2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging-Best Practices for Safety and Effectiveness, Part 1: Radiation Physics and Radiation Biology: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways

Feasibility, Efficacy, and Safety of Fluoroless Ablation of VT in Patients With Structural Heart Disease

BACKGROUND

Catheter ablation of ventricular tachycardia (VT) typically requires radiation exposure with its potential adverse health effects. A completely fluoroless ablation approach is achievable using a combination of electroanatomical mapping and intracardiac echocardiography. Nonetheless, data in patients undergoing VT ablation are limited.

OBJECTIVES

This study aimed to determine the feasibility, efficacy, and safety of VT ablation in patients with structural heart disease using a zero-fluoroscopy approach.

METHODS

This multicenter study included consecutive patients with ischemic and nonischemic cardiomyopathy undergoing fluoroless VT ablation. Patients requiring epicardial access or coronary angiography were excluded.

RESULTS

Between 2017 and 2023 a total of 198 patients (aged 66.4 ± 13.4 years, 76% male, 48% ischemic) were included. Most patients (95.4%) underwent left ventricular (LV) mapping and/or ablation, which was conducted via transseptal route in 54.5% (n = 103), via retrograde aortic route in 43.4% (n = 82), and using a combined approach in 2.1% (n = 4). Two-thirds of patients had a cardiac device, including a biventricular device in 15%; 2 patients had a LV assist device, and 1 patient had a mechanical aortic valve prosthesis. The mean total procedural time was 211 ± 70 minutes, and the total radiofrequency time was 30 ± 22 minutes. During a follow-up period of 22 ± 18 months, the freedom from VT recurrence was 80%, and 7.6% of patients underwent a repeated ablation. Procedural-related complications occurred in 6 patients (3.0%).

CONCLUSIONS

Fluoroless ablation of VT in structural heart disease is feasible, effective, and safe when epicardial mapping/ablation is not required.

Statewide Initiative to Reduce Patient Radiation Doses During Percutaneous Coronary Intervention

BACKGROUND

Improved radiation safety practices are needed across hospitals performing percutaneous coronary intervention (PCI). This study was performed to assess the temporal trend in PCI radiation doses concurrent with the conduct of a statewide radiation safety initiative.

METHODS

A statewide initiative to reduce PCI radiation doses was conducted in Michigan between 2017 and 2021 and included focused radiation safety education, reporting of institutional radiation doses, and implementation of radiation performance metrics for hospitals. Using data from a large statewide registry, PCI discharges between July 1, 2016, and July 1, 2022, having a procedural air kerma (AK) recorded were analyzed for temporal trends. A multivariable regression analysis was performed to determine whether declines in procedural AK over time were attributable to changes in known predictors of radiation doses.

RESULTS

Among 131 619 PCI procedures performed during the study period, a reduction in procedural AK was observed over time, from a median dose of 1.46 (0.86-2.37) Gy in the first year of the study to 0.97 (0.56-1.64) Gy in the last year of the study (P<0.001). The proportion of cases with an AK ≥5 Gy declined from 4.24% to 0.86% over the same time period (P<0.0001). After adjusting for variables known to impact radiation doses, a 1-year increase in the date of PCI was associated with a 7.61% (95% CI, 7.38%-7.84%) reduction in procedural AK (P<0.0001).

CONCLUSIONS

Concurrent with the conduct of a statewide initiative to reduce procedural radiation doses, a progressive and significant decline in procedural radiation doses was observed among patients undergoing PCI in the state of Michigan.

A novel robotic radiation shielding device for electrophysiologic procedures: A prospective study

BACKGROUND

A robotic Radiaction Shielding System (RSS) was developed to provide a full-body protection to all medical personnel during fluoroscopy-guided procedures, by encapsulating the imaging beam and blocking scattered radiation.

OBJECTIVES

We aimed to evaluate its efficacy in real-world electrophysiologic (EP) laboratory- both during ablations and cardiovascular implantable electronic devices (CIED) procedures.

