Pediatric Interventional Cardiology Research Articles

Improving a regional project on diagnostic reference levels for interventional procedures (OPRIPALC) with the support of a dose management system for the protection of patients and staff

Interventional radiology is a clinical practice with important benefits for patients, but which involves high radiation doses. The optimisation of radiation protection (RP) for paediatric interventional cardiology is a priority for both patients and staff. The use of diagnostic reference levels (DRLs) has been proposed by the International Commission on Radiological Protection to improve RP in imaging procedures. Dose management systems (DMSs) allow the automatic collection of dosimetric, geometric and technical data to assist the optimisation process, with a continuous audit of the procedures, generating alerts to implement corrective actions when necessary. Patient dose indicators may be analysed individually and for different radiation events (fluoroscopy and cine runs). Occupational doses per procedure may be analysed (if electronic dosimeters are available) and linked with patient doses for an integrated approach to RP. Regional optimisation programmes require data collection and processing from several countries to set and periodically update the DRLs. Patient data is anonymised, and each participating hospital has access to their data in a central computer server. Using DMSs may be one of the best ways to support these programs in the collection and analysis of data, raising alerts about high patient and occupational doses and suggesting optimisation actions.

Novel Uses of the SwiftNinja Steerable Microcatheter for Pediatric Cardiovascular Interventions.

In the present era, the intricacy of procedures undertaken by a pediatric interventional cardiologist has increased, primarily attributed to dealing with smaller, younger patients with more complex anatomies. To adapt to these smaller and more complex patients, we must adapt our interventions and our equipment to perform these procedures. This article outlines various innovative applications of the SwiftNinja steerable microcatheter within the pediatric cardiac catheterization laboratory.

X-ray Doses in Relation to Body Mass, Indication, and Substrate During Pediatric Electrophysiological Procedures on the Heart.

The main goal of this study is to determine typical values of dose area product (DAP) and difference in the effective dose (ED) for pediatric electrophysiological procedures on the heart in relation to patient body mass. This paper also shows DAP and ED in relation to the indication, the arrhythmia substrate determined during the procedure, and in relation to the reason for using radiation. Organ doses are described as well. The subjects were children who have had an electrophysiological study done with a 3D mapping system and X-rays in two healthcare institutions. Children with congenital heart defects were excluded. There were 347 children included. Significant difference was noted between mass groups, while heavier children had higher values of DAP and ED. Median DAP in different mass groups was between 4.00 (IQR 1.00-14.00) to 26.33 (IQR 8.77-140.84) cGycm2. ED median was between 23.18 (IQR 5.21-67.70) to 60.96 (IQR 20.64-394.04) µSv. The highest DAP and ED in relation to indication were noted for premature ventricular contractions and ventricular tachycardia-27.65 (IQR 12.91-75.0) cGycm2 and 100.73 (IQR 53.31-258.10) µSv, respectively. In arrhythmia substrate groups, results were similar, and the highest doses were in ventricular substrates with DAP 29.62 (IQR 13.81-76.0) cGycm2 and ED 103.15 (IQR 60.78-266.99) µSv. Pediatric electrophysiology can be done with very low doses of X-rays when using 3D mapping systems compared to X-rays-based electrophysiology, or when compared to pediatric interventional cardiology or adult electrophysiology.

Establishment of local diagnostic reference levels for radiation dose in paediatric interventional cardiology procedures in Brazil

