Advertisement

Pediatric Cardiology

, Volume 40, Issue 3, pp 638–649 | Cite as

Reducing Radiation Exposure in Cardiac Catheterizations for Congenital Heart Disease

  • Chandni PatelEmail author
  • Matthew Grossman
  • Veronika Shabanova
  • Jeremy Asnes
Original Article
  • 81 Downloads

Abstract

Ionizing radiation exposure is a necessary risk entailed during congenital cardiac catheterizations. The congenital catheterization lab at Yale New Haven Children’s Hospital employed quality improvement strategies to minimize radiation exposure in this vulnerable population. In two phases, we implemented six interventions, which included adding and utilizing lower fluoroscopy and digital angiography (DA) doses, increasing staff and physician radiation awareness, focusing on tighter collimation, and changing the default fluoroscopy and DA doses to lower settings. Post-intervention data were collected prospectively for all procedures in the congenital catheterization lab and compared to pre-intervention radiation data collected retrospectively. Radiation exposure was measured in total air kerma (mGy), dose area product per body weight (DAP/kg) (µGy m2/kg), and fluoroscopy time (min). Data were collected for a total of 312 cases. In considering all procedures, the DAP/kg decreased by 67.6% and air kerma decreased by 63%. Fluoroscopy time did not change over the study period. Significant decreases in radiation exposure (DAP/kg) by procedure type were seen for atrial septal defect, patent ductus arteriosus, and transcatheter pulmonary valve procedures with a 45%, 42% and 83% decrease, respectively. Air kerma decreased significantly for ASD and PDA procedures with an 80% and 72% decrease, respectively. When compared to national benchmarks, the median DAP/kg and air kerma for these procedures are lower at our institution. The decreases continue to be sustained 2 years post-interventions. Systems-based interventions can be readily implemented in the congenital cardiac catheterization lab with dramatic and sustainable radiation dose reduction for patients.

Keywords

Radiation exposure Pediatric catheterization Congenital heart disease 

Abbreviations

AK

Air kerma

ASD

Atrial septal defect

CHD

Congenital heart disease

CU

Copper

DA

Digital angiography

DAP

Dose area product

PDA

Patent ductus arteriosus

TPV

Transcatheter pulmonary valve

Notes

Compliance with Ethical Standards

Conflict of interest

The authors have no conflicts of interest and financial relationships relevant to this article to disclose.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed Consent

For this type of study, formal consent is not required.

