Pediatric Cardiac Catheterization Research Articles

Radiation dosage during pediatric diagnostic or interventional cardiac catheterizations using the "air gap technique" and an aggressive "as low as reasonably achievable" radiation reduction protocol in patients weighing

Background:Cardiac catheterizations expose both the patient and staff to the risks of ionizing radiation. Studies using the “air gap” technique (AGT) in various radiological procedures indicate that its use leads to reduction in radiation exposure but there are no data on its use for pediatric cardiac catheterization. The aim of this study was to retrospectively review the radiation exposure data for children weighing <20 kg during cardiac catheterizations using AGT and an “as low as reasonably achievable (ALARA)” radiation reduction protocol.Patients and Methods:All patients weighing <20 kg who underwent cardiac catheterization at the Children's Hospital at Montefiore (CHAM), New York, the United States from 05/2011 to 10/2013 were included. Transplant patients who underwent routine endomyocardial biopsy and those who had surgical procedures at the time of the catheterizations were excluded. The ALARA protocol was used in concert with AGT with the flat panel detector positioned 110 cm from the patient. Demographics, procedural data, and patient radiation exposure levels were collected and analyzed.Results:One-hundred and twenty-seven patients underwent 151 procedures within the study period. The median age was 1.2 years (range: 1 day to 7.9 years) and median weight was 8.8 kg (range: 1.9-19.7). Eighty-nine (59%) of the procedures were interventional. The median total fluoro time was 13 min [interquartile range (IQR) 7.3-21.8]. The median total air Kerma (K) product was 55.6 mGy (IQR 17.6-94.2) and dose area product (DAP) was 189 Gym2 (IQR 62.6-425.5).Conclusion:Use of a novel ALARA and AGT protocol for cardiac catheterizations in children markedly reduced radiation exposure to levels far below recently reported values.Abbreviations: AGT: Air gap technique, ALARA: As low as reasonably achievable.

Characterization of MOSFET Dosimeter Angular Response Using a Spherical Phantom for Fluoroscopic Dosimetry.

Metal-Oxide Semiconductor Field-Effect Transistor (MOSFET) dosimeters, placed in anthropomorphic phantoms, are a standard method for organ dosimetry in medical x-ray imaging applications. However, many x-ray applications, particularly fluoroscopy procedures, use variable projection angles. During dosimetry, the MOSFET detector active area may not always be perpendicular to the x-ray beam. The goal of this study was to characterize the dosimeter's angular response in the fluoroscopic irradiation involved in pediatric cardiac catheterization procedures, during which a considerable amount of fluoroscopic x-ray irradiation is often applied from various projection angles. A biological x-ray irradiator was used to simulate the beam quality of a biplane fluoroscopy imaging system. A custom-designed acrylic spherical scatter phantom was fabricated to measure dosimeter response (in mV) in two rotational axes, axial (ψ) and normal-to-axial (θ), in 30° increments, as well as four common oblique angles used in cardiac catheterization: a) 90° Left Anterior Oblique (LAO); b) 70° LAO/ 20° Cranial; c) 20° LAO/ 15° Cranial; and d) 30° Right Anterior Oblique (RAO). All results were normalized to the angle where the dosimeter epoxy is perpendicular to the beam or the Posterior-Anterior projection angle in the clinical setup. The relative response in the axial rotation was isotropic (within ± 10% deviation); that in the normal-to-axial rotation was isotropic in all angles except the ψ = 270° angle, where the relative response was 83 ± 9%. No significant deviation in detector response was observed in the four common oblique angles, with their relative responses being: a) 102 ± 3%; b) 90 ± 3%; c) 92 ± 3%; and d) 95 ± 3%, respectively. These angular correction factors will be used in future dosimetry studies for fluoroscopy. The spherical phantom may be useful for other applications, as it allows the measurement of dosimeter response in virtually all angles in the 3-dimensional spherical coordinates.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Adjusting for Risk Associated With Pediatric and Congenital Cardiac Catheterization: A Report From the NCDR IMPACT Registry.

