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Afroz S, Østerås BH, Thevathas US, Dohlen G, Stokke C, Robsahm TE, Olerud HM. Use of ionizing radiation in a Norwegian cohort of children with congenital heart disease: imaging frequency and radiation dose for the Health Effects of Cardiac Fluoroscopy and Modern Radiotherapy in Pediatrics (HARMONIC) study. Pediatr Radiol 2023; 53:2502-2514. [PMID: 37773444 PMCID: PMC10635954 DOI: 10.1007/s00247-023-05774-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND The European-funded Health Effects of Cardiac Fluoroscopy and Modern Radiotherapy in Pediatrics (HARMONIC) project is a multicenter cohort study assessing the long-term effects of ionizing radiation in patients with congenital heart disease. Knowledge is lacking regarding the use of ionizing radiation from sources other than cardiac catheterization in this cohort. OBJECTIVE This study aims to assess imaging frequency and radiation dose (excluding cardiac catheterization) to patients from a single center participating in the Norwegian HARMONIC project. MATERIALS AND METHODS Between 2000 and 2020, we recruited 3,609 patients treated for congenital heart disease (age < 18 years), with 33,768 examinations categorized by modality and body region. Data were retrieved from the radiology information system. Effective doses were estimated using International Commission on Radiological Protection Publication 60 conversion factors, and the analysis was stratified into six age categories: newborn; 1 year, 5 years, 10 years, 15 years, and late adolescence. RESULTS The examination distribution was as follows: 91.0% conventional radiography, 4.0% computed tomography (CT), 3.6% diagnostic fluoroscopy, 1.2% nuclear medicine, and 0.3% noncardiac intervention. In the newborn to 15 years age categories, 4-12% had ≥ ten conventional radiography studies, 1-8% underwent CT, and 0.3-2.5% received nuclear medicine examinations. The median effective dose ranged from 0.008-0.02 mSv and from 0.76-3.47 mSv for thoracic conventional radiography and thoracic CT, respectively. The total effective dose burden from thoracic conventional radiography ranged between 28-65% of the dose burden from thoracic CT in various age categories (40% for all ages combined). The median effective dose for nuclear medicine lung perfusion was 0.6-0.86 mSv and for gastrointestinal fluoroscopy 0.17-0.27 mSv. Because of their low frequency, these procedures contributed less to the total effective dose than thoracic radiography. CONCLUSION This study shows that CT made the largest contribution to the radiation dose from imaging (excluding cardiac intervention). However, although the dose per conventional radiograph was low, the large number of examinations resulted in a substantial total effective dose. Therefore, it is important to consider the frequency of conventional radiography while calculating cumulative dose for individuals. The findings of this study will help the HARMONIC project to improve risk assessment by minimizing the uncertainty associated with cumulative dose calculations.
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Affiliation(s)
- Susmita Afroz
- Department of Optometry, Radiography and Lighting Design, University of South-Eastern Norway, Grønland 58, Drammen, Norway.
- Department of Pediatric Cardiology, Oslo University Hospital, Oslo, Norway.
| | - Bjørn H Østerås
- Department of Physics and Computational Radiology, Oslo University Hospital, Oslo, Norway
| | - Utheya S Thevathas
- Department of Optometry, Radiography and Lighting Design, University of South-Eastern Norway, Grønland 58, Drammen, Norway
- Department of Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Gaute Dohlen
- Department of Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Caroline Stokke
- Department of Physics and Computational Radiology, Oslo University Hospital, Oslo, Norway
- Department of Physics, University of Oslo, Oslo, Norway
| | - Trude E Robsahm
- Research Department, Cancer Registry of Norway, Oslo, Norway
| | - Hilde M Olerud
- Department of Optometry, Radiography and Lighting Design, University of South-Eastern Norway, Grønland 58, Drammen, Norway
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Neofytou AP, Kowalik GT, Vidya Shankar R, Huang L, Moon T, Mellor N, Razavi R, Neji R, Pushparajah K, Roujol S. Automatic image-based tracking of gadolinium-filled balloon wedge catheters for MRI-guided cardiac catheterization using deep learning. Front Cardiovasc Med 2023; 10:1233093. [PMID: 37745095 PMCID: PMC10513169 DOI: 10.3389/fcvm.2023.1233093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/16/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction Magnetic Resonance Imaging (MRI) is a promising alternative to standard x-ray fluoroscopy for the guidance of cardiac catheterization procedures as it enables soft tissue visualization, avoids ionizing radiation and provides improved hemodynamic data. MRI-guided cardiac catheterization procedures currently require frequent manual tracking of the imaging plane during navigation to follow the tip of a gadolinium-filled balloon wedge catheter, which unnecessarily prolongs and complicates the procedures. Therefore, real-time automatic image-based detection of the catheter balloon has the potential to improve catheter visualization and navigation through automatic slice tracking. Methods In this study, an automatic, parameter-free, deep-learning-based post-processing pipeline was developed for real-time detection of the catheter balloon. A U-Net architecture with a ResNet-34 encoder was trained on semi-artificial images for the segmentation of the catheter balloon. Post-processing steps were implemented to guarantee a unique estimate of the catheter tip coordinates. This approach was evaluated retrospectively in 7 patients (6M and 1F, age = 7 ± 5 year) who underwent an MRI-guided right heart catheterization procedure with all images acquired in an orientation unseen during training. Results The overall accuracy, specificity and sensitivity of the proposed catheter tracking strategy over all 7 patients were 98.4 ± 2.0%, 99.9 ± 0.2% and 95.4 ± 5.5%, respectively. The computation time of the deep-learning-based segmentation step was ∼10 ms/image, indicating its compatibility with real-time constraints. Conclusion Deep-learning-based catheter balloon tracking is feasible, accurate, parameter-free, and compatible with real-time conditions. Online integration of the technique and its evaluation in a larger patient cohort are now warranted to determine its benefit during MRI-guided cardiac catheterization.
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Affiliation(s)
- Alexander Paul Neofytou
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Grzegorz Tomasz Kowalik
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Rohini Vidya Shankar
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Li Huang
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Tracy Moon
- Department of Paediatric Cardiology, Evelina London Children's Hospital, London, United Kingdom
| | - Nina Mellor
- Department of Paediatric Cardiology, Evelina London Children's Hospital, London, United Kingdom
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Radhouene Neji
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- MR Research Collaborations, Siemens Healthcare Limited, Camberley, United Kingdom
| | - Kuberan Pushparajah
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- Department of Paediatric Cardiology, Evelina London Children's Hospital, London, United Kingdom
| | - Sébastien Roujol
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
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Shelly E, Waldron MG, Field E, Moore N, Young R, Scally A, England A, Maher M, McEntee MF. Cumulative Radiation Dose from Medical Imaging in Children with Congenital Heart Disease: A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10040645. [PMID: 37189893 DOI: 10.3390/children10040645] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/18/2023] [Accepted: 03/27/2023] [Indexed: 05/17/2023]
Abstract
Children with congenital heart disease are exposed to repeated medical imaging throughout their lifetime. Although the imaging contributes to their care and treatment, exposure to ionising radiation is known to increase one's lifetime attributable risk of malignancy. A systematic search of multiple databases was performed. Inclusion and exclusion criteria were applied to all relevant papers and seven were deemed acceptable for quality assessment and risk of bias assessment. The cumulative effective dose (CED) varied widely across the patient cohorts, ranging from 0.96 mSv to 53.5 mSv. However, it was evident across many of the included studies that a significant number of patients were exposed to a CED >20 mSv, the current annual occupational exposure limit. Many factors affected the dose which patients received, including age and clinical demographics. The imaging modality which contributed the most radiation dose to patients was cardiology interventional procedures. Paediatric patients with congenital heart disease are at an increased risk of receiving an elevated cumulative radiation dose across their lifetime. Further research should focus on identifying risk factors for receiving higher radiation doses, keeping track of doses, and dose optimisation where possible.
