MRI Catheterization in Cardiopulmonary Disease

doi:10.1378/chest.13-1759

Chest

Volume 145, Issue 1, January 2014, Pages 30-36

https://doi.org/10.1378/chest.13-1759 Get rights and content

Diagnosis and prognostication in patients with complex cardiopulmonary disease can be a clinical challenge. A new procedure, MRI catheterization, involves invasive right-sided heart catheterization performed inside the MRI scanner using MRI instead of traditional radiographic fluoroscopic guidance. MRI catheterization combines simultaneous invasive hemodynamic and MRI functional assessment in a single radiation-free procedure. By combining both modalities, the many individual limitations of invasive catheterization and noninvasive imaging can be overcome, and additional clinical questions can be addressed. Today, MRI catheterization is a clinical reality in specialist centers in the United States and Europe. Advances in medical device design for the MRI environment will enable not only diagnostic but also interventional MRI procedures to be performed within the next few years.

Section snippets

Limitations of Catheterization

Catheterization techniques for measurement of cardiac output (necessary for the quantification of pulmonary vascular resistance) are subject to error. The thermodilution technique is inaccurate in patients with low flow states, intracardiac shunts, or significant valvular regurgitation (eg, tricuspid regurgitation).⁵ Thermodilution should, therefore, be avoided in patients with pulmonary hypertension who often have significant tricuspid regurgitation. The Fick technique is inaccurate in

Limitations of Noninvasive Evaluation

Echocardiography is typically the first test performed in patients with suspected pulmonary hypertension. The established method for estimating pulmonary artery pressure with echocardiography involves measuring the maximal velocity of tricuspid regurgitation.⁷ Alternative markers of pulmonary hypertension, including pulmonary artery acceleration time,⁸ flattening of the interventricular septum, and pulmonary regurgitant velocity, have been proposed in the absence of tricuspid regurgitation.⁹

MRI Catheterization Offers Additive Diagnostic Value Compared With Stand-alone MRI or Conventional Catheterization

MRI catheterization addresses all the previously mentioned limitations by simultaneously measuring the pressures, flows, and volumes of the desired cardiac chambers. Volumetric analysis of cardiac function (such as end-diastolic and end-systolic volumes) or MRI (velocity-encoded, also known as phase-contrast) flow techniques can measure stroke volume and pulmonic or systemic cardiac output. In addition, intracardiac shunts (Qp:Qs) can be identified from mismatched pulmonary artery and aortic

MRI Catheterization is a Clinical Reality Today

MRI catheterization is typically performed in a combined MRI and radiographic cardiac catheter laboratory (Fig 1). To enable interventional MRI procedures, the MRI room must be equipped with display monitors or projectors so the operator can view images and patient hemodynamic parameters/waveforms. MRI generates acoustic noise, so specialized sound-suppression headsets are required to allow the operator, patient, catheterization laboratory staff, and MRI technician to communicate while

Further Advantages of MRI Catheterization

In the pediatric population, both MRI and catheterization usually require sedation or general anesthesia. Combining them into a single procedure reduces the sedation requirement and associated risk to the patient, as well as the overall cost. Delineation of abnormal anatomy under fluoroscopic guidance requires iodinated contrast injections, particularly in children with complex corrected or noncorrected congenital heart disease, whereas MRI offers unrivalled anatomic imaging without the need

Added Value of Physiologic Provocation

The value of catheterization is enhanced when the assessment of pressures and right ventricular function are compared among different physiologic conditions. Many patients with cardiopulmonary disease, including those with elevated pulmonary artery pressure, are asymptomatic at rest and only develop symptoms with exercise. Yet we perform most of our evaluation (both invasive and noninvasive) at rest. Provocative testing with exercise or IV fluid volume can be useful to unmask latent symptoms

From Diagnostic to Interventional MRI Catheterization

Current MRI techniques for needle, catheter, or device visualization rely on creating an imaging artifact (eg, with ferrous material) or using contrast agents (eg, air or gadolinium-filled balloons). This strategy has limitations because it requires the device to be confined within the selected imaging slice, and in the case of balloon-tip catheters, the shaft of the device remains invisible. To improve visualization of the whole device, “active” MRI catheters can be specifically engineered to

Conclusions

The diagnosis of complex cardiopulmonary disease requires the integration of structural, functional, and hemodynamic parameters from a combination of noninvasive and invasive investigations. MRI catheterization addresses all these considerations in one single study and provides more information than either modality alone. This reduces the burden of medical investigations on the patient, simplifies the interpretation of multiple tests for the physician, and may reduce the overall cost. In the

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The sponsor provided salary support for all authors. The National Institutes of Health and Siemens Medical Systems have a collaborative research and development agreement for interventional cardiovascular MRI.