References

  1. 1.
    Justino H (2006) The ALARA concept in pediatric cardiac catheterization: techniques and tactics for managing radiation dose. Pediatr Radiol 36(Suppl 14):146–153.  https://doi.org/10.1007/s00247-006-0194-2 CrossRefGoogle Scholar
  2. 2.
    Hill KD, Wang C, Einstein AJ et al (2017) Impact of imaging approach on radiation dose and associated cancer risk in children undergoing cardiac catheterization. Catheter Cardiovasc Interv 89(5):888–897.  https://doi.org/10.1002/ccd.26630 CrossRefGoogle Scholar
  3. 3.
    Kobayashi D, Meadows J, Forbes TJ et al (2014) Standardizing radiation dose reporting in the pediatric cardiac catheterization laboratory—a multicenter study by the CCISC (congenital cardiovascular interventional study consortium). Catheter Cardiovasc Interv 84(5):786–793.  https://doi.org/10.1002/ccd.25467 CrossRefGoogle Scholar
  4. 4.
    Chida K, Ohno T, Kakizaki S et al (2010) Radiation dose to the pediatric cardiac catheterization and intervention patient. Am J Roentgenol 195(5):1175–1179.CrossRefGoogle Scholar
  5. 5.
    Onnasch DGW, Schröder FK, Fischer G, Kramer H-H (2007) Diagnostic reference levels and effective dose in paediatric cardiac catheterization. Br J Radiol 80(951):177–185.  https://doi.org/10.1259/bjr/19929794 CrossRefGoogle Scholar
  6. 6.
    Harbron RW, Dreuil S, Bernier M-O et al (2016) Patient radiation doses in paediatric interventional cardiology procedures: a review. J Radiol Prot 36(4):R131–R144.  https://doi.org/10.1088/0952-4746/36/4/R131 CrossRefGoogle Scholar
  7. 7.
    Shewhart WA, Deming W (1939) Statistical method from the viewpoint of quality control. The Graduate School of the Department of Agriculture, WashintonGoogle Scholar
  8. 8.
    Provost LP, Murray S (2011) The health care data guide: learning from data for improvement. Jossey-Bass, San FranciscoGoogle Scholar
  9. 9.
    R Core Team (2018) R: A language and environment for statistical computing. R Foundation for Statistical Computing, ViennaGoogle Scholar
  10. 10.
    Ghelani SJ, Glatz AC, David S et al (2014) Radiation dose benchmarks during cardiac catheterization for congenital heart disease in the United States. JACC 7:1060–1069Google Scholar
  11. 11.
    Bacher K (2005) Patient-specific dose and radiation risk estimation in pediatric cardiac catheterization. Circulation 111(1):83–89.  https://doi.org/10.1161/01.CIR.0000151098.52656.3A CrossRefGoogle Scholar
  12. 12.
    Cohen S, Liu A, Gurvitz M et al (2018) Exposure to low-dose ionizing radiation from cardiac procedures and malignancy risk in adults with congenital heart disease. Circulation 137(13):1334–1345.  https://doi.org/10.1161/CIRCULATIONAHA.117.029138 CrossRefGoogle Scholar
  13. 13.
    Hill KD, Frush DP, Han BK et al (2017) Radiation safety in children with congenital and acquired heart disease: a scientific position statement on multimodality dose optimization from the image gently alliance. JACC Cardiovasc Imaging 10(7):797–818.  https://doi.org/10.1016/j.jcmg.2017.04.003 CrossRefGoogle Scholar
  14. 14.
    Borik S, Devadas S, Mroczek D, Jin Lee K, Chaturvedi R, Benson LN (2015) Achievable radiation reduction during pediatric cardiac catheterization: how low can we go? Catheter Cardiovasc Interv 86(5):841–848.  https://doi.org/10.1002/ccd.26024 CrossRefGoogle Scholar
  15. 15.
    Mauriello DA, Fetterly KA, Lennon RJ et al (2014) Radiation reduction in pediatric and adult congenital patients during cardiac catheterization. Catheter Cardiovasc Interv 84(5):801–808.  https://doi.org/10.1002/ccd.25533 CrossRefGoogle Scholar
  16. 16.
    Glatz AC, Patel A, Zhu X et al (2014) Patient radiation exposure in a modern, large-volume, pediatric cardiac catheterization laboratory. Pediatr Cardiol 35(5):870–878.  https://doi.org/10.1007/s00246-014-0869-7 CrossRefGoogle Scholar
  17. 17.
    Cevallos PC, Armstrong AK, Glatz AC et al (2017) Radiation dose benchmarks in pediatric cardiac catheterization: a prospective multi-center C3PO-QI study. Catheter Cardiovasc Interv 90(2):269–280.  https://doi.org/10.1002/ccd.26911 CrossRefGoogle Scholar
  18. 18.
    FDA white paper: initiative to reduce unnecessary radiation exposure from medical imaging. FDA white paper. http://www.fda.gov/downloads/Radiation-EmittingProducts/RadiationSafety/RadiationDoseReduction/UCM200087.pdf. Published 2010. Accessed 11 April 2018
  19. 19.
    Have-a-heart and image gently. The image gently alliance. http://www.imagegently.org/Procedures/Cardiac-Imaging. Published 2014. Accessed 11 April 2018
  20. 20.
    Chambers CE, Fetterly K, Holzer R et al (2011) Radiation safety program for the cardiac catheterization laboratory. Catheter Cardiovasc Interv 77(January):546–556.  https://doi.org/10.1002/ccd.22867 CrossRefGoogle Scholar
  21. 21.
    Christopoulos G, Makke L, Christakopoulos G et al (2016) Optimizing radiation safety in the cardiac catheterization laboratory: a practical approach. Catheter Cardiovasc Interv 87(2):291–301.  https://doi.org/10.1002/ccd.25959 CrossRefGoogle Scholar
  22. 22.
    Smith BG, Tibby SM, Qureshi SA, Rosenthal E, Krasemann T (2012) Quantification of temporal, procedural, and hardware-related factors influencing radiation exposure during pediatric cardiac catheterization. Catheter Cardiovasc Interv 80(6):931–936.  https://doi.org/10.1002/ccd.24359 CrossRefGoogle Scholar
  23. 23.
    Hirshfeld JW, Balter S, Brinker JA et al (2004) ACCF/AHA/HRS/SCAI clinical competence statement on physician knowledge to optimize patient safety and image quality in fluoroscopically guided invasive cardiovascular procedures: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on clinical competence and training. J Am Coll Cardiol 44(11):2259–2282.  https://doi.org/10.1016/j.jacc.2004.10.014 CrossRefGoogle Scholar
  24. 24.
    Johnson JN, Hornik CP, Li JS et al (2014) Cumulative radiation exposure and cancer risk estimation in children with heart disease. Circulation 130(2):161–167.  https://doi.org/10.1161/CIRCULATIONAHA.113.005425 CrossRefGoogle Scholar
  25. 25.
    Ait-Ali L, Andreassi MG, Foffa I, Spadoni I, Vano E, Picano E (2010) Cumulative patient effective dose and acute radiation-induced chromosomal DNA damage in children with congenital heart disease. Heart 96(4):269–274.  https://doi.org/10.1136/hrt.2008.160309 CrossRefGoogle Scholar
  26. 26.
    McFadden SL, Hughes CM, Mooney RB, Winder RJ (2013) An analysis of radiation dose reduction in paediatric interventional cardiology by altering frame rate and use of the anti-scatter grid. J Radiol Prot 33(2):433–443.  https://doi.org/10.1088/0952-4746/33/2/433 CrossRefGoogle Scholar
  27. 27.
    Verghese GR, McElhinney DB, Strauss KJ, Bergersen L (2012) Characterization of radiation exposure and effect of a radiation monitoring policy in a large volume pediatric cardiac catheterization lab. Catheter Cardiovasc Interv 79(2):294–301.  https://doi.org/10.1002/ccd.23118 CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Pediatric CardiologyYale School of MedicineNew HavenUSA
  2. 2.PediatricsYale School of MedicineNew HavenUSA
  3. 3.Department of PediatricsYale UniversityNew HavenUSA

Personalised recommendations