Falconsai
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medical_summarization

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-license: apache-2.0
 language:
 - en
 pipeline_tag: summarization
 widget:
-- text: "the need for magnetic resonance imaging ( mri ) in patients with an implanted pacemaker or implantable cardioverter - defibrillator ( icd ) is a growing clinical issue . it is estimated that as many as 75% of active cardiac device recipients will become indicated for mri . currently , the vast majority of such devices are contraindicated for use with an mri . in european heart rhythm association survey , published recently for non - mri - certified icds ( 0.51.5 t field strength ) , the totally subcutaneous icd ( s - icd ) system , an implantable defibrillator with no leads that touch the heart , has recently been demonstrated to be a safe and effective defibrillator option for patients at risk for sudden cardiac death . it provides shock therapy and post - shock pacing therapy , but no long - term bradycardia pacing . although it has been shown as an alternative to the standard transvenous icd , its compatibility with mri remains unclear . various types of clinical mri systems currently use a superconductive magnet that creates a static magnetic field strength , typically 1.5 or 3 t. the use of mri with most pacemakers and icds is considered a contraindication due to potential hazards , including heating of the electrode that resides in or on the heart , damage to myocardium , elevation of pacing thresholds , unintended induction of ventricular tachycardia ( vt ) or ventricular fibrillation ( vf ) , pacing inhibition , permanent device malfunction , and distortion of the mri scan . recently , mr - conditional. mr - conditional indicates a lack of known hazards in a specified mri environment with specified conditions of use . due to the variety of mri scanners and scanning protocols , it is not practical to test even a single device under all conditions . hence , mr - conditional labelling dictates that the device is safe for use under certain scanning conditions , as well as how the cardiac device should be programmed before an exposure to the magnetic field in a mri scanner . the literature , although limited , provides some guidance for imaging patients with implanted pacemakers or icds that do not have mr - conditional labelling . this single - centre prospective non - controlled study describes the first use of mri in patients with an implanted s - icd . patients with implanted s - icd systems ( boston scientific sqrx model 1010 and q - trak model 3010 ) were enrolled for mri testing over a period of 18 months . the s - icd system implanted in this patient cohort was composed of a can implanted in a left mid - lateral pocket and a para - sternal subcutaneous electrode . the s - icd is currently not certified for use with an mri ; therefore , the ethics committee of homolka hospital , prague , czech republic approved our clinical study . patients with newly implanted s - icd systems ( < 6 weeks ) were excluded , and none of the patients had any intravascular leads . the patients were randomized for either a cardiac , brain , cervical , or lumbar spinal scan . one of the subjects underwent an additional knee examination , due to reported chronic pain . a total of 15 patients were enrolled into this study ( 12 males and three females , aged 2283 years , mean 53 years . subjects in our cohort ( table 1 ) underwent a total of 22 mri scans between 6 june 2012 and 24 december 2013 . in total , five brain scans , three cardiac scans , 12 lumbar scans , one knee , and one cervical spine scan were conducted ( table 2 ) . however , in one patient a minor disc protrusion was found , in other mri revealed stenosis of intervertebral foramen which was causing radicular pain of the nerve root l4 and based on this examination the patient was referred to ct - navigated periradicular therapy . table 1summary of patient anatomical data and scan locations , along with noted clinical eventsidagesexbmidgef , % indication for s - icdheating0164f20.5hcmp / vfs85secondary preventionnone0283m30.0post - mi / smvts post - catheter ablation/35secondary prevention ( post - transvenous icd extraction)none0331m25.3arvc / d / smvts68secondary preventionin - tolerable re - scanned0458m23.6post - mi / post - cabg30primary preventionnone0577m25.5post - mi30primary preventionnone0663m27.0post - mi30primary preventionnone0768m23.7post - mi / vfs / vts60secondary prevention post - transvenous icd extraction / svc occlusiontolerable0822m29.4brugada sy / vfs68secondary preventionin - tolerable re - scanned0959m27.1dcmp / vfs / post - mitral valve surgery/60secondary prev./post - transvenous icd extractionnone1041f24.6arvc / d70primary preventionnone1123f21.5lqts / vf60secondary preventionnone1266m36.9post - mi / vf / post - cabg50secondary prevention / post - repeat transvenous icd extractiontolerable1348m22.9dcmp(non - compaction)/vfs35secondary preventionnone1470m29systolic dysfunction of lv35primary preventionnone1526m33brugada sy65primary preventionnonehcmp , hypertrophic cardiomyopathy ; smvt , sustained monomorphic ventricular tachycardia ; mi , myocardial infarction ; arvc , arrhythmogenic right ventricular cardiomyopathy ; cabg , coronary artery by - pass graft ; lqts , long qt syndrom . table 2parmeters of s - icd and patient sensation during individual mri scansscan # idbody partheating sensationsshock zone ( b.p.m.)condit . shock zone ( b.p.m.)bat % episode num.101brainnone2302101001202brainnone240220861303l spinein - tolerable240220831403brainnone240220831504brainnone220190691605l spinenone220210541706l spinenone240220681807l spinetolerable240220582908l spinein - tolerablenananana1008brainnonenananana1108l spinenone2302108411209heartnone2402208911310l spinenone2301807911410heartnonenananana1511heartnone2301909711612l spinetolerable2001709721712l spinenone2001709421813c spinenone23019010041913l spinenone23019010042014l spinenone2301908612115kneenone25021010012215l spinenone2502101001s - icd parameters acquired prior- and post - mri were without any change , therefore only one value is presented.indices : na , not available ; l spine , lumbar spine ; c spine , cervical spine . summary of patient anatomical data and scan locations , along with noted clinical events hcmp , hypertrophic cardiomyopathy ; smvt , sustained monomorphic ventricular tachycardia ; mi , myocardial infarction ; arvc , arrhythmogenic right ventricular cardiomyopathy ; cabg , coronary artery by - pass graft ; lqts , long qt syndrom . parmeters of s - icd and patient sensation during individual mri scans s - icd parameters acquired prior- and post - mri were without any change , therefore only one value is presented . indices : na , not available ; l spine , lumbar spine ; c spine , cervical spine . studies were performed using a siemens avanto 1.5 t mri scanner ( vb17 software , quantum gradient coils ) . all scans were run in normal operating mode , which is limited to 2 w / kg whole body averaged specific absorption rate ( sar ) . clinically relevant mri sequences were used for evaluation ( see table 3 ) . table 3types of pulse sequences typically used for imaging of respective anatomical areasscan locationscan sequencesflairdwiflashfsehastesestirtruefispbrainxxxxheartxxxxcervical spinexxkneexxxxlumbar spinexxflair , fluid attenuated inversion recovery ; dwi , diffusion weighted imaging ; flash , fast low angle shot ; fse , fast spin echo ; haste , half acquisition single - shot turbo spin echo ; se , spin echo ; stir , short tau inversion recovery ; truefisp , true fast imaging with steady - state precession.fse sequence caused heating in subjects with a thermistor probe during lumbar spine examination ( see the text for details ) . types of pulse sequences typically used for imaging of respective anatomical areas flair , fluid attenuated inversion recovery ; dwi , diffusion weighted imaging ; flash , fast low angle shot ; fse , fast spin echo ; haste , half acquisition single - shot turbo spin echo ; se , spin echo ; stir , short tau inversion recovery ; truefisp , true fast imaging with steady - state precession . fse sequence caused heating in subjects with a thermistor probe during lumbar spine examination ( see the text for details ) . patients were asked to report immediately any pain , torqueing movement , or heating sensation in the area of the pocket or the electrode by pressing an emergency bulb . furthermore , all patients were questioned immediately following the mri procedure to ascertain any discomfort in the vicinity of the can or electrode . pulse oximetry and standard lead electrocardiogram ( ecg ) if discomfort occurred , the patient was asked if the scan could be repeated at a later time using a revised scan sequence or the subject was again randomized for another anatomical area . since none of the components of the s - icd system are on or in the heart , heating near or around however , heating near the electrode or can with the s - icd system may still cause serious patient discomfort . therefore , along with education of subjects , each patient was instrumented by taping an oesophageal temperature probe ( beta - therm model g22k7mcd8 ) on the skin over the mid - lateral implant site to record any temperature excursions that might be correlated to patient symptoms of heating / discomfort near the pocket . to minimize the risk of inappropriate therapy , the s - icd system was programmed to therapy each s - icd system was evaluated prior to and immediately after the scan to verify proper functioning , including interrogation , sensing , and battery voltage . after the completion of the mri , long - term regular clinical follow - up and checking of the device were performed . patients with implanted s - icd systems ( boston scientific sqrx model 1010 and q - trak model 3010 ) were enrolled for mri testing over a period of 18 months . the s - icd system implanted in this patient cohort was composed of a can implanted in a left mid - lateral pocket and a para - sternal subcutaneous electrode . the s - icd is currently not certified for use with an mri ; therefore , the ethics committee of homolka hospital , prague , czech republic approved our clinical study . patients with newly implanted s - icd systems ( < 6 weeks ) were excluded , and none of the patients had any intravascular leads . the patients were randomized for either a cardiac , brain , cervical , or lumbar spinal scan . one of the subjects underwent an additional knee examination , due to reported chronic pain . a total of 15 patients were enrolled into this study ( 12 males and three females , aged 2283 years , mean 53 years . subjects in our cohort ( table 1 ) underwent a total of 22 mri scans between 6 june 2012 and 24 december 2013 . in total , five brain scans , three cardiac scans , 12 lumbar scans , one knee , and one cervical spine scan were conducted ( table 2 ) . however , in one patient a minor disc protrusion was found , in other mri revealed stenosis of intervertebral foramen which was causing radicular pain of the nerve root l4 and based on this examination the patient was referred to ct - navigated periradicular therapy . table 1summary of patient anatomical data and scan locations , along with noted clinical eventsidagesexbmidgef , % indication for s - icdheating0164f20.5hcmp / vfs85secondary preventionnone0283m30.0post - mi / smvts post - catheter ablation/35secondary prevention ( post - transvenous icd extraction)none0331m25.3arvc / d / smvts68secondary preventionin - tolerable re - scanned0458m23.6post - mi / post - cabg30primary preventionnone0577m25.5post - mi30primary preventionnone0663m27.0post - mi30primary preventionnone0768m23.7post - mi / vfs / vts60secondary prevention post - transvenous icd extraction / svc occlusiontolerable0822m29.4brugada sy / vfs68secondary preventionin - tolerable re - scanned0959m27.1dcmp / vfs / post - mitral valve surgery/60secondary prev./post - transvenous icd extractionnone1041f24.6arvc / d70primary preventionnone1123f21.5lqts / vf60secondary preventionnone1266m36.9post - mi / vf / post - cabg50secondary prevention / post - repeat transvenous icd extractiontolerable1348m22.9dcmp(non - compaction)/vfs35secondary preventionnone1470m29systolic dysfunction of lv35primary preventionnone1526m33brugada sy65primary preventionnonehcmp , hypertrophic cardiomyopathy ; smvt , sustained monomorphic ventricular tachycardia ; mi , myocardial infarction ; arvc , arrhythmogenic right ventricular cardiomyopathy ; cabg , coronary artery by - pass graft ; lqts , long qt syndrom . table 2parmeters of s - icd and patient sensation during individual mri scansscan # idbody partheating sensationsshock zone ( b.p.m.)condit . shock zone ( b.p.m.)bat % episode num.101brainnone2302101001202brainnone240220861303l spinein - tolerable240220831403brainnone240220831504brainnone220190691605l spinenone220210541706l spinenone240220681807l spinetolerable240220582908l spinein - tolerablenananana1008brainnonenananana1108l spinenone2302108411209heartnone2402208911310l spinenone2301807911410heartnonenananana1511heartnone2301909711612l spinetolerable2001709721712l spinenone2001709421813c spinenone23019010041913l spinenone23019010042014l spinenone2301908612115kneenone25021010012215l spinenone2502101001s - icd parameters acquired prior- and post - mri were without any change , therefore only one value is presented.indices : na , not available ; l spine , lumbar spine ; c spine , cervical spine . summary of patient anatomical data and scan locations , along with noted clinical events hcmp , hypertrophic cardiomyopathy ; smvt , sustained monomorphic ventricular tachycardia ; mi , myocardial infarction ; arvc , arrhythmogenic right ventricular cardiomyopathy ; cabg , coronary artery by - pass graft ; lqts , long qt syndrom . parmeters of s - icd and patient sensation during individual mri scans s - icd parameters acquired prior- and post - mri were without any change , therefore only one value is presented . indices : na , not available ; l spine , lumbar spine ; c spine , cervical spine . studies were performed using a siemens avanto 1.5 t mri scanner ( vb17 software , quantum gradient coils ) . all scans were run in normal operating mode , which is limited to 2 w / kg whole body averaged specific absorption rate ( sar ) . clinically relevant mri sequences were used for evaluation ( see table 3 ) . table 3types of pulse sequences typically used for imaging of respective anatomical areasscan locationscan sequencesflairdwiflashfsehastesestirtruefispbrainxxxxheartxxxxcervical spinexxkneexxxxlumbar spinexxflair , fluid attenuated inversion recovery ; dwi , diffusion weighted imaging ; flash , fast low angle shot ; fse , fast spin echo ; haste , half acquisition single - shot turbo spin echo ; se , spin echo ; stir , short tau inversion recovery ; truefisp , true fast imaging with steady - state precession.fse sequence caused heating in subjects with a thermistor probe during lumbar spine examination ( see the text for details ) . types of pulse sequences typically used for imaging of respective anatomical areas flair , fluid attenuated inversion recovery ; dwi , diffusion weighted imaging ; flash , fast low angle shot ; fse , fast spin echo ; haste , half acquisition single - shot turbo spin echo ; se , spin echo ; stir , short tau inversion recovery ; truefisp , true fast imaging with steady - state precession . fse sequence caused heating in subjects with a thermistor probe during lumbar spine examination ( see the text for details ) . patients were asked to report immediately any pain , torqueing movement , or heating sensation in the area of the pocket or the electrode by pressing an emergency bulb . furthermore , all patients were questioned immediately following the mri procedure to ascertain any discomfort in the vicinity of the can or electrode . pulse oximetry and standard lead electrocardiogram ( ecg ) if discomfort occurred , the patient was asked if the scan could be repeated at a later time using a revised scan sequence or the subject was again randomized for another anatomical area . since none of the components of the s - icd system are on or in the heart , heating near or around the electrode can not harm the myocardium . however , heating near the electrode or can with the s - icd system may still cause serious patient discomfort . therefore , along with education of subjects , each patient was instrumented by taping an oesophageal temperature probe ( beta - therm model g22k7mcd8 ) on the skin over the mid - lateral implant site to record any temperature excursions that might be correlated to patient symptoms of heating / discomfort near the pocket . to minimize the risk of inappropriate therapy , the s - icd system was programmed to therapy each s - icd system was evaluated prior to and immediately after the scan to verify proper functioning , including interrogation , sensing , and battery voltage . after