantom. (C) The signal profile is mapped in normalized SNR units, and also displayed with a photographic overlay of the catheter in (D). The signal profile is larger than the catheter tip.
Figure 3
Figure 3
Representative force-versus-time curves of unmodified (passive, continuous) and modified (active, dotted line) laser catheters crossing porcine interatrial septal tissue ex vivo. Force declines precipitously when the laser crosses tissue (arrows). Both catheters accumulated comparable force before perforation.
Figure 4
Figure 4
A representative MRI laser septal puncture procedure. (A) The tip of the active laser is engaged against the fossa ovalis and causes characteristic “tenting” appearance. (B) The activated laser crosses into the left atrium. (C) The blunt catheter is advanced into the left atrial appendage (LAA).
Figure 5
Figure 5
Projection mode unambiguously displays catheter tips that are outside selected imaging slices. (A) shows anatomic references during real-time SSFP MRI. (B) Tomographic image of a laser catheter in the left atrium, which appears to be located near the interatrial septum (dotted red double-arrow). (C) Projection-mode image demonstrates that the tip of the catheter is instead near the lateral wall of the left atrium (dotted white double-arrow indicates corresponding points on the two images).
Figure 6
Figure 6
Intentional perforation under real-time SSFP MRI. (A) The aortic root is perforated and a jet of dephased spins appears black within the right atrium (arrow). (B) The left atrial appendage is perforated and a small effusion accumulates within the pericardium (arrow). Both findings were subtle on MRI and not detectable hemodynamically

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