The risk of radiation exposure always needs to be balanced vs. This does not mean that no radiation is the ultimate goal, since appropriate imaging is often crucial in performing complex EP procedures effectively and safely. Radiation should always be reduced according to the ALARA principle, i.e. Indeed, by properly implementing these techniques, electrophysiologists can reduce the radiation dose dramatically. Moreover, also for the X-ray use, which will remain a mainstay of the EP procedures in the near future, there are possibilities for filtration, pulsed fluoroscopy, collimation, real-time digital fluoro processing, and more, that should be used in all the labs. Magnetic resonance imaging is being used offline for 3D imaging, and being pioneered for online imaging during EP procedures as well. Different systems allow for non-fluoroscopic (‘electroanatomical’) localization of the catheters and the creation of 3D images. On the other hand, there are many technological tools and new developments that may help to reduce patient and operator exposure. Recent reports have for instance revealed that there may be an excess risk of brain tumours among interventional cardiologists. Also, the staff are exposed to increasing radiation hazards, ranging from cataract to malignancy. The patients may develop acute radiation injury, or have an increased risk of lifetime malignancy. Combined with more procedures and more complex anatomical situations, this evolution leads to a higher cumulative radiation exposure, both of the patients and the staff. Moreover, newer X-ray based technology, that offer highly accurate three-dimensional (3D) images, are often used to improve the anatomical information in combination with the mapping systems or in the 2D–3D fluoroscopic solutions (‘merging’). Most of those interventions are being performed under fluoroscopic guidance. Over the last 20 years, interventional electrophysiology (EP) has expanded significantly, both in the field of diagnostic studies, ablations, and device implantation. Report the procedural effective dose in the patient chart and to your team at the end of the procedure: daily feedback is the best motivator to improve on radiation dose reduction. Shield yourself (ideally behind a cabin or suspended system that also protects your head) and shield other cathlab personnel. Reduce the frame rate of fluoroscopy to ≤3/sec, reduce the energy per frame (ask for low-dose settings), do not use cine but store from fluoroscopy, and optimise collimation to only visualise what you really need to see.Īdjust frame rate, energy per frame and collimation throughout the procedure: assign a nurse with that specific task.Īlso with a non-fluoroscopic system, exposure reduction measures are needed. Estimate effective dose by converting dose-area product values, with conversion factors adjusted for age and female gender. To evaluate radiation exposure, think ‘effective dose’ (in mSv), not ‘fluoroscopy time’. We are confident that these suggestions are able to reduce patient and operator exposure by more than an order of magnitude, and therefore think that these recommendations are worth reading and implementing by any electrophysiological operator in the field. Finally, we suggest further improvements that can be implemented by both the physicians and the industry in the future. The potential and the pitfalls of different non-fluoroscopic guiding technologies are discussed. The text describes how customization of the X-ray system, workflow adaptations, and shielding measures can be implemented in the cath lab. After an introduction on how to quantify the radiation exposure and defining its current magnitude in electrophysiology compared with the other sources of radiation, this position paper wants to offer some very practical advice on how to reduce exposure to patients and staff. Apart from evaluating the need for and justifying the use of radiation to assist their procedures, physicians have to continuously explore ways to reduce the radiation exposure. Moreover, recent reports have also hinted at an excess risk of brain tumours among interventional cardiologists. The professional lifetime attributable excess cancer risk may be around 1 in 100 for the operators, the same as for a patient undergoing repetitive complex procedures. More and more complex procedures have the risk to increase the radiation exposure, both for the patients and the operators. Moreover, many patients receive additional X-ray imaging, such as cardiac computed tomography and others. Despite the advent of non-fluoroscopic technology, fluoroscopy remains the cornerstone of imaging in most interventional electrophysiological procedures, from diagnostic studies over ablation interventions to device implantation.
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