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The risk of treatment\u2010induced toxicity and geographic miss can be reduced with online MRI\u2010guidance on an MR\u2010linac. However, most VT patients carry cardiac implantable electronic devices (CIED), which compromise MR\u00a0images.<\/jats:p><\/jats:sec><jats:sec><jats:title>Purpose<\/jats:title><jats:p>Robust MR\u2010linac imaging sequences are required for cardiac visualization and accurate motion monitoring in presence of a CIED during MRI\u2010guided STAR. We optimized two clinically available cine sequences for cardiorespiratory motion estimation in presence of a CIED on a 1.5 T MR\u2010linac. The image quality, motion estimation accuracy, and geometric fidelity using these cine sequences were\u00a0evaluated.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Clinically available 2D balanced steady\u2010state free precession (bSSFP, voxel size = 3.0  3.0  10 mm<jats:sup>3<\/jats:sup>, T<jats:sub>scan<\/jats:sub> = 96 ms, bandwidth (BW) = 1884 Hz\/px) and \u2010spoiled gradient echo (\u2010GRE, voxel size = 4.0  4.0  10 mm<jats:sup>3<\/jats:sup>, T<jats:sub>scan<\/jats:sub> = 97 ms, BW = 500 Hz\/px) sequences were adjusted for real\u2010time cardiac visualization and cardiorespiratory motion estimation on a 1.5 T Unity MR\u2010linac (Elekta AB, Stockholm, Sweden), while complying with safety guidelines for MRI in presence of CIEDs (specific absorption rate  2 W\/kg and  80 mT\/s). Cine acquisitions were performed in five healthy volunteers, with and without an implantable cardioverter\u2013 defibrillator (ICD) placed on the clavicle, and a VT patient. Generalized divergence\u2010curl (GDC) deformable image registration (DIR) was used for automated landmark motion estimation in the left ventricle (LV). Gaussian processes (GP), a machine\u2010learning technique, was trained using GDC landmarks and deployed for real\u2010time cardiorespiratory motion prediction. \u2010mapping was performed to assess geometric image fidelity in the presence of\u00a0CIEDs.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>CIEDs introduced banding artifacts partially obscuring cardiac structures in bSSFP acquisitions. In contrast, the \u2010GRE was more robust to CIED\u2010induced artifacts at the expense of a lower signal\u2010to\u2010noise ratio. In presence of an ICD, image\u2010based cardiorespiratory motion estimation was possible for 85% (100%) of the volunteers using the bSSFP (\u2010GRE) sequence. The in\u2010plane 2D root\u2010mean\u2010squared deviation (RMSD) range between GDC\u2010derived landmarks and manual annotations using the bSSFP (T<jats:sub>1<\/jats:sub>\u2010GRE) sequence was 3.1\u20133.3 (3.3\u20134.1) mm without ICD and 4.6\u20134.6 (3.2\u20133.3) mm with ICD. Without ICD, the RMSD between the GP\u2010predictions and GDC\u2010derived landmarks ranged between 0.9 and 2.2 mm (1.3\u20133.0 mm) for the bSSFP (T<jats:sub>1<\/jats:sub>\u2010GRE) sequence. With ICD, the RMSD between the GP\u2010predictions and GDC\u2010derived landmarks ranged between 1.3 and 2.2 mm (1.2\u20133.2 mm) using the bSSFP (T<jats:sub>1<\/jats:sub>\u2010GRE) sequence resulting in an RMSD\u2010increase of 42%\u2013143% (bSSFP) and \u221261%\u2013142% (T<jats:sub>1<\/jats:sub>\u2010GRE). Lead\u2010induced spatial distortions ranged between \u22120.2 and 0.2 mm (\u22120.7\u20131.2 mm) using the bSSFP (\u2010GRE) sequence. The 98<jats:sup>th<\/jats:sup> percentile range of the spatial distortions in the gross target volume of the patient was between 0.0 and 0.4 mm (0.0\u20131.8 mm) when using bSSFP (\u2010GRE).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Tailored bSSFP and \u2010GRE sequences can facilitate real\u2010time cardiorespiratory estimation using GP trained with GDC\u2010derived landmarks in the majority of landmark locations in the LV despite the presence of CIEDs. The need for high temporal resolution noticeably reduced achievable spatial resolution of the cine MRIs. However, the effect of the CIED\u2010induced artifacts is device, patient and sequence dependent and requires specific assessment per\u00a0case.<\/jats:p><\/jats:sec>","DOI":"10.1002\/mp.17438","type":"journal-article","created":{"date-parts":[[2024,10,4]],"date-time":"2024-10-04T12:20:36Z","timestamp":1728044436000},"page":"99-112","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Evaluation of the impact of cardiac implantable electronic devices on cine MRI for real\u2010time adaptive cardiac radioablation on a 1.5 T MR\u2010linac"],"prefix":"10.1002","volume":"52","author":[{"given":"Osman","family":"Akdag","sequence":"first","affiliation":[{"name":"Department of Radiotherapy University Medical Center Utrecht Utrecht The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stefano","family":"Mandija","sequence":"additional","affiliation":[{"name":"Department of Radiotherapy University Medical Center Utrecht Utrecht The Netherlands"},{"name":"Computational Imaging Group for MR Diagnostics and Therapy Center for Image Sciences University Medical Center Utrecht Utrecht The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Pim T. 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