the completion of the mri , the s - icd system was reprogrammed to original settings . long - term regular clinical follow - up and checking of the device were performed . no anomalies were noted via pulse oximetry or ecg during the scans for any of the patients . eleven of 15 patients reported no sensation or pain from heating of the can , two of 15 patients reported feeling some heating , and two patients reported intolerable heating ( see table 2 ) . in patients with intolerable heating , the scan was halted within seconds and changed to a scan of the brain , which proceeded without incident . patient reports of heating in the vicinity of the can occurred only during lumbar scans with a thermistor probe ; no such reports occurred during scans of the brain , cardiac area , cervical spine , or without the probe . in two cases where heating in the vicinity of the can was reported by the patient , the scan sequence was altered to reduce the intensity of radiofrequency ( rf ) field exposure by reducing the turbo factor ( e.g. from 21 to 7 ) , increasing the repetition time ( e.g. to > 4000 ms ) , and reducing the flip angle ( e.g. from 170 to 120 ) . the target values were chosen arbitrarily to maintain image contrast ( flip angle ) and keep scan time at reasonable limits ( turbo factor and repetition time ) . less heating was noted by patients after these modifications to the scan parameters were made . 03 ) was observed to have a skin lesion , appearing to be a circular rash or ulcer on the surface of the skin over the can , approximately 35 mm in diameter . the cause of this skin anomaly is not known ; it was later noted to have fully healed at a follow - up 10 days after the scan . to ascertain the effect of heating due to the instrumented thermistor catheter , the two patients who experienced the heating ( examinations 9 and 16 , see table 2 ) were rescanned several weeks later without the thermistor catheter in place ( examinations 11 and 17 ) . first , modified sequence ( with even lower amount of energy deposited in the tissue ) was used , which caused no heating . as no sensation was reported by the subjects , they were asked to report even a minimal discomfort , and the lumbar scans were performed using the same settings that resulted in heating with the thermistor catheter in place in the first imaging session . the results of the rescans revealed that no heating was felt by the patients when the thermistor catheter was absent . there were no noted changes to battery voltage , ability to detect the qrs signal or stored diagnostic data . pacing thresholds can not be assessed by the s - icd system , so this was not evaluated . none of the patients reported any pulling or twisting of the can or pain from heating of the s - icd electrode . for scans of the brain , lumbar spine , knee , and cervical spine , no effect from image artefact was noted in the anatomical area of interest . however , for scans of the cardiac area , image artefact was noted to interfere with the ability to see parts of the left ventricle , though the right ventricle of the heart was unaffected and could be imaged usefully . this was due to the can and not the electrode ( see figure 1 ) , modifications to the protocol for the lumbar spine resulted in a lower signal - to - noise ratio ; however , the images remain in diagnostic quality ( see figure 2 ) . figure 1kinetic study in four - chamber view : the systolic ( a and c ) and diastolic ( b and d ) images of cine sequences , four - chamber view . the steady - state free precession ( ssfp ) sequence ( a and b ) shows more artefacts . in ssfp kinetic study , an inflow of dark blood from the left pulmonary veins was seen . it could be caused by s - icd but also by metallic ring in mitral annulus . the spoiled gradient echo ( gre ) sequence ( c and d ) is better , but an artefact at the lateral wall is obvious . figure 2lumbar spine imaging with icd : low sar t2 fse sequence ( upper image ) compared with normal t2 fse in the same subject ( lower image , for the scanning parameters see the discussion section ) . kinetic study in four - chamber view : the systolic ( a and c ) and diastolic ( b and d ) images of cine sequences , four - chamber view . the steady - state free precession ( ssfp ) sequence ( a and b ) shows more artefacts . in ssfp kinetic study , an inflow of dark blood from the left pulmonary veins was seen . it could be caused by s - icd but also by metallic ring in mitral annulus . the spoiled gradient echo ( gre ) sequence ( c and d ) is better , but an artefact at the lateral wall is obvious . lumbar spine imaging with icd : low sar t2 fse sequence ( upper image ) compared with normal t2 fse in the same subject ( lower image , for the scanning parameters see the discussion section ) . there were no noted changes to battery voltage , ability to detect the qrs signal or stored diagnostic data . pacing thresholds can not be assessed by the s - icd system , so this was not evaluated . none of the patients reported any pulling or twisting of the can or pain from heating of the s - icd electrode . for scans of the brain , lumbar spine , knee , and cervical spine , no effect from image artefact was noted in the anatomical area of interest . however , for scans of the cardiac area , image artefact was noted to interfere with the ability to see parts of the left ventricle , though the right ventricle of the heart was unaffected and could be imaged usefully . this was due to the can and not the electrode ( see figure 1 ) , modifications to the protocol for the lumbar spine resulted in a lower signal - to - noise ratio ; however , the images remain in diagnostic quality ( see figure 2 ) . figure 1kinetic study in four - chamber view : the systolic ( a and c ) and diastolic ( b and d ) images of cine sequences , four - chamber view . the steady - state free precession ( ssfp ) sequence ( a and b ) shows more artefacts . in ssfp kinetic study , an inflow of dark blood from the left pulmonary veins was seen . it could be caused by s - icd but also by metallic ring in mitral annulus . the spoiled gradient echo ( gre ) sequence ( c and d ) is better , but an artefact at the lateral wall is obvious . figure 2lumbar spine imaging with icd : low sar t2 fse sequence ( upper image ) compared with normal t2 fse in the same subject ( lower image , for the scanning parameters see the discussion section ) . kinetic study in four - chamber view : the systolic ( a and c ) and diastolic ( b and d ) images of cine sequences , four - chamber view . the steady - state free precession ( ssfp ) sequence ( a and b ) shows more artefacts . in ssfp kinetic study , an inflow of dark blood from the left pulmonary veins was seen . it could be caused by s - icd but also by metallic ring in mitral annulus . the spoiled gradient echo ( gre ) sequence ( c and d ) is better , but an artefact at the lateral wall is obvious . lumbar spine imaging with icd : low sar t2 fse sequence ( upper image ) compared with normal t2 fse in the same subject ( lower image , there are several reports in the current literature about mr - conditional pacemakers from several companies , but very limited reports about mr - conditional icds . biotronik announced in late 2011 release of their first mr - compatible icd device and defibrillator leads pro mri , but in the conditions of use excluded scanning of the torso and focused more on the extremities examination . in european heart rhythm association survey , 60% of centres did not implant any mri - certified icds , 34.3% implanted < 10 icd devices , and only 5.6% implanted 10 and more icds ; one - fifth of responders stated that mri - certified icds should be implanted in all patients but lack of reimbursement was indicated as a possible obstacle to implant more mri - certified pacemakers / icds by 47.1% of responding centres . none of the components of the s - icd system are on or in the heart . the s - icd depends less upon being in direct contact with the myocardium to function and instead uses far - field sensing and stimulation to provide the shock and post - shock pacing therapy . as a consequence , unlike transvenous systems heating near or around the electrode can not harm the myocardium , which could present with possible safety consequences such as an elevation in pacing thresholds or scarring of the myocardium , but it may still cause serious patient discomfort . because the s - icd is larger than modern transvenous icd 's , there may be more potential