Fluoroscopic Equipment Research Articles

Hand Surgical Operating Room Size Allocation: A Comparative Space Utilisation Study.

Background: This study evaluated operating room (OR) space required for various hand surgical procedures. We analysed the size requirements for hand surgical cases divided into four settings: (1) large OR setting requiring fluoroscopy and microsurgical equipment, (2) medium-sized OR setting for cases requiring fluoroscopy, (3) smaller OR setting and (4) minor procedural room without anaesthesia with the aim to describe room size requirements for hand surgery practices. Methods: A variety of hand surgical cases were selected: large cases (microvascular digit replantation), medium-sized cases (closed reduction percutaneous pinning [CRPP] of phalangeal fractures) and smaller cases (carpal tunnel release [CTR]) with and without anaesthesia. Space requirements were compared to general surgery cases (laparoscopic appendectomy) and general orthopaedic surgery cases (cephalomedullary nail [CMN]). Necessary operative equipment was measured (ft2) to calculate requirements for each procedure. Results: Large hand cases such as digit replantation necessitated the most OR space (125 ft2), followed by general orthopaedic cases (CMN; 118 ft2), medium-sized hand cases (CRPP phalanx; 107 ft2), general surgery laparoscopic appendectomy (68 ft2), small hand cases (CTR; 85 ft2) and minor procedures (49 ft2). Conclusions: Hand procedures can be divided into major procedures requiring significant OR space (125 ft2), medium procedures in standard OR suites (107 ft2), procedures in small ORs with anaesthesia (81 ft2) or office-based setting without anaesthesia (49 ft2). These findings help define space utilisation for hand procedures and may have practical implications related to efficiency, cost and patient safety in the hospital and outpatient setting. Level of Evidence: Level IV (Economic and Decision Analyses).

Aftermath Türkiye’s double earthquake: detailed analysis of fracture characteristics and acute management from a level I trauma center

BackgroundThis research investigated surgical interventions for the treatment of extremity and pelvic fractures and aimed to provide an analysis of management challenges under crisis conditions in a Level I Trauma Center after Türkiye’s February 6, 2023, earthquakes.MethodsThe study was a retrospective examination of the medical records of 243 fracture cases associated with the earthquakes. The age, gender, time of admission, types of extremity and pelvic fractures, anatomical localizations, and surgical treatment methods for fractures were recorded. The results of these parameters were evaluated in detail, together with the results of other surgical treatments performed in the hospital in the first week after the disaster, such as fasciotomy, amputation, and wound debridement.ResultsMost of the 243 (119 males and 124 females) patients with extremity fractures and pelvic fractures receiving surgical treatment were adults (n = 182, 74.9%). The most common lower extremity fractures among all fracture cases were tibial shaft (30.8%) and femoral shaft (20.6%) fractures. A total of 33 patients had surgical procedures for the treatment of two or more significant bone fractures involving either the extremity or the pelvic ring. The analysis showed that the median age of patients who underwent surgery due to extremity and pelvic fractures was 36 years, with a range of 1 to 91 years, which was statistically increased compared to patients who received surgery for other musculoskeletal injuries such as fasciotomy, amputation and debridement (p < 0.001).ConclusionFractures were one of the most common musculoskeletal injuries in the first days after earthquakes, and the management of fractures differs significantly from soft tissue injuries and amputation surgeries as they require implants, special instruments, and imaging devices. The delivery of healthcare is often critically impaired after a severe earthquake. Shortages of consumables such as orthopedic implants, power drills, fluoroscopy equipment, and the need for additional staff should be addressed immediately after the earthquake, ideally by the end of the first day.