As US health care increasingly focuses on outcomes as a means for quantifying quality, there is a growing demand for risk models that can account for the variability of patients treated at different hospitals so that equitable comparisons between institutions can be made. We sought to apply aspects of prior risk-standardization methodology to begin development of a risk-standardization tool for the National Cardiovascular Data Registry (NCDR) IMPACT (Improving Pediatric and Adult Congenital Treatment) Registry. Using IMPACT, we identified all patients undergoing diagnostic or interventional cardiac catheterization between January 2011 and March 2013. Multivariable hierarchical logistic regression was used to identify patient and procedural characteristics predictive of experiencing a major adverse event after cardiac catheterization. A total of 19,608 cardiac catheterizations were performed between January 2011 and March 2013. Among all cases, a major adverse event occurred in 378 of all cases (1.9%). After multivariable adjustment, 8 variables were identified as critical for risk standardization: patient age, renal insufficiency, single-ventricle physiology, procedure-type risk group, low systemic saturation, low mixed venous saturation, elevated systemic ventricular end-diastolic pressure, and elevated main pulmonary artery pressures. The model had good discrimination (C statistic, 0.70), confirmed by bootstrap validation (validation C statistic, 0.69). Using prior risk-standardization efforts as a foundation, we developed and internally validated a model to predict the occurrence of a major adverse event after cardiac catheterization for congenital heart disease. Future efforts should be directed toward further refinement of the model variables within this large, multicenter data set.

Use of Smart Technology for Remote Consultation in the Pediatric Cardiac Catheterization Laboratory.

To evaluate the use of smartphone and tablet technology ("smart technology" or ST) in remote consultation for pediatric and congenital cardiac catheterization. Two online surveys, to early-career (Mentees) and senior (Mentors) pediatric interventional cardiologists, designed to assess the current use and attitudes toward ST for remote consultation. In addition, the current literature is reviewed for use of remote consultations and potential legal and patient privacy concerns. Forty-six (40%) Mentees and 19 (48%) Mentors responded. 74% of Mentees report using ST for remote consultation, 26% for nearly every case, with 45% of communication occurring during a procedure. Over one-third of Mentees report they have performed an intervention for the first time based on ST consultation. Of Mentors that reported receiving ST consultation, 58% were comfortable providing advice via this method, but 42% felt that the imaging sent was inadequate to provide appropriate advice for at least one case. Both groups felt the speed of consultation was much faster using ST. Privacy measures were reportedly used in up to 85% of consultations, while only 12% of respondents obtained informed consent for the consultation. The most common barrier identified by Mentees for use of ST for consultations was patient privacy concerns. ST use is prevalent among early-career pediatric and congenital interventional cardiologists for consultation regarding catheterization procedures. There are many technologic, legal, and patient privacy concerns that will need to be addressed as the use of ST for remote consultation grows.

Assessment of DNA double‐strand breaks induced by intravascular iodinated contrast media following in vitro irradiation and in vivo, during paediatric cardiac catheterization

Paediatric cardiac catheterizations may result in the administration of substantial amounts of iodinated contrast media and ionizing radiation. The aim of this work was to investigate the effect of iodinated contrast media in combination with in vitro and in vivo X-ray radiation on lymphocyte DNA. Six concentrations of iodine (15, 17.5, 30, 35, 45, and 52.5 mg of iodine per mL blood) represented volumes of iodinated contrast media used in the clinical setting. Blood obtained from healthy volunteers was mixed with iodinated contrast media and exposed to radiation doses commonly used in paediatric cardiac catheterizations (0 mGy, 70 mGy, 140 mGy, 250 mGy and 450 mGy). Control samples contained no iodine. For in vivo experimentation, pre and post blood samples were collected from children undergoing cardiac catheterization, receiving iodine concentrations of up to 51 mg of iodine per mL blood and radiation doses of up to 400 mGy. Fluorescence microscopy was performed to assess γH2AX-foci induction, which corresponded to the number of DNA double-strand breaks. The presence of iodine in vitro resulted in significant increases of DNA double-strand breaks beyond that induced by radiation for ≥ 17.5 mg/mL iodine to blood. The in vivo effects of contrast media on children undergoing cardiac catheterization resulted in a 19% increase in DNA double-strand breaks in children receiving an average concentration of 19 mg/mL iodine to blood. A larger investigation is required to provide further information of the potential benefit of lowering the amount of iodinated contrast media received during X-ray radiation investigations.

