Radiation exposure during cardiac device implantation: Lessons learned from a multicenter registry

Abstract

Background:Little data are available about radiation exposure during cardiac electrical device implantation, and no dose reference levels have been published. This multicenter, prospective, observational study assesses patient and staff radiation exposure during cardiac device implantations, and aims at defining dose reference levels. Methods: Patient demographic, procedural, and radiation data were obtained for 657 procedures from nine institutions. Physician and staff exposure were measured using real-time dosimeters worn beneath and above lead apron. Statistical analysis included fluoroscopy time (FT), dose-area product (DAP), and DAP adjusted for FT and body mass index. Results: Pacemakers and cardioverter defibrillators were implanted in 481 and 176 patients, respectively. Of these, 152 were treated with cardiac resynchronization therapy (CRT). Median FTs were 837s (interquartile range [IQR]: 480-1323), 117s (IQR: 69-209), and 101s (IQR: 58-162), and median DAPs were 1410 (IQR: 807-2601), 150 (IQR: 72-338), and 129 (IQR: 72-332) cGy.cm 2 for biventricular, dual chamber, and ventricular device implantation, respectively. Dose reference levels correspond to the third quartile values. During CRT, higher exposure was observed with four X-ray systems than with the two newer and customizable ones (adjusted DAP of 0.90 [IQR: 0.26-1.01] and 0.29 [IQR: 0.23-0.39], respectively; P < .001). Conclusion: Based on real-life measurements, this multicenter registry provides dose reference levels and may help centers assess radiation exposure. Although biventricular device implantation was responsible for the highest radiation exposure, FT was meaningfully shortened compared to previously reported values. For a same FT, the use of new generators and custom settings has significantly reduced DAP. K E Y W O R D S cardiac resynchronization therapy, defibrillators, implantable, radiation exposure, radiation monitoring1 BACKGROUND Patient exposure to X-rays during cardiac interventions is high and may have deleterious effects, including an increased risk of develop-ing cancer. 1 Unlike most diagnostic procedures using ionizing radiation, dose reference levels in cardiology for coronary angioplasty have only recently been established from multicenter studies. 2 The complexity of cardiac rhythm device implantations is steadily increasing, Pacing Clin Electrophysiol. 2020;43:87-92. c

Aegrescit medendo: orthopedic disability in electrophysiology - call for fluoroscopy elimination—review and commentary

“…Radiation exposure increased from single lead to dual lead, with the highest exposure recorded with cardiac resynchronization (CRT) devices [15][16][17]. The radiation exposure to patients during a CRT implant resulted in a 2-9 times greater exposure than any other device implant [17][18][19][20]. Recent data from the RADAR study showed that the DDE radiation effects from atrial fibrillation ablation were comparable to implant procedures of CRT devices [21].…”

Comparison of clinical outcomes between transthoracic echocardiography and X‐ray guided left bundle branch pacing for bradycardia: A randomized control trial

“…Table 1 describes fluoroscopy times of cardiac devices demonstrating higher fluoroscopy time in CRT and LBBAP implants. Cumulative radiation exposure is a well‐documented operator risk that has been minimized through various approaches that include personal lead protection, lead shields, image intensifier position, reduced frame rate, and short acquisitions 7,8 . With the reduction in fluoroscopy time in this study, cumulative radiation exposure to implanters is further reduced through a novel method.…”

“…Cumulative radiation exposure is a well-documented operator risk that has been minimized through various approaches that include personal lead protection, lead shields, image intensifier position, reduced frame rate, and short acquisitions. 7,8 With the reduction in fluoroscopy time in this study, cumulative radiation exposure to implanters is further reduced through a novel method. The study reports that TTE proved to be a reliable alternative to fluoroscopy with no difference in left bundle area capture success rates and electrical parameters such as threshold, impedance and sensed R-wave.…”

Contemporary angiography in the diagnosis and treatment of cardiovascular disease

“…This was not specifically an investigation into low doses but none the less, demonstrates the current situation with median doses across multiple centres. (196) A further 2019 paper investigated ultra-low dose with a similar X-ray system with a slightly different detector (Siemens Artis Q.Zen). They reported SVT ablation doses of at 429…”