Interventional Cardiology Procedures Research Articles

Cardiologist’s exposure to radiation in cath lab measured with InstadoseTM dosimeter

Introduction: complex fluoroscopy-guided interventional procedures in cardiology are known to result in higher radiation doses for patients and staff. Purpose: to estimate the equivalent dose received in different regions of the cardiologist’s body in catheterism (CATH) and percutaneous coronary intervention (PCI) procedures, as well as to evaluate the effectiveness of monitoring the doses in the catheritization laboratory (cath lab) using a direct ion storage dosimeter. Materials and methods: the InstadoseTM and the thermoluminescent dosimeters (TLD-100) were fixed simultaneously in the following regions of the cardiologist’s body: near the eyes (left and right), the trunk region (over the lead apron) and the left ankle. Occupational doses were recorded during 86 procedures (60% CATH). Results: catheterization procedures showed third quartile dose values near to the left eye region equal to 0.10 mSv (TLD-100) and 0.12 (InstadoseTM) and for intervention 0.15 mSv (TLD-100 and InstadoseTM). The doses measured in the trunk region, over the lead apron, were about 13% higher for catheterization procedures and 20% higher for intervention procedures compared to left eye region measurements. The Wilcoxon–Mann–Whitney test was applied for unpaired data for all body regions, comparing the data obtained between the TLD-100 and InstadoseTM dosimeters. For CATH and PCI, the responses of the TLD-100 and InstadoseTM dosimeters are considered equal for all analysed regions (p > 0.05) with the exception of the right eye region. Conclusion: the InstadoseTM passive dosimeter can be useful as a complementary assessment in the monitoring of a cardiologist’s personal occupational doses in the cath lab.

Effectiveness of staff radiation protection devices for interventional cardiology procedures

PurposeTo evaluate the effectiveness of currently available radioprotective (RP) devices in reducing the dose to interventional cardiology staff, especially to the eye lens and brain. MethodsThe performances of five RP devices (masks, caps, patient drapes, staff lead and lead-free aprons and Zero-Gravity (ZG) suspended radiation protection system) were assessed by means of Monte Carlo (MC) simulations. A geometry representative of an interventional cardiology setup was modelled and several configurations, including beam projections and staff distance from the source, were investigated. In addition, measurements on phantoms were performed for masks and drapes. ResultsAn average dose reduction of 65% and 25% to the eyes and the brain respectively was obtained for the masks by MC simulations but a strong influence of the design was observed. The cap effectiveness for the brain ranges on average between 13% and 37%. Nevertheless, it was shown that only some upper parts of the brain were protected. There was no significant difference between the effectiveness of lead and lead-free aprons. Of all the devices, the ZG system offered the highest protection to the brain and eye lens and a protection level comparable to the apron for the organs normally covered. ConclusionAll investigated devices showed potential for dose reduction to specific organs. However, for masks, caps and drapes, it strongly depends on the design, exposure conditions and staff position. Therefore, for a clinical use, it is recommended to evaluate their effectiveness in the planned conditions of use.

Patient radiation dose during diagnostic and interventional cardiology procedures: A study in a tertiary hospital

BackgroundFluoroscopy-guided diagnostic and interventional cardiology (IC) procedures help to identify and treat several problems associated with the heart. However, these procedures expose patients, cardiologists, radiographers, and nurses to radiation doses. Due to the risk that ionizing radiation poses, concerns have been raised and studies are continually being done to ensure that optimization is achieved during such procedures. This study assessed patient radiation dose during diagnostic and interventional cardiology procedures as well as right heart studies at a tertiary hospital in Ghana to formulate the facility's diagnostic reference levels (DRLs) for optimization purposes. As this study was the first of its kind in Ghana, it was a vital step towards dose optimization within the local department, as well as contributing to future DRLs in Ghana. MethodsThe study collected dose (air kerma, and kerma area product (KAP) and procedural data, and assessed any correlation between parameters such as fluoroscopy time and KAP, and between body mass index (BMI) and KAP. The DRL values were determined as the 75th percentile level for the dose distribution for the various IC procedures including percutaneous coronary interventions (PCI), coronary angiography (CA), and right heart catheterization (RHC). Data were analyzed using SPSS version 23. ResultsCA was the most frequently performed IC procedure (77.3%), while RHC was the least recorded (3.3%). The highest mean KAP was observed during the PCI procedure. The proposed diagnostic reference levels (DRLs) were 162.0 Gy.cm2 (PCI), 69.4 Gy.cm2 (CA), 39.8 Gy.cm2 (RHC) and 159.9 Gy.cm2 (CA+PCI). Patients who presented for the CA+PCI and RHC procedures received the highest and lowest mean KAP of 159.9 Gy.cm2 and 39.8 Gy.cm2 of radiation respectively. ConclusionThis study, therefore, concludes that there is a need for dose optimization of radiation exposures for IC procedures at the cardiothoracic center in Ghana.