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Affiliation(s)
- Emer Shelly
- Discipline of Medical Imaging & Radiation Therapy, University College Cork, T12AK54 Cork, Ireland
| | - Michael G Waldron
- Department of Radiology, Cork University Hospital, T12 DC4A Cork, Ireland
| | - Erica Field
- Discipline of Medical Imaging & Radiation Therapy, University College Cork, T12AK54 Cork, Ireland
| | - Niamh Moore
- Discipline of Medical Imaging & Radiation Therapy, University College Cork, T12AK54 Cork, Ireland
| | - Rena Young
- Discipline of Medical Imaging & Radiation Therapy, University College Cork, T12AK54 Cork, Ireland
| | - Andy Scally
- Discipline of Medical Imaging & Radiation Therapy, University College Cork, T12AK54 Cork, Ireland
| | - Andrew England
- Discipline of Medical Imaging & Radiation Therapy, University College Cork, T12AK54 Cork, Ireland
| | - Michael Maher
- Department of Radiology, Cork University Hospital, T12 DC4A Cork, Ireland
- Department of Medicine, University College Cork, T12 AK54 Cork, Ireland
| | - Mark F McEntee
- Discipline of Medical Imaging & Radiation Therapy, University College Cork, T12AK54 Cork, Ireland
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Sanchez RM, Siiskonen T, Vano E. Current status of diagnostic reference levels in interventional cardiology. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2022; 42:041002. [PMID: 36379055 DOI: 10.1088/1361-6498/aca2b3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/15/2022] [Indexed: 06/16/2023]
Abstract
Interventional cardiology provides indisputable benefits for patients but uses a substantial amount of ionising radiation. The diagnostic reference level (DRL) is the tool recommended by the International Commission on Radiological Protection to optimise imaging procedures. In this work, a review of studies dealing with radiation dose or recommending DRL values for interventional cardiology since 2010 is presented, providing quantitative and qualitative results. There are many published papers on coronary angiography (CA) and percutaneous coronary intervention. The DRL values compiled for different continental regions are different: the DRL for CA is about 35 Gy cm2for Europe and 83 Gy cm2for North America. These differences emphasise the need to establish national DRLs considering different social and/or economic factors and the harmonisation of the survey methodology. Surveys with a large amount of data collected with the help of dose management systems provide more reliable information with less chance of statistical bias than those with a small amount of data. The complexity of procedures and improvements in technology are important factors that affect the radiation dose delivered to patients. There is a need for additional data on structural and electrophysiological procedures. The analysis of paediatric procedures is especially difficult because some studies present results split into age bands and others into weight bands. Diagnostic procedures are better described, but there is a great variety of therapeutic procedures with different DRL values (up to a factor of nine) and these require a dedicated review.
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Affiliation(s)
- Roberto M Sanchez
- Hospital Clinico Universitario San Carlos, Medical Physics, Madrid, Spain
| | - Teemu Siiskonen
- Radiation and Nuclear Safety Authority-STUK, Helsinki, Finland
| | - Eliseo Vano
- Radiology Department, Universidad Complutense de Madrid, Madrid, Spain
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Sarycheva SS. EFFECTIVE DOSE IN PEDIATRIC INTERVENTIONAL CARDIOLOGY. RADIATION PROTECTION DOSIMETRY 2021; 195:273-278. [PMID: 33836530 DOI: 10.1093/rpd/ncab053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/16/2021] [Accepted: 03/15/2021] [Indexed: 06/12/2023]
Abstract
The aim of this study was to estimate the effective doses (EDs) to children undergoing pediatric interventional cardiology examinations in hospitals of St.-Petersburg, to calculate associated dose conversion coefficients (DCCs) and to investigate their dependence of different parameters of the various procedures. Basic parameters of pediatric cardiology examinations and patient doses were studied in three main pediatric city hospitals. More than 300 examinations were under consideration. The technical, geometrical and dosimetric parameters, as well as patients' parameters, for each individual procedure were collected. All cardiac examinations were divided into five age groups (newborn, 1, 5, 10 and 15 y old). The EDs and the corresponding DCCs from the dose-area product to ED were calculated using PCXMC 2.0 software and based on the collected data. The study included the evaluation of the relations between the DCCs, patient age and parameters of examinations. The results of the study indicated significant dependence of the DCCs on the patients' age and the beam quality. The DCCs for the newborns and 15-year old groups differed by a factor of 10. The maximum estimated ED of 26 mSv was found in the newborn age group.
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Affiliation(s)
- S S Sarycheva
- Radiation Protection Laboratory, Saint-Petersburg Research Institute of Radiation Hygiene, Saint Petersburg, Mira st. 8, 197101 St.Petersburg, Russian Federation, Russia
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6
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Ploussi A, Brountzos E, Rammos S, Apostolopoulou S, Efstathopoulos EP. Radiation Exposure in Pediatric Interventional Procedures. Cardiovasc Intervent Radiol 2021; 44:857-865. [PMID: 34009422 DOI: 10.1007/s00270-020-02752-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/18/2020] [Indexed: 01/14/2023]
Abstract
The article is part of the series of articles on radiation protection. You can find further articles in the special section of the CVIR issue. The expanding applications of interventional procedures coupled with the potential harmful effects of ionizing radiation highlight the need to assess the delivered radiation dose and establish an effective radiation protection program, particularly in the radiosensitive pediatric population. Given the complexity and heterogeneity of interventional procedures as well as the unique characteristics of children, the management of radiation dose is proving to be quite challenging. The aim of the current article is to provide an overview of the radiation exposure in pediatric patients during interventional procedures focusing on the importance of radiation protection in the pediatric population, the reported radiation doses and the techniques of minimizing radiation dose.
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Affiliation(s)
- Agapi Ploussi
- 2nd Department of Radiology, Medical Physics Unit, National and Kapodistrian University of Athens, Attikon University Hospital, 12462, Athens, Greece
| | - Elias Brountzos
- 2nd Department of Radiology, Interventional Radiology Unit, National and Kapodistrian University of Athens, Attikon University Hospital, 12462, Athens, Greece
| | - Spyridon Rammos
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, "Onassis" Cardiac Surgery Center, Andrea Siggrou 356 Av., 17674, Kallithea, Greece
| | - Sotiria Apostolopoulou
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, "Onassis" Cardiac Surgery Center, Andrea Siggrou 356 Av., 17674, Kallithea, Greece
| | - Efstathios P Efstathopoulos
- 2nd Department of Radiology, Medical Physics Unit, National and Kapodistrian University of Athens, Attikon University Hospital, 12462, Athens, Greece.
