SCAI Multi-Society Position Statement on Occupational Health Hazards of the Catheterization Laboratory: Shifting the Paradigm for Healthcare Workers' Protection

Implementing a 'Lead [Apron]-Free' Cardiac Catheterization: Current Status

PURPOSE OF REVIEW

In this review, we discuss the status of novel radiation shielding and other methods to reduce radiation exposure and its associated health risks within the CCL.

RECENT FINDINGS

There are many devices on the market each with its unique advantages and inherent flaws. Several are available for widespread use with promising data, while others still in development. The field of percutaneous transcatheter interventions includes complex procedures often involving significant radiation exposure. Increased radiation exposes the proceduralist and CCL staff to potential harm from both direct effects of radiation but also from the ergonomic consequences of daily use of heavy personal protective equipment. Here we discuss several innovative efforts to reduce both radiation exposure and orthopedic injury within the CCL that are available, leading to a safer daily routine in a "lead [apron]-free" environment.

Radiation Exposure, Training, and Safety in Cardiology

Exposure to ionizing radiation is an inherent occupational health hazard in clinical cardiology. Health risks have been reported previously, including predilection to cancer. In addition, orthopedic injury due to prolonged wearing of heavy protective lead aprons, which are mandatory to reduce radiation risk, have been extensively documented. Cardiology as a specialty has grown with rising volumes of increasingly complex procedures. This includes electrophysiological, coronary, and structural intervention, advanced heart failure/transplant management, and diagnostic imaging. Both the operator as well imaging specialists are exposed to radiation, particularly in structural interventions where interventional cardiologists and structural imagers work closely. Increasingly, women interested in cardiology may deselect the field due to radiation concerns. This expert document highlights the risks of radiation exposure in cardiology, including practical tips within various subspecialty fields such as interventional/structural cardiology, electrophysiology, imaging, advanced heart failure, and pediatric cardiology.

Investigation of scatter radiation intensities in the cardiac catheter laboratory: novel versus traditional shielding solutions

A manufacturer has released a novel shielding solution (NSS): Rampart M1128 and claimed that the personal protective equipment (PPE) can be removed. This study investigates the scatter intensities with the NSS or the traditional shielding solutions (TSS) including the ceiling-suspended screen and the tableside lead drape. Isodose maps were generated by two series of measurements with an anthropomorphic phantom using NSS and TSS. Three survey meters were positioned at different heights to measure the scatter intensities at the eye, chest, and pelvic levels. Additional measurements were made at the primary and secondary operators? locations to evaluate the scatter intensities with different clinical projections. For the main operator positions, the isodose maps showed that NSS could result in a scatter dose that reduced by 80% to 95% compared to the same positions with TSS at the eye and chest levels. The corresponding result at the pelvic level was a reduction of 50%. These reductions should be compared to the additional protection by PPE: up to 80% reduction from lead eyeglasses and up to 95% from protective garments. Considering both operators at clinically relevant LAO projections, NSS resulted in scatter dose that was 80% to 96%, 76% to 96% and 25% to 60% lower than those of the TSS at eye, chest and pelvis levels. The protection of NSS is comparable with that of TSS alongside PPE at the eye but not at the chest and the pelvic levels under the setup of coronary angiography.

A Novel Spatial Position Prediction Navigation System Makes Surgery More Accurate

During intravascular interventional surgery, the 3D surgical navigation system can provide doctors with 3D spatial information of the vascular lumen, reducing the impact of missing dimension caused by digital subtraction angiography (DSA) guidance and further improving the success rate of surgeries. Nevertheless, this task often comes with the challenge of complex registration problems due to vessel deformation caused by respiratory motion and high requirements for the surgical environment because of the dependence on external electromagnetic sensors. This article proposes a novel 3D spatial predictive positioning navigation (SPPN) technique to predict the real-time tip position of surgical instruments. In the first stage, we propose a trajectory prediction algorithm integrated with instrumental morphological constraints to generate the initial trajectory. Then, a novel hybrid physical model is designed to estimate the trajectory's energy and mechanics. In the second stage, a point cloud clustering algorithm applies multi-information fusion to generate the maximum probability endpoint cloud. Then, an energy-weighted probability density function is introduced using statistical analysis to achieve the prediction of the 3D spatial location of instrument endpoints. Extensive experiments are conducted on 3D-printed human artery and vein models based on a high-precision electromagnetic tracking system. Experimental results demonstrate the outstanding performance of our method, reaching 98.2% of the achievement ratio and less than 3 mm of the average positioning accuracy. This work is the first 3D surgical navigation algorithm that entirely relies on vascular interventional robot sensors, effectively improving the accuracy of interventional surgery and making it more accessible for primary surgeons.

Update on Radiation Safety in the Cath Lab - Moving Toward a "Lead-Free" Environment

Radiation exposure in the cardiac catheterization laboratory (CCL) is an occupational hazard that predisposes health care workers to the development of adverse health effects such as cataracts, cancer, and orthopedic injury. To mitigate radiation exposure, personal protective shielding as well as permanently installed shields reduces these adverse effects. Yet, heavy protective lead aprons and poor ergonomics required for positioning movable shields remain barriers to a safer environment. Recent innovations to enhance personal protective equipment and revolutionize fixed shielding systems will permit the CCL team to work in a personal "lead-free" environment, markedly reducing occupational hazards. The purpose of this review is to update the status and future of radiation protection in the CCL.

