Remote Programming of Cardiac Implantable Electronic Devices in the Magnetic Resonance Imaging Suite

Dear Readers,

For many years, managing patients with a cardiac implantable electronic device (CIED) around the time of surgery was labor intensive and created resource challenges for the cardiac electrophysiologist, device team, and industry representatives. Except for rare situations, such as cardiac transplantation or surgeries that are performed near the device itself, most of these scenarios are now managed by application of a donut magnet by the surgical or anesthesia team and no longer require in-person reprogramming of the device.

In addition, magnetic resonance imaging (MRI) in patients with a CIED was also considered high risk for many years. After more data became available showing that scanning patients with a CIED could be performed safely when a specific protocol was followed,^1,2 such scans became more common, particularly at large academic medical centers. MRI-conditional devices are also now available, which are even safer in specific MRI environments and are labeled as such. In addition, imaging in these patients is reimbursable. This has resulted in a marked increase in patients with a CIED undergoing MRI scanning.

Most patients can now very safely undergo imaging. The usual workflow is that when a patient with a CIED is scheduled to undergo an MRI, that patient is flagged. The chart is then reviewed to exclude any high-risk features such as retained or epicardial leads. Although there are some devices that can automatically detect the MRI scanner and switch to an MRI-safe mode (much like an electrocautery mode), this feature is not yet common, and in-person reprogramming before and after the scan is still needed.

The exponential growth of MRI scans in CIED patients has created a new burden on the team who manages these patients in the hospital. This team includes the physicians, device nurses and technicians, and industry representatives who are qualified to evaluate the patient and program the device before and after the MRI. Unfortunately, a lot of the work is also not reimbursable. Interrogating and reprogramming a device may be reimbursed, but much of the screening and chart review to “clear” the patient is not. Who pays for these resources—the radiology department that bills for the scans, the cardiology department, or the device companies?

One possible solution to in-person management of CIED patients who require an MRI scan is remote device programming. This approach first gained attention during the COVID-19 pandemic.³ Kloosterman and colleagues were the first to describe use of remote control management of CIEDs in patients undergoing MRI scans.⁴ A similar but larger study was published recently in the Journal of Cardiovascular Electrophysiology.⁵ In this study, Siddamsetti and colleagues share their experience implementing a novel remote programming strategy to remotely reprogram CIEDs. The authors outline how, after first ensuring HIPAA compliance at their hospital, “the MRI technician started the session by contacting an off-site remote operator and placing a programmer wand from the 2090 Medtronic programmer over the CIED. The remote operator logged into a remote access software (Bomgar) and provided a unique access code to the MRI technician. After entering the access code into the programmer, the remote operator was able to program the device as needed.”⁵ One-quarter of the scans were performed urgently. All scans were successfully completed using remote programming, with no technical- or patient-related complications. The authors estimated that about 30 minutes was saved per scan.

Too many resources are currently required to manage patients with CIEDs undergoing an MRI scan, and much of this unreimbursed work is being performed by cardiology department personnel. Further development and implementation of remote programming options that are cybersecure and can easily be used by the MRI technician could greatly improve the current situation. 

Bradley P. Knight, MD, FACC, FHRS

@DrBradleyKnight
Editor-in-Chief, EP Lab Digest

Disclosures: Dr Knight reports that he has served as a consultant, speaker, investigator, and/or has received EP fellowship grant support from Abbott, AtriCure, Baylis Medical, Biosense Webster, Biotronik, Boston Scientific, CVRx, Medtronic, Philips, and Sanofi. He has no equity or ownership in any of these companies.

References

1. Nazarian S, Roguin A, Zviman MM, et al. Clinical utility and safety of a protocol for noncardiac and cardiac magnetic resonance imaging of patients with permanent pacemakers and implantable-cardioverter defibrillators at 1.5 tesla. Circulation. 2006;114(12):1277-1284. doi:10.1161/CIRCULATIONAHA.105.607655

2. Dandamudi S, Collins JD, Carr JC, et al. The safety of cardiac and thoracic magnetic resonance imaging in patients with cardiac implantable electronic devices. Acad Radiol. 2016;23(12):1498-1505. doi:10.1016/j.acra.2016.08.016

3. Okabe TA, Augostini RA, Hummel JD. Remote programming of cardiac implantable electronic devices: clinical implications in the era of COVID-19. EP Lab Digest. 2021;21(1):26-28.

4. Kloosterman EM, Rosenbaum M, La Starza B, Wilcox J, Rosman J. Remote control of cardiac implantable electronic devices: exploring the new frontier-first clinical application of real-time remote-control management of cardiac devices before and after magnetic resonance imaging. J Innov Card Rhythm Manag. 2019;10(1):3477-3784. doi:10.19102/icrm.2019.100102

5. Siddamsetti S, Shinn A, Gautam S. Remote programming of cardiac implantable electronic devices: a novel approach to program cardiac devices for magnetic resonance imaging. J Cardiovasc Electrophysiol. Published online March 3, 2022. doi:10.1111/jce.15434