Diagnostic and therapeutic interventional cardiology procedures are essential tools for evaluating congenital pathologies in paediatric patients. However, these procedures may expose patients to high levels of ionizing radiation. In this paper, we present the results of the radiation doses received by patients undergoing interventional cardiac procedures at a paediatric hospital in Brazil, aiming to establish local Diagnostic Reference Levels (DRL). The data were collected over a period of three years (2019–2022), and 148 procedures were analyzed, comprising 53% male (78) and 47% female (70) patients. These procedures included both diagnostic (59%) and therapeutic (41%) cardiac catheterization interventions. The average patient weight was 21.4 ± 1.7 kg (2.0–112.0 kg), with an average age of 5.3 ± 0.4 years (0.0–17.1 years). Comprehensive data for each procedure were extracted from Radiation Dose Structure Reports generated by the equipment. The results showed significant differences between diagnostic and therapeutic procedures, and the DRL values were estimated considering the age and weight of the patients. The DRL values correspond to the 3rd quartile of the dose distribution for each group. The following local DRL values were estimated, considering the patient's ages. For diagnostic procedures, the PKA defined according to the age groups <1, 1–5, 5–10, 10–15, and >15 years were respectively: 1.4, 2.8, 3.1, 4.3 and 12.0 Gy cm2. For therapeutic procedures, the DRL values for patients with the same ages were: 2.0, 3.7, 5.4, 7.4, and 30.9 Gy cm2. For the total procedures, the PKA values were 1.7, 3.2, 4.9, 6.6, and 24.5 Gy cm2, respectively. The suggested local DRL values for weight groups (<5, 5–15, 15–30, 30–50, and 50–80 kg) for PKA in diagnostic procedures were: 1.3, 2.2, 3.2, 4.1, and 7.9 Gy cm2, respectively. For therapeutic procedures, the PKA values were 1.1, 2.7, 5.4, 5.5, and 30.9 Gy cm2, respectively. For the total procedures, the PKA values were 1.25, 2.5, 4.6, 4.2, and 18.3 Gy cm2, respectively. For establishing PKA DRL, patient weight was found to be preferable over age, whereas for Ka,r, both approaches yielded nearly identical results.

An Approach to Establishing Diagnostic Reference Levels in Interventional Pediatric Cardiology from Different Regions of Brazil.

Diagnostic reference levels (DRLs) are a pivotal strategy to be implemented since pediatric interventional cardiology procedures are increasing. This work aimed to propose an initial set of Brazilian DRLs for pediatric interventional diagnostic and therapeutic (D&T) procedures. A retrospective study was carried out in four Brazilian states, distributed across the three regions of the country. Data were collected from pediatric patients undergoing cardiac interventional procedures (CIPs), including their age and anthropometric characteristics, and at least four parameters (number of images, exposure time, air kerma-area product-PKA, and cumulative air kerma). Data from 279 patients undergoing CIPs were gathered (147 diagnostic and 132 therapeutic procedures). There were no significant differences in exposure time and the number of images between the D&T procedures. A wide range of PKA was observed when the therapeutic procedures were compared to diagnostics for all age groups. There were significant differences between the D&T procedures, whether grouping data by patient weight or age. In terms of cumulative air kerma, it was noted that no value exceeded the level to trigger a monitoring process for patients. This study shows that it is possible to adopt them as the first proposal to establish national DRLs considering pediatric patient groups.

The Importance of Weight-Based Protocols and Reduction of Frame Rates in ASD Percutaneous Closure

Introduction: In the context of interventional and diagnostic cardiology procedures, there is a growing effort to minimize exposure to ionizing radiation. Most modern angiography machines allow selection of exposure parameters based on the patient's weight. Our experience has led us to question whether the use of weight-based protocols is the right approach for pediatric interventional cardiology exams. Aim and Materials: The purpose of this research is to investigate the efficacy of techniques aimed at reducing radiation exposure during ASD percutaneous closure in pediatric patients. Since 2020, in all patients we used predefined acquisition parameters with a low exposure level (CARD &lt;6Kg) and reduced pulsations to 4p/s. Therefore, from 2020 we used the lowest possible radiological pediatric protocol regardless of patient weight. We compared this group of patients (B) with an historical group of patients (A) with an ASD, in which a radiological protocol based only on patient’s weight was applied. Results: Group A included 92 patients with ostium secundum atrial septal defect. Group B included 114 patients with ostium secundum atrial septal defect. In this group, 22 patients received a Gore Cardioform ASD occluder device with the need of a biplane imaging. The two groups were comparable in terms of age (p=0.1) and weight (p=0.2). The absorbed dose in group A was significantly higher than in group B. Median total air kerma was 6.55 mGy(1.2-255,6 mGy) in group A and 5.25 mGy(0.4-140.5 mGy) in group B (p 0.001). Dose area product (DAP) was 130,2 μGym²(24.25-5774 μGym²) in group A and 67.1 μGym²(8.6-3107 μGym²) in group B(p 0.001). Conclusion: Our strategy resulted in a significant reduction in radiation exposure to the patients while maintaining good radioscopic resolution. This significance was maintained despite the use of new devices in 2021 in addition to Amplatzer (GORE-Occlutech).

Local Diagnostic Reference Levels for Pediatric Interventional Cardiology Procedures in Argentina.