Low-dose pulsed vs standard pulsed fluoroscopy during ERCP to reduce radiation without change in image quality: Prospective randomized study.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) poses the risk of radiation exposure (RE) to patients and staff and increases the risk of adverse biological effects such as cataracts, sterility, and cancer. Newer fluoroscopy equipment (C-Arm) provides options to limit radiation in the form of lower radiation dose and frame rate or time-limited "pulsed" settings. However, the impact of lower settings on image quality has not been assessed, and no standard protocol exists for fluoroscopy settings used during ERCP. Patients and methods This was a single-center, double-blind, prospective randomized study of consecutive adult patients undergoing standard-of-care ERCP at a tertiary academic medical center. Patients were randomized into two groups: 1) standard-dose pulsed and 2) low-dose pulsed. Pulsed mode (8 fps) was defined as x-ray exposure either in the manufacturer standard-dose or low-dose settings limited to 3 seconds each time the foot-operated switch was depressed. Results Seventy-eight patients undergoing ERCP were enrolled and randomized. No difference in age, gender, or body mass index was found between the two groups. No significant difference in image quality was found between standard-dose and low-dose fluoroscopy P = 0.925). The low-dose group was exposed to significantly less radiation when compared with standard-dose P < 0.05). Fluoroscopy time (minutes) was similar in both groups (2.0 vs 1.9), further suggesting that group assignment had no impact on image quality or procedure time. Conclusions Low-dose pulsed fluoroscopy is a reliable method that substantially reduces radiation without compromising image quality or affecting procedure or fluoroscopy times. This underscores the need for standardization in ERCP fluoroscopy settings to limit radiation exposure.

Impact of equipment technology on reference levels in fluoroscopy-guided gastrointestinal procedures

ObjectivesTo evaluate the effect of equipment technology on reference point air kerma (Ka,r), air kerma-area product (PKA), and fluoroscopic time for fluoroscopically-guided gastrointestinal endoscopic procedures and establish benchmark levels. MethodsThis retrospective study included the consecutive patients who underwent fluoroscopically-guided gastrointestinal endoscopic procedures from May 2016 to August 2023 at a tertiary care hospital in the U.S. Fluoroscopic systems included (a) Omega CS-50 e-View, (b) GE Precision 500D, and (c) Siemens Cios Alpha. Radiation dose was analyzed for four procedure types of endoscopic retrograde biliary, pancreas, biliary and pancreas combined, and other guidance. Median and 75th percentile values were computed using software package R (version 4.0.5, R Foundation). ResultsThis large study analyzed 9,459 gastrointestinal endoscopic procedures. Among four procedure types, median Ka,r was 108.8–433.2 mGy (a), 70–272 mGy (b), and 22–55.1 mGy (c). Median PKA was 20.9–49.5 Gy∙cm2 (a), 13.4–39.7 Gy∙cm2 (b), and 8.91–20.9 Gy∙cm2 (c). Median fluoroscopic time was 2.8–8.1 min (a), 3.6–9.2 min (b), and 2.9–9.4 min (c). Their median value ratio (a:b:c) was 8.5:4.8:1 (Ka,r), 2.7:2.1:1 (PKA), and 1.0:1.1:1 (fluoroscopic time). Median value and 75th percentile are presented for Ka,r, PKA, and fluoroscopic time for each procedure type, which can function as benchmark for comparison for dose optimization studies. ConclusionThis study shows manifold variation in doses (Ka,r and PKA) among three fluoroscopic equipment types and provides local reference levels (50th and 75th percentiles) for four gastrointestinal endoscopic procedure types. Besides procedure type, imaging technology should be considered for establishing diagnostic reference level. SummaryWith manifold (2 to 12 times) variation in doses observed in this study among 3 machines, we recommend development of technology-based diagnostic reference levels for gastrointestinal endoscopic procedures.

Radiation dose reduction during venous access port implantation: the importance of upgrading equipment and radiation-protection training.

Implantable central venous port systems are widely used in oncology. We upgraded our fluoroscopy machines, and all anesthetists completed two training courses focusing on the risks of ionizing radiation for patients and health workers. This study aimed to evaluate the impact of upgrading the machines and the radiation-protection training on ionizing radiation exposure during venous port system implantation. We retrospectively analyzed consecutive venous port implantations between 2019 and 2022. The older fluoroscopy machines were replaced by two new machines. A first training session about health worker radioprotection was organized. The medical staff completed a second training course focused on protecting patients from ionizing radiation. We defined four distinct time intervals (TI): venous port implantations performed with the old equipment, the new fluoroscopy machines, after the first training course, and after the second training course. The air kerma-area product (KAP) was compared between these four TI and fluoroscopy times and the number of exposures only with the new machines. We analyzed 2587 procedures. A 93% decrease in the median KAP between the first and last TI was noted (median KAP = 323.0mGy.cm2 vs. 24.0mGy.cm2, p < 0.0001). A decrease in the KAP was observed for each of the 11 anesthetists. We also noted a significant decrease in the time of fluoroscopy and the number of exposures. Upgrading the fluoroscopy equipment and completing two dedicated training courses allowed for a drastic decrease patient exposure to ionizing radiation during venous access port implantation by non-radiologist practitioners.