for the can to experience heating due to the magnetic gradient or rf field . we report results from what we believe is the first experience of mri scanning in patients with an implanted s - icd and in various anatomical areas . overall , mri was performed safely in all patients , which is in contrast to the current literature with mri imaging in patients with electrical - active devices which are not mri - conditional . in our study , the primary clinically significant event attributable to the mri scan was the occurrence of heating in the area of the pocket in the four patients that underwent lumbar scans . it was not known if this was due to the s - icd can itself or an artefact of the thermistor catheter used to measure skin temperature over the pocket . this required a revision of our protocol , which was to re - scan two of the patients who complained of heating . re - scanning of these patients without the thermistor probe resulted in no complaints of heating , so it is assumed that the thermistor catheter itself heated during the lumbar scans and caused the discomfort . as further evidence , all the heating complaints occurred during rf - intensive scan sequences ( namely fast spin echo ) with the temperature probe located axially near the centre of the bore , where rf fields are the highest . the thermistor catheter is constructed of insulated conductive cables connected to electrodes and should couple to the rf fields efficiently , causing heating at the electrodes and pain or damage on the surface of the skin where the probe was placed over the s - icd can . if the heating was due to the s - icd can itself , it would more likely occur during gradient - intensive scan sequences ( which can generate eddy currents on can surfaces and internal components ) and at locations in the bore where there are high gradient fields , such as near the bore edges . however , when the patient was scanned with gradient - intensive scan sequences ( e.g. flair dwi ) and with the s - icd system in high gradient field locations in the bore ( e.g. such as during a brain scan ) , patients did not detect any heating or discomfort . in addition , the subcutaneous lead , which was not instrumented with a thermistor catheter , never resulted in any heating sensation noted by the patient , even when exactly the same sequence that resulted in heating in the first session was used . the use of mri - compatible temperature monitors such as fibre optic temperature probes would have provided better confirmation of possible skin temperature elevation and would not have been affected by the rf fields . for cardiac imaging , the main problem to solve is metallic artefact , especially on the gradient - echo sequences . like in research performed by nazarian et al . , several scan protocols were used to see if any yielded different effects or reduced the qualitative extent of artefact . gradient mode was changed from normal to whisper , resulting in slower ramping of the field and therefore diminishing the changes of the magnetic field in time . artefacts when present were limited to blurring of the left ventricle during cardiac scans and most yielded clinically useful information . standard interrogation of the s - icd revealed no adverse effects upon the functioning of the system . while no adverse effects upon the post - scan s - icd device function were noted , not all possible scanning protocols were tested . it should be noted that , four of the s - icd 's were exposed to repeat mri scans without adverse effects to device function . in addition , because the s - icd does not provide long - term bradycardia pacing , it is assumed that pacemaker - dependent patients would not be implanted with this system . the inhibition of the pacemaker function during the scanning sequence and possible pacing threshold changes are a unique concern in patients implanted with transvenous icds . this study included only 15 patients and 22 scans done on the same 1.5 t mri scanner . thus , even these preliminary results should only be applied to 1.5 t mri scanners ( similarly as reported in the present literature for other implantable devices ) . device functionality was tested immediately after the scan but not for long - term effects . in addition , not all device functions were tested although the s - icd system does have a beeper / interrogation warning if battery levels or memory irregularities occur . however , patients were scheduled for regular check - up and no defect of the device was observed in following 725 months ( mean observation time 18 months ) . delayed enhancement mri for determining cardiac scarring was also not tested . also , there are other anatomical areas that were not evaluated , such as shoulder and knees . this study included only 15 patients and 22 scans done on the same 1.5 t mri scanner . thus , even these preliminary results should only be applied to 1.5 t mri scanners ( similarly as reported in the present literature for other implantable devices ) . device functionality was tested immediately after the scan but not for long - term effects . in addition , not all device functions were tested although the s - icd system does have a beeper / interrogation warning if battery levels or memory irregularities occur . however , patients were scheduled for regular check - up and no defect of the device was observed in following 725 months ( mean observation time 18 months ) . delayed enhancement mri for determining cardiac scarring was also not tested . also , there are other anatomical areas that were not evaluated , such as shoulder and knees . while more data are required to support a claim of mri - conditional , this study is the study to demonstrate the feasibility of exposing s - icd patients to mri using the scanning and monitor protocol described , with some precautionary measures including : ( i ) programming the device therapy off ; ( ii ) limiting the sar to 2.0 w / kg ; ( iii ) continuous monitoring of the patients pulse oximetry and ecg by qualified personnel and especially for any feelings of heating ; ( iv ) evaluate device function post scan ; ( v ) availability of full resuscitation facilities at the mri site . given the variables of different mri scanners , the decision to perform mri on patients with an implanted s - icd system should be balanced against the potential risks . in our study , the only heating was very likely introduced by not fully mri - compatible thermometer probe ; subjects rescanned without the probe did not report any abnormalities during the scan of any body area listed ( brain , cervical and lumbar spine , heart , and knee ) . this study was supported by iga mz r nt12094/2011 , research project charles university in prague , prvouk p34 and unce 204010/2012 . funding to pay the open access publication charges for this article was provided by iga mz r nt12094/2011 ."
 example_title: Summarization Example 1
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@@ -99,4 +543,4 @@ It is crucial to use this model responsibly and ethically, adhering to content g
 References
 Hugging Face Model Hub
 T5 Paper
-Disclaimer: The model's performance may be influenced by the quality and representativeness of the data it was fine-tuned on. Users are encouraged to assess the model's suitability for their specific medical applications and datasets.

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+license: mit
 language:
 - en
 pipeline_tag: summarization
 widget:
+- text: >-
+    the need for magnetic resonance imaging ( mri ) in patients with an
+    implanted pacemaker or implantable cardioverter - defibrillator ( icd ) is a
+    growing clinical issue . it is estimated that as many as 75% of active
+    cardiac device recipients will become indicated for mri . currently , the
+    vast majority of such devices are contraindicated for use with an mri . in
+    european heart rhythm association survey , published recently for non - mri
+    - certified icds ( 0.51.5 t field strength ) , the totally subcutaneous icd
+    ( s - icd ) system , an implantable defibrillator with no leads that touch
+    the heart , has recently been demonstrated to be a safe and effective
+    defibrillator option for patients at risk for sudden cardiac death . it
+    provides shock therapy and post - shock pacing therapy , but no long - term
+    bradycardia pacing . although it has been shown as an alternative to the
+    standard transvenous icd , its compatibility with mri remains unclear .
