The following are key points to remember about magnetic resonance imaging (MRI) and radiation exposure in patients with cardiovascular implantable electronic devices (CIEDs):

In recent years, the Food and Drug Administration has approved labeling of some CIEDs as MR conditional. MR nonconditional systems include all CIED systems other than those that meet MR conditional labeling.

Recommendations and Protocol for Management of the Patient With an MR Conditional Device Undergoing MRI

1. MR conditional devices should be considered MR conditional only when the product labeling is adhered to. Imaging should always be performed according to a rigorously applied protocol. (Class I)
2. Personnel with the skill to perform advanced cardiac life support should be in attendance and electrocardiogram (ECG) and pulse oximetry monitoring should be used. (Class I)
3. All resuscitative efforts and emergency treatments that involve the use of a defibrillator/monitor, device programming system, or any other MRI-unsafe equipment should be performed after moving the patient outside of the immediate MRI area [zone 4] (Class I).

Recommendations for Management of the Patient With an MR Nonconditional CIED who is to Have an MRI Scan

1. Device evaluation should be performed immediately pre- and post-MRI with documentation of pacing threshold(s), P- and R-wave amplitude, and lead impedance using a standardized protocol. (Class I)
2. A defibrillator/monitor (with external pacing function) and a manufacturer-specific device programming system should be immediately available. (Class I)
3. Continuous MR-conditional ECG and pulse oximetry monitoring should be used. (Class I)
4. Personnel with advanced cardiac life support skills should be in attendance. (Class I)
5. For patients who are pacing dependent, it is recommended that:
   1. Personnel with the skill to program the CIED be in attendance.
   2. A physician with the ability to establish temporary transvenous pacing and to direct CIED programming be immediately available.
6. For patients who are not pacing dependent, it is recommended that:
   1. Personnel with the skill to program the CIED be available on the premises of the imaging facility. (Class I)
   2. A physician with the ability to direct CIED programming be available on the premises. (Class I)
   3. For patient who is pacing dependent, the CIED should be programed to an asynchronous pacing mode. (Class I)
7. All tachyarrhythmia detections for ICD patients should be disabled prior to MRI. (Class I)
8. All resuscitative efforts and emergency treatments that involve the use of a defibrillator/monitor, device programming system, or any other MRI-unsafe equipment should be performed after moving the patient outside of the immediate MRI area. (Class I)

Recommendations and Protocol for the Management of the CIED Patient Undergoing Radiation Therapy

1. Prior to the initiation of radiation treatment, it is recommended that a complete CIED evaluation be performed and the treatment team be informed: a) Whether the device is a pacemaker or ICD, b) Whether the patient is pacing dependent, c) What is the minimum programmed pacing rate, d) What are the maximum programmed tracking and sensor rates. (Class I)
2. Non-neutron producing treatment is preferred over neutron producing treatment in CIED patients to minimize the risk of device reset. (Class I)
3. It is recommended to perform weekly complete CIED evaluation for the patient undergoing neutron-producing treatment. (Class I)
4. It is recommended that a complete CIED evaluation be performed at the conclusion of the course of radiation therapies. (Class I)
5. Continuous visual and voice contact is recommended during each radiation treatment. (Class I)
6. CIED relocation is recommended if it will interfere with adequate tumor treatment. (Class I)
7. It may be reasonable to perform a complete CIED evaluation weekly in patients that are pacing dependent undergoing non-neutron producing treatment. (Class IIb)
8. CIED relocation is not recommended for devices receiving a maximum cumulative incident dose of <5 Gy. (Class III)

Keywords: Advanced Cardiac Life Support, Arrhythmias, Cardiac, Cardiac Imaging Techniques, Defibrillators, Defibrillators, Implantable, Electric Impedance, Electrocardiography, Magnetic Resonance Imaging, Neoplasms, Oximetry, Pacemaker, Artificial, Radiation, Radiation Injuries, Resuscitation, Secondary Prevention, Tachycardia

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