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Radiation Exposure and Safety for the Electrophysiologist

  • Invasive Electrophysiology and Pacing (J Singh, Section Editor)
  • Published:
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Abstract

This review attempts to give practical advice for invasive electrophysiologists on personal radiation protection. Applying all measures of the “As low as reasonably achievable” ALARA concept should be a daily and indeed routine practice for all staff in the electrophysiology laboratory. A substantial number of technical options have been recently introduced which may enable the physician to lower the total radiation exposure significantly, but all require a substantial learning curve. Using these measures can arrive at very low or indeed close to ZERO fluoroscopy exposure even in complex ablation cases.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. [Munchener Medizinische Wochenschrift/20 March 1931 Contrast representation of the cavities of the living right half of the heart by Werner Forssmann, Eberswalde]. MMW, Munchener medizinische Wochenschrift 1978; 120(14): 489.

  2. Einstein AJ, Knuuti J. Cardiac imaging: does radiation matter? Eur Heart J. 2012;33(5):573–8.

    Article  PubMed  Google Scholar 

  3. Berrington de Gonzalez A, Mahesh M, Kim KP, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Archives of Intern Med. 2009;169(22):2071–7.

    Article  Google Scholar 

  4. Mettler Jr FA, Bhargavan M, Faulkner K, et al. Radiologic and nuclear medicine studies in the United States and worldwide: frequency, radiation dose, and comparison with other radiation sources–1950–2007. Radiology. 2009;253(2):520–31.

    Article  PubMed  Google Scholar 

  5. Berrington de Gonzalez A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet. 2004;363(9406):345–51.

    Article  PubMed  Google Scholar 

  6. Calkins H, Reynolds MR, Spector P, et al. Treatment of atrial fibrillation with antiarrhythmic drugs or radiofrequency ablation: two systematic literature reviews and meta-analyses. Circ Arrhythm Electrophysiol. 2009;2(4):349–61.

    Article  PubMed  CAS  Google Scholar 

  7. Commission. E. European Guidance on Estimating Population Doses from Medical X-Ray Procedures. Radiation Protection Report 154. 2008. p. http://ec.europa.eu/energy/nuclear/radiation_protection/doc/publication/154.zip.

  8. Kotre CJ, Reay J, Chapple CL. The influence of patient size on patient doses in cardiology. Radiation protection dosimetry. 2005;117(1–3):222–4.

    PubMed  CAS  Google Scholar 

  9. •• Cousins C, Miller DL, Bernardi G, et al. ICRP PUBLICATION 120: Radiological protection in cardiology. Ann ICRP. 2013;42(1):1–125. This report summarises current knowledge on radiation-induced cancer and tissue injuries relevant to cardiology, and provides guidance to assist the cardiologist in optimising clinical procedures and minimising staff doses.

  10. Schmidt B, Ernst S, Ouyang F, et al. External and endoluminal analysis of left atrial anatomy and the pulmonary veins in three-dimensional reconstructions of magnetic resonance angiography: the full insight from inside. J Cardiovasc Electrophysiol. 2006;17(9):957–64.

    Article  PubMed  Google Scholar 

  11. Lemola K, Sneider M, Desjardins B, et al. Computed tomographic analysis of the anatomy of the left atrium and the esophagus: implications for left atrial catheter ablation. Circulation. 2004;110(24):3655–60.

    Article  PubMed  Google Scholar 

  12. Hunter RJ, Ginks M, Ang R, et al. Impact of variant pulmonary vein anatomy and image integration on long-term outcome after catheter ablation for atrial fibrillation. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2010;12(12):1691–7.

    Article  Google Scholar 

  13. Reddy VY, Malchano ZJ, Holmvang G, et al. Integration of cardiac magnetic resonance imaging with three-dimensional electroanatomic mapping to guide left ventricular catheter manipulation: feasibility in a porcine model of healed myocardial infarction. J Am Coll Cardiol. 2004;44(11):2202–13.

    Article  PubMed  Google Scholar 

  14. de Chillou C, Andronache M, Abdelaal A, et al. Evaluation of 3D guided electroanatomic mapping for ablation of atrial fibrillation in reference to CT-Scan image integration. J Interv Card Electrophysiol. 2008;23(3):175–81.