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Marcu LG, Chau M, Bezak E. How much is too much? Systematic review of cumulative doses from radiological imaging and the risk of cancer in children and young adults. Crit Rev Oncol Hematol 2021; 160:103292. [DOI: 10.1016/j.critrevonc.2021.103292] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/20/2021] [Accepted: 02/27/2021] [Indexed: 01/18/2023] Open
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Haddad RN, Rizk C, Saliba Z, Farah J. Percutaneous closure of ventricular septal defects in children: key parameters affecting patient radiation exposure. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2021; 11:65-72. [PMID: 33815921 PMCID: PMC8012278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 01/11/2021] [Indexed: 09/28/2022]
Abstract
BACKGROUND Ventricular septal defect (VSD) transcatheter closure is gaining worldwide popularity despite its complexity. Reports on key factors affecting radiation exposure in children are scarce. AIMS This clinical study is the first to comprehensively analyze the impact of all relevant parameters on children's radiation exposure during VSD interventional closures. METHODS Between March 2016 and August 2019, all pediatric VSD cases percutaneously treated at a reference center for interventional congenital cardiology and equipped with a single-plane Innova 2100 X-ray unit were retrospectively reviewed. Multiple linear regression was performed to investigate the impact of clinical, technical, and procedural parameters on patients' radiation exposure assessed using total air kerma area product (PKA,T). RESULTS A total of 85 patients were included in this study and 82.4% had perimembranous defects. Device implantation was successful in 96.5% of cases. The procedure lasted for a median of 60 min with a median PKA,T of 19.6 Gy.cm2 (range, 1.1 to 244.8 Gy.cm2). Patients' weight (B = 1.679, P = 0.01), number of operators (B = 1.561, P = 0.02), device positioning complexity (B = 2.381, P = 0.002), and procedural incidents (B = 2.096, P = 0.008) significantly increased PKA,T. Patients' age (B = 1.053, P = 0.784), device design (B = -1.216, P = 0.780) and approach of delivery (B = -1.119, P = 0.511) did not significantly affect PKA,T. CONCLUSIONS Radiation exposure in children undergoing VSD percutaneous closure was highly variable. A higher patient's weight, numbers of operators, complexity in device positioning, and procedural incidents, were identified as key factors increasing patient dose for this kind of intervention.
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Affiliation(s)
- Raymond N Haddad
- Hotel Dieu de France University Medical Center, Department of Pediatrics, Saint Joseph UniversityBeirut, Lebanon
| | - Chadia Rizk
- Lebanese Atomic Energy Commission, National Council for Scientific Research11-8281 Beirut, Lebanon
| | - Zakhia Saliba
- Hotel Dieu de France University Medical Center, Department of Pediatric Cardiology, Saint Joseph UniversityBeirut, Lebanon
| | - Jad Farah
- Bicêtre Hospital, Department of Radiology and Nuclear Medicine, Paris-Sud University Hospitals94270 Le Kremlin-Bicêtre, Paris, France
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Karambatsakidou A, Steiner K, Fransson A, Poludniowski G. Age-specific and gender-specific radiation risks in paediatric angiography and interventional cardiology: conversion coefficients and risk reference values. Br J Radiol 2020; 93:20190869. [PMID: 32242740 PMCID: PMC10993205 DOI: 10.1259/bjr.20190869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 03/27/2020] [Accepted: 03/30/2020] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To estimate risk for exposure-induced cancer death (REID), organ-specific risks of exposure-induced cancer death (REIDHT) and associated conversion coefficients (CCREID:KAP=REID/kerma-area product (KAP), CCREIDHT:KAP=REIDHT/KAP) in paediatric cardiac catheterizations using data from radiation dose structured reports (RDSR). A novel risk surveillance tool consisting of age-specific and gender-specific risk reference values (RRVs) related to population cancer risk is suggested. METHODS The PCXMC v.2.0 code is used together with exposure-related information from RDSR from a cohort of 238 children to assess cancer risks and related conversion coefficients. The KAP corresponding to 1 in 1000 of increased REID is used to define age-specific and gender-specific KAP values to monitor risk in such patient cohorts, here denoted as RRVs. RESULTS The REID estimates ranged from below 1 up to 300 in 100,000, and the RRVs for the different age groups and gender ranged from 0.77 Gycm2 and 2.1 Gycm2 for neonates (female, male) to 11 Gycm2 and 25 Gycm2 for 15-year-olds (female, male). The CCREID:KAP and CCREIDHT:KAP decreased biexponentially with increased age, being notably higher for female patients. CONCLUSIONS Prominent risk contributing organs were the lungs and the (female) breast. The concept of age-specific and gender-specific RRVs related to population cancer risk is introduced and is intended to be used as a supporting tool for physicians performing such interventions. ADVANCES IN KNOWLEDGE Age-related and gender-related conversion coefficients for radiation risk, CCREID:KAP and CCREIDHT:KAP, are introduced and a novel risk surveillance concept, the RRV, is suggested for paediatric cardiac catheterizations.
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Affiliation(s)
- Angeliki Karambatsakidou
- Department of Medical Radiation Physics and Nuclear Medicine,
Karolinska University Hospital, 171 76
Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska
Institutet, 171 76 Stockholm,
Sweden
| | - Kristoffer Steiner
- Department of Women's and Children's Health, Karolinska
Institutet, 171 76 Stockholm,
Sweden
- Department of Paediatric Cardiology, Karolinska University
Hospital, Astrid Lindgrens Children´s Hospital
Solna, 171 76 Stockholm,
Sweden
| | - Annette Fransson
- Department of Medical Radiation Physics and Nuclear Medicine,
Karolinska University Hospital, 171 76
Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska
Institutet, 171 76 Stockholm,
Sweden
| | - Gavin Poludniowski
- Department of Medical Radiation Physics and Nuclear Medicine,
Karolinska University Hospital, 171 76
Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska
Institutet, 171 76 Stockholm,
Sweden
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Abuzaid M, Abdelrazig A, Sulieman A, Alkhorayef M, Babikir E, Alonazi B, Bradley D. Radiation dose to the paediatric undergoing diagnostic coronary angiography and percutaneous intervention procedures. Radiat Phys Chem Oxf Engl 1993 2020. [DOI: 10.1016/j.radphyschem.2019.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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11
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Stern H, Seidenbusch M, Hapfelmeier A, Meierhofer C, Naumann S, Schmid I, Spix C, Ewert P. Increased Cancer Incidence Following up to 15 Years after Cardiac Catheterization in Infants under One Year between 1980 and 1998-A Single Center Observational Study. J Clin Med 2020; 9:E315. [PMID: 31979109 PMCID: PMC7074298 DOI: 10.3390/jcm9020315] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 01/19/2020] [Accepted: 01/20/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate the incidence of cancer within the first 15 years of life in children who underwent cardiac catheterization under the age of one year. METHODS In this retrospective, single center study, 2770 infants (7.8% with trisomy 21) were studied. All infants underwent cardiac catheterization under one year of age between January 1980 and December 1998. Newly diagnosed cancer in the first 15 years of life was assessed through record linkage to the German Childhood Cancer Registry (GCCR). Cancer risk in study patients was compared to the GCCR population of children less than 15 years. Patients with trisomy 21 were compared to the Danish Cytogenic Register for trisomy 21. Effective radiation doses were calculated for each tumor patient and 60 randomly selected patients who did not develop cancer. RESULTS In total, 24,472.5 person-years were analyzed. Sixteen children developed cancer, while 3.64 were expected (standardized incidence ratio (SIR) = 4.4, 95% confidence interval (CI): 2.5-7.2, p < 0.001). There was no preferred cancer type. The observed incidence of leukemia and solid tumors in trisomy 21 was only slightly higher (1 in 476 py) than expected (1 in 609 py, p = 0.64). There was no direct relationship between the radiation dose and the incidence of cancer. CONCLUSION Cardiac catherization in the first year of life was associated with a significantly increased cancer risk in a population with congenital heart disease.