Venoarterial extracorporeal membrane oxygenation for cardiopulmonary resuscitation: A retrospective study comparing the outcomes of fluoroscopy

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) using venoarterial extracorporeal membrane oxygenation is performed for out-of-hospital cardiac arrest; however, it is associated with a risk of several complications. ObjectiveTo investigate whether the fluoroscopy equipment was removed from the emergency department (ED) and whether it would be beneficial to transport the patient to the fluoroscopy room to reduce vascular complications without affecting the induction time. MethodsThis single-center, retrospective, before-and-after analysis was conducted at a tertiary emergency medical center and included 59 patients who underwent ECPR for out-of-hospital cardiac arrest between May 2017 and March 2022. The patients were divided into two groups: those who underwent cannulation in the ED without fluoroscopy (ED-ECPR group) and those who were transferred directly from the ED to the cardiac angiography room (ECPR call group). ResultsThe rate of vascular complications associated with ECPR was significantly lower in the ECPR group than in the ED-ECPR group (40.6 % [14/32] vs. 10 % [2/20], respectively; p = 0.014). The duration from ED arrival to venoarterial extracorporeal membrane oxygenation initiation was similar in the two groups (median: 23.0 min in the ED-ECPR group vs. 25.5 min in the ECPR call group, p = 0.71). Results adjusted for confounding factors showed that performing ECPR under fluoroscopy was a consistent and independent element of vascular complication rates (adjusted odds ratio: 9.92, 95 % confidence interval: 2.04 to 81.2, p = 0.011). ConclusionsFluoroscopy-guided ECPR can significantly reduce the incidence of vascular complications even if the ED and fluoroscopy room are far apart. However, no significant difference was observed in the time required to establish ECPR in the cardiac catheterization laboratories.

LINEARITY TEST ANALYSIS OF AIRCRAFT RADIATION OUTPUT X-RAY FLUOROSCOPY

The number or intensity of X-ray photons produced correlates with the increase in tube current per time (mAs), which affects the image density on the final film. To ensure the consistency of the increase in X-ray radiation output and the Linear Coefficient of X-ray radiation output, is within the tolerance limits specified in PERKA BAPETEN Regulation Number 9 of 2011. The aim of this research is to determine the linearity of the X-ray Fluoroscopy radiation output in one of the houses. Jakarta sick. The method used is an experimental approach with a quantitative model. Measurement of radiation output using a PM1610 Personal Dosimeter on a Fluoroscopy aircraft. The results of measuring the linearity of X-ray radiation output with voltage variations of 40 kV, 50 kV, 60 kV, 70 kV show that the value of the Linearity Coefficient (CL) is (0.08 ; 0.06 ; 0.09 ; 0.07). So it can be said that the X-Ray Fluoroscopy equipment is in good condition because the CL value obtained in this study is below the Tolerance Limit Value according to PERKA BAPETEN Number 9 of 2011, namely CL ≤ 0.1 or ≤10%. This research can be carried out as a reference in further research

Changing Roles of a Radiographer in Fluoroscopy:

Fluoroscopic imaging services in Zambia have been available since 1972 when the first equipment was installed at the University Teaching Hospital (UTH). However, there is limited fluoroscopy equipment use due to a critical shortage of radiologists who are traditionally trained to carry out this role. Radiologists work alongside radiographers who provide technical support and patient care. To address the shortage of radiologists, radiographers in the United Kingdom (UK) have explicitly expanded their scope of practice and started performing and reporting on fluoroscopic examinations such as barium swallow, barium meal, small bowel follow-through, barium enema, and videofluoroscopy after undergoing appropriate training. Literature from the UK shows that gastrointestinal (GI) radiographers’ performance is of a high-quality standard. The initiative has been very effective and made a significant contribution to the delivery of fluoroscopic services in that country. Therefore, the aim of this article was to review the literature on role extension for GI radiographers to guide the development and practice of fluoroscopic studies in Zambia. It is anticipated that this article will bring awareness to stakeholders such as the Ministry of Health (MOH), Schools of Radiography, the Radiological Society of Zambia (RSZ), and the Zambia Medical Association (ZMA) on this important subject.

