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U. S. Department of Health and Human Services National Institutes of Health National Heart, U. S. Department of Health and Human Services National Institutes of Health National Heart, Lung, and Blood Institute Image-guided cardiovascular intervention using MRI + X-Ray Robert J. Lederman, MD Cardiovascular Section, Translational Medicine Branch Division of Intramural Research National Heart, Lung, and Blood Institute National Institutes of Health Bethesda, MD, USA [email protected] gov 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.

Real-time MRI Catheter Procedures Dick, Circulation, 2003; 108: 2899 Raval, Circulation, 2005; 112: 699 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 [In Press]

Catheter devices as “active” MRI antennae for navigation Steel-Braided n Steel braid destroys image Catheter devices as “active” MRI antennae for navigation Steel-Braided n Steel braid destroys image n Wires/braids heat during MRI n Remove steel: “MRI compatible” = “MRI invisible” n Catheters modified to serve as “active” MRI antennae, to prevent heating “MRICompatible” “Active”

U. S. Department of Health and Human Services Coronary artery intervention under realtime MRI? U. S. Department of Health and Human Services Coronary artery intervention under realtime MRI? National Institutes of Health National Heart, Lung, and Blood Institute Cardiovascular Intervention Program at NHLBI Not realistic using recognized technology

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

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

Co-Registration U. S. Department of Health and Human Services X-ray Fused with MRI (XFM) Co-Registration U. S. Department of Health and Human Services X-ray Fused with MRI (XFM) National Institutes of Health National Heart, Lung, and Blood Institute Cardiovascular Intervention Program at NHLBI Gutiérrez, Ozturk, et al PMB 2008

XFM Myocardial Injections: Region of Interest Roadmaps Green = Infarct Red = thickness < XFM Myocardial Injections: Region of Interest Roadmaps Green = Infarct Red = thickness < 6 mm De Silva, et al, Circulation 2006

Unusual myocardial biopsy in human Gutiérrez, et al CCI 2007 Unusual myocardial biopsy in human Gutiérrez, et al CCI 2007

XFM Guided Treatment of Structural Heart Disease (Membranous Ventricular Septal Defect) Ratnayaka, JACC Intervent XFM Guided Treatment of Structural Heart Disease (Membranous Ventricular Septal Defect) Ratnayaka, JACC Intervent 2009

Transcatheter mitral cerclage annuloplasty June-Hong Kim, JACC, 2009 Transcatheter mitral cerclage annuloplasty June-Hong Kim, JACC, 2009

Patients (n>250) at Kings College London Interventional (n=70) Diagnostic (n=180) Over 250 patients XMR Patients (n>250) at Kings College London Interventional (n=70) Diagnostic (n=180) Over 250 patients XMR guided catheterisations EP studies PVR studies Reza Razavi Vivek Muthurangu Tobias Schaeffter Device placement

Works-in-Progress: Respiratory & Cardiac Motion Correction end inspiration end expiration end inspiration Anthony Z. Works-in-Progress: Respiratory & Cardiac Motion Correction end inspiration end expiration end inspiration Anthony Z. Faranesh, Ph. D

MRI to Enhance & Perform Catheter Intervention n Soft-tissue & 3 -dimensional imaging – MRI to Enhance & Perform Catheter Intervention n Soft-tissue & 3 -dimensional imaging – Context – Novel procedures n Radiation-sparing – Pediatrics – Complex procedures n MRI Roadmaps + Live X-Ray (XFM) – Features of above, available “now”

Acknowledgements Collaborators – – Peter Kellman, Ph. D [Lab Cardiac Energetics] Michael Slack, MD, Acknowledgements Collaborators – – Peter Kellman, Ph. D [Lab Cardiac Energetics] Michael Slack, MD, [CNMC] June-Hong Kim, MD [Pusan U, Korea] Daniel Herzka, Ph. D [Johns Hopkins U] Alumni – – – – Amish Raval, MD [Univ. Wisconsin] Cengizhan Ozturk, MD/Ph. D [Bogazici, Turkey] Alexander J. Dick, MD [Univ. Toronto] Brenno S. S. Pessanha, MD [Peoria, IL] Ronnier J. Aviles, MD [Seattle, WA] Ranil De. Silva, FRCP [Brompton, London] James Telep, MD [Fairfax, VA] Abdalla Elagha, MD [U. Cairo] – – – – Elliot Mc. Veigh, Ph. D [Johns Hopkins U] Michael Guttman, MSc [Surgi-Vision] 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] Cardiovascular Intervention Lab – Kanishka Ratnayaka, MD [Children’s, DC] – Israel M. Barbash, MD [Sheba Med, Israel] – Venkatesh K Raman, MD [Takoma Park, MD] – Jessica Colyer, MD [Children’s, DC] – Victor J. Wright, BS – Bill Schenke, BS – Annette M. Stine, RN – Laurie Grant, RN Imaging & Catheter Engineering – Anthony Z Faranesh, Ph. D – Ozgur Kocaturk, Ph. D – Michael S. Hansen, Ph. D – Christina E Saikus, MSTP [Emory/GA tech] – J. Andrew Derbyshire, Ph. D – Vincent Wu, BS – Jamie Bell. BS – Merdim Sonmez, MS Slides – Reza Razavi & Tobias Schaeffter, Kings College London