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Affiliation(s)
- Heiko Stern
- German Heart Center Munich, Clinic for Pediatric Cardiology and Congenital Heart Disease, Lazarettstrasse 36, D-80636 Muenchen, Germany; (C.M.); (S.N.); (P.E.)
| | - Michael Seidenbusch
- German Research Center for Environmental Health, Institute of Radiation Protection, Ingolstaedter Landstrasse 1, D-85764 Neuherberg, Munich, Germany;
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics and Epidemiology, Technical University Munich, Grillparzerstr. 18, Alexander Hapfelmeier, D-81675 Muenchen, Germany;
| | - Christian Meierhofer
- German Heart Center Munich, Clinic for Pediatric Cardiology and Congenital Heart Disease, Lazarettstrasse 36, D-80636 Muenchen, Germany; (C.M.); (S.N.); (P.E.)
| | - Susanne Naumann
- German Heart Center Munich, Clinic for Pediatric Cardiology and Congenital Heart Disease, Lazarettstrasse 36, D-80636 Muenchen, Germany; (C.M.); (S.N.); (P.E.)
| | - Irene Schmid
- Department of Pediatric Oncology and Hematology, Dr. von Hauner Childrens Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstrasse 4, 80337 Muenchen, Germany;
| | - Claudia Spix
- German Childhood Cancer Registry (GCCR), Institute for Medical Biostatistics, Epidemiology and Informatics, Johannes Gutenberg-University, Obere Zahlbacher Strasse 69, 55131 Mainz, Germany;
| | - Peter Ewert
- German Heart Center Munich, Clinic for Pediatric Cardiology and Congenital Heart Disease, Lazarettstrasse 36, D-80636 Muenchen, Germany; (C.M.); (S.N.); (P.E.)
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Rizk C, Fares G, Vanhavere F, Saliba Z, Farah J. Diagnostic Reference Levels, Deterministic and Stochastic Risks in Pediatric Interventional Cardiology Procedures. HEALTH PHYSICS 2020; 118:85-95. [PMID: 31764423 DOI: 10.1097/hp.0000000000001114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
To establish diagnostic reference levels (DRLs) and investigate deterministic and stochastic risks in pediatric interventional cardiology (IC) procedures. Exposure parameters were retrospectively reviewed for 373 patients treated between May 2016 and November 2018 at a single specialized hospital. Weight specific DRLs were derived for pediatric IC procedures. Additionally, peak skin dose (Dskin,max) was measured using thermoluminescent dosimeters for a sample of 7 diagnostic and 43 therapeutic procedures. Finally, using PCXMC software, organ doses were computed and the risk of exposure-induced cancer death (REID) was estimated using the risk models of the Biological Effects of Ionizing Radiation VII committee. DRLs for ventricular septal defect (VSD) occlusions, lacking in the literature, in terms of air kerma at patient entrance reference point (388 and 629 mGy) and total air kerma-area product (28 and 61 Gycm) were proposed for patients weight-groups 5 - < 15 kg and 15 - < 30 kg, respectively. The mean (range) Dskin,max was 15 (1-30) mGy and 94 (1-491) mGy for diagnostic and therapeutic procedures, respectively. Meanwhile, VSD occlusion involved the highest organ doses where the lungs, liver, stomach, and breasts mean doses were 57, 37, 6, and 10 mGy, respectively, and the associated REID were 0.5% and 0.3% in female and male patients, respectively. DRLs were proposed for pediatric IC procedures; these will help optimize patient exposure. Dskin,max values were lower than the 2 Gy threshold for skin injuries. Pediatric organ doses and the REID were the highest during VSD occlusion and may be critical for repetitive procedures.
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Affiliation(s)
| | - Georges Fares
- Faculty of Sciences, Saint Joseph University, 11-514 Beirut, Lebanon
| | - Filip Vanhavere
- Belgian Nuclear Research Centre (SCK-CEN), BE-2400 Mol, Belgium
| | - Zakhia Saliba
- Department of pediatrics, Hotel Dieu de France Hospital, Beirut, Lebanon
| | - Jad Farah
- Radiology and Nuclear Medicine Department, Paris-Sud University Hospitals, 94270 Le Kremlin-Bicêtre, France
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13
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Ubeda C, Salazar L, Retana V, Gutierrez R, Nocetti D, Reyes C. Organ doses in paediatric interventional cardiology. First values for patients in Costa Rica. Radiat Phys Chem Oxf Engl 1993 2019. [DOI: 10.1016/j.radphyschem.2019.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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14
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Ubeda C, Vano E, Miranda P, Figueroa X. Organ and effective doses detriment to paediatric patients undergoing multiple interventional cardiology procedures. Phys Med 2019; 60:182-187. [PMID: 31000081 DOI: 10.1016/j.ejmp.2019.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/10/2019] [Accepted: 03/19/2019] [Indexed: 11/29/2022] Open
Abstract
The aims of the present study were to present the frequency of multiple interventional cardiac procedures for a certain group of patients obtained at one of the largest paediatric hospitals in Chile. In addition it has been analysed cumulative kerma area product (KAP) and cumulative air kerma (CAK), and calculated organ doses for the patient groups undergoing 2, 3 and ≥ 4 procedures, using Monte Carlo software. Effective doses were also estimated for epidemiological purposes and to permit comparison with other imaging procedures. The sample used corresponds to the last 9 years and refers to a total of 1521 paediatric patients and 1824 interventional cardiac procedures. The results for frequency were: 13.7% of patients underwent 2 procedures, 4.1% underwent 3 procedures and 1.4% underwent 4 or more procedures. The median KAP and CAK values measured for the cumulative procedures in these three groups of patients were 3.7, 5.4 and 10.8 Gy·cm2 and 59.9, 83.2 and 147.6 mGy, respectively. In terms of the most irradiated organs during interventional cardiac procedures, the highest median values (for the group of ≥4 procedures) were: active bone marrow 5.0 mGy, lungs 23.5 mGy, oesophagus 15.2 mGy, thyroid 7.8 mGy and breast 11.0 mGy. Median dose value to the heart (for the group of ≥4 procedures) was 12.7 mGy. Median values in terms of calculated effective dose for the three patient groups (with 2, 3 and ≥4 procedures) were 3.4, 5.9 and 8.7 mSv, respectively.
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Affiliation(s)
- Carlos Ubeda
- Medical Technology Department, Health Sciences Faculty, Universidad de Tarapacá, Arica, Chile.
| | - Eliseo Vano
- Radiology Department, Faculty of Medicine, Complutense University and IdIS, San Carlos Hospital, 28040 Madrid, Spain
| | - Patricia Miranda
- Hemodynamic Department, Cardiovascular Service, Luis Calvo Mackenna Hospital, Santiago, Chile
| | - Ximena Figueroa
- Medical Technology Department, Health Sciences Faculty, Universidad de Tarapacá, Arica, Chile
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Calculating organ and effective doses in paediatric interventional cardiac radiology based on DICOM structured reports – Is detailed examination data critical to dose estimates? Phys Med 2019; 57:17-24. [DOI: 10.1016/j.ejmp.2018.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 11/09/2018] [Accepted: 12/12/2018] [Indexed: 11/19/2022] Open
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Journy N, Dreuil S, Rage E, De Zordo-Banliat F, Bonnet D, Hascoët S, Malekzadeh-Milani S, Petit J, Laurier D, Bernier MO, Baysson H. Projected Future Cancer Risks in Children Treated With Fluoroscopy-Guided Cardiac Catheterization Procedures. Circ Cardiovasc Interv 2018; 11:e006765. [DOI: 10.1161/circinterventions.118.006765] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Neige Journy
- Ionizing Radiation Epidemiology Laboratory (LEPID) (N.J., E.R., F.D.Z.-B., D.L., M.-O.B., H.B.)
- INSERM Unit 1018, Centre for Research in Epidemiology and Population Health (CESP), Cancer and Radiations group, Gustave Roussy, Villejuif, France (N.J.)
| | - Serge Dreuil
- Medical Radiation Protection Assessment Unit (UEM) (S.D.) and Institute for Radiation Protection and Nuclear Safety (IRSN), Fontenayaux-Roses, France
| | - Estelle Rage
- Ionizing Radiation Epidemiology Laboratory (LEPID) (N.J., E.R., F.D.Z.-B., D.L., M.-O.B., H.B.)
| | | | - Damien Bonnet
- Department of Congenital and Pediatric Cardiology, Centre de Référence des Malformations Cardiaques Congénitales Complexes (M3C), Necker Hospital, APHP, Paris, France (D.B., S.M.-M.)