Vesicoureteral reflux by contrast ultrasound, comparison with voiding and retrograde urethrocystography: A prospective accuracy study

Diagnosis of vesicoureteral reflux (VUR) plays an important role in the management and follow-up of children presenting with urinary tract infection. This study compared voiding uronosography (VUS) as a diagnostic method for the diagnosis of VUR with the "gold standard", voiding or micturating cystourethrography (MCU). The objective of the study is not only to compare the effectiveness of both methods, but also to assess the feasibility of implementing VUS technically and economically in a large tertiary radiology center in South America. This was a prospective accuracy study that include 41 patients (a total of 85 ureteral units) aged between 1 month and 16 years. VUS was performed in an alternative form as regular MCU, by injecting microbubble contrast solution (SonoVue©) into the bladder through an intermittent catheter and evaluating the presence of reflux with ultrasound. MCU was always performed immediately after VUS. One pediatric radiologist evaluated all VUS exams, while a second independent pediatric radiologist evaluated all MCU exams, with both blinded to each other's assessments. Comparing VUS with MCU in the diagnosis of VUR, we observed a sensitivity of 92.3% (95% CI 74.9-99.1%), specificity of 98.3% (95% CI 90.9-100%), positive predictive value of 96.0% (95% CI 79.6-99.9%), negative predictive value of 96.7% (95% CI 88.5-99.6%) and a Kappa of 0.916 (0.822-1.000). When comparing the VUR grading between VUS and MCU the agreement between the two methods was high with a Kendall's Tau-b > 0.9. VUS failed to diagnose two grade 1 VUR reflux cases in teenagers while diagnosing one grade 4 VUR in a very dilated kidney-ureter unit, which was missed on MCU. VUS and MCU had similar costs when considering the price of the ultrasound contrast agent. VUS is a reliable alternative method to MCU for the diagnosis of VUR with the advantages of not exposing the child to ionizing radiation and potentially being more accessible due to the greater availability of ultrasound equipment. Limitations to this study include the usage of a single ultrasound equipment, which limits its generalizability and not evaluating the interobserver variability. Consideration should be given to implementing VUS for the diagnosis of VUR, particularly in centers without fluoroscopy equipment available, since the exam's performance and cost are comparable to those of the MCU.

P296 WHAT IF CARDIAC SURGEONS PERFORM TRANS–CATHETER AORTIC VALVE INTERVENTIONS?

Abstract Background and aim Aim of this study is to present the results of our aortic valve interventions program embedding surgical (SAVR) and trans–catheter treatment, both in the hands of cardiac surgeons. Methods Data of patients who had isolated aortic valve interventions during the period 2016–2022 were reviewed. SAVR was performed mainly through a minimally invasive approach . TAVI included either TF or TA access procedures, all performed in a cardiac surgery theatre with fluoroscopy equipment. Results During the study period, 1435 patients underwent isolated aortic valve intervention: 1022 surgical AVR (665 mini AVR, 357 FS) and 413 TAVI (333 TF and 80 TA). TAVI were introduced during 2018 and gained a wider application over the years with the progressive adoption of awake procedures and fully percutaneous access (Figure 1). The global volume of aortic valve procedures increased of 38% comparing the full–years 2021 with 2018 (295 vs 213 cases). Multivariable logistic regression showed that TAVI was significantly associated with increased age, female gender, a higher rate of comorbidities and lower LVEF. Overall in–hospital mortality was 0.6% – mini AVR 0.3%, FS 0.3%, TF TAVI 1% and TA TAVI 3%. Permanent neurologic injury was recorded in 0.7% of the patients. Permanent PM implantation was higher after TAVI (87/413 vs 32/1022 patients who had surgical AVR). Conclusions TAVI procedures can be safely performed by cardiac surgeons. The expertise in both surgical and trans–catheter treatment translated in the possibility of treating aortic valve disease in a higher volume of patients including older and comorbid patients with excellent early results.