Zero-fluoroscopy ablation for cardiac arrhythmias: A single-center experience in Japan

BACKGROUND

Exposure to radiation during catheter ablation procedures poses a risk to the heath of both the patient and electrophysiology laboratory staff. Recently, the feasibility and effectiveness of zero-fluoroscopy ablation have been reported. However, studies on the outcomes of zero-fluoroscopy ablation in Japan remain limited. This study investigated the outcomes of zero-fluoroscopy ablation for cardiac arrhythmias at a Japanese institute.

METHODS AND RESULTS

We present a retrospective analysis of the safety, efficacy, and feasibility data from 221 consecutive patients who underwent zero-fluoroscopy ablation. Of these patients, 181 had atrial fibrillation, 17 had paroxysmal supraventricular tachycardia, 13 had atrial tachycardia, 6 had ventricular tachycardia, and 4 had ventricular premature contractions. We performed zero-fluoroscopy ablation using three-dimensional electro-anatomical mapping systems and intracardiac echocardiography imaging. Ultrasound-guided sheath insertion was performed on all cases. Our experience includes exclusively endocardial cardiac ablations. The mean follow-up was 24 months. The recurrence rates were 25.4% for atrial fibrillation, 5.9% for paroxysmal supraventricular tachycardia, 15.4% for atrial tachycardia, 33.3% for ventricular tachycardia, and 25% for ventricular premature contraction. Complications occurred in two patients (0.9%), and there was no occurrence of death. A fluoroscopic guide was used in three cases for the confirmation of vascular access (one case) and for complications (two cases).

CONCLUSIONS

Zero-fluoroscopy ablation was routinely performed without compromising on safety and efficacy. This approach may eliminate the exposure to radiation for all individuals involved in this procedure.

Impact of Patient BMI on Patient and Operator Radiation Dose During Percutaneous Coronary Intervention

AIMS

This study sought to investigate patient and operator radiation dose in patients undergoing percutaneous coronary intervention (PCI) and the impact of body mass index (BMI) on patient and operator dose.

METHODS

In patients undergoing PCI, radiation dose parameters, baseline characteristics and procedural data were collected in a tertiary centre for 3.5 years. Operators wore real time dosimeters. Patients were grouped by BMI. Dose area product (DAP) and operator radiation dose were compared across patient BMI categories. Multivariable analysis was performed to investigate the impact of patient BMI and other procedural variables on patient and operator dose.

RESULTS

2,043 patients underwent 2,197 PCI procedures. Each five-unit increase in BMI increased patient dose (expressed as DAP) by an average 31% (95% CI: 29-33%) and operator dose by 27% (95% CI: 20-33%). Patient dose was 2.3 times higher and operator dose was 2.4 times higher in patients with a BMI>40 than for normal BMI patients. Multivariable analysis indicated that there were many procedural factors that were predictors for increasing operator dose and patient dose but that patient BMI was a major contributor for both operator dose and patient dose.

CONCLUSION

Increasing BMI increases the DAP and operator dose for PCI procedures and BMI is demonstrated to be a major factor that contributes to both patient and operator radiation dose.

Enhancing occupational safety in the X-ray laboratory

Despite more than 80% of interventional operators reporting one or more orthopedic injuries attributed to the X-ray laboratory, there has been limited adoption of various strategies and equipment to minimize these injuries. A comprehensive review of these methods to reduce musculoskeletal strain is lacking in the current literature, and is essential in order to ensure a long, healthy, and productive interventional career.

Primary operator radiation dose in the cardiac catheter laboratory

OBJECTIVES

Radiation from cardiac angiography procedures is harmful to patients and the staff performing them. This study sought to investigate operator radiation dose for a range of procedures and different operators in order to investigate trends and optimise dose.

METHODS

Real-time dosemeters (RTDs) were worn by operators for angiography procedures for 3 years. Dose-area product (DAP) and RTD were collected. RTD was normalised to DAP (RTD/DAP) to compare radiation dose and radiation protection measures. Comparisons were made across procedure categories and individual operators.

RESULTS

In 7626 procedures, median and 75th percentile levels were established for operator dose for 8 procedure categories. There was a significant difference in all operator dose measures and DAP across procedure categories (p<0.001). DAP, RTD, and RTD/DAP were significantly different across 22 individual operators (p<0.001).

CONCLUSION

DAP was significantly different across procedure categories and a higher RTD was seen with higher DAP. RTD/DAP can demonstrate radiation protection effectiveness and identified differences between procedures and individual operators with this measure. Procedures and individuals were identified where further optimisation of radiation protection measures may be beneficial. A reference level for operator dose can be created and audited against on a regular basis.

ADVANCES IN KNOWLEDGE

This study demonstrates that operator dose can be easily and routinely measured on a case by case basis to investigate dose trends for different procedures. Normalising the operator dose to DAP demonstrates radiation protection effectiveness for the individual operator which can then be optimised as part of an ongoing audit program.