- Paris-Descartes University, Sorbonne Paris Cité, France (D.B.)
| | - Sebastien Hascoët
- Department of Congenital Heart Disease, Centre de Référence des Malformations Cardiaques Congénitales Complexes (M3C), Marie Lannelongue Hospital, Le Plessis-Robinson, France (S.H., J.P.)
- INSERM, UMR-S 999, Paris-Sud School of Medicine, Paris-Saclay University, Le Kremlin-Bicêtre, France (S.H., J.P.)
| | - Sophie Malekzadeh-Milani
- Department of Congenital and Pediatric Cardiology, Centre de Référence des Malformations Cardiaques Congénitales Complexes (M3C), Necker Hospital, APHP, Paris, France (D.B., S.M.-M.)
| | - Jérôme Petit
- Department of Congenital Heart Disease, Centre de Référence des Malformations Cardiaques Congénitales Complexes (M3C), Marie Lannelongue Hospital, Le Plessis-Robinson, France (S.H., J.P.)
- INSERM, UMR-S 999, Paris-Sud School of Medicine, Paris-Saclay University, Le Kremlin-Bicêtre, France (S.H., J.P.)
| | - Dominique Laurier
- Ionizing Radiation Epidemiology Laboratory (LEPID) (N.J., E.R., F.D.Z.-B., D.L., M.-O.B., H.B.)
| | - Marie-Odile Bernier
- Ionizing Radiation Epidemiology Laboratory (LEPID) (N.J., E.R., F.D.Z.-B., D.L., M.-O.B., H.B.)
| | - Hélène Baysson
- Ionizing Radiation Epidemiology Laboratory (LEPID) (N.J., E.R., F.D.Z.-B., D.L., M.-O.B., H.B.)
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Towards the definition of Institutional diagnostic reference levels in paediatric interventional cardiology procedures in Greece. Phys Med 2018. [PMID: 29519409 DOI: 10.1016/j.ejmp.2018.01.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This study aimed to evaluate paediatric radiation doses in a dedicated cardiology hospital, with the objective of characterising patterns in dose variation. The ultimate purpose was to define Local (Institutional) Diagnostic Reference Levels (LDRLs) for different types of paediatric cardiac interventional procedures (IC), according to patient age. From a total of 710 cases performed during three consecutive years, by operators with more than 15 years of experience, the age was noted in only 477 IC procedures. The median values obtained for Fluoroscopy Time (FT), Number of Frames (N) and Kerma Area Product (PKA) by age range were 5.8 min, 1322 and 2.0 Gy.cm2 for <1 y; 6.5 min, 1403 and 3.0 Gy.cm2 for 1 to <5 y; 5.9 min, 950 and 7.0 Gy.cm2 for 5 to <10 y; 5.7 min, 940 and 14.0 Gy.cm2 for 10 to <16 y, respectively. A large range of patient dose data is observed, depending greatly on procedure type and patient age. In all age groups the range of median FT, N and PKA values was 3.1-15.8 min, 579-1779 and 1.0-20.8 Gy.cm2 respectively. Consequently, the definition of LDRLs presents challenges mainly due to the multiple clinical and technical factors affecting the outcome. On the other hand the lack of paediatric IC DRLs makes the identification of good practices more difficult. A consensus is needed on IC procedures nomenclature and grouping in order to allow a common assessment and comparison of doses.
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Jones TP, Brennan PC, Ryan E. THE IMPACT OF DIGITAL TECHNOLOGY ON DOSE REDUCTION IN PAEDIATRIC CARDIAC CATHETERISATION WITHIN A LARGE METROPOLITAN CHILDREN'S HOSPITAL. RADIATION PROTECTION DOSIMETRY 2018; 179:358-363. [PMID: 29309695 DOI: 10.1093/rpd/ncx294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 12/06/2017] [Indexed: 06/07/2023]
Abstract
This study examines the kerma-area product (PKA) levels from paediatric cardiac catheterisations at a major Children's Hospital over three different time periods in order to gain an understanding of the causation of dose variations over time and to present a model for dose reduction. A retrospective review of 1245 paediatric procedural records was undertaken. This cohort consisted of patients that were catheterised over a period from November 2007 to July 2009, October 2009 to November 2011 and January 2016 to December 2016. The age distribution was from newborn to 18 years. Archived (PKA) readings were retrieved and analysed. The 75th percentile PKA values for the specific age categories over time periods (1, 2, 3) were 0-30 days-(5.47, 1.37, 1.37) Gy cm2; 1-12 months-(6.42, 2.03, 1.06) Gy cm2; 1-3 years-(11.25, 3.20, 1.25) Gy cm2; 3-5 years-(12.65, 3.72, 2.88) Gy cm2; 5-10 years-(12.80, 8.53, 3.52) Gy cm2; 10-15 years-(27.92, 10.85, 2.97) Gy cm2; >15 years-(29.09, 27.81, 11.65) Gy cm2. Using newer imaging technologies, optimising dose reduction strategies and regular dose auditing can transform radiation dose delivery for paediatric x-ray examinations. Our centre provides a template for dose reduction success worldwide.
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Affiliation(s)
- T P Jones
- Medical Imaging Optimisation and Perception Group (MIOPeG), Discipline of Medical Radiation Sciences, Faculty of Health Science, University of Sydney, 75 East Street, Lidcombe NSW 2141, Australia
| | - P C Brennan
- Medical Imaging Optimisation and Perception Group (MIOPeG), Discipline of Medical Radiation Sciences, Faculty of Health Science, University of Sydney, 75 East Street, Lidcombe NSW 2141, Australia
| | - E Ryan
- Medical Imaging Optimisation and Perception Group (MIOPeG), Discipline of Medical Radiation Sciences, Faculty of Health Science, University of Sydney, 75 East Street, Lidcombe NSW 2141, Australia
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Abstract
OBJECTIVES The aims of this study were to describe radiation level at our institution during transcatheter patent ductus arteriosus occlusion and to evaluate the components contributing to radiation exposure. BACKGROUND Transcatheter occlusion relying on X-ray imaging has become the treatment of choice for patients with patent ductus arteriosus. Interventionists now work hard to minimise radiation exposure in order to reduce risk of induced cancers. METHODS We retrospectively reviewed all consecutive children who underwent transcatheter closure of patent ductus arteriosus from January 2012 to January 2016. Clinical data, anatomical characteristics, and catheterisation procedure parameters were reported. Radiation doses were analysed for the following variables: total air kerma, mGy; dose area product, Gy.cm2; dose area product per body weight, Gy.cm2/kg; and total fluoroscopic time. RESULTS A total of 324 patients were included (median age=1.51 [Q1-Q3: 0.62-4.23] years; weight=10.3 [6.7-17.0] kg). In all, 322/324 (99.4%) procedures were successful. The median radiation doses were as follows: total air kerma: 26 (14.5-49.3) mGy; dose area product: 1.01 (0.56-2.24) Gy.cm2; dose area product/kg: 0.106 (0.061-0.185) Gy.cm2/kg; and fluoroscopic time: 2.8 (2-4) min. In multivariate analysis, a weight >10 kg, a ductus arteriosus width <2 mm, complications during the procedure, and a high frame rate (15 frames/second) were risk factors for an increased exposure. CONCLUSION Lower doses of radiation can be achieved with subsequent recommendations: technical improvement, frame rate reduction, avoidance of biplane cineangiograms, use of stored fluoroscopy as much as possible, and limitation of fluoroscopic time. A greater use of echocardiography might even lessen the exposure.