Cardiac resynchronization therapy device implantation using suspended personal radiation protection system: Examination of radiation protection effectiveness by dosimetry at 51 exposure sites.

Cardiologists often use fluoroscopic equipment for treatment such as cardiac implantable electronic device implantation, catheter ablation, percutaneous coronary intervention, and other procedures. Difficulties arise in protecting the head and optical lens from the exposure of radiation, which is a significant concern among physicians1,2. Currently available radiation protective clothing consists of a collar for the thyroid gland and a sleeveless apron. Although higher radiation protection can be expected by increasing the lead content of the protective clothing, there is a limit to additional lead content due to the increased weight.

Radiation dose during interventional cardiology procedures: portable C-arm vs. a new generation fluoroscopy system

IntroductionOccupational exposure to ionizing radiation poses health risks for veterinary interventionalists. There are limited veterinary studies evaluating radiation dose in the cardiac catheterization laboratory. The purpose of this study was to report direct radiation dose exposure to patients during common interventional cardiology procedures and compare these doses between two fluoroscopy units. AnimalsOne hundred and fifty-four client-owned dogs. Materials and MethodsPatient dose during procedures using a portable C-arm were retrospectively analyzed and compared to those performed in a contemporary interventional suite. Fluoroscopy equipment, procedure type, operator, patient weight, fluoroscopy time, dose area product, and air kerma were recorded and statistically modeled using univariable and multivariable linear regression to evaluate the effect of each factor. ResultsPatient dose population (154 dogs), comprised 61 patent ductus arteriosus occlusions, 60 balloon pulmonary valvuloplasties, and 33 pacemaker implantations. Patient dose was significantly lower in the group utilizing a newer generation fluoroscopy unit vs. the group utilizing an older portable C-arm, positively correlated with patient weight, and highest during balloon pulmonary valvuloplasties compared to patent ductus arteriosus occlusions or pacemaker implantations (all P<0.010). DiscussionNewer fluoroscopy systems can be equipped with technologies that improve image quality while reducing patient dose and radiation exposure to interventional personnel. ConclusionsWe documented a significant reduction in patient radiation dose using a newer fluoroscopy system as compared to an older portable C-arm for interventional cardiology procedures in animals. Improved knowledge of patient radiation dose factors may promote better radiation safety protocols in veterinary interventional cardiology.

A wearable active-type X-ray dosimeter having novel functions to derive both incident direction and absolute exposure dose

Currently, interventional radiology (IVR) procedures using X-ray fluoroscopic equipment are widely used to perform medical diagnosis and treatment, and during these procedures medical staff are often exposed to scattered X-rays. This study aims to propose a concept of a novel dosimetric system that can analyze both the X-ray incident angle and radiation exposure dose simultaneously. Our dosimeter consists of three active-type detectors. Absolute dose rates can be determined by the center detector, and the side detectors can derive incident direction. Incident windows of the side detectors have symmetrically-sloped titanium filters to enlarge the angular dependence. These filters create a difference in the responses measured by the left and right detectors when X-rays are incident to a centered position; from this, the incident angle of the X-rays can be calculated. To verify the concept, basic experiments using a clinical fluoroscopic system were performed. It was found that our dosimeter can derive the incident angle of X-rays between ± 50° and determine the absolute dose with proper angular dependence correction. Furthermore, a fluoroscopic procedure was mimicked using a human body phantom and a mannequin on which our dosimeter with a wearable optical camera was placed. Although commercial dosimeters can determine exposure doses with a systematic uncertainty of ± 13.4%, our dosimetric system can analyze absolute exposure doses with a systematic uncertainty of ± 4.2%.