Clinical Outcome of Intravascular Ultrasound Guided Percutaneous Coronary Intervention of Isolated Ostial Left Anterior Descending Artery Lesions

Purpose: Despite recent advances in interventional cardiology procedures, isolated ostial left anterior descending (LAD) lesions remain a challenge in cardiology. Due to the probability of left main (LM) affection, an LM bifurcation stenting technique may be required in certain individuals. So we evaluated result of Intravascular Ultrasound (IVUS) guided percutaneous coronary intervention (PCI) in isolated LAD coronary artery lesions, either by crossing over the ostium or not, with a focus on major adverse cardiovascular events (MACE).
 Methodology: Our prospective study from January2021 to November 2022 included 79 isolated ostial LAD patients with Ostial LAD stenting (OS) or LM to LAD cross-over (CO) stenting at the National Heart Institute. As per the recommended guidelines, the participants were divided into two groups: the first one had IVUS guided PCI and Group (2) had Angiography guided PCI. The data was collected and statistically analyzed with SPSS 23.0 program.
 Findings: No statistically significant difference was present between the groups regarding socio-demographic or clinical data (P-value > 0.05). It was discovered that an increase in Rotablator use, a decrease in Fluoroscopy time (min), a decrease in Contrast volume (ml), and a decrease in PCI duration (min) in patients who had IVUS guided PCI, with statistically significant difference when compared to other group who had Angiography guided PCI (P-value < 0.05). In addition, it was discovered that an increase in the necessity for a cross-over stenting method in group (1), with no statistically significant difference (P-value > 0.05). High prevalence of mortality and morbidity among IVUS guided PCI patients was present with statistical significance regarding TVR (P-value < 0.05).
 Recommendations: IVUS can offer valuable information on vascular lumen, plaque features, stent deployment, & device failure causes. As a result, IVUS-guided PCI may enhance clinical impact among participants, particularly those with complicated coronary lesions & those at high risk. Further reduction in IVUS’s cost, cardiologists’ education and enhancing IVUS use at PCI should be adapted next.

Post-mortem distribution of Iodinated Contrast Media (ICM) (iodixanol versus iopromide) in the porcine kidney after multiple bolus injections in vivo into the supra-renal aorta1.

Iodinated contrast media (ICM) are widely used for diagnostic and interventional procedures in radiology and cardiology. Ideally, they should not interact with blood cells or vascular wall cells to avoid deteriorations of the blood circulation. However, it is well known that ICM can affect erythrocytes as well as endothelial cells which consequently might perturb especially the microcirculation. In former studies the influence of two ICM (iodixanol versus iopromide) on the vascular system, the development of blood stasis, on changes in renal resistive index (RRI) and vascular diameters, and on the post-mortem distribution of iodine as marker for ICM in the explanted kidneys was examined. The modus of ICM application into the supra-renal aorta followed the regime in interventional cardiology, so that 10 bolus injections were administered at steady intervals (iopromide 4,32 ml / iodixanol 5 ml) accompanied by infusion of 500 ml isotonic NaCl-solution.In the present study, the post-mortem X-ray analysis revealed that there were no differences in iodine content in the regions of the mid-cortex and the medullo-pelvic transition zone of the kidneys after application of both ICM. Remarkable differences, however, were found in the region of the capsule-near cortex, where the application of iopromide led to a significantly lower iodine content in the microcirculation. This is in good agreement with former studies, in which a maldistribution in this area, presumably due to a decrease in arteriolar inflow as a result of stasis/occlusion was shown.

