Silent active device tracking for MR-guided interventional procedures.

PURPOSE: To evaluate a silent MR active catheter tracking sequence that allows conducting catheter interventions with low acoustic noise levels. METHODS: To reduce the acoustic noise associated with MR catheter tracking, we implemented a technique previously used in conventional MRI. The gradient waveforms are modified to reduce the sound pressure level (SPL) and avoid acoustic resonances of the MRI system. The efficacy of the noise reduction was assessed by software-predicted SPL and verified by measurements. Furthermore, the quality of the catheter tracking signal was assessed in a phantom experiment and during interventional cardiovascular MRI sessions targeted at isthmus-related flutter ablation. RESULTS: The maximum measured SPL in the scanner room was 104 dB(A) for real-time imaging, and 88 dB(A) and 69 dB(A) for conventional and silent tracking, respectively. The SPL measured at different positions in the MR suite using silent tracking were 65-69 dB(A), and thus within the range of a normal conversation. Equivalent signal quality and tracking accuracy were obtained using the silent variant of the catheter tracking sequence. CONCLUSION: Our results indicate that silent MR catheter tracking capabilities are identical to conventional catheter tracking. The achieved acoustic noise reduction comes at no penalty in terms of tracking quality or temporal resolution, improves comfort and safety, and can overcome the need for MR-compatible communication equipment and background noise suppression during the actual interventional procedure.

Improved catheter tracking during cardiovascular magnetic resonance-guided cardiac catheterization using overlay visualization.

INTRODUCTION: Cardiovascular magnetic resonance (CMR)-guided cardiac catheterization is becoming more widespread due to the ability to acquire both functional CMR measurements and diagnostic catheterization data without exposing patients to ionizing radiation. However, the real-time imaging sequences used for catheter guidance during these procedures are limited in resolution and the anatomical detail they can provide. In this study, we propose a passive catheter tracking approach which simultaneously improves catheter tracking and visualization of the anatomy. METHODS: 60 patients with congenital heart disease underwent CMR-guided cardiac catheterization on a 1.5T CMR scanner (Ingenia, Philips Healthcare, Best the Netherlands) using the Philips iSuite system. The proposed T1-overlay technique uses a commercially available heavily T1-weighted sequence to image the catheter, and overlays it on a high-resolution 3D dataset within iSuite in real-time. Suppressed tissue in the real-time images enables the use of a thick imaging slab to assist in tracking of the catheter. Improvement in catheter visualization time was compared between T1-overlay and the conventional invasive CMR (iCMR) balanced steady state free precession (bSSFP) sequence. This technique also enabled selective angiography visualization for real-time evaluation of blood flow dynamics (such as pulmonary transit time), similar to direct contrast injection under standard fluoroscopy. Estimates of pulmonary transit time using iCMR were validated using x-ray fluoroscopy in 16 patients. RESULTS: The T1-overlay approach significantly increased the time that the catheter tip was kept in view by the technologist compared to the bSSFP sequence conventionally used for iCMR. The resulting images received higher ratings for blood/balloon contrast, anatomy visualization, and overall suitability for iCMR guidance by three cardiologists. iCMR selective angiography using T1-overlay also provided accurate estimates of pulmonary transit time that agreed well with x-ray fluoroscopy. CONCLUSION: We demonstrate a new passive catheter tracking technique using the iSuite platform that improves visualization of the catheter and cardiac anatomy. These improvements significantly increase the time that the catheter tip is seen throughout the procedure. We also demonstrate the feasibility of iCMR selective angiography for the measurement of pulmonary transit time.

MRI for Guided Right and Left Heart Cardiac Catheterization: A Prospective Study in Congenital Heart Disease.