METHODS

A prospective controlled study comparing consecutive real-life EP procedures with and without RSS using highly sensitive sensors in different locations.

RESULTS

Thirty-five ablations and 19 CIED procedures were done without RSS installed and 31 ablations and 24 CIED procedures (17 with usage levels ≥70%) were done with RSS. Overall, there was 95% average usage level for ablations and 88% for CIEDs. For all procedures with ≥70% usage level and for all sensors, the radiation with RSS was significantly lower than radiation without RSS. For ablations, there was 87% reduction in radiation with RSS (76%-97% for different sensors). For CIEDs, there was 83% reduction in radiation with RSS (59%-92%). RSS usage did not increase procedure time and radiation time. User feedback showed a high-level of integration in the clinical workflow and safety profile for all types of EP procedures.

CONCLUSIONS

For both CIED and ablation procedures the radiation with RSS was significantly lower than without RSS. Higher usage level brings higher reduction rates. Thus, RSS may have an important role in full-body protection to all medical personnel from scattered radiation during EP and CIED procedures. Until more data is available, it is recommended to maintain existing standard shielding.

Opportunities and Challenges of Computed Tomography Coronary Angiography in the Investigation of Chest Pain in the Emergency Department-A Narrative Review

Chest pain is one of the most common presentations to emergency departments. However, only 5.1% will be diagnosed with an acute coronary syndrome, representing considerable time and expense in the diagnosis and investigation of the patients eventually found not to be suffering from an acute coronary syndrome. PubMed and Medline databases were searched with variations of the terms "chest pain", "emergency department", "computed tomography coronary angiography". After review, 52 articles were included. Computed tomography coronary angiography (CTCA) is a class I endorsement for investigating chest pain in major international societal guidelines. CTCA offers excellent sensitivity and negative predictive value in identifying patients with coronary disease, with prognostic data impacting patient management. If CTCA is to be applied to all comers, it is pertinent to discuss the advantages and potential pitfalls if use in the Australian system is to be increased.

Transseptal versus retrograde approach for ablation of left-sided accessory pathways: impact on radiation exposure

Management of left-sided accessory pathways (APs) is based on catheter ablation through an antegrade or retrograde approach. Both are safe and effective but are associated with exposure to x-rays; however, recipients of ablation are generally young. We sought to evaluate the impact of the approach chosen on dose-area product (DAP). A total of 95 patients who underwent radiofrequency ablation of a left-sided AP between January 2011 and January 2020 were included. The primary endpoint was the radiation dose received by the patient. Secondary endpoints were procedural success and complication and recurrence rates. The mean age of the study population was 34.3 ± 16.6 years. The antegrade transseptal approach was used in 63.5% of cases. By multivariate analysis, the antegrade transseptal approach was associated with a 53% reduction in DAP (p< 0.001). The radiation dose received was also significantly associated with body mass index and total fluoroscopy time (p< 0.001). There was no significant difference in other secondary endpoints between approaches. The use of an antegrade transseptal approach is associated with a significant reduction in DAP compared with the retrograde approach, and procedural success and complication and recurrence rates are similar.

Operator Radiation Exposure During Transfemoral Transcatheter Aortic Valve Replacement

Background

The level of radiation exposure received by operators performing transcatheter aortic valve replacement (TAVR) is not well investigated. The aim of this study is to measure the amount of radiation received by operators performing transfemoral TAVR and to identify various patient and procedural characteristics associated with increased radiation exposure.

Methods

Primary (operator 1) and secondary (operator 2) operators' equivalent radiation doses in micro Sieverts (µSv) were calculated prospectively using real-time radiation dosimeters for a total of 140 consecutive transfemoral TAVRs. Corresponding eye and thorax radiation exposures between the operators were compared. Associations between various patient and procedural characteristics and the radiation exposure were tested using the t-test and Wilcoxon Mann-Whitney rank-sum test with Monte Carlo estimation. Multivariable regression analysis was also conducted.

