Magnetic resonance imaging in a patient with cardiac resynchronization therapy-defibrillator and two abandoned leads.

An 85‐year‐old patient presented to our department to discuss interventional left atrial appendage occlusion (LAAO). In the last month, the patient had suffered from recurrent transient focal neurological episodes originating from right‐sided sulcal subarachnoid hemorrhage at the central/precentral sulcus, as well as minimal bleeding in the area of the left‐sided tentorium while taking Dabigatran for paroxysmal atrial fibrillation. A subarachnoid hemorrhage had already occurred in the left central sulcus while taking Edoxaban 3 years ago. After intense discussion with our neurological department, cranial magnetic resonance imaging (cMRI) was planned to detect microbleeds/cerebral amyloid angiopathy for further risk assessment and to answer whether a dual antiplatelet therapy can be given after LAAO. For secondary prophylaxis after ventricular fibrillation and ischemic heart disease, a biventricular defibrillator was implanted in 2010. In 2017, generator replacement (Boston Scientific ORIGEN™ CRT‐D [model no. G058]) due to battery depletion and implantation of RV‐pace‐sense electrode (Boston Scientific INGEVITY™ [model no. 7740]) as well as new LV‐pacing lead (Medtronic ATTAIN ABILITY™ [model no. 4196]) because of RV‐pace‐sense electrode failure due to insulation break and fracture of the LV‐lead were performed. The old LV‐lead (Boston Scientific EASYTRAK™ 2 [model no. 4544]) and the pace‐sense part of the old defibrillator‐lead (Boston Scientific ENDOTAK RELIANCE™ [model no. 0272]) were left in place. The RA‐lead (Boston Guidant MFGR 006) is from 2010 (Figure 1A,B). Interrogation of the cardiac resynchronization therapy defibrillator (CRT‐D) device showed complete pacing dependency without an inherent rhythm faster than 30 bpm and third‐degree atrioventricular‐block, and all active leads showed good pacing and sensing parameters.

FIGURE 1

(A) and (B): Chest X‐ray showing cardiac resynchronization therapy‐defibrillator and two abandoned leads. (C) and (D): Axial and midline sagittal T1‐weighted cranial magnetic resonance imaging showing discrete siderosis in individual sulci, consistent with the history of the subarachnoid hemorrhage—No new bleeding events and no evidence of microbleeds/cerebral amyloid angiopathy.

Based on an individual benefit–risk assessment, the decision to perform cMRI (Philips Ingenia 1.5 T‐MR‐system) under constant monitoring was made in consensus with the patient after being informed about the limited clinical experience with MRI in patients with CRT‐D devices and abandoned leads. , , Device interrogation was performed prior to and immediately after MRI, during the MRI the device was programmed in the specific MRI mode (Enable MRI protection, DOO 80). The patient did not report any palpitations, discomfort, heating, or sensations during or after the exam, there were no abnormal vital signs or arrhythmias during monitoring (ECG monitoring, O2 saturation monitoring, external defibrillator close by, CPR trained staff on site) and no device malfunction was detected, that is, no change of pacing rate, no change in battery voltage, no power‐on reset events and no changes of CRT‐D programming, and no change in lead parameters. Fortunately, the cMRI did not show evidence of microbleeds/cerebral amyloid angiopathy. There was only discrete siderosis in individual sulci, consistent with the history of the subarachnoid hemorrhage—no new bleeding events (Figure 1C,D). Interventional LAAO was performed 2 weeks later without any complications.

FUNDING INFORMATION

There was no funding for this study.

CONFLICT OF INTEREST

None.

ETHICS STATEMENT

All ethical standards were met in writing and submitting this correspondence.