BACKGROUND: Improvements in outcomes for patients with congenital heart disease (CHD) have increased the need for diagnostic and interventional procedures. Cumulative radiation risk is a growing concern. MRI-guided interventions are a promising ionizing radiation-free, alternative approach. PURPOSE: To assess the feasibility of MRI-guided catheterization in young patients with CHD using advanced visualization passive tracking techniques. STUDY TYPE: Prospective. POPULATION: A total of 30 patients with CHD referred for MRI-guided catheterization and pulmonary vascular resistance analysis (median age/weight: 4 years / 15 kg). FIELD STRENGTH/SEQUENCE: 1.5T; partially saturated (pSAT) real-time single-shot balanced steady-state free-precession (bSSFP) sequence. ASSESSMENT: Images were visualized by a single viewer on the scanner console (interactive mode) or using a commercially available advanced visualization platform (iSuite, Philips). Image quality for anatomy and catheter visualization was evaluated by three cardiologists with >5 years' experience in MRI-catheterization using a 1-5 scale (1, poor, 5, excellent). Catheter balloon signal-to-noise ratio (SNR), blood and myocardium SNR, catheter balloon/blood contrast-to-noise ratio (CNR), balloon/myocardium CNR, and blood/myocardium CNR were measured. Procedure findings, feasibility, and adverse events were recorded. A fraction of time in which the catheter was visible was compared between iSuite and the interactive mode. STATISTICAL TESTS: T-test for numerical variables. Wilcoxon signed rank test for categorical variables. RESULTS: Nine patients had right heart catheterization, 11 had both left and right heart catheterization, and 10 had single ventricle circulation. Nine patients underwent solely MRI-guided catheterization. The mean score for anatomical visualization and contrast between balloon tip and soft tissue was 3.9 ± 0.9 and 4.5 ± 0.7, respectively. iSuite provided a significant improvement in the time during which the balloon was visible in relation to interactive imaging mode (66 ± 17% vs. 46 ± 14%, P < 0.05). DATA CONCLUSION: MRI-guided catheterizations were carried out safely and is feasible in children and adults with CHD. The pSAT sequence offered robust and simultaneous high contrast visualization of the catheter and cardiac anatomy. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY STAGE: 1.

Feasibility study of MR-guided transgluteal targeted in-bore biopsy for suspicious lesions of the prostate at 3 Tesla using a freehand approach.

OBJECTIVE: The aim of our study was (1) to establish an in-bore targeted biopsy of suspicious prostate lesions, avoiding bowel penetration using a transgluteal approach and (2) to assess operator setup, patient comfort and safety aspects in the clinical setting for freehand real-time MR-guidance established for percutaneous procedures in an open MR-scanner. MATERIAL AND METHODS: 30 patients with suspect prostate lesions were biopsied in a cylindrical 3T-MRI system using a transgluteal approach in freehand technique. One to three biopsies were sampled using continuous dynamic imaging. Size, location and visibility of the lesion, intervention time, needle artefact size, interventional complications and histopathological diagnosis were recorded. RESULTS: All biopsies were technically successful. Nineteen patients showed evidence of prostate carcinoma. Cancer detection rate was 50 % in patients with previously negative TRUS-biopsy. The average intervention time was 26 min including a learning curve as the time was 13 min by the end of the study. No antibiotic prophylaxis was performed as none of the patients showed signs of infection. CONCLUSIONS: MR-guided targeted freehand biopsies of prostate lesions using a transgluteal approach are both technically feasible and time efficient in a standard closed-bore 3T-MR scanner as well as safe for the individual patient. KEY POINTS: • Open-bore freehand interventional principles were adapted to closed-bore systems. • Prostate MR-guided freehand biopsies were feasible in a clinical setting. • A transgluteal approach provides a short and simplified work flow. • An inoculation of the prostate with bowel flora is avoided. • The intervention time is comparable to the stereotactic approach.

Magnetic resonance imaging guided transatrial electrophysiological studies in swine using active catheter tracking - experience with 14 cases.

OBJECTIVES: To evaluate the feasibility of performing comprehensive Cardiac Magnetic resonance (CMR) guided electrophysiological (EP) interventions in a porcine model encompassing left atrial access. METHODS: After introduction of two femoral sheaths 14 swine (41 ± 3.6 kg) were transferred to a 1.5 T MR scanner. A three-dimensional whole-heart sequence was acquired followed by segmentation and the visualization of all heart chambers using an image-guidance platform. Two MR conditional catheters were inserted. The interventional protocol consisted of intubation of the coronary sinus, activation mapping, transseptal left atrial access (n = 4), generation of ablation lesions and eventually ablation of the atrioventricular (AV) node. For visualization of the catheter tip active tracking was used. Catheter positions were confirmed by passive real-time imaging. RESULTS: Total procedure time was 169 ± 51 minutes. The protocol could be completed in 12 swine. Two swine died from AV-ablation induced ventricular fibrillation. Catheters could be visualized and navigated under active tracking almost exclusively. The position of the catheter tips as visualized by active tracking could reliably be confirmed with passive catheter imaging. CONCLUSIONS: Comprehensive CMR-guided EP interventions including left atrial access are feasible in swine using active catheter tracking. KEY POINTS: • Comprehensive CMR-guided electrophysiological interventions including LA access were conducted in swine. • Active catheter-tracking allows efficient catheter navigation also in a transseptal approach. • More MR-conditional tools are needed to facilitate left atrial interventions in humans.