Radiation Dose Exposure to Patients During Transcatheter Patent Ductus Arteriosus Closure via the Arterial Route

Objective This study aims to evaluate the radiation dose for transcatheter patent ductus arteriosus (PDA) viathe arterial route and compare it with previously published benchmarks. Background Exposure to radiation in the catheterization lab can cause skin injury and cancer in the long run, especially in pediatric patients with complex heart conditions, which necessitate serial catheterizations. Therefore, measuring the patient radiation dose and establishing a benchmark for each cardiac interventional procedure is essential. Material and methods In this prospective study, 34 patients with transcatheter patent ductus arteriosus closure via an arterial route were included. Patients who had silent PDAs, no left heart dilatation and PDA size of less than 2mm had PDA closed via an arterial route. All the study group patients received an Amplatzer duct occluder II-additional size device (St. Jude Medical Corp, St. Paul, MN) using biplane flat-panel fluoroscopy equipment adjusted in accordance with the pediatric parameters. Patients' dose area product, air kerma and fluoroscopytime were recorded in the catheterization lab and finally compared with internationally published reference data. Results Of 73 patients who had transcatheter patent ductus arteriosus closure between April 2021 to December 2021, 34patients who had a PDA closure via an arterial route were enrolled. The median age and weight were 11.5 (4-168) months and 10.5 (6-31) kg. Twenty-one (61.8%) were males, and 13 (38.2%) were males. The median radiation dose parameters were as follows: air kerma 11 (3-42) milliGray, dose area product 131 (33-443) microGray per m2, median dose area product indexed to weight 12 (1-48) microGray m2 per kg, fluoroscopy time 2 (2-4) min and frame rate 15 (7.5-15) frames per second. Due to many factors, our radiation dose parameters were less than internationally published reference values for transcatheter PDA closure. Conclusion Patient selection, detailed pre-catheterization echocardiography and procedure planning are essential for accomplishing device closure of PDA with a significant reduction in radiation dose. Hemodynamic assessment in the catheterization lab is unnecessary for most PDA patients. Additionally, a next-generation imaging platform equipped with flat-panel detectors and adjusted for pediatric settings and a fluoro recording option can be used to reduce radiation exposure.

Complications of TAVR From an Anesthesia Perspective.

Description Transcatheter aortic valve replacement (TAVR) has become the predominant technique for aortic valve replacement in the United States. Initially approved for high surgical risk patients, TAVR is now approved for most patients requiring valve therapy, including younger, lower-risk patients. The procedure is ideally performed in a hybrid operating room equipped with fluoroscopic equipment and transesophageal echocardiogram (TEE) imaging that can be viewed simultaneously by the operating team. The operating room should also be equipped to allow initiation of cardiopulmonary bypass, if necessary. Cardiac anesthesia teams are often involved with the management of these patients. This mini-review is designed to summarize potential complications that anesthesiologists may contend with during TAVR.

Dosimetry assessment for mobile c-arm: use of badge attached to the equipment

The use of fluoroscopy equipment in surgical procedures exposes professionals to ionizing radiation. An important safety aspect is the correct use of personal protective equipment and monitoring of dose levels in workers. In Brazil, the Resolution of the Collegiate Board of Directors (RDC) No. 330/2019 demands the use of individual dosimeter for professionals who exceed the public dose limits. However, when personal dosimeters are not available, the International Atomic Energy Agency (IAEA) recommends attaching a dosimeter to the C-Arm, close to the detector, to estimate the dose received by medical personnel. The objective of this research was to evaluate the levels of exposure in professionals during surgical procedures in the operation room. This analysis was performed by placing OSL dosimeters on the C-arm equipment for eleven months and comparing them with the quantitative values extracted from the equipment in the routine. Two mobile fluoroscopies C-Arm equipment were used in this study. A total of 1231 procedures were evaluated, with a mean dose value of 5.8µSv per procedure. Thus, the maximum number of procedures that the same professional can perform was 140 procedures per day for a staff member considering worker dose limits and 7 procedures per day for staff members using the required protective aprons considering the public dose limits. Although the study shows that the dose limits established by regulatory bodies are above the doses recorded in clinical practice, this situation should not promote false safety in the use of ionizing radiation.