Apport de la fusion d'images de scanner en salle de cathétérisme

Fusion imaging is developing fast, allowing improvements in interventional cardiology procedures workup and guidance. Computed-tomography (CT) scan and fluoroscopy fusion guidance used in procedures such as left appendage occlusion or perivalvular leak closure permit prediction and simulation of the appropriatedevice, as well as implantation guidance. In the era of tailored medicine, CT/fluoroscopy fusion imaging guidance is an interesting tool for individualizing and adapting the devices implanted to each patient, as well as improving the outcomes and safety of each procedure.

Mechanical circulatory support in ventricular arrhythmias.

In atrial and ventricular tachyarrhythmias, reduced time for ventricular filling and loss of atrial contribution lead to a significant reduction in cardiac output, resulting in cardiogenic shock. This may also occur during catheter ablation in 11% of overall procedures and is associated with increased mortality. Managing cardiogenic shock and (supra) ventricular arrhythmias is particularly challenging. Inotropic support may exacerbate tachyarrhythmias or accelerate heart rate; antiarrhythmic drugs often come with negative inotropic effects, and electrical reconversions may risk worsening circulatory failure or even cardiac arrest. The drop in native cardiac output during an arrhythmic storm can be partly covered by the insertion of percutaneous mechanical circulatory support (MCS) devices guaranteeing end-organ perfusion. This provides physicians a time window of stability to investigate the underlying cause of arrhythmia and allow proper therapeutic interventions (e.g., percutaneous coronary intervention and catheter ablation). Temporary MCS can be used in the case of overt hemodynamic decompensation or as a “preemptive strategy” to avoid circulatory instability during interventional cardiology procedures in high-risk patients. Despite the increasing use of MCS in cardiogenic shock and during catheter ablation procedures, the recommendation level is still low, considering the lack of large observational studies and randomized clinical trials. Therefore, the evidence on the timing and the kinds of MCS devices has also scarcely been investigated. In the current review, we discuss the available evidence in the literature and gaps in knowledge on the use of MCS devices in the setting of ventricular arrhythmias and arrhythmic storms, including a specific focus on pathophysiology and related therapies.

A Hybrid Catheter Localisation Framework in Echocardiography Based on Electromagnetic Tracking and Deep Learning Segmentation.

Interventional cardiology procedure is an important type of minimally invasive surgery that deals with the catheter-based treatment of cardiovascular diseases, such as coronary artery diseases, strokes, peripheral arterial diseases, and aortic diseases. Ultrasound imaging, also called echocardiography, is a typical imaging tool that monitors catheter puncturing. Localising a medical device accurately during cardiac interventions can help improve the procedure's safety and reliability under ultrasound imaging. However, external device tracking and image-based tracking methods can only provide a partial solution. Thus, we proposed a hybrid framework, with the combination of both methods to localise the catheter tip target in an automatic way. The external device used was an electromagnetic tracking system from North Digital Inc (NDI), and the ultrasound image analysis was based on UNet, a deep learning network for semantic segmentation. From the external method, the tip's location was determined precisely, and the deep learning platform segmented the exact catheter tip automatically. This novel hybrid localisation framework combines the advantages of external electromagnetic (EM) tracking and the deep learning-based image method, which offers a new solution to identify the moving medical device in low-resolution ultrasound images.

ANGIOGRAPHIC PREDICTORS OF CTO PCI SUCCESS: HOW TO GUIDE DECISION MAKING BEYOND THE J-CTO SCORE

ANGIOGRAPHIC PREDICTORS OF CTO PCI SUCCESS: HOW TO GUIDE DECISION MAKING BEYOND THE J-CTO SCORE

Eye lens dose assessment in interventional cardiology

Introduction: Medical professionals performing fluoroscopy guided interventional procedures in cardiology are exposed to a risk of radiation induced cataract, especially if the eye lens dose exceeds the annual dose limit of 20 mSv. Aim: The aim of the current study is to measure the eye lens exposure in three interventional cardiology departments, to analyze the relationship between patient dose and eye lens dose and to study the effectiveness of lead goggles without side protection. Material and methods: Measurements were performed in three departments with participation of 4 interventional cardiologists and 6 nurses. The exposure of the eye lens was measured with EYE-DTM (Radcard) passive dosimeters. Results: For nurses the annual eye lens dose varied from 1.6 mSv to 4.3 mSv. For the interventional cardiologists the results were between 3.2 mSv and 31.4 mSv. The dose reduction factor of the studied safety goggles without side protection is 1 and 1.1. Conclusions: There is a risk of exceeding the annual exposure limit of 20 mSv among interventional cardiologists The eye lens exposure depends on the workload and the clinical complexity of the procedures, as well as on the use of radiation protection devices. Due to the specifics of the procedures, the use of goggles with side protection is recommended. The eye lens dose for nurses is lower than the annual limit, which can be explained with the larger distance between the patient and the nurses and partial shielding by the main operator. Lead glasses without side shielding are not recommended because the exposure occurs from the side.

