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Assessment of a novel radiation reduction protocol for pediatric and adult congenital device implantation

  • Bradley C. ClarkEmail author
  • Christopher M. Janson
  • Scott R. Ceresnak
  • Frank A. Osei
  • William J. Bonney
  • Lynn Nappo
  • Robert H. Pass
Article
  • 67 Downloads

Abstract

Purpose

Device implantation requires fluoroscopic guidance, which carries inherent risks of ionizing radiation. We evaluated the impact of a low-dose fluoroscopic protocol on radiation exposure during device implantation.

Methods

All patients who underwent pacemaker or ICD implantation with new transvenous leads from July 2011 to January 2018 were included. A novel ALARA protocol consisting of ultra-low frame rates (2–3 frames/s), low dose/frame (6–18 mGy/frame), and use of the “air-gap” technique in patients < 20 kg was employed. Demographics, procedural data, and radiation exposure levels were collected and analyzed.

Results

Thirty patients underwent device implantation without additional catheterization, electrophysiology study, or ablation procedure (median age 15 years; range 5–50) with a total of 43 leads placed. Forty-seven percent of patients had a primary rhythm disturbance, 33% had cardiomyopathy, and 20% had congenital heart disease. Fifty percent were pacemakers (53% dual-chamber, 27% ventricle, 20% atrial) and 50% of devices implanted were ICDs (87% single-chamber). All implants were acutely successful with acceptable atrial and ventricular sensing and capture thresholds. The median fluoroscopy time was 11.5 min (inter-quartile range (IQR) 8.0–18.2), median air kerma dose 4.0 mGy (IQR 2.5–19.5), and median dose-area product 27.8 μGy/m2 (IQR 17.1–106.5). Median implant procedure time was 133 min. One patient required revision secondary to device migration without lead derangement 2 days post-procedure.

Conclusions

Use of a novel fluoroscopic protocol may help decrease radiation exposure to patients and staff without affecting efficacy or risk. These data may represent benchmarks against which future device implantation procedures can be compared.

Keywords

Radiation reduction Fluoroscopy Pacemaker Implantable cardioverter defibrillator Pediatric Adult congenital 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional Review Board at the Einstein College of Medicine and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was not obtained as this manuscript represents a retrospective review of prior studies.

