Weight-Guided Constraints for Body Model and Lead Selection in Pediatric CIED MRI Safety Simulations

Pediatric patients with cardiac implantable electronic devices (CIEDs) face limited MRI access due to RF-induced heating, and computational modeling is increasingly used to characterize this risk. The validity of these simulations, however, depends on pairing body models with clinically realistic lead configurations, guidance that is currently lacking. We retrospectively analyzed 302 CIED surgeries in 281 pediatric patients to derive weight-based constraints for simulation design. Weight alone discriminated epicardial from endocardial lead implantation with AUC = 0.90, and adding age and height yielded no improvement, supporting weight as a sufficient single-parameter selection metric. The probabilistic crossover between approaches occurred at 44 kg, substantially higher than the 10 to 15 kg threshold commonly cited in the literature, with a broad transition zone of 21 to 66 kg in which both lead types were routinely used. Lead length was likewise weight-constrained: only 25 cm leads were observed in patients below 6 kg, and leads of 45 cm or longer were uncommon below 50 kg. These findings yield a three-tier framework, with epicardial-only configurations below 21 kg, dual configurations within 21 to 66 kg, and weight-thresholded lead lengths throughout, enabling MRI safety simulations to focus on clinically realizable anatomy and device combinations.