U S Department of Health and Human Services

U. S. Department of Health and Human Services MRI to conduct interventional cardiovascular procedures Robert J. Lederman, MD National Institutes of Health Cardiovascular & Pulmonary Branch Division of Intramural Research National Heart, Lung, and Blood Institute National Institutes of Health Bethesda, MD, USA lederman@nih. gov National Heart, Lung, and Blood Institute Disclosures : Cardiovascular Intervention Program at NHLBI • No conflicts of interest. NIH & Siemens have a Collaborative R&D Agreement • These are non-clinical or investigational procedures.

Acknowledgements Collaborators – Peter Kellman, Ph. D [Lab Cardiac Energetics] – June-Hong Kim, MD [Pusan U, Korea] – Michael Slack, MD, [CNMC] Alumni Clinical – – – – Amish Raval, MD [Univ. Wisconsin] Cengizhan Ozturk, MD/Ph. D [Bogazici, Turkey] Alexander J. Dick, MD [Ottowa Heart] Ronnier J. Aviles, MD [Seattle, WA] Ranil De. Silva, FRCP [Brompton, London] James Telep, MD [Fairfax, VA] Abdalla Elagha, MD [U. Cairo] Venkatesh K Raman, MD [Takoma Park, MD] Alumni Scientists – – – – – Elliot Mc. Veigh, Ph. D [Johns Hopkins U] Michael Guttman, MSc [Surgi-Vision, Inc] Parag Karmarkar, MS [Surgi-Vision, Inc] Richard Thompson, Ph. D [U Edmonton] Dana Peters, Ph. D [Harvard BIDMC] Luis Gutierrez, Ph. D [Philips Research] Smita Sampath, Ph. D [Yale U] Christina E. Saikus, MSTP [Emory/GA tech] Vincent Wu, BS [NYU SOM] Clinicians – – – Kanishka Ratnayaka, MD [Children’s, DC] Israel M. Barbash, MD [Sheba Med, Israel] Victor J. Wright, BS Bill Schenke, BS Annette M. Stine, RN Laurie Grant, RN Scientists & Engineers – – – Anthony Z Faranesh, Ph. D Ozgur Kocaturk, Ph. D Michael S. Hansen, Ph. D J. Andrew Derbyshire, Ph. D Jamie A. Bell, BS Merdim Sonmez, MS

XMR Suite for MRI Catheterization in patients

Real-time MRI Catheter Procedures Dick, Circulation, 2003; 108: 2899 Raval, Circulation, 2005; 112: 699 Raman, JACC, 2005; 45: 2069 Raval, CCI, 2006; 67: 637 Guttman, JMRI 2007; 26: 1429 Saybasili, JMRI 2010; 31: 1015

MRI to Enhance & Perform Catheter Intervention n Radiation-sparing – Pediatrics – Complex procedures n Soft-tissue & 3 -dimensional imaging – Context – Novel procedures – Not coronary artery intervention n MRI Roadmaps Co-registered with X-Ray (XFM) – Features of interventional MRI, available “now”

Safe but Conspicuous: the challenges of devices in MRI n Projectiles – Safety procedures – Compatible equipment n Heating – Long wires & cables & loops n Image distortion – Ferrous materials MR Safe MR Conditional MR Unsafe

MRI Catheters Conductive steel catheters heat and distort MRI “Compatible” catheters (steel removed) are invisible “Active” antenna-catheters are conspicuous for profiling or tracking

MRI Catheter Visualization Passive Active Tracking Micron-sized iron particles marking plastic catheters • Simple • Signal void or “negative” contrast • No unique image signature = confusing in practice Permission from M. Boch, Saikus i. JACC 2009 Balloon in RA Active Profiling Active guidewire in Aorta Active tracking coil in RV • Synthesized position marker • Combined tissue & device imaging • Requires special tracking sequences • Whole-device imaging Christina E. Saikus

Endoluminal Intervention: Coarctation Stent; Recognize complications positioning Raval, et al, Circulation 2005 deployment

Peripheral Chronic Total Occlusion RCA LCA RSCAD SVC Carotid Trunk T Raval et al, Circulation, 2006

Pre Post DSA 17 % success Pre Post MRI 79% success Patent Raval et al, Circulation, 2006

Real-Time MRI Guided Atrial Septal Puncture: Towards Extra-anatomic Bypass Elagha, et al, JVIR, 2008 Raval, et al, Catheter Cardiovasc Interven, 2006; 67: 637

Multiplanar targeted myocardial cell injection Needle marker red Mesenchymal stromal cells black Dick, Circulation, 2003 “Adaptive projection” mode Guttman, JMRI, 2007

Heart surgery without surgery: Direct entry to and closure of the left ventricle Israel M. Barbash; Christina E. Saikus; Kanishka Ratnayaka; Ozgur Kocaturk; Anthony Z. Faranes

Perventricular access: Trajectory planning Roadmap VSD Roadmap IMA • Skin-to-target trajectory geometry • Avoid bystander injury • Minimize lung traversal Christina E. Saikus; Haris Saybasili; Kanishka Ratnayaka;

Permissive pericardial tamponade 1. Needle access 2. Instill pericardial fluid to separate visceral & parietal layers (separate catheter) 3. Deploy closure device INSIDE pericardium 4. Withdraw pericardial fluid Barbash et al, Cathet Cardiovasc Interven 201

Pericardial entrapment “tethers open” the myocardial hole Angio-Seal suture Visceral pericardium Parietal pericardium 2010 -07 -20#27812 CIMG 2102. JPG Bleeding

Heart surgery without surgery: Direct entry to and closure of the left ventricle Israel M. Barbash; Christina E. Saikus; Kanishka Ratnayaka; Ozgur Kocaturk; Anthony Z. Faranesh

Direct transthoracic repair of ventricular septal defect using real-time MRI Kanishka Ratnayaka, Ozgur Kocaturk, Israel M. Barbash, Christina E. Saikus, et al

MRI-Guided EP ablation & thermometry Kolandaivelu. . Halperin, Circ EP, 2010

U. S. Department of Health and Human Services Co-Registration Work-In-Progress National Institutes of Health National Heart, Lung, and Blood Institute Cardiovascular Intervention Program at NHLBI Correction for Respiratory and Cardiac Motion of Roadmaps using a Piecewise Affine Model Anthony Z. Faranesh, Ph. D

Correction for Respiratory & Cardiac Motion using an Image-Based Navigator Free Breathing Breath hold Kellman P, et al. MRM. 2008 Chefd’hotel C et al. ISBI 2002 Anthony Z. Faranesh, Ph. D

Transcatheter mitral cerclage annuloplasty June-Hong Kim, et al, JACC 2009; 54: 638

Summary: Interventional MRI n Rationale n – Reduce or avoid X-rays in pediatrics – Instantaneous blood & tissue imaging – Context and complications n “Active” catheters are essential Structural heart – – n Direct transthoracic access Valve repair Valve replacement Extra-anatomic bypass PAD – Chronic total occlusion recanalization – Endograft therapy n Cardiac Electrophysiology – Image-guided ablation n Tumor Ablation – Easier than cardiovascular applications! lederman@nih. gov