Results

Operator 1 had significantly higher cumulative equivalent radiation exposure than operator 2 (86 µSv vs 38 µSv, p-value: <0.0001) which was consistent at the level of the thorax (67 µSv vs 22 µSv, p-value: <0.0001), but not at the level of the eye (16.5 µSv vs 15 µSv, p-value: 0.30). On multivariable analysis, patient obesity and intraprocedural complications were associated with higher radiation exposure to both operators. Ad hoc percutaneous coronary intervention led to excessive radiation exposure to the secondary operator.

Conclusions

Transfemoral TAVR is associated with a modest amount of radiation exposure to operators and is significantly higher for the primary operator than for the secondary operator.

The use of digital magnification to reduce radiation dose in the cardiac catheter laboratory

OBJECTIVES

To audit whether using magnification of images by use of a large viewing screen using digital matrix magnification which enlarges the image by 33% without using the X-ray machine zoom magnification protocols on a Siemens Artis Zee X-ray machine in a cardiac catheter laboratory results in a reduction of kerma-area product (KAP) for both diagnostic and interventional procedures. This reduction was predicted in an in vitro study in our laboratory, which has previously shown a 20.4% reduction in KAP.

METHODS

A retrospective analysis was conducted of the radiation exposure to compare the measured KAP recorded during the period when conventional magnification with automatic brightness and dose control was used on a Siemens Artis Zee X-ray machine with a flat panel detector and when magnification settings were avoided by using a large screen to enlarge and project a non-magnified image by digital magnification. The analysis was carried out for patients having a diagnostic coronary angiogram and those having an interventional coronary procedure.

RESULTS

For diagnostic coronary angiograms the median KAP per procedure in the period using conventional magnification was 2124.5 µGy.m² compared to 1401 µGy.m² when image matrix magnification was used, a 34% reduction (p < 0.0001). For interventional coronary procedures, the median KAP per procedure in the period using conventional magnification was 3791 µGy.m² compared to 2568.5 µGy.m² when image matrix magnification was used, a 32% reduction (p < 0.0001).

CONCLUSION

Avoiding using conventional magnification in the cardiac catheter laboratory and using a large screen to magnify images was associated with a statistically significant greater than 30% reduction in KAP.

ADVANCES IN KNOWLEDGE

This paper is the proof in clinical practice of a theoretical conclusion that radiation dose (KAP) is reduced by use of Image matrix magnification using a large viewing screen without the need to use X-ray tube magnification without significant loss of image resolution in interventional cardiology. The same approach will be useful in interventional radiology.

The ethical dilemma of emergency department patients with low-risk chest pain

Millions of patients present to US EDs each year with symptoms concerning for acute coronary syndrome (ACS), but fewer than 10% are ultimately diagnosed with ACS. Well-tested and externally validated accelerated diagnostic protocols were developed to aid providers in risk stratifying patients with possible ACS and have become central components of current ED practice guidelines. Nevertheless, the fear of missing ACS continues to be a strong motivator for ED providers to pursue further testing for their patients. An ethical dilemma arises when the provider must balance the risk of ACS if the patient is discharged compared with the potential harms caused by a cardiac workup. Providers should be familiar with the ethical principles relevant to this dilemma in order to determine what is in the best interests of the patient.

Peripheral Interventions Radiation Exposure Reduction Using a Sensor-Based Navigation System: A Proof-of-Concept Study

Background

Intravascular catheter positioning is done with radiography imaging. Increasing evidence indicates excessive ionizing radiation exposure for patients and physicians during catheterization procedures, making solutions to reduce radiation exposure a priority. This study evaluated the feasibility and impact of using sensor-based magnetic navigation on (i) fluoroscopy time and (ii) positioning accuracy and safety of a peripheral angioplasty balloon catheter.

Methods

All patients (n = 10) underwent a balloon-positioning protocol using 2 navigation methods sequentially: (i) magnetic navigation with minimal fluoroscopy; (ii) fluoroscopic navigation. The navigation method order was randomized, and 4 consecutive placements per method were performed. A target vascular bifurcation was used as a fiduciary landmark for both methods to determine accuracy.