Real-time magnetic resonance-guided ablation of typical right atrial flutter using a combination of active catheter tracking and passive catheter visualization in man: initial results from a consecutive patient series.

AIMS: Recently cardiac magnetic resonance (CMR) imaging has been found feasible for the visualization of the underlying substrate for cardiac arrhythmias as well as for the visualization of cardiac catheters for diagnostic and ablation procedures. Real-time CMR-guided cavotricuspid isthmus ablation was performed in a series of six patients using a combination of active catheter tracking and catheter visualization using real-time MR imaging. METHODS AND RESULTS: Cardiac magnetic resonance utilizing a 1.5 T system was performed in patients under deep propofol sedation. A three-dimensional-whole-heart sequence with navigator technique and a fast automated segmentation algorithm was used for online segmentation of all cardiac chambers, which were thereafter displayed on a dedicated image guidance platform. In three out of six patients complete isthmus block could be achieved in the MR scanner, two of these patients did not need any additional fluoroscopy. In the first patient technical issues called for a completion of the procedure in a conventional laboratory, in another two patients the isthmus was partially blocked by magnetic resonance imaging (MRI)-guided ablation. The mean procedural time for the MR procedure was 109 ± 58 min. The intubation of the CS was performed within a mean time of 2.75 ± 2.21 min. Total fluoroscopy time for completion of the isthmus block ranged from 0 to 7.5 min. CONCLUSION: The combination of active catheter tracking and passive real-time visualization in CMR-guided electrophysiologic (EP) studies using advanced interventional hardware and software was safe and enabled efficient navigation, mapping, and ablation. These cases demonstrate significant progress in the development of MR-guided EP procedures.

Prospective active marker motion correction improves statistical power in BOLD fMRI.

Group level statistical maps of blood oxygenation level dependent (BOLD) signals acquired using functional magnetic resonance imaging (fMRI) have become a basic measurement for much of systems, cognitive and social neuroscience. A challenge in making inferences from these statistical maps is the noise and potential confounds that arise from the head motion that occurs within and between acquisition volumes. This motion results in the scan plane being misaligned during acquisition, ultimately leading to reduced statistical power when maps are constructed at the group level. In most cases, an attempt is made to correct for this motion through the use of retrospective analysis methods. In this paper, we use a prospective active marker motion correction (PRAMMO) system that uses radio frequency markers for real-time tracking of motion, enabling on-line slice plane correction. We show that the statistical power of the activation maps is substantially increased using PRAMMO compared to conventional retrospective correction. Analysis of our results indicates that the PRAMMO acquisition reduces the variance without decreasing the signal component of the BOLD (beta). Using PRAMMO could thus improve the overall statistical power of fMRI based BOLD measurements, leading to stronger inferences of the nature of processing in the human brain.

Detection of RF unsafe devices using a parallel transmission MR system.

PURPOSE: The permanent presence of devices (pacemakers) inside a patient, or the need to use other devices (catheters), for diagnosis and treatment, usually represents a contraindication for a magnetic resonance examination. To help overcome this problem, a novel and noninvasive magnetic resonance system-based concept is proposed to detect potentially unsafe radio frequency (RF) conditions of such devices to ensure patient safety. METHODS: This concept makes use of parallel transmit technology by monitoring currents in individual RF transmit coil elements during RF transmission using suitable current sensors. For interventional devices, current changes can be directly measured, whereas for implanted devices, the use of reference signals is proposed, which cannot be measured in the patient. RESULTS: Coupling of unsafe devices to transmit coils led to detectable current changes in the elements because of energy absorption into the device. The concept was successfully tested on interventional and implantable devices and turned out to be so sensitive that even very weak RF coupling to these devices was detectable. CONCLUSION: In this study, basic feasibility to detect RF unsafe conditions was successfully demonstrated. In the future, RF patient safety may be improved in the presence of implanted devices, as well as during interventions using this concept.

