ICD lead and primary metal artifact detection and inpainting in cardiac CT images

Background: Quantifying cardiac motion on pre-treatment CT imaging for stereotactic arrhythmia radiotherapy patients is difficult due to image artifacts caused by metal leads of implantable cardioverter-defibrillators (ICDs). The CT scanners’ onboard metal artifact reduction tool does not sufficiently reduce these artifacts. More advanced artifact reduction techniques require the raw CT projection data and thus do not apply to already reconstructed CT images. New methods are needed to accurately reduce the primary metal artifacts from ICD leads in already reconstructed CTs to recover the otherwise lost anatomical information. Purpose: To develop a methodology to automatically detect the ICD lead wires and surrounding primary metal artifacts in cardiac CT scans and inpaint the affected volume with anatomically consistent structures and values. Methods: Breath-hold ECG-gated 4DCT scans of 12 patients who underwent cardiac radiation therapy for treating ventricular tachycardia were collected. The primary metal artifacts in the images caused by the ICD leads were manually contoured. A 2D U-Net deep learning (DL) model was developed to segment the metal artifacts automatically using eight patients for training, two for validation, and two for testing. A dataset of 592 synthetic CTs was prepared by adding segmented metal artifacts from the patient 4DCT images to artifact-free cardiac CTs of 148 patients. A 3D image inpainting DL model was trained to refill the metal artifact portion in the synthetic images with realistic image contents that approached the ground truth artifact-free images. The trained inpainting model was evaluated by analyzing the automated segmentation results of the four heart chambers with and without artifacts on the synthetic dataset. Additionally, the raw cardiac patient images with metal artifacts were processed using the inpainting model and the results of metal artifact reduction were qualitatively inspected. Results: The artifact detection model worked well and produced a Dice score of 0.958 ± 0.008. The inpainting model for synthesized cases was able to recreate images nearly identical to the ground truth with a structural similarity index of 0.988 ± 0.012. With the chamber segmentations on the artifact-free images as the reference, the average surface Dice scores improved from 0.684 ± 0.247 to 0.964 ± 0.067 and the Hausdorff distance reduced from 3.4 ± 3.9 mm to 0.7 ± 0.7 mm. The inpainting model's use on cardiac patient CTs was visually inspected and the artifact-inpainted images were visually plausible. Conclusion: We successfully developed two deep models to detect and inpaint the ICD leads and primary metal artifacts in cardiac CT images. These deep models are useful to improve the heart chamber segmentation and cardiac motion analysis in CT images corrupted by metal artifacts. The trained models and example data are available to the public through GitHub.