Results

Balloon placements were successful with both navigation methods in all subjects, and no adverse events occurred. Magnetic guidance led to significant reductions in fluoroscopy time (0.37 ± 1.5 vs 15.0 ± 8.1 seconds, P < 0.001) and dose (0.3 ± 1.2 vs 24.1 ± 23.8 μGy.m², P < 0.01). The time duration for balloon alignment was similar for the 2 navigation methods (4.8 ± 1.4 vs 4.8 ± 2.3 seconds, P = 0.89), and the accuracy was almost identical (0.51 ± 0.41 vs 0.51 ± 0.32 mm, P = 0.97).

Conclusions

These results demonstrate the feasibility of using sensor-based magnetic guidance during simple peripheral interventional procedures; a significant reduction in ionizing radiation was achieved, with excellent positioning accuracy and safety. The clinical applications of magnetic guidance for device navigation during more complex percutaneous procedures should be evaluated.

Radiation-Induced Cardiovascular Disease: Review of an Underrecognized Pathology

Radiation therapy demonstrates a clear survival benefit in the treatment of several malignancies. However, cancer survivors can develop a wide array of cardiotoxic complications related to radiation. This pathology is often underrecognized by clinicians and there is little known on how to manage this population. Radiation causes fibrosis of all components of the heart and significantly increases the risk of coronary artery disease, cardiomyopathy, valvulopathy, arrhythmias, and pericardial disease. Physicians should treat other cardiovascular risk factors aggressively in this population and guidelines suggest obtaining regular imaging once symptomatology is established. Patients with radiation‐induced cardiovascular disease tend to do worse than their traditional counterparts for the same interventions. However, there is a trend toward fewer complications and lower mortality with catheter‐based rather than surgical approaches, likely because radiation makes these patients poor surgical candidates. When appropriate, these patients should be referred for percutaneous management of valvulopathy and coronary disease.

Radiation safety and knowledge: an international survey of 708 interventional pain physicians

INTRODUCTION

Interventional pain procedures have increased in complexity, often requiring longer radiation exposure times and subsequently higher doses. The practicing physician requires an in-depth knowledge and evidence-based knowledge of radiation safety to limit the health risks to themselves, patients and healthcare staff. The objective of this study was to examine current radiation safety practices and knowledge among interventional pain physicians and compare them to evidence-based recommendations.

MATERIALS AND METHODS

A 49-question survey was developed based on an extensive review of national and international guidelines on radiation safety. The survey was web-based and distributed through the following professional organizations: Association of Pain Program Directors, American Academy of Pain Medicine, American Society of Regional Anesthesia and Pain Medicine, European Society of Regional Anesthesia and Pain Therapy, International Neuromodulation Society, and North American Neuromodulation Society. Responses to radiation safety practices and knowledge questions were evaluated and compared with evidence-based recommendations. An exploratory data analysis examined associations with radiation safety training/education, geographical location, practice type, self-perceived understanding, and fellowship experience.

RESULTS

Of 708 responding physicians, 93% reported concern over the health effects of radiation, while only 63% had ever received radiation safety training/education. Overall, ≥80% physician compliance with evidence-based radiation safety practice recommendations was demonstrated for only 2/15 survey questions. Physician knowledge of radiation safety principles was low, with 0/10 survey questions having correct response rates ≥80%.

CONCLUSION

We have identified deficiencies in the implementation of evidence-based practices and knowledge gaps in radiation safety. Further education and training are warranted for both fellowship training and postgraduate medical practice. The substantial gaps identified should be addressed to better protect physicians, staff and patients from unnecessary exposure to ionizing radiation during interventional pain procedures.

Zero-fluoroscopy catheter ablation of premature ventricular contractions at left coronary cusp near left main coronary artery

The left coronary cusp is the commonest site of origin for coronary cusp PVC. Catheter ablation without fluoroscopy is highly effective, feasible, and safe but it could be related to risks because of proximity to the coronary arteries. The use of ICE integration allowed an improvement in the safety and efficiency of these procedures.