References

  1. 1.
    Sutton NJ, Lamour J, La G, Pass RH. Pediatric patient radiation dosage during endomyocardial biopsies and right heart catheterization using a standard “ALARA” radiation reduction protocol in the modern fluoroscopic era. Catheter Cardiovasc Interv. 2014;83(1):80–3.  https://doi.org/10.1002/ccd.25058.
  2. 2.
    Pass RH, Gates GG, La G, Nappo L, Ceresnak SR. Reducing patient radiation exposure during paediatric SVT ablations: use of CARTO® 3 in concert with “ALARA” principles profoundly lowers total dose. Cardiol Young. 2014;25:1–6.  https://doi.org/10.1017/S1047951114001474.CrossRefGoogle Scholar
  3. 3.
    Andreassi MG, Ait-Ali L, Botto N, Manfredi S, Mottola G, Picano E. Cardiac catheterization and long-term chromosomal damage in children with congenital heart disease. Eur Heart J. 2006;27(22):2703–8.  https://doi.org/10.1093/eurheartj/ehl014.CrossRefPubMedGoogle Scholar
  4. 4.
    Beausejour Ladouceur V, Lawler PR, Gurvitz M, Pilote L, Eisenberg MJ, Ionescu-Ittu R, et al. Exposure to low-dose ionizing radiation from cardiac procedures in patients with congenital heart disease: 15-year data from a population-based longitudinal cohort. Circulation. 2016;133(1):12–20.  https://doi.org/10.1161/circulationaha.115.019137.CrossRefPubMedGoogle Scholar
  5. 5.
    Gerber TC, Carr JJ, Arai AE, Dixon RL, Ferrari VA, Gomes AS, et al. Ionizing radiation in cardiac imaging: a science advisory from the American Heart Association Committee on Cardiac Imaging of the Council on Clinical Cardiology and Committee on Cardiovascular Imaging and Intervention of the Council on Cardiovascular Radiology and Intervention. Circulation. 2009;119(7):1056–65.  https://doi.org/10.1161/CIRCULATIONAHA.108.191650.
  6. 6.
    Clay MA, Campbell RM, Strieper M, Frias PA, Stevens M, Mahle WT. Long-term risk of fatal malignancy following pediatric radiofrequency ablation. Am J Cardiol. 2008;102(7):913–5.  https://doi.org/10.1016/j.amjcard.2008.05.033.CrossRefPubMedGoogle Scholar
  7. 7.
    Jan M, Žižek D, Rupar K, Mazić U, Kuhelj D, Lakič N, et al. Fluoroless catheter ablation of various right and left sided supra-ventricular tachycardias in children and adolescents. Int J Card Imaging. 2016;32(11):1609–16.  https://doi.org/10.1007/s10554-016-0952-7.
  8. 8.
    Drago F, Silvetti MS, Di Pino A, Grutter G, Bevilacqua M, Leibovich S. Exclusion of fluoroscopy during ablation treatment of right accessory pathway in children. J Cardiovasc Electrophysiol. 2002;13(8):778–82.CrossRefPubMedGoogle Scholar
  9. 9.
    Kerst G, Parade U, Weig HJ, Hofbeck M, Gawaz M, Schreieck J. A novel technique for zero-fluoroscopy catheter ablation used to manage Wolff-Parkinson-White syndrome with a left-sided accessory pathway. Pediatr Cardiol. 2012;33(5):820–3.  https://doi.org/10.1007/s00246-012-0207-x.CrossRefPubMedGoogle Scholar
  10. 10.
    Bigelow AM, Smith G, Clark JM. Catheter ablation without fluoroscopy: current techniques and future direction. J Atr Fibrillation. 2014;6(6):7–12.Google Scholar
  11. 11.
    Bharmanee A, Gowda S, Singh HR. Feasibility, accuracy, and safety of 3-dimensional electroanatomic mapping without fluoroscopy in patients with congenital heart defects. Heart Rhythm. 2016;13(8):1667–73.  https://doi.org/10.1016/j.hrthm.2016.04.010.CrossRefPubMedGoogle Scholar
  12. 12.
    Bigelow AM, Crane SS, Khoury FR, Clark JM. Catheter ablation of supraventricular tachycardia without fluoroscopy during pregnancy. Obstet Gynecol. 2015;125(6):1338–41.  https://doi.org/10.1097/aog.0000000000000601.CrossRefPubMedGoogle Scholar
  13. 13.
    Gellis LA, Ceresnak SR, Gates GJ, Nappo L, Pass RH. Reducing patient radiation dosage during pediatric SVT ablations using an “ALARA” radiation reduction protocol in the modern fluoroscopic era. Pacing Clin Electrophysiol. 2013;36(6):688–94.  https://doi.org/10.1111/pace.12124.CrossRefPubMedGoogle Scholar
  14. 14.
    Attanasio P, Mirdamadi M, Wielandts J-Y, Pieske B, Blaschke F, Boldt L-H, et al. Safety and efficacy of applying a low-dose radiation fluoroscopy protocol in device implantations. Europace. 2017;19(8):1364–8.  https://doi.org/10.1093/europace/euw189.
  15. 15.
    Ghelani SJ, Glatz AC, David S, Leahy R, Hirsch R, Armsby LB, et al. Radiation dose benchmarks during cardiac catheterization for congenital heart disease in the United States. JACC Cardiovasc Interv. 2014;7(9):1060–9.  https://doi.org/10.1016/j.jcin.2014.04.013.
  16. 16.
    Hill KD, Frush DP, Han BK, Abbott BG, Armstrong AK, DeKemp RA, et al. 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. 2017;10(7):797–818.  https://doi.org/10.1016/j.jcmg.2017.04.003.
  17. 17.
    Clark BC, Sumihara K, McCarter R, Berul CI, Moak JP. Getting to zero: impact of electroanatomical mapping on fluoroscopy use in pediatric catheter ablation. J Interv Card Electrophysiol. 2016;46(2):183–9.  https://doi.org/10.1007/s10840-016-0099-4.CrossRefPubMedGoogle Scholar
  18. 18.
    Patel AR, Ganley J, Zhu X, Rome JJ, Shah M, Glatz AC. Radiation safety protocol using real-time dose reporting reduces patient exposure in pediatric electrophysiology procedures. Pediatr Cardiol. 2014;35(7):1116–23.  https://doi.org/10.1007/s00246-014-0904-810.1007/s00246-014-0904-8.
  19. 19.
    Nagaraju L, Menon D, Aziz PF. Use of 3D electroanatomical navigation (CARTO-3) to minimize or eliminate fluoroscopy use in the ablation of pediatric supraventricular tachyarrhythmias. Pacing Clin Electrophysiol. 2016;39(6):574–80.  https://doi.org/10.1111/pace.12830.CrossRefPubMedGoogle Scholar
  20. 20.
    Hartz J, Clark BC, Ito S, Sherwin ED, Berul CI. Transvenous nonfluoroscopic pacemaker implantation during pregnancy guided by 3-dimensional electroanatomic mapping. Heart Rhythm Case Rep. 2017;3(10):490–2.  https://doi.org/10.1016/j.hrcr.2017.07.020.CrossRefGoogle Scholar
  21. 21.
    Tuzcu V, Gul EE, Erdem A, Kamali H, Saritas T, Karadeniz C, et al. Cardiac interventions in pregnant patients without fluoroscopy. Pediatr Cardiol. 2015;36(6):1304–7.  https://doi.org/10.1007/s00246-015-1181-x.
  22. 22.
    Pass RH, Sutton NJ. Letter to the editor regarding Cevallos PC et al. Radiation dose benchmarks in pediatric cardiac catheterization: a prospective multi-center C3P0-QI study. Catheter Cardiovasc Interv. 2017;90(2):269–80.  https://doi.org/10.1002/ccd.27381.CrossRefGoogle Scholar

Copyright information

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

Authors and Affiliations

  1. 1.Children’s Hospital at MontefioreBronxUSA
  2. 2.Albert Einstein College of MedicineBronxUSA
  3. 3.Children’s Hospital of PhiladelphiaPhiladelphiaUSA
  4. 4.Lucile Packard Children’s HospitalPalo AltoUSA
  5. 5.University of Mississippi Medical CenterTupeloUSA

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