Minimizing the risk of patient head injury in cardiac catheterization laboratory

Purpose: Head injury is a reportable event in hospital. Although the occurrence of unexpected head injury during cardiac catheterization examination is somewhat unpredictable, it is believed that to a certain extent, this type of unexpected head injury may be preventable, or at least the risk can be minimized.Methods: The National Heart Centre Singapore (NHCS) nursing team, together with Singapore Institute of Technology (SIT) faculty members from Health and Social Sciences and Engineering clusters, aimed to design a “protective Guard” that could easily be mounted onto the diagnostic fluoroscopic imaging equipment, for the purpose of minimize the risk of head injury that caused by patients who may suddenly tried to get up or lift up his head and hit their head against the diagnostic fluoroscopic imaging machine during cardiac invasive procedure.Results: A disposable “Protective Guard” was manufactured by SIT with inputs from the NHCS Cardiac Catherization Laboratory team. It can easily be mounted and dismantled and can effectively serve as a shock absorbent if the head hit against the diagnostic fluoroscopic imaging machine. The staff in the Cardiac Catheterization Laboratory were given some samples for trial. Their responses on user satisfaction survey were very good.Conclusion: As part of the spirit of continuous improvement, the NHCS nursing team has constantly been on the lookout for areas to improve patient experience and address preventable issues.Here, we are showcasing a collaborative qualitative improvement project between SIT and NHCS on minimizing the potential risk of patient head injury during cardiac invasive procedures. Although head injury incident is extremely rare, it has a significant impact to the hospital and staff working in the Cardiac Catheterization Laboratory. Indeed, patient safety and experience always the no.1 priority in the healthcare industry. Purpose: Head injury is a reportable event in hospital. Although the occurrence of unexpected head injury during cardiac catheterization examination is somewhat unpredictable, it is believed that to a certain extent, this type of unexpected head injury may be preventable, or at least the risk can be minimized. Methods: The National Heart Centre Singapore (NHCS) nursing team, together with Singapore Institute of Technology (SIT) faculty members from Health and Social Sciences and Engineering clusters, aimed to design a “protective Guard” that could easily be mounted onto the diagnostic fluoroscopic imaging equipment, for the purpose of minimize the risk of head injury that caused by patients who may suddenly tried to get up or lift up his head and hit their head against the diagnostic fluoroscopic imaging machine during cardiac invasive procedure. Results: A disposable “Protective Guard” was manufactured by SIT with inputs from the NHCS Cardiac Catherization Laboratory team. It can easily be mounted and dismantled and can effectively serve as a shock absorbent if the head hit against the diagnostic fluoroscopic imaging machine. The staff in the Cardiac Catheterization Laboratory were given some samples for trial. Their responses on user satisfaction survey were very good. Conclusion: As part of the spirit of continuous improvement, the NHCS nursing team has constantly been on the lookout for areas to improve patient experience and address preventable issues. Here, we are showcasing a collaborative qualitative improvement project between SIT and NHCS on minimizing the potential risk of patient head injury during cardiac invasive procedures. Although head injury incident is extremely rare, it has a significant impact to the hospital and staff working in the Cardiac Catheterization Laboratory. Indeed, patient safety and experience always the no.1 priority in the healthcare industry.

Demonstration of Use of a Novel 3D Printed Simulator for Mitral Valve Transcatheter Edge-to-Edge Repair (TEER).

Mitral regurgitation is a common valvular disorder. Transcatheter edge-to-edge repair (TEER) is a minimally invasive technique which involves holding together the middle segments of the mitral valve leaflets, thereby reducing regurgitation. To date, MitraClip™ is the only Food and Drug Administration (FDA)-approved device for TEER. The MitraClip procedure is technically challenging, characterised by a steep learning curve. Training is generally performed on simplified models, which do not emphasise anatomical features, realistic materials, or procedural scenarios. The aim of this study is to propose a novel, 3D printed simulator, with a major focus on reproducing the anatomy and plasticity of all areas of the heart involved and specifically the ones of the mitral valve apparatus. A three-dimensional digital model of a heart was generated by segmenting computed tomography (CT). The model was subsequently modified for: (i) adding anatomical features not fully visible with CT; (ii) adapting the model to interact with the MitraClip procedural equipment; and (iii) ensuring modularity of the system. The model was manufactured with a Polyjet technology printer, with a differentiated material assignment among its portions. Polypropylene threads were stitched to replicate chordae tendineae. The proposed system was successfully tested with MitraClip equipment. The simulator was assessed to be feasible to practice in a realistic fashion, different procedural aspects including access, navigation, catheter steering, and leaflets grasping. In addition, the model was found to be compatible with clinical procedural imaging fluoroscopy equipment. Future studies will assess the effect of the proposed training system on improving TEER training.