Efficiency of the RADPAD Surgical Cap in Reducing Brain Exposure During Pacemaker and Defibrillator Implantation

OBJECTIVES

This study sought to investigate the RADPAD No Brainer (Worldwide Innovation and Technologies, Overland Park, Kansas) efficiency in reducing brain exposure to scattered radiation.

BACKGROUND

Cranial radioprotective caps such as the RADPAD No Brainer are being marketed as devices that significantly reduce operator's brain exposure to scattered radiation. However, the efficiency of the RADPAD No Brainer in reducing brain exposure in clinical practice remains unknown to date.

METHODS

Five electrophysiologists performing device implantations over a 2-month period wore the RADPAD cap with 2 strips of 11 thermoluminescent dosimeter pellets covering the front head above and under the shielded cap. Phantom measurements and Monte Carlo simulations were performed to further investigate brain dose distribution.

RESULTS

Our study showed that the right half of the operators' front head was the most exposed region during left subpectoral device implantation; the RADPAD cap attenuated the skin front-head exposure but provided no protection to the brain. The exposure of the anterior part of the brain was decreased by a factor of 4.5 compared with the front-head skin value thanks to the skull. The RADPAD cap worn as a protruding horizontal plane, however, reduced brain exposure by a factor of 1.7 (interquartile range: 1.3 to 1.9).

CONCLUSIONS

During device implantation, the RADPAD No Brainer decreased the skin front head exposure but had no impact on brain dose distribution. The RADPAD No Brainer worn as a horizontal plane worn around the neck reduces brain exposure and confirms that the exposure comes from upward scattered radiation.

Comprehensive strategies to minimize radiation exposure during Interventional electrophysiology procedures: state-of-the-art review

INTRODUCTION

Cardiac electrophysiology (EP) procedures are frequently performed in patients with cardiac arrhythmias, chronic heart failure, and sudden cardiac death. Most EP procedures involve fluoroscopy, which results in radiation exposure to physicians, patients, and EP lab staff. Accumulated radiation exposure is a known health detriment to patients and physicians.

AREA COVERED

This review will summarize radiation exposure, dose metrics, complications of radiation exposure, factors affecting radiation exposure, minimizing radiation exposure, zero or near-zero fluoroscopy strategies, and up-to-date research in the area of reducing radiation exposure and best practices.

EXPERT COMMENTARY

Comprehensive strategies should be implemented in EP laboratories to minimize radiation exposure with standard fluoroscopy. There are routine techniques that can mitigate significant amounts of radiation exposure using standard equipment within the EP lab. The operators need to emphasize that EP practices routinely incorporate non-ionizing radiation sources for cardiac imaging (e.g. magnetic resonance imaging, advanced electroanatomical mapping systems, intracardiac ultrasonography) in addition to other novel technologies to mitigate radiation exposure to patients and physicians.

Systolic High-Pitch Coronary CT Angiography for Evaluation of the Coronary Arteries in Heart Transplant Recipients

OBJECTIVE. The purpose of this study was to evaluate the feasibility, image quality, and radiation dose of high-pitch coronary CT angiography (CCTA) in orthotopic heart transplant (OHT) recipients. SUBJECTS AND METHODS. Twenty-two consecutive OHT recipients (16 men, six women; median age, 66.5 years [interquartile range, 51.3-70.3 years]; median heart rate, 91 beats/min [interquartile range, 79.3-97.3 beats/min]) underwent CCTA with a third-generation dual-source CT scanner in high-pitch mode to rule out coronary allograft vasculopathy. Data acquisition was triggered at 30% of the R-R interval. Two independent observers blindly assessed image quality on a per-segment, per-vessel, and per-patient basis using a 4-point scale (4, excellent; 1, not evaluative). Scores 2-4 indicated diagnostic quality. Studies were compared with previously performed retrospective ECG-gated examinations, when available. Interobserver agreement on the image quality was assessed with kappa statistics. Radiation dose was recorded. RESULTS. A total of 322 coronary segments were evaluated. Diagnostic image quality was observed in 97.5% of the segments. Interobserver agreement for image quality assessment was very good on a per-patient (κ = 0.82), per-vessel (κ = 0.83), and per-segment basis (κ = 0.89). The median per-patient image quality score was 4.0 (3.0-4.0) for the entire coronary tree. A comparison of image quality scores between high-pitch and retrospective ECG-gated CCTA examinations showed no significant differences, but the estimated mean radiation dose was significantly lower for the high-pitch mode (median dose-length product, 31.6 mGy × cm [interquartile range, 23.1-38.8 mGy × cm] vs 736.5 mGy × cm [interquartile range, 655.5-845.7 mGy × cm], p < 0.001). CONCLUSION. Performing single-heartbeat high-pitch CCTA during the systolic phase of the cardiac cycle in OHT recipients results in diagnostic image quality in coronary angiograms at very low radiation dose.