ON THE PLACEMENT OF APRON DOSEMETERS AND DOSE ASSESSMENT IN INTERVENTIONAL CARDIOLOGY PROCEDURES: PRELIMINARY RESULTS.

Personnel involved in interventional practices are likely to be exposed to higher radiation doses than other workers in the medical field. Personnel monitoring and radiation protection measures play a crucial role in keeping these doses below the limits. EURADOS (European Radiation Dosimetry Group) Working Group 12 performed a series of investigations showing how the complexity of the scattered field reaching the operators can influence the doses to the operators. The present work was aimed at determining the possible effects on the registered doses of the scattered field and the actual position of a dosemeter on apron. This study has been performed through Monte Carlo simulations and it was validated through measurements. It does not claim to identify the 'best' position for the dosemeter, but to assess the variability of its response, showing how a variability of the order of +/- 30% to 40 should be taken into account.

Evaluation of a Direct Ion Storage dosimeter efficiency to measure dose during interventional cardiology procedures

Intracardiac electrophysiological invasive procedures guided by fluoroscopy aim to study the cardiac depolarization process. Depending on the complexity of the clinical case, both patients and professionals are subjected to radiation for a prolonged period. This work evaluated if a direct ions storage (DIS) dosimeter could measure occupational doses in different regions of the physician's body during these procedures. Doses were monitored close to the left eye (LE), right eye (RE), extremity (left ankle), and thorax, as well as the environmental dose, positioning the dosimeter in the center of the equipment gantry. These doses were evaluated in 31 procedures using 01 DIS dosimeter in each region. The Mann-Whitney U test demonstrated that the values obtained in the different regions represent different samples, while the Spearman test demonstrated that there is no evidence that there is a correlation between the data recorded in the different regions. DIS was effective in recording the doses in the LE region and the doses of dispersed radiation (Arc), with the values obtained: (30 quartile / maximum): LE (0.07 / 0.20 mSv); Arc (0.38 / 1.53 mSv). It was not possible to compare occupational doses between different regions of the physician's body, limiting its use as a complementary monitor in the control of occupational doses.

Harnessing the parallax for better spatial awareness.

Despite easy access to imaging diagnostic procedures and an abundance of spatial data, most cardiac interventions are still performed under two-dimensional fluoroscopy. Incorporating anatomical data from scans into procedures plans has the potential to improve the swiftness and outcomes of percutaneous cardiac interventions. Therefore, procedure planning based on the specific anatomy is becoming a new standard of excellence in interventional cardiology. Still, we often tend to disregard specific spatial relations and the actual direction of catheter tip movement inside the body, relying on a try and error approach. The precise spatial orientation of instruments and prosthetic devices is crucial, especially during structural heart interventions. Here, we present how deliberate movements of objects under fluoroscopy can reveal the spatial orientation of catheters and other devices. We also propose a novel "two-point rule" for identifying three-dimensional relations between points in space. Understanding and applying this rule might substantially increase the spatial awareness of operators performing cardiovascular interventions. Although the concept is pretty simple, using it "live" during interventional cardiology procedures requires thorough understanding and practice. We propose the "two-point rule" as a crucial rule to develop expertise in spatial orientation under fluoroscopy and ensure high-quality outcomes.