    Article  PubMed  Google Scholar 

  15. Kistler PM, Rajappan K, Jahngir M, et al. The impact of CT image integration into an electroanatomic mapping system on clinical outcomes of catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2006;17(10):1093–101.

    Article  PubMed  Google Scholar 

  16. Yamaji H, Hina K, Kawamura H, et al. Sufficient pulmonary vein image quality of non-enhanced multi-detector row computed tomography for pulmonary vein isolation by catheter ablation. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2012;14(1):52–9.

    Article  Google Scholar 

  17. Schneider C, Ernst S, Bahlmann E, et al. Transesophageal echocardiography: a screening method for pulmonary vein stenosis after catheter ablation of atrial fibrillation. European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology. 2006;7(6):447–56.

    Article  Google Scholar 

  18. Stavrakis S, Madden GW, Stoner JA, Sivaram CA. Transesophageal echocardiography for the diagnosis of pulmonary vein stenosis after catheter ablation of atrial fibrillation: a systematic review. Echocardiography. 2010;27(9):1141–6.

    Article  PubMed  Google Scholar 

  19. • Picano E, Vano E. Radiation exposure as an occupational hazard. EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology. 2012;8(6):649–53. This paper gives a good overview about exposure and protection measures.

    Article  Google Scholar 

  20. • Russo GL, Picano E. The effects of radiation exposure on interventional cardiologists. Eur Heart J. 2012;33(4):423–4. Article highlighting the importance of maintaining good radiation protection practices whilst greater insight is gained into the damaging, or beneficial, biochemical and cellular changes associated with exposure to low levels of radiation.

  21. • Roguin A, Goldstein J, Bar O. Brain tumours among interventional cardiologists: a cause for alarm? Report of four new cases from two cities and a review of the literature. EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology. 2012;7(9):1081–6. Concerning report on brain tumours as a consequence of extented radiation exposure.

    Article  Google Scholar 

  22. Hammer GP, Blettner M, Langner I, Zeeb H. Cosmic radiation and mortality from cancer among male German airline pilots: extended cohort follow-up. Eur J Epidemiol. 2012;27(6):419–29. Report on another professional group with relevant radiaiton exposure but also better monitoring.

    Article  PubMed  Google Scholar 

  23. Yong LC, Sigurdson AJ, Ward EM, et al. Increased frequency of chromosome translocations in airline pilots with long-term flying experience. Occup Environ Med. 2009;66(1):56–62.

    Article  PubMed  CAS  Google Scholar 

  24. Bottollier-Depois JF, Trompier F, Clairand I, et al. Exposure of aircraft crew to cosmic radiation: on-board intercomparison of various dosemeters. Radiation protection dosimetry. 2004;110(1–4):411–5.

    Article  PubMed  CAS  Google Scholar 

  25. Limacher MC, Douglas PS, Germano G, et al. ACC expert consensus document. Radiation safety in the practice of cardiology. J Am Coll Cardiol. 1998;31(4):892–913.

    Article  PubMed  CAS  Google Scholar 

  26. Fadl YY, Ellenbogen KA, Grubb Jr RL, Khoo-Summers L, Lindsay BD. A review of spinal injuries in the invasive cardiologist II: prevention and treatment. Pacing Clin Electrophysiol. 2007;30(9):1149–57.

    Article  PubMed  Google Scholar 

  27. De Buck S, La Gerche A, Ector J, et al. Asymmetric collimation can significantly reduce patient radiation dose during pulmonary vein isolation. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2012;14(3):437–44. Interesting technical solution to collimation which reduces overall exposure significantly.

    Article  Google Scholar 

  28. Shpun S, Gepstein L, Hayam G, Ben-Haim SA. Guidance of radiofrequency endocardial ablation with real-time three-dimensional magnetic navigation system. Circulation. 1997;96(6):2016–21.

    Article  PubMed  CAS  Google Scholar 

  29. Schilling RJ, Peters NS, Davies DW. Feasibility of a noncontact catheter for endocardial mapping of human ventricular tachycardia. Circulation. 1999;99(19):2543–52.