Operators' radiation exposure reduction during cardiac catheterization using a removable shield

Cardiac catheterization through radial access is associated with significant ionizing radiation exposure for the operator. We aimed at evaluating whether a removable shield placed upon the patient could impact favorably on annual radiation exposure for the operator. We designed a pre-post study comparing radiation exposure in a total of five operators under standard protection procedures (first period) and after applying a removable shield (second period). Each period included all the procedures performed in 1 year. Radiation exposure was measured through three dosimeters on each operator. A total of 1610 procedures were performed during the first period, and 1670 during the second period. For each operator, Fluoroscopy Time (FT) per exam did not differ between the two periods (13.1 ± 1 vs 12.9 ± 2 min/exam, p = 0.73), whereas Dose-Area Product (DAP) per procedure was slightly higher in the second period (5.247 ± 651 vs 6.374 ± 967 mGy/cm², p < 0.01). The use of a removable shield significantly reduced operators' radiation dose at the left bracelet (64.3 ± 13.3 μSv/exam vs 23.8 ± 6.0 μSv/exam, p = 0.003). This remained significant even after adjustment for DAP per procedure (p = 0.015) and number of operators participating to each procedure (p = 0.013), whereas no significant difference was observed for card (5.6 ± 10.5 μSv/exam vs 0.9 ± 0.3 μSv/exam, p = 0.36) and neck bands (3.3 ± 4.5 μSv/exam vs 2.0 ± 2.0 μSv/exam, p = 0.36) dosimeters. The use of a removable shield during cardiac catheterization reduces radiation exposure at the level of the operator's upper limb, whereas no difference was found for other body parts. This may help in reducing radiation exposure of operator's hand. DAP increase merits further investigation.

2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness-A Review for the Cardiac Anesthesiologist

The American College of Cardiology, in collaboration with the American Society of Nuclear Cardiology, Heart Rhythm Society, Mended Hearts, North American Society for Cardiovascular Imaging, Society for Cardiovascular Angiography and Interventions, Society for Cardiovascular Computed Tomography, and Society of Nuclear Medicine and Molecular Imaging, recently published a consensus document recommending best practices for the use of ionizing radiation in cardiovascular medicine. With the increase in number and complexity of catheter-based cardiovascular interventions, cardiothoracic anesthesiologists are being requested to consult and provide care for these patients. This review summarizes the salient portions of the consensus document as it pertains to the anesthesiologist. Radiation exposure for both patients and providers should be minimized to be as low as reasonably achievable. For the anesthesiologist involved in the procedure, the authors recommend wearing protective garments including apron, vest, neck collar, and glasses of at least 0.25-mm lead or lead equivalent. The addition of a portable shield also is strongly recommended. The anesthesiologist should maintain the maximum distance allowable from the x-ray source, remembering that radiation intensity is inversely proportional to the square of the distance from the x-ray source. Monitoring radiation exposure is done best by both collar and under-apron film badge. A 0.5-mm lead-equivalent apron is expected to shield approximately 95% of the radiation. By using these recommendations, the anesthesiologist should be able to keep radiation exposure under 20 mSv per year as recommended by the International Commission on Radiation Protection.

