A man with a pacemaker and implantable cardiac defibrillator died after receiving an MRI at Premier Radiology in Brentwood, Tennessee on July 11, 2025. The State Health Facilities Commission is investigating the death, focusing on conflicting accounts about whether the patient’s cardiac devices were properly set to MRI safe mode and whether staff were adequately trained to use emergency medical equipment, according to local TV reports.
ICE Magazine interviewed MRI safety expert Tobias Gilk after he obtained a State Health Facilities Commission about the event. He shared his expert insights and an edited recording of the 911 call. The recording was edited for anonymity and length.
Q: What facts do you know about the event?
GILK: A cardiac device patient went to a Premier Radiology outpatient center for an MRI and appears to have had a major cardiac rhythm disruption on the MRI table during his MRI exam. There is discrepant information about whether the cardiac device was properly configured for an MRI study. There is no explanation as to why patient monitoring failed to identify the rhythm issue (though the accounts do describe the patient as having pulled off the pulse-ox monitor previously during the MRI exam … I suppose we’re supposed to infer that that happened again). The staff at the site were unable to get the site’s AED assembled and operational before paramedics arrived. The site was cited by the state for failing to have effective safety governance, failing to follow its own documented policies with regard to the frequency of AED checks, failing to provide staff with clear emergency procedures and training. The MRI patient ultimately died.
It’s unclear, with the given information, whether the death was a result of a negative interaction between the pacemaker/ICD device and the MRI scanner (for example, a mix-matched device set, failure to set the device correctly for the MRI scan, or perhaps a complete pacing device malfunction), a failure of patient monitoring to detect a problem earlier when intervening may have had a greater chance of success, or whether the fact that the patient was undergoing an MRI was purely coincidental to the cardiac failure.
Q: What processes should be in place to prevent these types of events?
GILK: While it’s not outside the scope of an outpatient imaging facility’s license (if they’re in a state that even requires that these facilities be licensed) to image cardiac device patients, it’s important to recognize the emergent care resource-gap as compared to hospitals. An outpatient MRI facility should undergo a very deliberate and intentional set of steps before taking on patients with active implanted cardiac devices. These should include a policy for active coordination with cardiology/EP to assess the “cardiac fragility” of the patient, as well as MRI-mode device programming settings. In my opinion, patients with a high degree of device dependence or cardiac fragility should only receive MRI exams in locations with ECG monitoring and the capability to respond with Advanced Cardiac Life Support (ACLS), which typically means direct cardiology/EP support for the MRI exam. These capabilities can reliably be found in many hospitals, but require additional steps to put in place at outpatient imaging centers.
Q: How important is it for states or the federal government to enact laws and/or regulations regarding MR safety?
GILK: The interesting thing is that there’s already a structure in place that could help with MRI safety standards at outpatient facilities: CMS Conditions for Coverage and the 2008 MIPPA law. MIPPA designates MRI as one of the “Advanced Diagnostic Imaging” (ADI) modalities (which include CT, PET, and MRI), for which CMS-partnering states are supposed to have minimum quality and safety standards. All states have safety standards for ionizing radiation devices (CT and PET, from the MIPPA list), but in my explorations I have yet to come across a U.S. state that has point-of-care minimum safety requirements for MRI in hospital licensing, and none that even touch the issue of state MRI safety standards for outpatient imaging providers.
If CMS was serious about MIPPA safety standards, they could simply start auditing the compliance of their partnering states for MRI safety standards at the state level. The mechanism appears to be there, but the individual states appear to have never taken this on, and CMS has appeared to be quite comfortable with “letting sleeping dogs lie,” even when we’re seeing a pretty remarkable uptick of horrific MRI accident stories making their way into the popular press.