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Abstract
The field of pediatric and adult congenital cardiac catheterization has evolved rapidly in recent years. This review will focus on some of the newer endovascular technological and management strategies now being applied in the pediatric interventional laboratory. Emerging imaging techniques such as three-dimensional (3D) rotational angiography, multi-modal image fusion, 3D printing, and holographic imaging have the potential to enhance our understanding of complex congenital heart lesions for diagnostic or interventional purposes. While fluoroscopy and standard angiography remain procedural cornerstones, improved equipment design has allowed for effective radiation exposure reduction strategies. Innovations in device design and implantation techniques have enabled the application of percutaneous therapies in a wider range of patients, especially those with prohibitive surgical risk. For example, there is growing experience in transcatheter duct occlusion in symptomatic low-weight or premature infants and stent implantation into the right ventricular outflow tract or arterial duct in cyanotic neonates with duct-dependent pulmonary circulations. The application of percutaneous pulmonary valve implantation has been extended to a broader patient population with dysfunctional ‘native’ right ventricular outflow tracts and has spurred the development of novel techniques and devices to solve associated anatomic challenges. Finally, hybrid strategies, combining cardiosurgical and interventional approaches, have enhanced our capabilities to provide care for those with the most complex of lesions while optimizing efficacy and safety.
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Affiliation(s)
- Sok-Leng Kang
- Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, The Labatt Family Heart Center, The University of Toronto School of Medicine, Toronto, Canada.,Department of Pediatric Cardiology, Bristol Royal Hospital for Children, Bristol, BS2 OJJ, UK
| | - Lee Benson
- Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, The Labatt Family Heart Center, The University of Toronto School of Medicine, Toronto, Canada
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21
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Borrego D, Lowe EM, Kitahara CM, Lee C. Assessment of PCXMC for patients with different body size in chest and abdominal x ray examinations: a Monte Carlo simulation study. Phys Med Biol 2018; 63:065015. [PMID: 29465419 DOI: 10.1088/1361-6560/aab13e] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A PC Program for x ray Monte Carlo (PCXMC) has been used to calculate organ doses in patient dosimetry and for the exposure assessment in epidemiological studies of radiogenic health related risks. This study compared the dosimetry from using the built-in stylized phantoms in the PCXMC to that of a newer hybrid phantom library with improved anatomical realism. We simulated chest and abdominal x ray projections for 146 unique body size computational phantoms, 77 males and 69 females, with different combinations of height (125-180 cm) and weight (20-140 kg) using the built-in stylized phantoms in the PCXMC version 2.0.1.4 and the hybrid phantom library using the Monte Carlo N-particle eXtended transport code 2.7 (MCNPX). Unfortunately, it was not possible to incorporate the hybrid phantom library into the PCXMC. We compared 14 organ doses, including dose to the active bone marrow, to evaluate differences between the built-in stylized phantoms in the PCXMC and the hybrid phantoms (Cristy and Eckerman 1987 Technical Report ORNL/TM-8381/V1, Oak Ridge National Laboratory, Eckerman and Ryman 1993 Technical Report 12 Oak Ridge, TN, Geyer et al 2014 Phys. Med. Biol. 59 5225-42). On average, organ doses calculated using the built-in stylized phantoms in the PCXMC were greater when compared to the hybrid phantoms. This is most prominent in AP abdominal exams by an average factor of 2.4-, 2.8-, and 2.8-fold for the 10-year-old, 15-year-old, and adult phantoms, respectively. For chest exams, organ doses are greater by an average factor of 1.1-, 1.4-, and 1.2-fold for the 10-year-old, 15-year-old, and adult phantoms, respectively. The PCXMX, due to its ease of use, is often selected to support dosimetry in epidemiological studies; however, it uses simplified models of the human anatomy that fail to account for variations in body morphometry for increasing weight. For epidemiological studies that use PCXMC dosimetry, associations between radiation-related disease risks and organ doses may be underestimated, and to a greater degree in pediatric, especially obese pediatric, compared to adult patients.
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Affiliation(s)
- David Borrego
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, 9609 Medical Center Drive, Bethesda, MD 20892-9778, United States of America
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22
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Marshall EL, Borrego D, Tran T, Fudge JC, Bolch WE. Evaluation of the UF/NCI hybrid computational phantoms for use in organ dosimetry of pediatric patients undergoing fluoroscopically guided cardiac procedures. Phys Med Biol 2018; 63:055006. [PMID: 29405126 DOI: 10.1088/1361-6560/aaad1d] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Epidemiologic data demonstrate that pediatric patients face a higher relative risk of radiation induced cancers than their adult counterparts at equivalent exposures. Infants and children with congenital heart defects are a critical patient population exposed to ionizing radiation during life-saving procedures. These patients will likely incur numerous procedures throughout their lifespan, each time increasing their cumulative radiation absorbed dose. As continued improvements in long-term prognosis of congenital heart defect patients is achieved, a better understanding of organ radiation dose following treatment becomes increasingly vital. Dosimetry of these patients can be accomplished using Monte Carlo radiation transport simulations, coupled with modern anatomical patient models. The aim of this study was to evaluate the performance of the University of Florida/National Cancer Institute (UF/NCI) pediatric hybrid computational phantom library for organ dose assessment of patients that have undergone fluoroscopically guided cardiac catheterizations. In this study, two types of simulations were modeled. A dose assessment was performed on 29 patient-specific voxel phantoms (taken as representing the patient's true anatomy), height/weight-matched hybrid library phantoms, and age-matched reference phantoms. Two exposure studies were conducted for each phantom type. First, a parametric study was constructed by the attending pediatric interventional cardiologist at the University of Florida to model the range of parameters seen clinically. Second, four clinical cardiac procedures were simulated based upon internal logfiles captured by a Toshiba Infinix-i Cardiac Bi-Plane fluoroscopic unit. Performance of the phantom library was quantified by computing both the percent difference in individual organ doses, as well as the organ dose root mean square values for overall phantom assessment between the matched phantoms (UF/NCI library or reference) and the patient-specific phantoms. The UF/NCI hybrid phantoms performed at percent differences of between 15% and 30% for the parametric set of irradiation events. Among internal logfile reconstructed procedures, the UF/NCI hybrid phantoms performed with RMS organ dose values between 7% and 29%. Percent improvement in organ dosimetry via the use of hybrid library phantoms over the reference phantoms ranged from 6.6% to 93%. The use of a hybrid phantom library, Monte Carlo radiation transport methods, and clinical information on irradiation events provide a means for tracking organ dose in these radiosensitive patients undergoing fluoroscopically guided cardiac procedures.
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Affiliation(s)
- Emily L Marshall
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, United States of America. Present address: Diagnostic Physics Residency Program, Department of Radiology, University of Chicago, Chicago, IL 60637, United States of America
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Jones TP, Brennan PC, Ryan E. Cumulative Effective and Individual Organ Dose Levels in Paediatric Patients Undergoing Multiple Catheterisations for Congenital Heart Disease. RADIATION PROTECTION DOSIMETRY 2017; 176:252-257. [PMID: 28115657 DOI: 10.1093/rpd/ncx003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 01/06/2017] [Indexed: 06/06/2023]
Abstract
This study examines the cumulative radiation dose levels received by a group of children who underwent multiple cardiac catheterisation procedures during the investigation and management of congenital heart disease (CHD). The purpose is to calculate cumulative doses, identify higher dose individuals, outline the inconsistencies with risk assessment and encourage the establishment of dose databases in order to facilitate the longitudinal research necessary to better understand health risks. A retrospective review of patient records for 117 paediatric patients who have undergone two or more cardiac catheterisations for the investigation of CHD was undertaken. This cohort consisted of patients who were catheterised over a period from September 2002 to August 2014. The age distribution was from newborn to 17 y. Archived kerma-area product (PKA) and fluoroscopy time (T) readings were retrieved and analysed. Cumulative effective and individual organ doses were determined. The cumulative PKA levels ranged from 1.8 to 651.2 Gycm2, whilst cumulative effective dose levels varied from 2 to 259 mSv. The cumulative fluoroscopy time was shown to vary from 8.1 to 193.5 min. Median cumulative organ doses ranged from 3 to 94 mGy. Cumulative effective dose levels are highly variable but may exceed 250 mSv. Individual organ and effective dose measurements remain useful for comparison purposes between institutions although current methodologies used for determining lifetime risks are inadequate.