Ionizing Radiation in Interventional Cardiology and Electrophysiology

Fluoroscopy-guided procedures constitute a major part in the practice of cardiology. These procedures are also a source of human-made ionizing radiation. Although the benefits of performing the procedure surpass the radiogenic risks in most cases, the risks are not negligible. Exposure to ionizing radiation may lead to tissue injuries and potential increase in risk of cancer. Both patients and operating physicians are exposed to these risks in variable degrees. The institution of radiation safety practices alone significantly reduces radiation exposure. Beyond the interventional laboratory, increasing physicians' awareness to health-related risks of ionizing radiation is crucial in reducing unnecessary testing and increases receptiveness to patient risks. Incorporating the radiogenic risks of a future procedure in patient-informed consent also increases patients' awareness to potential consequences. Innovation in imaging technology resulted in a plethora of alternate modalities. Electroanatomical mapping, magnetic navigation systems, robotic and magnetic resonance imaging (MRI)-assisted techniques are examples of clinically used modalities that limit the exposure of patients and operating physicians to radiation. Documentation of patients' exposure in their medical records is essential. Tracking of patients' cumulative exposure can be implemented at an institutional level. Identifying patients with the highest exposure would help shed light on a blind spot in our current practice, as the implications are unclear.

Radiation exposure during image-guided endoscopic procedures: The next quality indicator for endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently used image-guided procedures in gastrointestinal endoscopy. Post-ERCP pancreatitis is an important concern, and prophylaxis, cannulation and other related technical procedures have been well documented by endoscopists. In addition, medical radiation exposure is of great concern in the general population because of its rapidly increasing frequency and its potential carcinogenic effects. International organizations and radiological societies have established diagnostic reference levels, which guide proper radiation use and serve as global standards for all procedures that use ionizing radiation. However, data on gastrointestinal fluoroscopic procedures are still lacking because the demand for these procedures has recently increased. In this review, we present the current status of quality indicators for ERCP and the methods for measuring radiation exposure in the clinical setting as the next quality indicator for ERCP. To reduce radiation exposure, knowledge of its adverse effects and the procedures for proper measurement and protection are essential. Additionally, further studies on the factors that affect radiation exposure, exposure management and diagnostic reference levels are necessary. Then, we can discuss how to manage medical radiation use in these complex fluoroscopic procedures. This knowledge will help us to protect not only patients but also endoscopists and medical staff in the fluoroscopy unit.

Occupational and patient radiation doses in a modern cardiac electrophysiology laboratory

PURPOSE

Technological advancements have greatly expanded the field of cardiac electrophysiology, requiring greater demands on imaging systems and potentially delivering higher radiation doses to patients and operators. With little contemporary research on occupational and patient radiation risk in the electrophysiology laboratory, the aim of this study was to analyze radiation doses, including occupational fetal doses, over approximately the last decade. We benchmarked the occupational data to our patient radiation dose data to allow for comparison and to put into perspective the associated radiation risks.

METHODS

Occupational radiation dosimetry analyzed included data from an 11-year period for physicians, a 7-year period for nurses, and a 9-year period for fetal doses. Patient-related dose metrics over an 8-year period were also analyzed.

RESULTS

In the physician and nursing groups, there was a nearly 70% decrease in the average occupational radiation doses over the given periods. Within the electrophysiology department, the average fetal occupational doses were very low, close to 0 μSv. The average reference point air kerma per patient for all electrophysiology procedures decreased from nearly 600 mGy/procedure in 2010 to just over 100 mGy/procedure in 2017.

CONCLUSIONS

Patient and occupational radiation doses in our laboratories significantly decreased over the periods analyzed as a result of clinical and technical staff efforts as well as advances in imaging technology. The radiation-related risk to individuals working in our electrophysiology laboratories, including pregnant women, is very low. Data reported herein could be used by other institutions to evaluate their occupational and patient radiation safety practices.