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Magnetic resonance imaging (MRI) is a noninvasive imaging technique to obtain an anatomical image with high resolution and excellent soft-tissue contrast. These properties have made MRI an indispensable diagnostic tool and is increasingly used for interventional guidance, such as high-intensity focused ultrasound (Wijlemans et al., 2012), catheter guidance during surgery (Rogers et al., 2014), and radiotherapy (Raaymakers et al., 2009; Mutic and Dempsey, 2014). MRI must be acquired, reconstructed, and processed with high accuracy in real-time for interventional guidance applications.
Convolutional neural networks (CNNs) are increasingly adopted in medical imaging, e.g., to reconstruct high-quality images from undersampled magnetic resonance imaging (MRI) acquisitions or estimate subject motion during an examination. MRI is naturally acquired in the complex domain $C$ , obtaining magnitude and phase information in k-space. However, CNNs in complex regression tasks are almost exclusively trained to minimize the L2 loss or maximizing the magnitude structural similarity (SSIM), which are possibly not optimal as they do not take full advantage of the magnitude and phase information present in the complex domain. This work identifies that minimizing the L2 loss in the complex field has an asymmetry in the magnitude/phase loss landscape and is biased, underestimating the reconstructed magnitude. To resolve this, we propose a new loss function for regression in the complex domain called $⊥$ -loss, which adds a novel phase term to established magnitude loss functions, e.g., L2 or SSIM. We show $⊥$ -loss is symmetric in the magnitude/phase domain and has favourable properties when applied to regression in the complex domain. Specifically, we evaluate the $⊥$ + $ℓ^{2}$ -loss and $⊥$ +SSIM-loss for complex undersampled MR image reconstruction tasks and MR image registration tasks. We show that training a model to minimize the $⊥$ + $ℓ^{2}$ -loss outperforms models trained to minimize the L2 loss and results in similar performance compared to models trained to maximize the magnitude SSIM while offering high-quality phase reconstruction. Moreover, $⊥$ -loss is defined in $R^{n}$ , and we apply the loss function to the $R^{2}$ domain by learning 2D deformation vector fields for image registration. We show that a model trained to minimize the $⊥$ + $ℓ^{2}$ -loss outperforms models trained to minimize the end-point error loss.
Interventional Cardiovascular Magnetic Resonance
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Cardiovascular magnetic resonance (CMR) presents a number of unique opportunities to guide transcatheter cardiovascular interventions. Advances in real-time pulse sequences and user interfaces now allow catheter navigation with temporal resolution approaching that of x-ray fluoroscopy and simultaneous soft tissue visualization similar to echocardiography but unlimited by acoustic windows, and all without ionizing radiation or nephrotoxic contrast. In this chapter we will review the hardware and software components required to build an interventional CMR suite, consider the catheter and device engineering challenges in the CMR environment, and explore current and future clinical applications for this exciting technology.
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Magnetic resonance image guidance for cardiovascular interventions has grown in recent years from a research tool to translation into clinical practice. The scope of improved visualization of cardiovascular anatomy, tissue characterization, physiologic information, and reduced ionizing radiation from cardiovascular magnetic resonance (CMR) is attractive compared to conventional fluoroscopic cardiac catheterization techniques. This is particularly relevant to a pediatric population who are more at risk from radiation, and more likely to need repeat interventions in the future.
Industry support has increased the development of interventional CMR systems. New generation scanners allow for faster scanning protocols, which translate into improved catheter visualization and tracking. The platforms for interacting with these images are also more intuitive. CMR conditional hardware in the form of catheters and guidewires is more available, although more work is still needed in this area.
These advances are balanced with the need to maintain safety issues in a CMR environment and any risks from heating. While there is some limitation in the available hardware options for sole CMR guidance, x-ray fused with CMR allows physiologic testing in the assessment of pulmonary avascular resistance as an example. There is now a growing body of early human experience or interventional cases, electrophysiology testing, and radiofrequency ablation in the CMR environment. These are discussed in the chapter.
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Citation Excerpt :
In addition, a major advantage resulted from the ability of phase-contrast MR imaging to noninvasively measure flow rates and pressure gradients,101,102 replacing the invasive catheters previously required. Unfortunately, navigation in the PAs is quite difficult without MR imaging–compatible guidewires so that although a few human interventions have been performed,2,34,103–108 their frequency has tapered off or they have been replaced by X-MR imaging approaches in which X-ray is used for navigation. The recent development of MR imaging–compatible guidewires may rekindle this field.

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Funding/Support: This study was supported by the Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health [Z01-HL005062] to Dr Lederman.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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Chest

CommentaryAhead of The CurveMRI Catheterization in Cardiopulmonary Disease

Section snippets

Limitations of Catheterization

Limitations of Noninvasive Evaluation

MRI Catheterization Offers Additive Diagnostic Value Compared With Stand-alone MRI or Conventional Catheterization

MRI Catheterization is a Clinical Reality Today

Further Advantages of MRI Catheterization

Added Value of Physiologic Provocation

From Diagnostic to Interventional MRI Catheterization

Conclusions

Acknowledgments

Chest

Am J Med

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Coll Cardiol

Chest

J Am Coll Cardiol

Am J Cardiol

Lancet

J Cardiovasc Magn Reson

J Am Coll Cardiol

J Am Coll Cardiol

J Cardiovasc Magn Reson

JACC Cardiovasc Interv

J Cardiovasc Magn Reson

Circulation

Eur Heart J

Survival in patients with primary pulmonary hypertension. Results from a national prospective registry

Ann Intern Med

The estimation of oxygen consumption

Cardiovasc Res

Noninvasive estimation of right ventricular systolic pressure by Doppler ultrasound in patients with tricuspid regurgitation

Circulation

Continuous-wave Doppler echocardiographic detection of pulmonary regurgitation and its application to noninvasive estimation of pulmonary artery pressure

Circulation

Right ventricular systolic function assessment: rank of echocardiographic methods vs. cardiac magnetic resonance imaging

Eur J Echocardiogr

Doppler echocardiographic evaluation of pulmonary artery pressure in chronic obstructive pulmonary disease. A European multicentre study. Working Group on Noninvasive Evaluation of Pulmonary Artery Pressure. European Office of the World Health Organization, Copenhagen

Eur Heart J

Right ventricular function and failure: Report of a National Heart, Lung, and Blood Institute working group on cellular and molecular mechanisms of right heart failure

Circulation

Commentary
Ahead of The Curve
MRI Catheterization in Cardiopulmonary Disease