Multimodality infarct identification for optimal image-guided intramyocardial cell injections

Background Intramyocardial cell injections in the context of cardiac regenerative therapy can currently be performed using electromechanical mapping (EMM) provided by theNOGA®XP catheter injection system. The gold standard technique to determine infarct size and location, however, is late gadolinium enhanced magnetic resonance imaging (LGEMRI). In this article we describe a practical and accurate technique to co-register LGE-MRI andNOGA®XP datasets during the injection procedures to ultimately perform imageguided injections to the border zone of the infarct determined by LGE-MRI. Materials and methods LGE-MRI and EMM were obtained in three pigs with chronic myocardial infarction. MRI and EMM datasets were registered using the in-house developed 3D CartBox image registration toolbox consisting of three steps: 1) landmark registration, 2) surface registration, and 3) manual optimization. The apex and the coronary ostia were used as landmarks. Results Image registration was successful in all datasets, and resulted in a mean registration error of 3.22±1.86 mm between the MRI surface mesh and EMM points. Visual assessment revealed that the locations and the transmural extent of the infarctions measured by LGE-MRI only partly overlap with the infarct areas identified by the EMM parameters. Conclusions The 3D CartBox image registration toolbox enables registration of EMM on pre-procedurally acquired MRI during the catheter injection procedure. This allows the operator to perform real-time image-guided cell injections into the border zone of the infarct as assessed by LGE-MRI. The 3D CartBox thereby enables, for the first time, standardisation of the injection location for cardiac regenerative therapy.