+    various types of clinical mri systems currently use a superconductive magnet
+    that creates a static magnetic field strength , typically 1.5 or 3 t. the
+    use of mri with most pacemakers and icds is considered a contraindication
+    due to potential hazards , including heating of the electrode that resides
+    in or on the heart , damage to myocardium , elevation of pacing thresholds ,
+    unintended induction of ventricular tachycardia ( vt ) or ventricular
+    fibrillation ( vf ) , pacing inhibition , permanent device malfunction , and
+    distortion of the mri scan . recently , mr - conditional. mr - conditional
+    indicates a lack of known hazards in a specified mri environment with
+    specified conditions of use . due to the variety of mri scanners and
+    scanning protocols , it is not practical to test even a single device under
+    all conditions . hence , mr - conditional labelling dictates that the device
+    is safe for use under certain scanning conditions , as well as how the
+    cardiac device should be programmed before an exposure to the magnetic field
+    in a mri scanner . the literature , although limited , provides some
+    guidance for imaging patients with implanted pacemakers or icds that do not
+    have mr - conditional labelling . this single - centre prospective non -
+    controlled study describes the first use of mri in patients with an
+    implanted s - icd . patients with implanted s - icd systems ( boston
+    scientific sqrx model 1010 and q - trak model 3010 ) were enrolled for mri
+    testing over a period of 18 months . the s - icd system implanted in this
+    patient cohort was composed of a can implanted in a left mid - lateral
+    pocket and a para - sternal subcutaneous electrode . the s - icd is
+    currently not certified for use with an mri ; therefore , the ethics
+    committee of homolka hospital , prague , czech republic approved our
+    clinical study . patients with newly implanted s - icd systems ( < 6 weeks )
+    were excluded , and none of the patients had any intravascular leads . the
+    patients were randomized for either a cardiac , brain , cervical , or lumbar
+    spinal scan . one of the subjects underwent an additional knee examination ,
+    due to reported chronic pain . a total of 15 patients were enrolled into
+    this study ( 12 males and three females , aged 2283 years , mean 53 years .
+    subjects in our cohort ( table 1 ) underwent a total of 22 mri scans between
+    6 june 2012 and 24 december 2013 . in total , five brain scans , three
+    cardiac scans , 12 lumbar scans , one knee , and one cervical spine scan
+    were conducted ( table 2 ) . however , in one patient a minor disc
+    protrusion was found , in other mri revealed stenosis of intervertebral
+    foramen which was causing radicular pain of the nerve root l4 and based on
+    this examination the patient was referred to ct - navigated periradicular
+    therapy . table 1summary of patient anatomical data and scan locations ,
+    along with noted clinical eventsidagesexbmidgef , % indication for s -
+    icdheating0164f20.5hcmp / vfs85secondary preventionnone0283m30.0post - mi /
+    smvts post - catheter ablation/35secondary prevention ( post - transvenous
+    icd extraction)none0331m25.3arvc / d / smvts68secondary preventionin -
+    tolerable re - scanned0458m23.6post - mi / post - cabg30primary
+    preventionnone0577m25.5post - mi30primary preventionnone0663m27.0post -
+    mi30primary preventionnone0768m23.7post - mi / vfs / vts60secondary
+    prevention post - transvenous icd extraction / svc
+    occlusiontolerable0822m29.4brugada sy / vfs68secondary preventionin -
+    tolerable re - scanned0959m27.1dcmp / vfs / post - mitral valve
+    surgery/60secondary prev./post - transvenous icd extractionnone1041f24.6arvc
+    / d70primary preventionnone1123f21.5lqts / vf60secondary
+    preventionnone1266m36.9post - mi / vf / post - cabg50secondary prevention /
+    post - repeat transvenous icd extractiontolerable1348m22.9dcmp(non -
+    compaction)/vfs35secondary preventionnone1470m29systolic dysfunction of
+    lv35primary preventionnone1526m33brugada sy65primary preventionnonehcmp ,
+    hypertrophic cardiomyopathy ; smvt , sustained monomorphic ventricular
+    tachycardia ; mi , myocardial infarction ; arvc , arrhythmogenic right
+    ventricular cardiomyopathy ; cabg , coronary artery by - pass graft ; lqts ,
+    long qt syndrom . table 2parmeters of s - icd and patient sensation during
+    individual mri scansscan # idbody partheating sensationsshock zone (
+    b.p.m.)condit . shock zone ( b.p.m.)bat % episode
+    num.101brainnone2302101001202brainnone240220861303l spinein -
+    tolerable240220831403brainnone240220831504brainnone220190691605l
+    spinenone220210541706l spinenone240220681807l spinetolerable240220582908l
+    spinein - tolerablenananana1008brainnonenananana1108l
+    spinenone2302108411209heartnone2402208911310l
+    spinenone2301807911410heartnonenananana1511heartnone2301909711612l
+    spinetolerable2001709721712l spinenone2001709421813c
+    spinenone23019010041913l spinenone23019010042014l
+    spinenone2301908612115kneenone25021010012215l spinenone2502101001s - icd
+    parameters acquired prior- and post - mri were without any change ,
+    therefore only one value is presented.indices : na , not available ; l spine
+    , lumbar spine ; c spine , cervical spine . summary of patient anatomical
+    data and scan locations , along with noted clinical events hcmp ,
+    hypertrophic cardiomyopathy ; smvt , sustained monomorphic ventricular
+    tachycardia ; mi , myocardial infarction ; arvc , arrhythmogenic right
+    ventricular cardiomyopathy ; cabg , coronary artery by - pass graft ; lqts ,
+    long qt syndrom . parmeters of s - icd and patient sensation during
+    individual mri scans s - icd parameters acquired prior- and post - mri were
+    without any change , therefore only one value is presented . indices : na ,
+    not available ; l spine , lumbar spine ; c spine , cervical spine . studies
+    were performed using a siemens avanto 1.5 t mri scanner ( vb17 software ,
+    quantum gradient coils ) . all scans were run in normal operating mode ,
+    which is limited to 2 w / kg whole body averaged specific absorption rate (
+    sar ) . clinically relevant mri sequences were used for evaluation ( see
+    table 3 ) . table 3types of pulse sequences typically used for imaging of
+    respective anatomical areasscan locationscan
+    sequencesflairdwiflashfsehastesestirtruefispbrainxxxxheartxxxxcervical
+    spinexxkneexxxxlumbar spinexxflair , fluid attenuated inversion recovery ;
+    dwi , diffusion weighted imaging ; flash , fast low angle shot ; fse , fast
+    spin echo ; haste , half acquisition single - shot turbo spin echo ; se ,
+    spin echo ; stir , short tau inversion recovery ; truefisp , true fast
+    imaging with steady - state precession.fse sequence caused heating in
+    subjects with a thermistor probe during lumbar spine examination ( see the
+    text for details ) . types of pulse sequences typically used for imaging of
+    respective anatomical areas flair , fluid attenuated inversion recovery ;
+    dwi , diffusion weighted imaging ; flash , fast low angle shot ; fse , fast
+    spin echo ; haste , half acquisition single - shot turbo spin echo ; se ,
+    spin echo ; stir , short tau inversion recovery ; truefisp , true fast
+    imaging with steady - state precession . fse sequence caused heating in
+    subjects with a thermistor probe during lumbar spine examination ( see the
+    text for details ) . patients were asked to report immediately any pain ,
+    torqueing movement , or heating sensation in the area of the pocket or the
+    electrode by pressing an emergency bulb . furthermore , all patients were
+    questioned immediately following the mri procedure to ascertain any
+    discomfort in the vicinity of the can or electrode . pulse oximetry and
+    standard lead electrocardiogram ( ecg ) if discomfort occurred , the patient
+    was asked if the scan could be repeated at a later time using a revised scan
+    sequence or the subject was again randomized for another anatomical area .