Thermoluminescent response of LaAlO3:Pr3+ under X-ray beams effect

Thermoluminescent (TL) dosimeters are the most used, since they can store information, due to exposure to radiation. Rare earth doped lanthanum aluminate (LaAlO3) ceramic has attracted great attention in recent years for many applications because it shows excellent properties such as thermal stability, color light emission as well as high thermoluminescent intensity. In the present work, TL glow curve under diagnostic X-ray beam was obtained. According to the literature, procedures in interventional cardiology are Thermoluminescent glow curve was analyzed using a Harshaw 3500 TL reader coupled to a personal computer for storage information and future analysis. For irradiation processes was used a diagnostic X-ray source Siemens 256-slice computed tomography (CT) Somaton drive model. TL response of trivalent praseodymium doped lanthanum aluminate as a function of dopant concentration was increasing as concentrations of Pr3+ ion in LaAlO3 was increased. The increase in TL glow peak sensitivity was increased up to 2 % concentration of Pr3+ ion. This TL glow curve exhibited a broad peak centered at 190°C and little shoulder which is consider as the second peak centered at 260°C respectively. The nature of the glow curve form in samples is attributed to at least one type of the trap with relates at least one type of the defect. After experimental results LaAlO3:Pr3+ can be used as thermoluminescent material for diagnostic X-ray beams measurements.

Setting up regional diagnostic reference levels for pediatric interventional cardiology in Latin America and the Caribbean countries: preliminary results and identified challenges

The goal of the present study was to propose a set of preliminary regional diagnostic reference levels (DRLs) for pediatric interventional cardiology (IC) procedures in Latin America and the Caribbean countries, classified by age and weight groups. The study was conducted in the framework of the Optimization of Protection in Pediatric Interventional Radiology in Latin America and the Caribbean program coordinated by the World Health Organization and the Pan American Health Organization in cooperation with the International Atomic Energy Agency. The first step of the program was focused on pediatric IC. Dose data from diagnostic and therapeutic procedures were collected between December 2020 and December 2021. Regional DRLs were set as the third quartile of patient dose data (kerma area product) collected in 18 hospitals from 10 countries in an initial sample of 968 procedures. DRLs were set for four age bands and five weight ranges. The values obtained for the four age bands (<1 yr, 1 to <5 yr, 5 to <10 yr and 10 to <16 yr) were 2.9, 6.1, 8.8 and 14.4 Gy cm2 for diagnostic procedures, and 4.0, 5.0, 10.0 and 38.1 Gy cm2 for therapeutic procedures, respectively. The values obtained for the five weight bands (<5 kg, 5 to <15 kg, 15 to <30 kg, 30 to <50 kg and 50 to <80 kg) were 3.0, 4.5, 8.1, 9.2 and 26.8 Gy cm2 for diagnostic procedures and 3.7, 4,3, 7.3, 16.1 and 53.4 Gy cm2 for therapeutic procedures, respectively. While initial data were collected manually as patient dose management systems (DMSs) were not available in most of the hospitals involved in the program, a centralized automatic DMS for the collection and management of patient dose indicators has now been introduced and is envisaged to increase the sample size. The possibility of alerting on high dose values and introducing corrective actions will help in optimization.

FDXR Gene Expression after in Vivo Radiation Exposure of Pediatric Patients Undergoing Interventional Cardiology Procedures.

Ferredoxin reductase (FDXR) has already been reported as a promising biomarker for estimating radiation doses in radiotherapy. This study aimed to investigate the responsiveness of FDXR on pediatric population exposed to ionizing radiation (X-rays) during pediatric interventional cardiology (IC) procedures. Peripheral blood was collected by venipuncture from 24 pediatric donors before and 24 hours after the IC procedure. To estimate the effective dose, demographic data and Air Kerma-Area Product (PKA) were recorded for each patient. The relative quantification (RQ) of the FDXR gene in irradiated patient blood samples compared to the non-irradiated blood samples was determined using qPCR analysis. The relative values of FDXR were log- transformed. The effective dose ranged from 0.002 mSv to 8.004 mSv. Over this radiation exposure range, the FDXR gene expression varied randomly with the effective dose. Up-regulation in FDXR expression was observed in 17 patients and down-regulation in 7 patients. Further studies in a larger cohort of pediatric patients along with the record of clinical data are needed to determine whether FDXR gene expression is an effective biomarker for radiation exposure estimation in pediatric imaging.

Randomized comparison of atrioventricular node re-entry tachycardia and atrial flutter catheter ablation with and without fluoroscopic guidance: ZeroFluoro study.

