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SECTION 2 – LEAD INFORMATION
Abandoned/
Epicardial Lead(s)
RA RV LV
☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No
☐ Note: CXR
may identify
if abandoned/
epicardial leads
are present.
Manufacturer &
Model #
Manufacturer &
Model #
Manufacturer &
Model #
SECTION 4 – PRE- & POST-MRI DEVICE PARAMETERS
RA RV LV
Pre-MRI Post-MRI Pre-MRI Post-MRI Pre-MRI Post-MRI
Sensing (mV)
Capture reshold
(V @ _____ms)
Impedance (Ω) Pace
Shock
Pace
Shock
Battery Voltage (V)
SECTION 5 – MANAGEMENT FOLLOWING MRI
☐ Keep on ECG monitor aer MRI until initial device programming has been restored
and patient is assessed and declared stable to return to unmonitored status.
☐ Restore all original programming unless pacing output or sensing needs to be
adjusted based upon post-MRI CIED evaluation.
☐ Advise follow-up in device clinic in 3–6 months aer MRI unless earlier follow-up
(within a week) is indicated for the following : Any capture threshold increase >1.0
V, sensing drop >50%, pacing impedance change >50 Ω, or shock impedance change
>5 Ω.