+    since none of the components of the s - icd system are on or in the heart ,
+    heating near or around however , heating near the electrode or can with the
+    s - icd system may still cause serious patient discomfort . therefore ,
+    along with education of subjects , each patient was instrumented by taping
+    an oesophageal temperature probe ( beta - therm model g22k7mcd8 ) on the
+    skin over the mid - lateral implant site to record any temperature
+    excursions that might be correlated to patient symptoms of heating /
+    discomfort near the pocket . to minimize the risk of inappropriate therapy ,
+    the s - icd system was programmed to therapy each s - icd system was
+    evaluated prior to and immediately after the scan to verify proper
+    functioning , including interrogation , sensing , and battery voltage .
+    after the completion of the mri , long - term regular clinical follow - up
+    and checking of the device were performed . patients with implanted s - icd
+    systems ( boston scientific sqrx model 1010 and q - trak model 3010 ) were
+    enrolled for mri testing over a period of 18 months . the s - icd system
+    implanted in this patient cohort was composed of a can implanted in a left
+    mid - lateral pocket and a para - sternal subcutaneous electrode . the s -
+    icd is currently not certified for use with an mri ; therefore , the ethics
+    committee of homolka hospital , prague , czech republic approved our
+    clinical study . patients with newly implanted s - icd systems ( < 6 weeks )
+    were excluded , and none of the patients had any intravascular leads . the
+    patients were randomized for either a cardiac , brain , cervical , or lumbar
+    spinal scan . one of the subjects underwent an additional knee examination ,
+    due to reported chronic pain . a total of 15 patients were enrolled into
+    this study ( 12 males and three females , aged 2283 years , mean 53 years .
+    subjects in our cohort ( table 1 ) underwent a total of 22 mri scans between
+    6 june 2012 and 24 december 2013 . in total , five brain scans , three
+    cardiac scans , 12 lumbar scans , one knee , and one cervical spine scan
+    were conducted ( table 2 ) . however , in one patient a minor disc
+    protrusion was found , in other mri revealed stenosis of intervertebral
+    foramen which was causing radicular pain of the nerve root l4 and based on
+    this examination the patient was referred to ct - navigated periradicular
+    therapy . table 1summary of patient anatomical data and scan locations ,
+    along with noted clinical eventsidagesexbmidgef , % indication for s -
+    icdheating0164f20.5hcmp / vfs85secondary preventionnone0283m30.0post - mi /
+    smvts post - catheter ablation/35secondary prevention ( post - transvenous
+    icd extraction)none0331m25.3arvc / d / smvts68secondary preventionin -
+    tolerable re - scanned0458m23.6post - mi / post - cabg30primary
+    preventionnone0577m25.5post - mi30primary preventionnone0663m27.0post -
+    mi30primary preventionnone0768m23.7post - mi / vfs / vts60secondary
+    prevention post - transvenous icd extraction / svc
+    occlusiontolerable0822m29.4brugada sy / vfs68secondary preventionin -
+    tolerable re - scanned0959m27.1dcmp / vfs / post - mitral valve
+    surgery/60secondary prev./post - transvenous icd extractionnone1041f24.6arvc
+    / d70primary preventionnone1123f21.5lqts / vf60secondary
+    preventionnone1266m36.9post - mi / vf / post - cabg50secondary prevention /
+    post - repeat transvenous icd extractiontolerable1348m22.9dcmp(non -
+    compaction)/vfs35secondary preventionnone1470m29systolic dysfunction of
+    lv35primary preventionnone1526m33brugada sy65primary preventionnonehcmp ,
+    hypertrophic cardiomyopathy ; smvt , sustained monomorphic ventricular
+    tachycardia ; mi , myocardial infarction ; arvc , arrhythmogenic right
+    ventricular cardiomyopathy ; cabg , coronary artery by - pass graft ; lqts ,
+    long qt syndrom . table 2parmeters of s - icd and patient sensation during
+    individual mri scansscan # idbody partheating sensationsshock zone (
+    b.p.m.)condit . shock zone ( b.p.m.)bat % episode
+    num.101brainnone2302101001202brainnone240220861303l spinein -
+    tolerable240220831403brainnone240220831504brainnone220190691605l
+    spinenone220210541706l spinenone240220681807l spinetolerable240220582908l
+    spinein - tolerablenananana1008brainnonenananana1108l
+    spinenone2302108411209heartnone2402208911310l
+    spinenone2301807911410heartnonenananana1511heartnone2301909711612l
+    spinetolerable2001709721712l spinenone2001709421813c
+    spinenone23019010041913l spinenone23019010042014l
+    spinenone2301908612115kneenone25021010012215l spinenone2502101001s - icd
+    parameters acquired prior- and post - mri were without any change ,
+    therefore only one value is presented.indices : na , not available ; l spine
+    , lumbar spine ; c spine , cervical spine . summary of patient anatomical
+    data and scan locations , along with noted clinical events hcmp ,
+    hypertrophic cardiomyopathy ; smvt , sustained monomorphic ventricular
+    tachycardia ; mi , myocardial infarction ; arvc , arrhythmogenic right
+    ventricular cardiomyopathy ; cabg , coronary artery by - pass graft ; lqts ,
+    long qt syndrom . parmeters of s - icd and patient sensation during
+    individual mri scans s - icd parameters acquired prior- and post - mri were
+    without any change , therefore only one value is presented . indices : na ,
+    not available ; l spine , lumbar spine ; c spine , cervical spine . studies
+    were performed using a siemens avanto 1.5 t mri scanner ( vb17 software ,
+    quantum gradient coils ) . all scans were run in normal operating mode ,
+    which is limited to 2 w / kg whole body averaged specific absorption rate (
+    sar ) . clinically relevant mri sequences were used for evaluation ( see
+    table 3 ) . table 3types of pulse sequences typically used for imaging of
+    respective anatomical areasscan locationscan
+    sequencesflairdwiflashfsehastesestirtruefispbrainxxxxheartxxxxcervical
+    spinexxkneexxxxlumbar spinexxflair , fluid attenuated inversion recovery ;
+    dwi , diffusion weighted imaging ; flash , fast low angle shot ; fse , fast
+    spin echo ; haste , half acquisition single - shot turbo spin echo ; se ,
+    spin echo ; stir , short tau inversion recovery ; truefisp , true fast
+    imaging with steady - state precession.fse sequence caused heating in
+    subjects with a thermistor probe during lumbar spine examination ( see the
+    text for details ) . types of pulse sequences typically used for imaging of
+    respective anatomical areas flair , fluid attenuated inversion recovery ;
+    dwi , diffusion weighted imaging ; flash , fast low angle shot ; fse , fast
+    spin echo ; haste , half acquisition single - shot turbo spin echo ; se ,
+    spin echo ; stir , short tau inversion recovery ; truefisp , true fast
+    imaging with steady - state precession . fse sequence caused heating in
+    subjects with a thermistor probe during lumbar spine examination ( see the
+    text for details ) . patients were asked to report immediately any pain ,
+    torqueing movement , or heating sensation in the area of the pocket or the
+    electrode by pressing an emergency bulb . furthermore , all patients were
+    questioned immediately following the mri procedure to ascertain any
+    discomfort in the vicinity of the can or electrode . pulse oximetry and
+    standard lead electrocardiogram ( ecg ) if discomfort occurred , the patient
+    was asked if the scan could be repeated at a later time using a revised scan
+    sequence or the subject was again randomized for another anatomical area .
