Multimodality infarct identification for optimal image-guided intramyocardial cell injections

F.J. van Slochteren, R. van Es, S. Koudstaal, T.I.G. Spoel, van der, J.P.G. Sluijter, J. Verbree, R.H.R. Pruim, J. Pluim, T. Leiner, P. A. Doevendans, S.A.J. Chamuleau

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Intramyocardial cell injections in the context of cardiac regenerative therapy can currently be performed using electromechanical mapping (EMM) provided by the NOGA®XP catheter injection system. The gold standard technique to determine infarct size and location, however, is late gadolinium enhanced magnetic resonance imaging (LGE-MRI). In this article we describe a practical and accurate technique to co-register LGE-MRI and NOGA®XP datasets during the injection procedures to ultimately perform image-guided 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.


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.


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.

Original languageEnglish
Pages (from-to)493-500
Number of pages7
JournalNetherlands Heart Journal
Issue number11
Publication statusPublished - Nov 2014


  • Cardiac regenerative therapy
  • Intramyocardial injections
  • Electromechanical mapping
  • Myocardial fibrosis
  • MRI
  • Late Gadolinium enhancement


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