Use of local anesthetic (0.25% bupivacaine) for pain control after pediatric cardiac catheterization: A randomized controlled trial.

To investigate the effects of local infiltration of 0.25% bupivacaine on post-operative pain and analgesic use in children undergoing cardiac catheterization procedures. In pediatric catheterization procedures performed under general anesthesia, a local anesthetic is often used prior to femoral sheath removal. There are no published reports of the impact of local anesthetic infiltration on pain after pediatric procedures, and mixed reports on its effectiveness in adults. A randomized controlled trial was undertaken of 140 children, aged 7-18 years undergoing cardiac catheterization under general anesthesia via the femoral vein or artery. Participants received a subcutaneous infiltration of 0.25% bupivacaine at the access site prior to sheath removal, or usual care without bupivacaine. Outcomes included patient reported pain scores and analgesic use up to 6 hr after the procedure. Pain scores were similar between groups through the 6-hr post-procedure period. The proportion of children reporting a maximal pain score of ≤2/10 was higher in the bupivacaine group (64% vs. 44%, P = 0.03). A significantly higher proportion of children in the control group required IV morphine (18.8% vs. 4.5%, P = 0.02). Morphine use can be reduced with the use of 0.25% bupivacaine given prior to femoral sheath removal and should be considered for post-procedural pain control for pediatric patients undergoing cardiac catheterization. This study is the first to contribute evidence to the effectiveness of 0.25% bupivacaine after pediatric cardiac catheterization.

CRISP: Catheterization RISk score for Pediatrics: A Report from the Congenital Cardiac Interventional Study Consortium (CCISC).

We sought to develop a scoring system that predicts the risk of serious adverse events (SAE's) for individual pediatric patients undergoing cardiac catheterization procedures. Systematic assessment of risk of SAE in pediatric catheterization can be challenging in view of a wide variation in procedure and patient complexity as well as rapidly evolving technology. A 10 component scoring system was originally developed based on expert consensus and review of the existing literature. Data from an international multi-institutional catheterization registry (CCISC) between 2008 and 2013 were used to validate this scoring system. In addition we used multivariate methods to further refine the original risk score to improve its predictive power of SAE's. Univariate analysis confirmed the strong correlation of each of the 10 components of the original risk score with SAE attributed to a pediatric cardiac catheterization (P < 0.001 for all variables). Multivariate analysis resulted in a modified risk score (CRISP) that corresponds to an increase in value of area under a receiver operating characteristic curve (AUC) from 0.715 to 0.741. The CRISP score predicts risk of occurrence of an SAE for individual patients undergoing pediatric cardiac catheterization procedures.

Anaesthesia outside of the operating room: the paediatric cardiac catheterization laboratory.

The focus of cardiac catheterization has changed from principally a diagnostic procedure to providing therapeutic options at various stages of childhood and adult congenital heart disease. The paediatric cardiac catheterization laboratory functions as a 'satellite' operating room. Combined ('hybrid') procedures with interventional cardiologists and cardiac surgeons present additional challenges for anaesthesia. The increased patient and procedure complexity represents higher risk for anaesthesia-related adverse events. This review concentrates on the recent efforts to determine these patient and procedure-related risks. Multicentre registries have been developed, generating information regarding adverse events and patient outcomes. Standardized adverse events ratios allow comparisons between institutions and providers. Models to identify high-risk groups have been developed. Advances in paediatric cardiac catheterization have created significant challenges for delivering anaesthesia in this environment. Anaesthetists need to have an integral role in the cardiac catheterization team, understanding and anticipating the risks for patients and leading the organization of workflow. Techniques used to improve systems in the operating room have been introduced to the cardiac catheterization laboratory to promote patient safety.

Direct physician reporting is associated with reductions in radiation exposure in pediatric cardiac catheterizations.

