Cumulative Transfer Function for Assessment of MRI-Induced RF Heating Risk in Pediatric Patients Implanted with Bifurcated Leads

Purpose: RF-induced heating remains a major barrier to MRI access for patients with epicardial cardiac implantable electronic devices (CIEDs). Although ISO/TS 10974 Tier-3 transfer function (TF) methods are established for unbranched leads, no analogous framework exists for bifurcated leads, in which branch asymmetry and inter-branch coupling may substantially alter heating. We developed and validated a cumulative transfer function (cTF) framework to address this gap. Methods: Following ISO/TS 10974 Tier-3 formalism, we measured, calibrated, and validated cTFs for a commercial 35 cm bipolar epicardial lead at 1.5 T. The framework explicitly accounts for branch-specific response and cross-branch coupling. Validation was performed with 24 canonical lead configurations in a homogeneous phantom and, without recalibration, in a heterogeneous anthropomorphic pediatric phantom with clinically derived trajectories. A single-branch TF approximation served as a comparator. The validated cTF was applied to predict RF heating across adult and pediatric human models at multiple imaging landmarks. Results: Compared with the single-branch TF approximation, the cTF reduced prediction error by nearly 70% in the primary validation dataset. In secondary validation, the cTF maintained low error across clinically relevant trajectories and imaging landmarks. In human models, the framework revealed marked anatomy- and landmark-dependent variation in predicted heating for the tested 35 cm lead, with low predicted heating in pediatric models and substantially higher heating in selected adult chest and upper abdominal imaging scenarios. Conclusion: The cTF provides a validated framework for RF-heating assessment of bifurcated leads and substantially improves prediction accuracy over single-branch TF approximations that neglect branch coupling.