Interventional cardiology procedures may expose patients and staff to considerable radiation doses. We aimed to assess whether exposure to ionizing radiation during catheter ablation of supraventricular tachycardia (SVT) can be completely avoided. In this prospective randomized study, patients with SVT (atrioventricular re-entrant tachycardia n = 94, typical atrial flutter n = 29) were randomly assigned in a 1:1 ratio to catheter ablation with conventional fluoroscopic guidance (CF group) or with the EnSite Precision mapping system [zerofluoro (ZF) group]. Acute procedural parameters, increased stochastic risk of cancer incidence and 6-month follow-up data were assessed. Between May 2019 and August 2020, 123 patients were enrolled. Clinical parameters were comparable. Median procedural time was 60.0 and 58.0 min, median fluoroscopy time and estimated median effective dose were 240 s vs. 0 and 0.38 mSv vs. 0 and arrhythmia recurrence was 5% and 7.9% in the CF and ZF groups, respectively. The acute success rate was 98.4% in both groups. No procedure-related complications were reported. At an average age of 55.5 years and median radiation exposure of 0.38 mSv, the estimate of increased incidence was approximately 1 in 14 084. The estimated mortality rate was 1 per 17 857 exposed persons. The procedural safety and efficacy of the zero-fluoroscopic approach are similar to those of conventional fluoroscopy-based ablation for atrioventricular nodal re-entrant tachycardia and atrial flutter. Under the assumption of low radiation dose, the excessive lifetime risk of malignancy in the CF group due to electrophysiology procedure is reasonably small, whilst totally reduced in zero fluoroscopy procedures.

Performance evaluation of two interventional fluoroscope suites for cardiovascular imaging.

Interventional cardiology involves catheter‐based treatment of heart disease, generally through fluoroscopically guided interventional procedures. Patients can be subject to considerable radiation dose due to prolonged fluoroscopy time and radiographic exposure, and therefore efforts to minimize patient dose should always be undertaken. Developing standardized, effective quality control programs for these systems is a difficult task owing to cross‐vendor differences and automated control of imaging protocols. Furthermore, analyses of radiation dose should be performed in the context of its associated effects on image quality.The aim of the study is to investigate radiation dose and image quality in two fluoroscopic systems used for interventional cardiology procedures. Image quality was assessed in terms of spatial resolution and modulation transfer function, signal‐to‐noise and contrast‐to‐noise ratios, and spatial–temporal resolution of fluoroscopy and cineradiography images with phantoms simulating various patient thicknesses under routine cardiology protocols. The entrance air kerma (or air kerma rate) was measured and used to estimate entrance surface dose (or dose rate) in the phantoms.

Assessment of occupational dose reduction with the use of a floor mounted mobile lead radiation protection shield

With the increasing number and complexity of interventional cardiology procedures, there is the potential for higher occupational radiation doses to the interventionists. In order to reduce the radiation exposure to interventionists, a number of different radiation protection measures can be implemented; the most common of which being personal protective equipment in the form of a lead-equivalent apron. However, significant development has been achieved with mobile lead equivalent radiation protection devices, which provide enhanced radiation protection without the requirement of being directly worn by staff. The RAMPART M1128 radiation protection shield is one of these devices. The dose reduction provided to staff within a Cardiac Catheterisation Laboratory was assessed via the use of electronic personal dosimeters with the Philips live dosimetry system DoseAware (Philips DoseAware). A 60% dose reduction to the primary operator can be achieved with the Rampart device. Further dose reductions are possible for other individuals in the range of 65%–84%. Additionally, dose rate measurements were taken in a simulated clinical set-up using a phantom, which showed that the device provided a 65% dose reduction at eye level and a 90% dose reduction at chest level for the primary operator position. This significant dose reduction means that there is the potential for at least the primary operator to wear a lead apron of reduced lead equivalence specification when the Rampart device is in use, without increasing their occupational exposure and potentially reducing musculoskeletal pain due to the reduced weight.

Correlation between aortic valve calcification and routine laboratory test results in patients with aortic valve sclerosis

Background and Aims : Aortic valve calcification (AVC) has been associated with increased risk for cardiovascular disease and vascular thrombosis and has also been proposed as a predictor of adverse outcomes in many interventional cardiology procedures,such as the transcutaneous aortic valve replacement (TAVR).The aim of this study was to investigate and correlate biochemical measurements in patients with aortic sclerosis