The objective is to quantify radiation dose in children undergoing cardiac catheterization and determine the impact of increased reporting transparency on total radiation exposure. Cardiac catheterization (cath) can result in significant radiation exposure in children. There has been growing interest in quantifying and reducing radiation exposure in pediatric cath procedures. Our center underwent a slight change in practice recently that resulted in direct physician reporting of radiation dose following every case. We reviewed cath procedures across three different eras in four cath categories: post-heart transplant annual cath, unilateral pulmonary artery (PA) stent placement, pre-Fontan cath, and pre-Glenn cath. The eras were defined as: Era 1, 1/2009-1/2011; Era 2, 1/2011-9/2013; and Era 3, 9/2013-5/2014. In Era 3, the physician performing the cath was responsible for reporting the radiation data. Across the three eras, there were significant decreases in cumulative air KERMA (mGy) among all four cath categories. From Era 2 to Era 3, the greatest decreases in radiation were noted, particularly in dose area product (cGy·cm2) in the transplant annual evaluation and pre-Glenn cases. In Era 1, 2 cases (1.2%) had a frame rate reduction, while in Era 2, 22 cases (12.0%), and in Era 3, 83 cases (21.6%) had frame rate changes (P<0.01). Increased physician awareness of radiation exposure is associated with a significant reduction in radiation dose across a variety of cath procedures. This is seen not only by the overall reduction in radiation across case types, but also as the frame rate was more frequently changed during individual cases, indicating an important change in physician behavior and practice.

Adverse events in pediatric cardiac catheterization: Initial experience of Sohag university hospital

Abstract Objective To determine incidence and risk factors of adverse events associated with pediatric cardiac catheterization in the initial experience of our institution. Patients and methods The retrospective cohort study was conducted on 262 children with congenital heart disease who received cardiac catheterization in our catheterization between April 2010 and April 2013. Diagnostic CC was performed in 176 patients and therapeutic CC in 86 patients. All children’s electronic and paper chart records were reviewed to obtain demographic, procedural, and treatment data. The severities of AE were further classified into minor, moderate and higher severity AE including levels 3, 4 or 5 AE. Results Of 262 patients (147 females, 55.4%), AE occurred in 31 studies (11.8%), in children ranging in age from 3 days to 16 years. There were 7 patients with higher severity AE (2.7%), 7 patients with moderate AE (2.7%) and 17 patients (6.5%) with minor AE. Vascular complications represented the majority (n = 12; 38.7%). Two children died within 24 h (0.7% of total case numbers). The risk factors for a complication included patient low body weight and the second year of our institution experience. Conclusions Pediatric cardiac catheterization by well trained team of pediatric cardiologists in a new center is effective. The rate of occurrence of AEs approximated to those which are reported by various interventional pediatric cardiology centers around the world. The lower body weight and the second year of initial experience are risk factors for occurrence of AE.

Optimization of dose and image quality of paediatric cardiac catheterization procedure

The purpose of this study is to quantify the quality of the available imaging modes for various iodine-based contrast agent concentration in paediatric cardiology. The figure of merit (FOM) was defined as the squared signal to noise ratio divided by a patient dose related parameter. An in house constructed phantom simulated a series of vessel segments with iodine concentrations from 10% or 30 mg/cc to 16% or 48 mg/cc of iodine in a blood plasma solution, all within the dimensional constraints of a paediatric patient. The phantom also used test inserts of tin (Sn). Measurements of Entrance Surface Air Kerma (ESAK) and exit dose rate were performed along with calculations of the signal-to-noise ratio (SNR) of all the objects. A first result showed that it was favourable to employ low dose fluoroscopy mode and lower frame rate modes in cine acquisition if dynamic information is not critical. Normal fluoroscopy dose mode provided a considerably higher dose level (in comparison to low dose mode) with only a slight improvement in SNR. Higher frame rate cine modes should be used however when the clinical situation dictates so. This work also found that tin should not be intended as iodine replacement material for research purposes due to the mismatching SNR, particularly on small vessel sizes.

Balloon valvuloplasty for congenital aortic stenosis: Multi-center safety and efficacy outcome assessment.