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Affiliation(s)
- T P Jones
- Medical Imaging Optimisation and Perception Group (MIOPeG), Discipline of Medical Radiation Sciences, Faculty of Health Science, University of Sydney, 75 East Street, Lidcombe, NSW2141, Australia
| | - P C Brennan
- Medical Imaging Optimisation and Perception Group (MIOPeG), Discipline of Medical Radiation Sciences, Faculty of Health Science, University of Sydney, 75 East Street, Lidcombe, NSW2141, Australia
| | - E Ryan
- Medical Imaging Optimisation and Perception Group (MIOPeG), Discipline of Medical Radiation Sciences, Faculty of Health Science, University of Sydney, 75 East Street, Lidcombe, NSW2141, Australia
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Gould R, McFadden SL, Hughes CM. Radiation dose in paediatric cardiac catheterisation: A systematic literature review. Radiography (Lond) 2017; 23:358-364. [PMID: 28965901 DOI: 10.1016/j.radi.2017.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 02/01/2017] [Accepted: 02/03/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVES It is believed that children are more sensitive to ionising radiation than adults. This work reviewed the reported radiation dose estimates for paediatric cardiac catheterisation. A systematic literature review was performed by searching healthcare databases for studies reporting radiation dose using predetermined key words relating to children having cardiac catheterisation. The quality of publications was assessed using relevant Critical Appraisal Skills Programme questions and their reported radiation exposures were evaluated. KEY FINDINGS It is only in recent years that larger cohort observations have been undertaken. Although radiation dose from paediatric cardiac catheterisation has decreased in recent years, the literature indicated that it remains varied and potentially substantial. CONCLUSION Standardisation of weight categories and procedure types such as those recommended by the PiDRL project could help compare current and future radiation dose estimates.
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Affiliation(s)
- R Gould
- Institute of Nursing and Health Research, Ulster University, Jordanstown Campus, Shore Road, Newtownabbey, BT37 OQB, United Kingdom.
| | - S L McFadden
- Institute of Nursing and Health Research, Ulster University, Jordanstown Campus, Shore Road, Newtownabbey, BT37 OQB, United Kingdom
| | - C M Hughes
- Institute of Nursing and Health Research, Ulster University, Jordanstown Campus, Shore Road, Newtownabbey, BT37 OQB, United Kingdom
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Gould R, McFadden SL, Sands AJ, McCrossan BA, Horn S, Prise KM, Doyle P, Hughes CM. Removal of scatter radiation in paediatric cardiac catheterisation: a randomised controlled clinical trial. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2017; 37:742-760. [PMID: 28721947 DOI: 10.1088/1361-6498/aa80a4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE This study sought to determine if DNA integrity was compromised by ionising radiation from paediatric cardiac catheterisations and if dose optimisation techniques allowed DNA integrity to be maintained. MATERIALS AND METHODS Children were imaged using either: (i) an anti-scatter grid (current departmental protocol), (ii) no anti-scatter grid or, (iii) no anti-scatter grid and a 15 cm air-gap between the child and the x-ray detector. Dose area product and image quality were assessed, lifetime attributable cancer risk estimates were calculated and DNA double-strand breakages quantified using the γH2AX assay. RESULTS Consent was obtained from 70 parents/guardians/children. Image quality was sufficient for each procedure performed. Removal of the anti-scatter grid resulted in dose reductions of 20% (no anti-scatter grid) and 30% (15 cm air-gap), DNA double-strand break reductions of 30% (no anti-scatter grid) and 20% (15 cm air-gap) and a reduction of radiation-induced cancer mortality risk of up to 45%. CONCLUSION Radiation doses received during paediatric cardiac catheterisation procedures resulted in a significant increase in DNA damage while maintaining acceptable image quality and diagnostic efficacy. It is feasible to remove the anti-scatter grid resulting in a reduction in DNA damage to the patient. The γH2AX assay may be used for assessment of dose optimisation strategies in children.
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Affiliation(s)
- Richard Gould
- Institute of Nursing and Health Research, Ulster University, Jordanstown Campus, Shore Road, Newtownabbey, United Kingdom
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26
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Ubeda C, Miranda P, Vano E, Nocetti D, Manterola C. Organ and effective doses from paediatric interventional cardiology procedures in Chile. Phys Med 2017; 40:95-103. [PMID: 28743619 DOI: 10.1016/j.ejmp.2017.07.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/26/2017] [Accepted: 07/16/2017] [Indexed: 10/19/2022] Open
Abstract
The aim of this study was to present the results of organ and effective doses for paediatric patients for different types of interventional cardiology procedures for age and weight groups, derived from a patient dosimetry pilot programme carried out in Chile, under the auspices of the International Atomic Energy Agency. Over seven years, a retrospective collection of demographic and patient dose data was obtained: age, gender, weight, height, number of cine series, total number of cine frames, fluoroscopy time, dose-area product (DAP) and cumulative dose at patient entrance reference point. Monte Carlo software was used to calculate organ and effective doses. 1506 procedures were divided into four age and seven weight groups. Organ doses (median values) for diagnostic and therapeutic procedures were: active bone marrow 0.90 and 0.64mGy; heart 1.99 and 1.46mGy; lungs 3.56 and 2.59mGy; thyroid 1.27 and 0.83; and breast (in the case of females) 1.78 and 1.36mGy. The ranges for effective doses (median values) and weight bands were 1.2-3.9mSv for diagnostic procedures and 1.0-2.5mSv for therapeutic procedures. The resulting conversion factors (median values) to estimate effective dose from DAP (in mSv/Gy.cm2) were: 1.70; 0.89; 0.58; and 0.40, for age groups of <1year, 1-<5years, 5-<10years and 10-<16years, respectively. The obtained set of dose values will enable comparisons with other imaging procedures (comparing the same age bands) for justification and optimization purposes.
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Affiliation(s)
- Carlos Ubeda
- Medical Technology Department, Radiological Sciences Center, Health Sciences Faculty, Tarapaca University, Arica, Chile.
| | - Patricia Miranda
- Hemodynamic Department, Cardiovascular Service, Luis Calvo Mackenna Hospital, Santiago, Chile
| | - Eliseo Vano
- Radiology Department, Faculty of Medicine, Complutense University and IdIS, San Carlos Hospital, 28040 Madrid, Spain
| | - Diego Nocetti
- Medical Technology Department, Radiological Sciences Center, Health Sciences Faculty, Tarapaca University, Arica, Chile
| | - Carlos Manterola
- Hepatobiliary Surgery Unit, Department of Surgery, Faculty of Medicine, Universidad de la Frontera, Temuco, Chile
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Harbron RW, Chapple CL, O'Sullivan JJ, Best KE, Berrington de González A, Pearce MS. Survival adjusted cancer risks attributable to radiation exposure from cardiac catheterisations in children. Heart 2017; 103:341-346. [PMID: 27540181 PMCID: PMC5529982 DOI: 10.1136/heartjnl-2016-309773] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 07/26/2016] [Accepted: 07/27/2016] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES To estimate the risk of developing cancer in relation to the typical radiation doses received from a range of X-ray guided cardiac catheterisations in children, taking variable survival into account. METHODS Radiation doses were estimated for 2749 procedures undertaken at five UK hospitals using Monte Carlo simulations. The lifetime attributable risk (LAR) of cancer incidence was estimated using models developed by the Biological Effects of Ionising Radiation committee, based on both normal life expectancy, and as a function of attained age, from 20 to 80 years, to take reduced life expectancy into account. RESULTS The radiation-related risks from these procedures are dominated by lung and breast cancer (for females). Assuming normal life expectancy, central LAR estimates for cancer incidence, based on median doses, ranged from <1 in 2000 for atrial septal defect occlusions to as high as 1 in 150 for valve replacements. For a reduced life expectancy of 50 years, estimated risks are lower by a factor of around 7. For conditions with especially poor survival (age 20 years), such as hypoplastic left heart syndrome, estimated cancer risks attributable to radiation were <1 in 20 000. CONCLUSIONS Based on recent UK radiation dose levels, the risk of cancer following cardiac catheterisations is relatively low and strongly modified by survival and the type of procedure. The risk of breast cancer, especially following pulmonary artery angioplasty and valve replacements, is the greatest concern.