+    since none of the components of the s - icd system are on or in the heart ,
+    heating near or around the electrode can not harm the myocardium . however ,
+    heating near the electrode or can with the s - icd system may still cause
+    serious patient discomfort . therefore , along with education of subjects ,
+    each patient was instrumented by taping an oesophageal temperature probe (
+    beta - therm model g22k7mcd8 ) on the skin over the mid - lateral implant
+    site to record any temperature excursions that might be correlated to
+    patient symptoms of heating / discomfort near the pocket . to minimize the
+    risk of inappropriate therapy , the s - icd system was programmed to therapy
+    each s - icd system was evaluated prior to and immediately after the scan to
+    verify proper functioning , including interrogation , sensing , and battery
+    voltage . after the completion of the mri , the s - icd system was
+    reprogrammed to original settings . long - term regular clinical follow - up
+    and checking of the device were performed . no anomalies were noted via
+    pulse oximetry or ecg during the scans for any of the patients . eleven of
+    15 patients reported no sensation or pain from heating of the can , two of
+    15 patients reported feeling some heating , and two patients reported
+    intolerable heating ( see table 2 ) . in patients with intolerable heating ,
+    the scan was halted within seconds and changed to a scan of the brain ,
+    which proceeded without incident . patient reports of heating in the
+    vicinity of the can occurred only during lumbar scans with a thermistor
+    probe ; no such reports occurred during scans of the brain , cardiac area ,
+    cervical spine , or without the probe . in two cases where heating in the
+    vicinity of the can was reported by the patient , the scan sequence was
+    altered to reduce the intensity of radiofrequency ( rf ) field exposure by
+    reducing the turbo factor ( e.g. from 21 to 7 ) , increasing the repetition
+    time ( e.g. to > 4000 ms ) , and reducing the flip angle ( e.g. from 170 to
+    120 ) . the target values were chosen arbitrarily to maintain image contrast
+    ( flip angle ) and keep scan time at reasonable limits ( turbo factor and
+    repetition time ) . less heating was noted by patients after these
+    modifications to the scan parameters were made . 03 ) was observed to have a
+    skin lesion , appearing to be a circular rash or ulcer on the surface of the
+    skin over the can , approximately 35 mm in diameter . the cause of this skin
+    anomaly is not known ; it was later noted to have fully healed at a follow -
+    up 10 days after the scan . to ascertain the effect of heating due to the
+    instrumented thermistor catheter , the two patients who experienced the
+    heating ( examinations 9 and 16 , see table 2 ) were rescanned several weeks
+    later without the thermistor catheter in place ( examinations 11 and 17 ) .
+    first , modified sequence ( with even lower amount of energy deposited in
+    the tissue ) was used , which caused no heating . as no sensation was
+    reported by the subjects , they were asked to report even a minimal
+    discomfort , and the lumbar scans were performed using the same settings
+    that resulted in heating with the thermistor catheter in place in the first
+    imaging session . the results of the rescans revealed that no heating was
+    felt by the patients when the thermistor catheter was absent . there were no
+    noted changes to battery voltage , ability to detect the qrs signal or
+    stored diagnostic data . pacing thresholds can not be assessed by the s -
+    icd system , so this was not evaluated . none of the patients reported any
+    pulling or twisting of the can or pain from heating of the s - icd electrode
+    . for scans of the brain , lumbar spine , knee , and cervical spine , no
+    effect from image artefact was noted in the anatomical area of interest .
+    however , for scans of the cardiac area , image artefact was noted to
+    interfere with the ability to see parts of the left ventricle , though the
+    right ventricle of the heart was unaffected and could be imaged usefully .
+    this was due to the can and not the electrode ( see figure 1 ) ,
+    modifications to the protocol for the lumbar spine resulted in a lower
+    signal - to - noise ratio ; however , the images remain in diagnostic
+    quality ( see figure 2 ) . figure 1kinetic study in four - chamber view :
+    the systolic ( a and c ) and diastolic ( b and d ) images of cine sequences
+    , four - chamber view . the steady - state free precession ( ssfp ) sequence
+    ( a and b ) shows more artefacts . in ssfp kinetic study , an inflow of dark
+    blood from the left pulmonary veins was seen . it could be caused by s - icd
+    but also by metallic ring in mitral annulus . the spoiled gradient echo (
+    gre ) sequence ( c and d ) is better , but an artefact at the lateral wall
+    is obvious . figure 2lumbar spine imaging with icd : low sar t2 fse sequence
+    ( upper image ) compared with normal t2 fse in the same subject ( lower
+    image , for the scanning parameters see the discussion section ) . kinetic
+    study in four - chamber view : the systolic ( a and c ) and diastolic ( b
+    and d ) images of cine sequences , four - chamber view . the steady - state
+    free precession ( ssfp ) sequence ( a and b ) shows more artefacts . in ssfp
+    kinetic study , an inflow of dark blood from the left pulmonary veins was
+    seen . it could be caused by s - icd but also by metallic ring in mitral
+    annulus . the spoiled gradient echo ( gre ) sequence ( c and d ) is better ,
+    but an artefact at the lateral wall is obvious . lumbar spine imaging with
+    icd : low sar t2 fse sequence ( upper image ) compared with normal t2 fse in
+    the same subject ( lower image , for the scanning parameters see the
+    discussion section ) . there were no noted changes to battery voltage ,
+    ability to detect the qrs signal or stored diagnostic data . pacing
+    thresholds can not be assessed by the s - icd system , so this was not
+    evaluated . none of the patients reported any pulling or twisting of the can
+    or pain from heating of the s - icd electrode . for scans of the brain ,
+    lumbar spine , knee , and cervical spine , no effect from image artefact was
+    noted in the anatomical area of interest . however , for scans of the
+    cardiac area , image artefact was noted to interfere with the ability to see
+    parts of the left ventricle , though the right ventricle of the heart was
+    unaffected and could be imaged usefully . this was due to the can and not
+    the electrode ( see figure 1 ) , modifications to the protocol for the
+    lumbar spine resulted in a lower signal - to - noise ratio ; however , the
+    images remain in diagnostic quality ( see figure 2 ) . figure 1kinetic study
+    in four - chamber view : the systolic ( a and c ) and diastolic ( b and d )
+    images of cine sequences , four - chamber view . the steady - state free
+    precession ( ssfp ) sequence ( a and b ) shows more artefacts . in ssfp
+    kinetic study , an inflow of dark blood from the left pulmonary veins was
+    seen . it could be caused by s - icd but also by metallic ring in mitral
+    annulus . the spoiled gradient echo ( gre ) sequence ( c and d ) is better ,
+    but an artefact at the lateral wall is obvious . figure 2lumbar spine
+    imaging with icd : low sar t2 fse sequence ( upper image ) compared with
+    normal t2 fse in the same subject ( lower image , for the scanning
+    parameters see the discussion section ) . kinetic study in four - chamber
+    view : the systolic ( a and c ) and diastolic ( b and d ) images of cine
+    sequences , four - chamber view . the steady - state free precession ( ssfp
+    ) sequence ( a and b ) shows more artefacts . in ssfp kinetic study , an
+    inflow of dark blood from the left pulmonary veins was seen . it could be
+    caused by s - icd but also by metallic ring in mitral annulus . the spoiled
+    gradient echo ( gre ) sequence ( c and d ) is better , but an artefact at
+    the lateral wall is obvious . lumbar spine imaging with icd : low sar t2 fse
+    sequence ( upper image ) compared with normal t2 fse in the same subject (
+    lower image , there are several reports in the current literature about mr -
+    conditional pacemakers from several companies , but very limited reports
+    about mr - conditional icds . biotronik announced in late 2011 release of
+    their first mr - compatible icd device and defibrillator leads pro mri , but
+    in the conditions of use excluded scanning of the torso and focused more on