The aim of this work was to propose a preliminary local diagnostic reference levels (DRL) for pediatric interventional cardiology (PIC) procedures in Argentina, for different ranges of age and weight. This work has been conducted in the framework of the "Optimization of Protection in Pediatric Interventional Radiology in Latin America and the Caribbean" (OPRIPALC) program coordinated by the World Health Organization and the Pan American Health Organization in cooperation with the International Atomic Energy Agency to ensuring that radiation exposures of pediatric patients are the minimum necessary during fluoroscopy-guided interventional procedures. The local DRL values presented in this paper by weight group and age group were 7.1 Gy·cm2 (<5 kg), 10.7 Gy·cm2 (5-15 kg), 18.0 Gy·cm2 (15-30 kg), 15.9 Gy·cm2 (30-50 kg), and 28.2 Gy·cm2 (50-80 kg) and 5.3 Gy·cm2 (<1), 11.2 Gy·cm2 (1 to 5<), 19.6 Gy·cm2 (5 to 10<), and 21.4 Gy·cm2 (10 to 16<), respectively. Our dose results are among the values found in other international studies; however, there is great potential for dose optimization.

Physical Image Quality Metrics for the Characterization of X-ray Systems Used in Fluoroscopy-Guided Pediatric Cardiac Interventional Procedures: A Systematic Review.

Pediatric interventional cardiology procedures are essential in diagnosing and treating congenital heart disease in children; however, they raise concerns about potential radiation exposure. Managing radiation doses and assessing image quality in angiographs becomes imperative for safe and effective interventions. This systematic review aims to comprehensively analyze the current understanding of physical image quality metrics relevant for characterizing X-ray systems used in fluoroscopy-guided pediatric cardiac interventional procedures, considering the main factors reported in the literature that influence this outcome. A search in Scopus and Web of Science, using relevant keywords and inclusion/exclusion criteria, yielded 14 relevant articles published between 2000 and 2022. The physical image quality metrics reported were noise, signal-to-noise ratio, contrast, contrast-to-noise ratio, and high-contrast spatial resolution. Various factors influencing image quality were investigated, such as polymethyl methacrylate thickness (often used to simulate water equivalent tissue thickness), operation mode, anti-scatter grid presence, and tube voltage. Objective evaluations using these metrics ensured impartial assessments for main factors affecting image quality, improving the characterization of fluoroscopic X-ray systems, and aiding informed decision making to safeguard pediatric patients during procedures.

Diagnostic Reference Levels in Interventional Pediatric Cardiology: Two-Year Experience in a Tertiary Referral Hospital in Latin America.

The goal of the present study was to propose the first local diagnostic reference levels (DRLs) for interventional pediatric cardiology procedures in a large hospital in Colombia. The data collection period was from April 2020 to July 2022. The local DRLs were calculated as the 3rd quartile of patient-dose distributions for the kerma-area product (Pka) values. The sample of collected clinical procedures (255) was divided into diagnostic and therapeutic procedures and grouped into five weight and five age bands. The Pka differences found between diagnostic and therapeutic procedures were statistically significant in all weight and age bands, except for the 1-5-year age group. The local DRLs for weight bands were 3.82 Gy·cm2 (<5 kg), 7.39 Gy·cm2 (5-<15 kg), 19.72 Gy·cm2 (15-<30 kg), 28.99 Gy·cm2 (30-<50 kg), and 81.71 Gy·cm2 (50-<80 kg), respectively. For age bands, the DRLs were 3.97 Gy·cm2 (<1 y), 9.94 Gy·cm2 (1-<5 y), 20.82 Gy·cm2 (5-<10 y), 58.00 Gy·cm2 (10-<16 y), and 31.56 Gy·cm2 (<16 y), respectively. In conclusion, when comparing our results with other existing DRL values, we found that they are similar to other centers and thus there is scope to continue optimizing the radiation dose values. This will contribute to establishing national DRLs for Colombia in the near future.

Measurement of Occupational Eye and Thyroid Radiation Doses in Pediatric Interventional Cardiologists at a Tertiary Hospital.