Combined prospective and retrospective correction to reduce motion-induced image misalignment and geometric distortions in EPI.

Despite rigid-body realignment to compensate for head motion during an echo-planar imaging time-series scan, nonrigid image deformations remain due to changes in the effective shim within the brain as the head moves through the B(0) field. The current work presents a combined prospective/retrospective solution to reduce both rigid and nonrigid components of this motion-related image misalignment. Prospective rigid-body correction, where the scan-plane orientation is dynamically updated to track with the subject's head, is performed using an active marker setup. Retrospective distortion correction is then applied to unwarp the remaining nonrigid image deformations caused by motion-induced field changes. Distortion correction relative to a reference time-frame does not require any additional field mapping scans or models, but rather uses the phase information from the echo-planar imaging time-series itself. This combined method is applied to compensate echo-planar imaging scans of volunteers performing in-plane and through-plane head motions, resulting in increased image stability beyond what either prospective or retrospective rigid-body correction alone can achieve. The combined method is also assessed in a blood oxygen level dependent functional MRI task, resulting in improved Z-score statistics.

Echo-planar imaging with prospective slice-by-slice motion correction using active markers.

Head motion is a fundamental problem in functional magnetic resonance imaging and is often a limiting factor in its clinical implementation. This work presents a rigid-body motion correction strategy for echo-planar imaging sequences that uses micro radiofrequency coil "active markers" for real-time, slice-by-slice prospective correction. Before the acquisition of each echo-planar imaging-slice, a short tracking pulse-sequence measures the positions of three active markers integrated into a headband worn by the subject; the rigid-body transformation that realigns these markers to their initial positions is then fed back to dynamically update the scan-plane, maintaining it at a fixed orientation relative to the head. Using this method, prospectively-corrected echo-planar imaging time series are acquired on volunteers performing in-plane and through-plane head motions, with results demonstrating increased image stability over conventional retrospective image-realignment. The benefit of this improved image stability is assessed in a blood oxygenation level dependent functional magnetic resonance imaging application. Finally, a non-rigid-body distortion-correction algorithm is introduced to reduce the remaining signal variation.

In vivo evaluation and proof of radiofrequency safety of a novel diagnostic MR-electrophysiology catheter.

An MR-electrophysiology (EP) catheter is presented that provides full diagnostic EP functionality and a high level of radiofrequency safety achieved by custom-designed transmission lines. Highly resistive wires transmit intracardiac electrograms and currents for intracardiac pacing. A transformer cable transmits the localization signal of a tip coil. Specific absorption rate simulations and temperature measurements at 1.5 T demonstrate that a wire resistance > 3 kΩ/m limits dielectric heating to a physiologically irrelevant level. Additional wires do not increase tip specific absorption rate significantly, which is important because some clinical catheters require up to 20 electrodes. It is further demonstrated that radiofrequency-induced and pacing-induced resistive heating of the wires is negligible under clinical conditions. The MR-EP catheters provided uncompromised recording of electrograms and cardiac pacing in combination with a standard EP recorder in MR-guided in vivo EP studies, and the tip coil enabled fast and robust catheter localization. In vivo temperature measurements during such a study did not detect any device-related heating, which confirms the high level of safety of the catheter, whereas unacceptable heating was found with a standard EP catheter. The presented concept for the first time enables catheters with full diagnostic EP functionality and active tracking and at the same time a sufficient level of radiofrequency safety for MRI without specific absorption rate-related limitations.

Accelerated 3D catheter visualization from triplanar MR projection images.