To describe contemporary outcomes of balloon aortic valvuloplasty (BAVP) performed in 22 US centers. BAVP constitutes first-line therapy for congenital aortic stenosis (cAS) in many centers. We used prospectively-collected data from two active, multi-institutional, pediatric cardiac catheterization registries. Acute procedural success was defined, for purposes of this review, as a residual peak systolic gradient≤35 mm Hg and no more than mild aortic regurgitation (AR) for patients with isolated cAS. For patients with mixed aortic valve disease, a residual peak systolic gradient≤35 mm Hg without worsening of AR was considered successful outcome. In 373 patients with a median age of 8 months (1 day to 40 years of age) peak systolic gradient had a median of 59 [50, 71] mm Hg pre-BAVP and 22 [15, 30] mm Hg post-BAVP (P<0.001). Procedural success was achieved in 160 patients (71%). The factors independently associated with procedural success were: first time intervention (OR=2.0 (1.0, 4.0) P=0.04), not-prostaglandin dependent, (OR=3.5 (1.5, 8.1); P=0.003), and isolated cAS (absence of AR) (OR=2.1 (1.1-3.9); P=0.03). Twenty percent of patients experienced adverse events, half of which were of high severity. There was no procedural mortality. Neonatal status was the only factor associated with increased risk of high severity adverse events (OR 3.7; 95% CI 1.5-9.0). In the current era, BAVP results in procedural success (gradient reduction with minimal increase in AR) in 71% of patients treated at US centers where BAVP is considered first-line therapy relative to surgery.

Achievable radiation reduction during pediatric cardiac catheterization: How low can we go?

To assess the effectiveness of radiation-reduction measures implemented during pediatric catheterization, and provide data on the radiation doses for common interventional and diagnostic procedures, indexed to body weight. Ionizing radiation exposure must be minimized to "as low as reasonably achievable," by instituting radiation-limiting techniques and knowledge of expected radiation exposure. Radiation-reduction measures included pulsed-fluoroscopy at 7.5 pulses/second (0.032-0.045 µGy/pulse), an air-gap magnification technique for children<20 kg, operator awareness, and additional exposure reduction techniques through projection optimization. Radiation doses for procedures performed between 2007 through 2014 were retrospectively reviewed, including dose area product (DAP) and DAP/kg of body weight for 25 procedural types. Median doses were compared with those previously published from other large centers and multi-institutional databases and assessed for changes over time. Reviewed were 5,196 cases, which included 2,819 interventional, 710 endomyocardial biopsies and 1,667 diagnostic studies, documenting a significant difference in exposure between various procedures and body weights. The absolute exposure was significantly greater in larger children (e.g., for ductal closure median DAP/kg: 17 µGy*m2/kg 10-20 kg children vs. 37 µGy*m2 /kg for those>30 kg, P<0.001). Dose exposure using radiation-reduction techniques were the lowest reported in the literature for all procedure types compared (e.g. median DAP for pulmonary valvuloplasty 163 µGy*m2 vs. 405 to 1,230 µGy*m2 reported by 3 large centers). Reduction of fluoroscopy acquisition to 7.5 pulses/second nearly halved radiation exposure (P<0.001). Implementing a radiation dose reduction and awareness program can lead to documented reduction in exposure, across a variety of procedures performed by multiple operators.

Sedation and Anesthesia in Pediatric and Congenital Cardiac Catheterization: A Prospective Multicenter Experience

Sedation/anesthesia is critical to cardiac catheterization in the pediatric/congenital heart patient. We sought to identify current sedation/anesthesia practices, the serious adverse event rate related to airway, sedation, or anesthesia, and the rate of intra-procedural conversion from procedural sedation to the use of assisted ventilation or an artificial airway. Data from 13,611 patients who underwent catheterization at eight institutions were prospectively collected from 2007 to 2010. Ninety-four (0.69 %) serious sedation/airway-related adverse events occurred; events were more likely to occur in smaller patients (<4 kg, OR 4.4, 95 % CI 2.3-8.2, p < 0.001), patients with non-cardiac comorbidities (OR 1.7, 95 % CI 1.1-26, p < 0.01), and patients with low mixed venous oxygen saturation (OR 2.3, 95 % CI 1.4-3.6, p < 0.001). Nine thousand three hundred and seventy-nine (69 %) patients were initially managed with general endotracheal anesthesia, LMA, or tracheostomy, whereas 4232 (31 %) were managed with procedural sedation without an artificial airway, of which 75 (1.77 %) patients were converted to assisted ventilation/general anesthesia. Young age (<12 months, OR 5.2, 95 % CI 2.3-11.4, p < 0.001), higher-risk procedure (category 4, OR 10.1, 95 % CI 6.5-15.6, p < 0.001), and continuous pressor/inotrope requirement (OR 11.0, 95 % CI 8.6-14.0, p < 0.001) were independently associated with conversion. Cardiac catheterization in pediatric/congenital patients was associated with a low rate of serious sedation/airway-related adverse events. Smaller patients with non-cardiac comorbidities or low mixed venous oxygen saturation may be at higher risk. Patients under 1 year of age, undergoing high-risk procedures, or requiring continuous pressor/inotrope support may be at higher risk of requiring conversion from procedural sedation to assisted ventilation/general anesthesia.