+    the extremities examination . in european heart rhythm association survey ,
+    60% of centres did not implant any mri - certified icds , 34.3% implanted <
+    10 icd devices , and only 5.6% implanted 10 and more icds ; one - fifth of
+    responders stated that mri - certified icds should be implanted in all
+    patients but lack of reimbursement was indicated as a possible obstacle to
+    implant more mri - certified pacemakers / icds by 47.1% of responding
+    centres . none of the components of the s - icd system are on or in the
+    heart . the s - icd depends less upon being in direct contact with the
+    myocardium to function and instead uses far - field sensing and stimulation
+    to provide the shock and post - shock pacing therapy . as a consequence ,
+    unlike transvenous systems heating near or around the electrode can not harm
+    the myocardium , which could present with possible safety consequences such
+    as an elevation in pacing thresholds or scarring of the myocardium , but it
+    may still cause serious patient discomfort . because the s - icd is larger
+    than modern transvenous icd 's , there may be more potential for the can to
+    experience heating due to the magnetic gradient or rf field . we report
+    results from what we believe is the first experience of mri scanning in
+    patients with an implanted s - icd and in various anatomical areas . overall
+    , mri was performed safely in all patients , which is in contrast to the
+    current literature with mri imaging in patients with electrical - active
+    devices which are not mri - conditional . in our study , the primary
+    clinically significant event attributable to the mri scan was the occurrence
+    of heating in the area of the pocket in the four patients that underwent
+    lumbar scans . it was not known if this was due to the s - icd can itself or
+    an artefact of the thermistor catheter used to measure skin temperature over
+    the pocket . this required a revision of our protocol , which was to re -
+    scan two of the patients who complained of heating . re - scanning of these
+    patients without the thermistor probe resulted in no complaints of heating ,
+    so it is assumed that the thermistor catheter itself heated during the
+    lumbar scans and caused the discomfort . as further evidence , all the
+    heating complaints occurred during rf - intensive scan sequences ( namely
+    fast spin echo ) with the temperature probe located axially near the centre
+    of the bore , where rf fields are the highest . the thermistor catheter is
+    constructed of insulated conductive cables connected to electrodes and
+    should couple to the rf fields efficiently , causing heating at the
+    electrodes and pain or damage on the surface of the skin where the probe was
+    placed over the s - icd can . if the heating was due to the s - icd can
+    itself , it would more likely occur during gradient - intensive scan
+    sequences ( which can generate eddy currents on can surfaces and internal
+    components ) and at locations in the bore where there are high gradient
+    fields , such as near the bore edges . however , when the patient was
+    scanned with gradient - intensive scan sequences ( e.g. flair dwi ) and with
+    the s - icd system in high gradient field locations in the bore ( e.g. such
+    as during a brain scan ) , patients did not detect any heating or discomfort
+    . in addition , the subcutaneous lead , which was not instrumented with a
+    thermistor catheter , never resulted in any heating sensation noted by the
+    patient , even when exactly the same sequence that resulted in heating in
+    the first session was used . the use of mri - compatible temperature
+    monitors such as fibre optic temperature probes would have provided better
+    confirmation of possible skin temperature elevation and would not have been
+    affected by the rf fields . for cardiac imaging , the main problem to solve
+    is metallic artefact , especially on the gradient - echo sequences . like in
+    research performed by nazarian et al . , several scan protocols were used to
+    see if any yielded different effects or reduced the qualitative extent of
+    artefact . gradient mode was changed from normal to whisper , resulting in
+    slower ramping of the field and therefore diminishing the changes of the
+    magnetic field in time . artefacts when present were limited to blurring of
+    the left ventricle during cardiac scans and most yielded clinically useful
+    information . standard interrogation of the s - icd revealed no adverse
+    effects upon the functioning of the system . while no adverse effects upon
+    the post - scan s - icd device function were noted , not all possible
+    scanning protocols were tested . it should be noted that , four of the s -
+    icd 's were exposed to repeat mri scans without adverse effects to device
+    function . in addition , because the s - icd does not provide long - term
+    bradycardia pacing , it is assumed that pacemaker - dependent patients would
+    not be implanted with this system . the inhibition of the pacemaker function
+    during the scanning sequence and possible pacing threshold changes are a
+    unique concern in patients implanted with transvenous icds . this study
+    included only 15 patients and 22 scans done on the same 1.5 t mri scanner .
+    thus , even these preliminary results should only be applied to 1.5 t mri
+    scanners ( similarly as reported in the present literature for other
+    implantable devices ) . device functionality was tested immediately after
+    the scan but not for long - term effects . in addition , not all device
+    functions were tested although the s - icd system does have a beeper /
+    interrogation warning if battery levels or memory irregularities occur .
+    however , patients were scheduled for regular check - up and no defect of
+    the device was observed in following 725 months ( mean observation time 18
+    months ) . delayed enhancement mri for determining cardiac scarring was also
+    not tested . also , there are other anatomical areas that were not evaluated
+    , such as shoulder and knees . this study included only 15 patients and 22
+    scans done on the same 1.5 t mri scanner . thus , even these preliminary
+    results should only be applied to 1.5 t mri scanners ( similarly as reported
+    in the present literature for other implantable devices ) . device
+    functionality was tested immediately after the scan but not for long - term
+    effects . in addition , not all device functions were tested although the s
+    - icd system does have a beeper / interrogation warning if battery levels or
+    memory irregularities occur . however , patients were scheduled for regular
+    check - up and no defect of the device was observed in following 725 months
+    ( mean observation time 18 months ) . delayed enhancement mri for
+    determining cardiac scarring was also not tested . also , there are other
+    anatomical areas that were not evaluated , such as shoulder and knees .
+    while more data are required to support a claim of mri - conditional , this
+    study is the study to demonstrate the feasibility of exposing s - icd
+    patients to mri using the scanning and monitor protocol described , with
+    some precautionary measures including : ( i ) programming the device therapy
+    off ; ( ii ) limiting the sar to 2.0 w / kg ; ( iii ) continuous monitoring
+    of the patients pulse oximetry and ecg by qualified personnel and especially
+    for any feelings of heating ; ( iv ) evaluate device function post scan ; (
+    v ) availability of full resuscitation facilities at the mri site . given
+    the variables of different mri scanners , the decision to perform mri on
+    patients with an implanted s - icd system should be balanced against the
+    potential risks . in our study , the only heating was very likely introduced
+    by not fully mri - compatible thermometer probe ; subjects rescanned without
+    the probe did not report any abnormalities during the scan of any body area
+    listed ( brain , cervical and lumbar spine , heart , and knee ) . this study
+    was supported by iga mz r nt12094/2011 , research project charles university
+    in prague , prvouk p34 and unce 204010/2012 . funding to pay the open access
+    publication charges for this article was provided by iga mz r nt12094/2011 .
 example_title: Summarization Example 1
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 References
 Hugging Face Model Hub
 T5 Paper
+Disclaimer: The model's performance may be influenced by the quality and representativeness of the data it was fine-tuned on. Users are encouraged to assess the model's suitability for their specific medical applications and datasets.