One major obstacle for MR-guided catheterizations is long acquisition times associated with visualizing interventional devices. Therefore, most techniques presented hitherto rely on single-plane imaging to visualize the catheter. Recently, accelerated three-dimensional (3D) imaging based on compressed sensing has been proposed to reduce acquisition times. However, frame rates with this technique remain low, and the 3D reconstruction problem yields a considerable computational load. In X-ray angiography, it is well understood that the shape of interventional devices can be derived in 3D space from a limited number of projection images. In this work, this fact is exploited to develop a method for 3D visualization of active catheters from multiplanar two-dimensional (2D) projection MR images. This is favorable to 3D MRI as the overall number of acquired profiles, and consequently the acquisition time, is reduced. To further reduce measurement times, compressed sensing is employed. Furthermore, a novel single-channel catheter design is presented that combines a solenoidal tip coil in series with a single-loop antenna, enabling simultaneous tip tracking and shape visualization. The tracked tip and catheter properties provide constraints for compressed sensing reconstruction and subsequent 2D/3D curve fitting. The feasibility of the method is demonstrated in phantoms and in an in vivo pig experiment.

Prospective real-time correction for arbitrary head motion using active markers.

Patient motion during an MRI exam can result in major degradation of image quality, and is of increasing concern due to the aging population and its associated diseases. This work presents a general strategy for real-time, intraimage compensation of rigid-body motion that is compatible with multiple imaging sequences. Image quality improvements are established for structural brain MRI acquired during volunteer motion. A headband integrated with three active markers is secured to the forehead. Prospective correction is achieved by interleaving a rapid track-and-update module into the imaging sequence. For every repetition of this module, a short tracking pulse-sequence remeasures the marker positions; during head motion, the rigid-body transformation that realigns the markers to their initial positions is fed back to adaptively update the image-plane-maintaining it at a fixed orientation relative to the head-before the next imaging segment of k-space is acquired. In cases of extreme motion, corrupted lines of k-space are rejected and reacquired with the updated geometry. High-precision tracking measurements (0.01 mm) and corrections are accomplished in a temporal resolution (37 ms) suitable for real-time application. The correction package requires minimal additional hardware and is fully integrated into the standard user interface, promoting transferability to clinical practice.

Clinical workflow and applicability of electrophysiological cardiovascular magnetic resonance-guided radiofrequency ablation of isthmus-dependent atrial flutter.

Aims: To determine safety and efficacy of electrophysiological cardiovascular magnetic resonance (EP-CMR)-guided radiofrequency (RF) ablation in patients with typical right atrial flutter in a routine clinical setting. Methods and results: Thirty patients with typical right atrial flutter underwent clinically indicated EP-CMR-guided cavotricuspid isthmus ablation. EP-CMR protocols included pre- and post-ablation CMR imaging (whole heart, T2-weighted, and early-/late-gadolinium enhancement) together with electroanatomic mapping of the right atrium. Coronary sinus cannulation time and total ablation procedure duration were used as performance measures to determine the learning experience of the EP-CMR interventionalist and for comparison with conventional, fluoroscopy-guided atrial flutter ablation. Procedural safety and success rates were evaluated at 1 week and 3 months follow-up. Safety and success rates of EP-CMR were similar to conventional flutter ablations (primary success rate, 93% vs. 100%; recurrence rate, 0% vs. 3%, respectively). EP-CMR procedure duration indicated a learning experience (first vs. last six patients, 54.2 ± 23.1 vs. 29.7 ± 20.0 min) and the minimum number of procedures needed to achieve a level of competency was n = 12. An isthmus angle <110° and the presence of pouch-like isthmus anatomy were indicative of significantly prolonged EP-CMR procedure duration. CMR-defined ablation lesion size was not associated with total RF-ablation time or RF-induced maximum temperature. Conclusion: In a routine clinical setting, EP-CMR demonstrated its safety and high efficacy for the treatment of typical right atrial flutter with performance and outcome measures similar to conventional, fluoroscopy-guided flutter ablation. Hence, EP-CMR represents a valid alternative to conventional right atrial flutter ablation.

MRI-guided transurethral insonation of silica-shell phase-shift emulsions in the prostate with an advanced navigation platform.

