Is metal artefact reduction mandatory in cardiac PET/CT imaging in the presence of pacemaker and implantable cardioverter defibrillator leads?

Cardiac PET/CT imaging is often performed in patients with pacemakers and implantable cardioverter defibrillator (ICD) leads. However, metallic implants usually produce artefacts on CT images which might propagate to CT-based attenuation-corrected (CTAC) PET images. The impact of metal artefact reduction (MAR) for CTAC of cardiac PET/CT images in the presence of pacemaker, ICD and ECG leads was investigated using both qualitative and quantitative analysis in phantom and clinical studies.

The study included 14 patients with various leads undergoing perfusion and viability examinations using dedicated cardiac PET/CT protocols. The PET data were corrected for attenuation using both artefactual CT images and CT images corrected using the MAR algorithm. The severity and magnitude of metallic artefacts arising from these leads were assessed on both linear attenuation coefficient maps (μ-maps) and attenuation-corrected PET images. CT and PET emission data were obtained using an anthropomorphic thorax phantom and a dedicated heart phantom made in-house incorporating pacemaker and ICD leads attached at the right ventricle of the heart. Volume of interest-based analysis and regression plots were performed for regions related to the lead locations. Bull’s eye view analysis was also performed on PET images corrected for attenuation with and without the MAR algorithm.

In clinical studies, the visual assessment of PET images by experienced physicians and quantitative analysis did not reveal erroneous interpretation of the tracer distribution or significant differences when PET images were corrected for attenuation with and without MAR. In phantom studies, the mean differences between tracer uptake obtained without and with MAR were 10.16±2.1% and 6.86±2.1% in the segments of the heart in the vicinity of metallic ICD or pacemaker leads, and were 4.43±0.5% and 2.98±0.5% in segments far from the leads.

Although the MAR algorithm was able to effectively improve the quality of μ-maps, its clinical impact on the interpretation of PET images was not significant. Therefore cardiac PET images corrected for attenuation using CTAC in the presence of metallic leads can be interpreted without correction for metal artefacts. It should however be emphasized that in some special cases with multiple ICD leads attached to the myocardium wall, MAR might be useful for accurate attenuation correction.