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Affiliation(s)
- Richard W Harbron
- Newcastle University, Institute of Health and Society, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
- NIHR Health Protection Research Unit in Chemical and Radiation Threats and Hazards, Newcastle University, Newcastle upon Tyne, UK
| | - Claire-Louise Chapple
- Regional Medical Physics Department, Freeman Hospital, Newcastle-upon-Tyne hospitals NHS trust, Newcastle upon Tyne, UK
| | - John J O'Sullivan
- Paediatric Cardiology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Kate E Best
- Newcastle University, Institute of Health and Society, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | | | - Mark S Pearce
- Newcastle University, Institute of Health and Society, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
- NIHR Health Protection Research Unit in Chemical and Radiation Threats and Hazards, Newcastle University, Newcastle upon Tyne, UK
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28
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Cevallos PC, Armstrong AK, Glatz AC, Goldstein BH, Gudausky TM, Leahy RA, Petit CJ, Shahanavaz S, Trucco SM, Bergersen LJ. Radiation dose benchmarks in pediatric cardiac catheterization: A prospective multi-center C3PO-QI study. Catheter Cardiovasc Interv 2017; 90:269-280. [PMID: 28198573 DOI: 10.1002/ccd.26911] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/17/2016] [Accepted: 12/12/2016] [Indexed: 11/06/2022]
Abstract
OBJECTIVES This study sought to update benchmark values to use a quality measure prospectively. BACKGROUND Congenital Cardiac Catheterization Outcomes Project - Quality Improvement (C3PO-QI), a multi-center registry, defined initial radiation dose benchmarks retrospectively across common interventional procedures. These data facilitated a dose metric endorsed by the American College of Cardiology in 2014. METHODS Data was collected prospectively by 9 C3PO-QI institutions with complete case capture between 1/1/2014 and 6/30/2015. Radiation was measured in total air kerma (mGy), dose area product (DAP) (µGy*M2 ), DAP per body weight, and fluoroscopy time (min), and reported by age group as median, 75th and 95th %ile for the following six interventional procedures: (1) atrial septal defect closure; (2) aortic valvuloplasty; (3) treatment of coarctation of the aorta; (4) patent ductus arteriosus closure; (5) pulmonary valvuloplasty; and (6) transcatheter pulmonary valve implantation. RESULTS The study was comprised of 1,680 unique cases meeting inclusion criteria. Radiation doses were lowest for pulmonary valvuloplasty (age <1 yrs, median mGy: 59, DAP: 249) and highest in transcatheter pulmonary valve implantation (age >15 yrs, median mGy: 1835, DAP: 17990). DAP/kg standardized outcome measures across weights within an age group and procedure type significantly more than DAP alone. Radiation doses decreased for all procedures compared to those reported previously by both median and median weight-based percentile curves. These differences in radiation exposure were observed without changes in median fluoroscopy time. CONCLUSIONS This study updates previously established benchmarks to reflect QI efforts over time. These thresholds can be applied for quality measurement and comparison. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Aimee K Armstrong
- Department of Cardiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Andrew C Glatz
- Cardiac Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bryan H Goldstein
- Department of Cardiology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Todd M Gudausky
- Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Ryan A Leahy
- Department of Cardiology, Kosair Children's Hospital, Louisville, Kentucky
| | - Christopher J Petit
- Department of Cardiology, Children's Healthcare of Atlanta Sibley Heart Center, Atlanta
| | - Shabana Shahanavaz
- Division of Pediatric Cardiology, St. Louis Children's Hospital, St. Louis, Missouri
| | - Sara M Trucco
- Division of Pediatric Cardiology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lisa J Bergersen
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
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29
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Update on the Role of Cardiac Magnetic Resonance Imaging in Congenital Heart Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:2. [PMID: 28144782 DOI: 10.1007/s11936-017-0504-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OPINION STATEMENT Cardiac magnetic resonance imaging (CMR) is an important imaging modality in the evaluation of congenital heart diseases (CHD). CMR has several strengths including good spatial and temporal resolutions, wide field-of-view, and multi-planar imaging capabilities. CMR provides significant advantages for imaging in CHD through its ability to measure function, flow and vessel sizes, create three-dimensional reconstructions, and perform tissue characterization, all in a single imaging study. Thus, CMR is the most comprehensive imaging modality available today for the evaluation of CHD. Newer MRI sequences and post-processing tools will allow further development of quantitative methods of analysis, and opens the door for risk stratification in CHD. CMR also can interface with computer modeling, 3D printing, and other methods of understanding the complex anatomic and physiologic relationships in CHD.
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30
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Harbron RW, Dreuil S, Bernier MO, Pearce MS, Thierry-Chef I, Chapple CL, Baysson H. Patient radiation doses in paediatric interventional cardiology procedures: a review. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2016; 36:R131-R144. [PMID: 27893455 DOI: 10.1088/0952-4746/36/4/r131] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
A large number of investigations into the radiation doses from x-ray guided interventional cardiology procedures in children have been carried out in recent years. A review was conducted of these studies, gathering data on kerma area product (P KA), fluoroscopic screening time (FT), air kerma, and estimates of effective dose and organ doses. The majority of studies focus on P KA and FT with no estimation of dose to the patient. A greater than ten-fold variation in average P KA was found between different studies, even where data were stratified by patient age or weight. Typical values of P KA were 0.6-10 Gy · cm2 (<1 year/10 kg), 1.5-30 Gy · cm2 (1-5 years), 2-40 Gy · cm2 (5-10 years), 5-100 Gy · cm2 (10-16 years) and 10-200 Gy · cm2 (>16 years). P KA was lowest for heart biopsy (0.3-10 Gy · cm2 for all ages combined) and atrial septostomy (0.4-4.0 Gy · cm2), and highest for pulmonary artery angioplasty (1.5-35 Gy · cm2) and right ventricular outflow tract dilatation (139 Gy · cm2). Most estimates of patient dose were in the form of effective dose (typically 3-15 mSv) which is of limited usefulness in individualised risk assessment. Few studies estimated organ doses. Despite advances in radiation protection, recent publications have reported surprisingly large doses, as represented by P KA and air kerma. There is little indication of a fall in these dose indicators over the last 15 years. Nor is there much suggestion of a fall in doses associated with the use of flat panel detectors, as opposed to image intensifiers. An assessment of the impact of radiation dose in the context of overall patient outcome is required.
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Affiliation(s)
- R W Harbron
- Institute of Health and Society, Newcastle University, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-upon-Tyne, NE1 4LP, UK. NIHR Health Protection Research Unit in Chemical and Radiation Threats and Hazards, Newcastle University, Newcastle-upon-Tyne, UK
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