Feasibility of adenosine stress cardiovascular magnetic resonance perfusion imaging in patients with MR-conditional transvenous permanent pacemakers and defibrillators

Abstract

Background: The use of stress perfusion-cardiovascular magnetic resonance (CMR) imaging remains limited in patients with implantable devices. The primary goal of the study was to assess the safety, image quality, and the diagnostic value of stress perfusion-CMR in patients with MR-conditional transvenous permanent pacemakers (PPM) or implantable cardioverter-defibrillators (ICD).

Methods: Consecutive patients with a transvenous PPM or ICD referred for adenosine stress-CMR were enrolled in this single-center longitudinal study. The CMR protocol was performed using a 1.5 T system according to current guidelines while all devices were put in MR-mode. Quality of cine, late-gadolinium-enhancement (LGE), and stress perfusion sequences were assessed. An ischemia burden of ≥ 1.5 segments was considered significant. We assessed the safety, image quality and the occurrence of interference of the magnetic field with the implantable device. In case of ischemia, we also assessed the correlation with the presence of significant coronary lesions on coronary angiography.

Results: Among 3743 perfusion-CMR examinations, 66 patients had implantable devices (1.7%). Image quality proved diagnostic in 98% of cases. No device damage or malfunction was reported immediately and at 1 year. Fifty patients were continuously paced during CMR. Heart rate and systolic blood pressure remained unchanged during adenosine stress, while diastolic blood pressure decreased (p = 0.007). Six patients (9%) had an ischemia-positive stress CMR and significant coronary stenoses were confirmed by coronary angiography in all cases.

Conclusion: Stress perfusion-CMR is safe, allows reliable ischemia detection, and provides good diagnostic value.

Keywords: Adenosine; Cardiovascular magnetic resonance; Implantable cardioverter defibrillator; Implantable device; MRI conditional; Pacemaker; Safety; Stress test.

Conflict of interest statement

Beyond the study’s interests, Prof Schwitter received research grants from Bayer Healthcare, Switzerland. Other authors have nothing to disclose.

© 2021. The Author(s).

Figures

Fig. 1

study flowchart

Fig. 2

Stress perfusion-CMR in a permanent pacemaker dependent (PPM) patient. A 74-year-old man was referred to stress perfusion CMR due to exertional dyspnea and angor. A double chamber PPM was implanted for a 2-degree atrioventricular block and the patient was PPM-dependent (Panel A). X-ray coronary angiography showed a severe stenosis of the proximal portion of the left anterior descending artery (Panel B, C, yellow arrowed) that was treated by drug-eluting stent implantation. Stress perfusion CMR, performed before x.ray coronary angiography showed an extensive hypoperfusion in the anterior and septal wall (Panel D–G, red arrowed) without the presence of myocardial scar in late gadolinium (LGE) images (Panel H, I, L, M) indicating a positive stress test, consistent with the lesion found in x-ray coronary angiography

Fig. 3

Stress perfusion-CMR in a PPM dependent patient. 67-year-old with known an antero-septal myocardial infarction, was referred to stress perfusion CMR to exclude myocardial ischemia after implantation of a MR-conditional implantable cardiodefibrillator (ICD) for primary prevention. A Cine fast-gradient echo acquisition of a 4-chamber view demonstrating a mural thrombus (Th) in the apex and the artifact of the ICD electrode (red arrow). B Corresponding standard phase sensitive inversion recovery (PSIR) 4-chamber view with visualization of the post-infarct scar in septal and apical segments as well as the apical thrombus (Th) and the ICD electrode (red arrow). Standard short-axis PSIR in C (with bandwidth of 140 Hz/pixel) and PSIR with increased bandwidth in D (300 Hz/pixel) to eliminate the ICD-related artifact on the anterior wall (black arrow in C), electrode (red arrow). The mural thrombus (Th) and the antero-lateral scar is visualized. E/F/G: Myocardial perfusion upslope maps of motion-compensated perfusion images in the basal (E), mid-ventricular (F) and apical (G) slices. Visualization of hypoperfused scar (black arrow heads) thereby excluding ischemia in this patient. Hypoperfusion of the mural thrombus in G (Th)

Fig. 4

Hemodynamic parameters. Panel A heart rate response in patients under pacing (red) or not-paced (green), Panel B systolic blood pressure (BP) changes in patients under pacing (red) or not-paced (green), Panel C Diastolic BP changes under pacing (red) or not-paced (p = 0.007) (green)