Dexmedetomedine-Ketamine versus Propofol-Ketamine as anaesthetic agents in paediatric cardiac catheterization

Introduction: Anaesthesia for these patients undergoing for interventional procedures in paediatric patients with congenital cardiac anomalies remains a challenge for the anaesthesiologist. There are no specific techniques to follow and anaesthetic procedure is modified according to the cardiac anomalies, clinical condition of the patients and the cardiologist’s requirements. Basically the anaesthesiologist can either provide sedation or general anaesthesia. Objective: The aim of this study was to compare the sedation level, haemodynamic effects and recovery patterns in paediatric patients undergoing sedation for cardiac catheterization either with dexmedetomidine-ketamine or propofol-ketamine combination. Materials &amp; Methods: Sixty patients between the ages of 1 to 12 years were scheduled for cardiac catheterization at Cardiac Catheterization Laboratory of Narayana Hrudayalaya Institute of Medical Sciences, Bangalore, India for a period of six months (April to September 2012) for evaluation and intervention of congenital heart disease. Patients were randomly divided into 2 groups of 30 each. All patients were premedicated with intravenous midazolam (0.05mg/kg upto 2 mg) and glycopyrrolate (10 ?g/kg) 5 minutes before the procedure and anaesthesia was induced with ketamine 1mg/kg. The dexmedetomidine-ketamine group (group D, n=30), received dexmedetomidine 1?g/kg over 10 minutes. 19 JAFMC Bangladesh. Vol 10, No 1 (June) 2014 Propfol-ketamine group (group P, n=30) received 50?g/kg/min of propofol by infusion. Heart rate (HR), Systolic Blood Pressure ( SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP), peripheral oxygen saturation (SpO2), respiratory rate (RR), and modified Steward score of all patients was recorded at baseline, after induction and every 10 minutes thereafter. The time to reach a modified Steward score of &gt;or=6 was recorded. Results: Recovery time was significantly less in group P (mean 39±12.32mins) than in group D (mean 48±15.15mins). Statistical significant difference (p&lt;0.05) was found between group D and P regarding systolic blood pressure (64.48 ± 11.21mmHg vs 56.06 ± 10.13mmHg), diastolic blood pressure (40.08 ± 8.00 mmHg vs 35.05 ± 6.64 mmHg) and mean arterial pressure (48.32 ± 8.34 mmHg vs 42.39 ± 7.98 mmHg). For maintenance less additional ketamine was required in group D (22.76±11.87mg) than group P (25.10±20.73mg) but this was not statistically significant. Conclusion: Clinical outcome of both groups was similar and there was no significant difference in the recovery patterns and haemodynamic status and hence it is concluded that either of the techniques is suitable for children undergoing catheterization and interventional procedures. DOI: http://dx.doi.org/10.3329/jafmc.v10i1.22898 Journal of Armed Forces Medical College Bangladesh Vol.10(1) 2014

Follow-up of children exposed to ionising radiation from cardiac catheterisation: the Coccinelle study.