PURPOSE: In this study, the efficacy of transurethral prostate ablation in the presence of silica-shell ultrasound-triggered phase-shift emulsions (sUPEs) doped with MR contrast was evaluated. The influence of sUPEs on MR imaging assessment of the ablation zone was also investigated. METHODS: sUPEs were doped with a magnetic resonance (MR) contrast agent, Gd2 O3 , to assess ultrasound transition. Injections of saline (sham), saline and sUPEs alone, and saline and sUPEs with Optison microbubbles were performed under guidance of a prototype interventional MRI navigation platform in a healthy canine prostate. Treatment arms were evaluated for differences in lesion size, T1  contrast, and temperature. In addition, non-perfused areas (NPAs) on dynamic contrast-enhanced (DCE) MRI, 55°C isotherms, and areas of 240 cumulative equivalent minutes at 43°C (CEM43 ) dose or greater computed from MR thermometry were measured and correlated with ablated areas indicated by histology. RESULTS: For treatment arms including sUPEs, the computed correlation coefficients between the histological ablation zone and the NPA, 55°C isotherm, and 240 CEM43 area ranged from 0.96-0.99, 0.98-0.99, and 0.91-0.99, respectively. In the absence of sUPEs, the computed correlation coefficients between the histological ablation zone and the NPA, 55°C isotherm, and 240 CEM43 area were 0.69, 0.54, and 0.50, respectively. Across all treatment arms, the areas of thermal tissue damage and NPAs were not significantly different (P = 0.47). Areas denoted by 55°C isotherms and 240 CEM43 dose boundaries were significantly larger than the areas of thermal damage, again for all treatment arms (P = 0.009 and 0.003, respectively). No significant differences in lesion size, T1 contrast, or temperature were observed between any of the treatment arms (P > 0.0167). Lesions exhibiting thermal fixation on histological analysis were present in six of nine insonations involving sUPE injections and one of five insonations involving saline sham injections. Significantly larger areas (P = 0.002), higher temperatures (P = 0.004), and more frequent ring patterns of restricted diffusion on ex vivo diffusion-weighted imaging (P = 0.005) were apparent in lesions with thermal fixation. CONCLUSIONS: T1 contrast suggesting sUPE transition was not evident in sUPE treatment arms. The use of MR imaging metrics to predict prostate ablation was not diminished by the presence of sUPEs. Lesions generated in the presence of sUPEs exhibited more frequent thermal fixation, though there were no significant changes in the ablation areas when comparing arms with and without sUPEs. Thermal fixation corresponded to some qualitative imaging features.

An MR guidewire based on micropultruded fiber-reinforced material.

A novel fiber-reinforced material for the realization of MR guidewires, made using a newly-developed production process, is presented. The MR-safe artificial material provides a high stiffness and torque and allows the production, in a large range of sizes, of nonmetallic MR guidewires with similar mechanical properties as conventional metallic guidewires. Based on this material, a passively visualized MR guidewire has been developed, and was found to conform to existing standards on mechanical stability. Handling and steerability were evaluated in animal studies and were found to be comparable with conventional metallic guidewires. X-ray visibility is provided by a BaSO(4)- and tungsten-doped jacket. A hydrophilic coating improves sliding properties and hemocompatibility.

Fast and accurate automatic registration for MR-guided procedures using active microcoils.

A fast, robust, accurate, and automatic registration technique based on magnetic resonance (MR) active microcoils (active markers) for registration of tracked medical devices to preprocedural MR-images is presented. This allows for a straight-forward integration of position measurement systems into clinical procedures. The presented method is useful for guidance purposes in clinical applications with high demands on accuracy and ease-of-use (e.g., neurosurgical or orthopedic applications). The determination of the positions of the active markers is integrated into the preparation phase of the actual MR imaging scan. The technique features a generic interface using DICOM standards for communication with navigation workstations linked to an MR system. The position of the active markers is fixed with respect to a reference system of an optical positioning measurement system (OPMS) and thus the coregistration of the MR system and the OPMS is established. In a phantom study, a mean overall targeting accuracy of 0.9+/-0.1 mm was achieved and compared favorably to results obtained from manual registration tests (1.8+/-0.3 mm) carried out in parallel. For a test person trained for both registration methods, workflow improvements of 3-6 min per registration step were found. The need for manual interaction is entirely eliminated thus avoiding user-bias, which is advantageous for the usage in clinical routine. The method improves the ease-of-use of tracking equipment during stereotactic guidance. The method is finally demonstrated in a volunteer study using a model of a Mayfield skull clamp with integrated active and optical reference markers.

Development, Preclinical Validation, and Clinical Translation of a Cardiac Magnetic Resonance - Electrophysiology System With Active Catheter Tracking for Ablation of Cardiac Arrhythmia.