    Article  PubMed  CAS  Google Scholar 

  30. Ouyang F, Bansch D, Ernst S, et al. Complete isolation of left atrium surrounding the pulmonary veins: new insights from the double-Lasso technique in paroxysmal atrial fibrillation. Circulation. 2004;110(15):2090–6.

    Article  PubMed  Google Scholar 

  31. Ouyang F, Ernst S, Chun J, et al. Electrophysiological findings during ablation of persistent atrial fibrillation with electroanatomic mapping and double Lasso catheter technique. Circulation. 2005;112(20):3038–48.

    Article  PubMed  Google Scholar 

  32. Rolf S, Sommer P, Gaspar T, et al. Ablation of atrial fibrillation using novel 4-dimensional catheter tracking within autoregistered left atrial angiograms. Circ Arrhythm Electrophysiol. 2012;5(4):684–90.

    Article  PubMed  Google Scholar 

  33. Kerst G, Weig HJ, Weretka S, et al. Contact force-controlled zero-fluoroscopy catheter ablation of right-sided and left atrial arrhythmia substrates. Heart Rhythm. 2012;9(5):709–14. ZERO exposure is important for "vulnerable" patients and can be achieved with modern technologiy without increasing the risk for complications.

    Article  PubMed  Google Scholar 

  34. Casella M, Pelargonio G, Dello Russo A, et al. "Near-zero" fluoroscopic exposure in supraventricular arrhythmia ablation using the EnSite NavX mapping system: personal experience and review of the literature. J Interv Card Electrophysiol. 2011;31(2):109–18.

    Article  PubMed  Google Scholar 

  35. Ernst S, Babu-Narayan SV, Keegan J, et al. Remote-controlled magnetic navigation and ablation with 3D image integration as an alternative approach in patients with intra-atrial baffle anatomy. Circ Arrhythm Electrophysiol. 2012;5(1):131–9. Demonstration of effect of remote navigation and 3D image integration in the most complex patient cohort of adult congenital heart disease.

    Article  PubMed  Google Scholar 

  36. Mantziari L, Rigby M, Till J, Ernst S. Accessory Pathway Ablation in a 6-Year-Old Girl Using Remote Magnetic Navigation as an Alternative to Cryoablation. Pediatric Cardiol. 2012.

  37. Schwagten B, Witsenburg M, De Groot NM, Jordaens L, Szili-Torok T. Effect of magnetic navigation system on procedure times and radiation risk in children undergoing catheter ablation. Am J Cardiol. 2010;106(1):69–72.

    Article  PubMed  Google Scholar 

  38. Casella M, Dello Russo A, Pelargonio G, et al. Rationale and design of the NO-PARTY trial: near-zero fluoroscopic exposure during catheter ablation of supraventricular arrhythmias in young patients. Cardiol Young. 2012;22(5):539–46.

    Article  PubMed  Google Scholar 

  39. Wu J, Deisenhofer I, Ammar S, et al. Acute and long-term outcome after catheter ablation of supraventricular tachycardia in patients after the Mustard or Senning operation for D-transposition of the great arteries. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2013.

  40. Rogers DP, England F, Lozhkin K, Lowe MD, Lambiase PD, Chow AW. Improving safety in the electrophysiology laboratory using a simple radiation dose reduction strategy: a study of 1007 radiofrequency ablation procedures. Heart. 2011;97(5):366–70.

    Article  PubMed  Google Scholar 

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Conflict of Interest

Sabine Ernst has been a consultant for Biosense Webster and Stereotaxis; has received grant support from CardioInsight; has received payment for development of educational presentations including service on speakers' bureaus from Biosense, St. Jude Medical, Stereotaxis, Biotronik; and has received travel/accommodations expenses covered or reimbursed from Biosense, St. Jude Medical, Stereotaxis, Biotronik.

Isabel Castellano declares that she has no conflict of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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Correspondence to Sabine Ernst.

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This article is part of the Topical Collection on Invasive Electrophysiology and Pacing

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Ernst, S., Castellano, I. Radiation Exposure and Safety for the Electrophysiologist. Curr Cardiol Rep 15, 402 (2013). https://doi.org/10.1007/s11886-013-0402-2

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