Cardiac catheterisation has become an essential tool in the diagnosis and treatment of children with a wide variety of congenital and acquired forms of cardiovascular disease. Despite the clear clinical benefit to the patient, radiation exposure from paediatric cardiac catheterisation procedures (CCPs) may be substantial. Given children's greater sensitivity to radiation and the longer life span during which radiation health effects can develop, an epidemiological cohort study, named Coccinelle or 'Ladybird' (French acronym for 'Cohorte sur le risque de cancer après cardiologie interventionnelle pédiatrique'), is carried out in France to evaluate the risks of leukaemia and solid cancers in this population. A total number of 8000 included children are expected. Individual CCP-related doses will be assessed for each child included in the cohort. For each CCP performed, dosimetric parameters (dose-area product, fluoroscopy time and total number of cine frames) are retrieved retrospectively. Organ doses, especially to the lung, the oesophagus and the thyroid, are calculated with PCXMC software. The cohort will be followed up through linkage with French paediatric cancer registries.

The lateral plane delivers higher dose than the frontal plane in biplane cardiac catheterization systems.

The objective of the study is to compare radiation dose between the frontal and lateral planes in a biplane cardiac catheterization laboratory. Tube angulation progressively increases patient and operator radiation dose in single-plane cardiac catheterization laboratories. This retrospective study captured biplane radiation dose in a pediatric cardiac catheterization laboratory between April 2010 and January 2014. Raw and time-indexed fluoroscopic, cineangiographic and total (fluoroscopic + cineangiographic) air kerma (AK, mGy) and kerma area product (PKA, µGym(2)/Kg) for each plane were compared. Data for 716 patients were analyzed: 408 (56.98 %) were male, the median age was 4.86 years, and the median weight was 17.35 kg. Although median beam-on time (minutes) was 4.2 times greater in the frontal plane, there was no difference in raw median total PKA between the two planes. However, when indexed to beam-on time, the lateral plane had a higher median-indexed fluoroscopic (0.75 vs. 1.70), cineangiographic (16.03 vs. 24.92), and total (1.43 vs. 5.15) PKA (p < 0.0001). The median time-indexed total PKA in the lateral plane is 3.6 times the frontal plane. This is the first report showing that the lateral plane delivers a higher dose than the frontal plane per unit time. Operators should consciously reduce the lateral plane beam-on time and incorporate this practice in radiation reduction protocols.

小児心臓カテーテル治療：麻酔科医の視点から

小児心臓カテーテル治療：麻酔科医の視点から

0378: Stents in pediatric and adult congenital cardiac catheterization in France in 2013

Stents have contributed to the development of the interventional catheterization of congenital heart diseases (CHD). The aim of this study was to describe current indications and results. Participation to this study was proposed to all catheterization laboratories specialized in CHD in France (M3C network). All cases with stents implantation in 2013 in pediatric and adult CHD were retrospectively included. Adverse events were assessed using the Bergersen classification. Risk markers were searched using univariate and multivariate analysis. 174 stents were implanted in 127 patients. Patients were aged 15.7±15.1 year old (min 5 day-old - max 70 year-old). Main indications were transcatheter pulmonary valve replacement (prestenting and revalvulation; n=29 patients, 23.0%), pulmonary artery branches angioplasty (n=34, 27.0%), aortic coarctation or recoarctation stenting (n=37, 29.4%) and ductus arteriosus stenting (n=11, 8.7%). 18 Patients (14.3%) were under one-year old and 35 (27.8%) were over 18 year-old. Main pathologies were tetralogy of Fallot and variants (ACC-CHD 8.3, n=45, 35.7%), and aortic coarctation (ACCCHD 9.2, n=36, 28.6%). More than one stent was implanted in 32 procedures (24.4%, max. 5 stents). Main stents implanted were the CP stent (33.0%), EV3 LD max (22.0%), Valeo (16.2%) and valved stents (15.0%). 98.5% Procedures were considered as successful. Adverse events were observed in 16.7% procedures (stent related in 12.1% procedures). Serious adverse events were observed in 12.9%. After uni- and multivariate adjustment, only procedure type was related to the risk of total adverse events but not to stent related adverse events. Age, weight, center, type of stents, genetic disorder and type of CHD were not significantly related to the risk of adverse events. Stents are used in various CHD catheterization procedures, from infancy to adult age. Adverse events rate is significant and seems related to the type of procedure.