OBJECTIVES: This study sought to develop an actively tracked cardiac magnetic resonance-guided electrophysiology (CMR-EP) system and perform first-in-human clinical ablation procedures. BACKGROUND: CMR-EP offers high-resolution anatomy, arrhythmia substrate, and ablation lesion visualization in the absence of ionizing radiation. Implementation of active tracking, where catheter position is continuously transmitted in a manner analogous to electroanatomic mapping (EAM), is crucial for CMR-EP to take the step from theoretical technology to practical clinical tool. METHODS: The setup integrated a clinical 1.5-T scanner, an EP recording and ablation system, and a real-time image guidance platform with components undergoing ex vivo validation. The full system was assessed using a preclinical study (5 pigs), including mapping and ablation with histological validation. For the clinical study, 10 human subjects with typical atrial flutter (age 62 ± 15 years) underwent MR-guided cavotricuspid isthmus (CTI) ablation. RESULTS: The components of the CMR-EP system were safe (magnetically induced torque, radiofrequency heating) and effective in the CMR environment (location precision). Targeted radiofrequency ablation was performed in all animals and 9 (90%) humans. Seven patients had CTI ablation completed using CMR guidance alone; 2 patients required completion under fluoroscopy, with 2 late flutter recurrences. Acute and chronic CMR imaging demonstrated efficacious lesion formation, verified with histology in animals. Anatomic shape of the CTI was an independent predictor of procedural success. CONCLUSIONS: CMR-EP using active catheter tracking is safe and feasible. The CMR-EP setup provides an effective workflow and has the potential to change the way in which ablation procedures may be performed.

Modality-integrated magnetic catheter tracking for x-ray vascular interventions.

A novel setup for the integration of a magnetic tracking system (MTS) into a catheter laboratory environment by attaching the field generator of the MTS to the C-arm of the x-ray system was investigated. The metal interference of the x-ray system with the MTS then becomes static and can be calibrated. The registration of a tracked catheter to 2D live x-ray images with high and well-defined accuracy is thus possible for arbitrary C-arm positions. Interference with imaging by blocking the field of view is avoided. Real-time registration methods to maintain the registration of the catheter also to static 2D or 3D images (roadmaps), regardless of the C-arm rotation during catheter tracking, were investigated. Residual registration errors of the tracked catheter with respect to the static roadmaps (2D and 3D) were reduced by using the vessel geometry and shape information. The algorithms potentially allow for motion correction (e.g. due to respiration). Using the shape-based correction algorithms the average registration accuracies to static roadmaps for different C-arm angulations and catheter positions were determined to be 3.3-4.2 mm. The magnetic registration of the C-arm was furthermore allowed to compute the imaging geometry (position of the C-arm) and to produce virtual angiographic preview images before contrast injection and x-ray dose application. Thus, optimal projection geometries and collimator settings for the target region can be chosen in an 'off line' fashion. The proposed MTS-supported navigation setup on both 3D (static) and 2D (live and static) roadmaps merges the high resolution and real-time feedback of 2D x-ray images with the navigation support from 3D static images.

Motion compensated coronary interventional navigation by means of diaphragm tracking and elastic motion models.

Current catheter tracking in the x-ray catheter laboratory during coronary interventions is performed using 2D fluoroscopy. Although this features real-time navigation on high-resolution images, drawbacks such as overlap and foreshortening exist and hamper the diagnosis and treatment process. An alternative to fluoroscopy-based tracking is device tracking by means of a magnetic tracking system (MTS). Having measured the 3D location of the interventional device, its position can be reconstructed on 3D images or virtual roadmaps of the organ or vessel structure under examination. In this paper, a method is presented which compensates the interventional device location measured by the MTS for organ motion and thus registers it dynamically to a 3D virtual roadmap. The motion compensation is accomplished by using an elastic motion model which is driven by the ECG signal and a respiratory sensor signal derived from ultrasonic diaphragm tracking. The model is updated during the intervention itself, thus allowing for a local refinement in regions which bear a complex geometric structure, such as stenoses and bifurcations. The evaluation is done by means of a phantom-based study using a dynamic heart-phantom. The mean displacement caused by the overall motion of the heart is improved from 10.4+/-4.8 mm in the uncompensated case to 2.1+/-1.2 mm in the motion compensated case.