Diagnostic Reference Levels for Fluoroscopy-guided Gastrointestinal Procedures in Japan from the REX-GI Study: A Nationwide Multicentre Prospective Observational Study

SummaryBackgroundDiagnostic reference levels (DRLs) are required to optimize medical exposure. However, data on DRLs for interventional fluoroscopic procedures are lacking, especially in gastroenterology. This study aimed to prospectively collect currently used radiation doses and help establish national DRLs for fluoroscopy-guided gastrointestinal procedures in Japan.MethodsThis multicentre, prospective, observational study collected actual radiation dose data from endoscopic retrograde cholangiopancreatography (ERCP), interventional endoscopic ultrasound (EUS), balloon-assisted enteroscopy (BAE), enteral metallic stent placement, and enteral tube placement from May 2019 to December 2020. The study outcomes were fluoroscopy time (FT: min), air kerma at the patient entrance reference point (Ka,r: mGy), air kerma area product (PKA: Gycm2), and radiation dose rate (RDR: mGy/min). Additionally, the basic settings of fluoroscopy equipment and the factors related to each procedure were investigated. This study was registered in the UMIN Clinical Trial Registry (UMIN 000036525).FindingsOverall, 12959 fluoroscopy-guided gastrointestinal procedures were included from 23 hospitals in Japan. For 11162 ERCPs, the median/third quartile values of Ka,r (mGy), PKA (Gycm2), and FT (min) were 69/145 mGy, 16/32 Gycm2, and 11/20 min, respectively. Similarly, these values were 106/219 mGy, 23/41 Gycm2 and 17/27 min for 374 interventional EUSs; 53/104 mGy, 16/32 Gycm2 and 10/15 min for 523 metallic stents; 56/104 mGy, 28/47 Gycm2, and 12/18 min for 599 tube placements; and 35/81 mGy, 16/43 Gycm2 and 7/15 min for 301 BAEs, respectively. For the overall radiation dose rate, the median/third quartile values of RDR were 5.9/9.4 (mGy/min). The RDR values at each institution varied widely.InterpretationThis study reports the current radiation doses of fluoroscopy-guided gastrointestinal procedures expressed as DRL quantities. This will serve as a valuable reference for national DRL values.FundingThis work was supported by a clinical research grant from the Japanese Society of Gastroenterology.

Transthoracic echo-guided pacemaker implantation reduces fluoroscopic use in dogs

Echocardiographic guidance provides an alternative method when fluoroscopy is unavailable, equipment or power failure of fluoroscopic equipment during a procedure occurs or to decrease radiation risk. Recently, transthoracic (TTE) and transesophageal echocardiography were reported as an alternative method to guide interventional procedures in dogs. Therefore, we hypothesized that TTE could be used as an alternative method to visualize endocardial leads during pacemaker implantation in dogs, largely avoiding the use of fluoroscopy. A prospective consecutive case series of pacemaker implantation was performed using TTE guidance. The endocardial lead was imaged by TTE during its intracardiac advancement until the lead tip was positioned at the right ventricular apex. Echocardiographic right parasternal views, optimized to visualize the pacing lead, were used, starting with a short axis image of the right atrium and ending with a long axis view of the right ventricle (RV) optimized to image the RV apex. Proper lead placement was confirmed by both capture threshold, impedance and fluoroscopy.Twenty-one pacemaker implantation procedures by TTE monitoring were successfully performed. The TTE guidance provided images of a quality sufficient to clearly monitor implantation in real-time and allowed for immediate corrections to pacing lead malpositioning or excessive looping. Fluoroscopy was used to confirm the correct placement of the lead that was guided echocardiographically in the initial three procedures, after which a single radiographic image (no cine-mode) was used to identify lead placement and redundancy in the remaining eighteen cases. Static imaging (radiography using the fluoroscope) was used to assess the proper lead redundancy in all procedures because this cannot be evaluated echocardiographically. Pacemaker leads were successfully implanted in the RV of dogs using TTE monitoring. A larger cases series is needed for validation of safety and effectiveness of TTE during this interventional procedure in dogs.