Background Advances in imaging techniques have led to increased utilization of imaging devices in catheterization laboratories. Invasive surgical procedures for cardiac disorders have been largely replaced by fluoroscopic cardiac catheterization. With this increase, concerns and risks associated with exposure to ionizing radiation among interventional cardiologists are growing. This study aims to measure and compare the occupational doses to the eye lens and thyroid of pediatric interventional cardiologists during different procedures in the catheterization laboratory and its significance. Methodology In this study, cardiologists wore bandanas with attached dosimeters to measure the absorbed doses to the eyes and thyroid gland. The dosimeters were collected for reading. The procedure types were also collected. In addition, the total fluoroscopy time and tube voltage of the biplane machine were measured. SPSS version 23 (IBM Corp., Armonk, NY, USA) was used to analyze the data. The characteristics of the study sample were described using simple counts and percentages, whereas means and standard deviations were used for continuous variables.Statistical significance was set at p-values <0.05. Results A total of 93 procedures were evaluated. The mean absorbed doses for all 93 procedures in both eyes and thyroid were 0.09 mGy and 0.08 mGy, respectively. A significant difference was found between the left and right eye measurements (p = 0.034), with higher doses administered to the left eye. However, no significant difference was observed between the right and left thyroid doses (p = 0.281). Significant correlations were found between the eye and thyroid doses and the procedure type (p = 0.02 and p = 0.009, respectively). Conclusions A significant amount of radiation was measured in the measurements of both organs. In addition, radiation dose measurements varied between different types of procedures. Our current results indicate the importance and necessity of applying the radiation protection concept of dose optimization.

Occupational Radition Dose of Personal in Pediatric Interventional Cardiology

This study aimed to determine the effective doses of the cardiologist, nurses, and technical staff in the pediatric angiography laboratory during their diagnostic and therapeutic applications. This study also compares the radiation dose in the applications performed in the country with the effective doses exposed on a world scale. A total of 39 coronary angiography (CA) + percutaneous transluminal angioplasty (PTCA) methods were performed in the pediatric angiography laboratory during the study. The radiation dose received for each person in a single application was determined, and the total dose values were measured in sequential applications. If the annual workload is taken into consideration, it is calculated that the person with a high workload may be exposed to a dose of 1384.7 μSv per year. Furthermore, from the total effective dose values, the doses per procedure were calculated to be in the range of 6.5 to 11.1 μSv. These results are consistent with the literature.

Strategies and techniques for percutaneous Veno-Arterial ECMO cannulation and decannulation in children.

To describe the techniques used for percutaneous veno-arterial extracorporeal membrane oxygenation (VA-ECMO) cannulation and decannulation in children with the pediatric interventional cardiologist (PIC) as the primary operator, and present outcomes of this initial clinical experience. Percutaneous VA-ECMO during cardiopulmonary resuscitation (CPR) has been successfully performed in adults, but currently, not much data exists on children. This is a single-center study including VA-ECMO cannulations performed by the PIC between 2019 and 2021. Efficacy was defined as the successful initiation of VA-ECMO without surgical cutdown. Safety was defined as the absence of additional procedures related to cannulation. Twenty-threepercutaneous VA-ECMO cannulations were performed by PIC on 20 children with 100% success. Fourteen (61%) were performed during ongoing CPR, and nine for cardiogenic shock. The Median age was 15 (0.15-18) years, and the median weight was 65 (3.3-180) kg. All arterial cannulations were via the femoral artery except in one, 8-week-old infant who was cannulated in the carotid artery. A distal perfusion cannula was placed in the ipsilateral limb in 17 (78%). The median time from initiating cannulation to ECMO flow was 35 (13-112) minutes. Two patients required arterial graft placement at the time of decannulation and one needed below-knee amputation. ECMO support was maintained for a median of 4 (0.3-38) days. Thirty-day survival was 74%. Percutaneous VA-ECMO cannulations can be effectively performed, even during CPR with the Pediatric Interventional Cardiologist being the primary operator. This is an initial clinical experience. Future outcome studies compared with standard surgical cannulations are necessary to advocate routine percutaneous VA-ECMO in children.

Palliation of a Heterotaxy Single Ventricle Neonate with Pulmonary Atresia and Obstructed TAPVR

Patients born with obstructed total anomalous pulmonary venous return have a high risk of morbidity and mortality in the neonatal period, which only increases when combined with single ventricle physiology and non-cardiac congenital anomalies such as heterotaxy syndrome. Despite advances in management of congenital heart disease, surgery within the first weeks of life to repair the pulmonary venous connection and establish pulmonary blood flow with a systemic-to-pulmonary shunt has historically led to disappointing outcomes. A multidisciplinary approach with pediatric interventional cardiology and cardiac surgery is required to reduce morbidity and mortality in this extremely high-risk patient population. Extending the time between birth and cardiac surgery can lessen postoperative complications and mortality risk, especially in patients with abnormal thoracoabdominal relationships. Our team was able to successfully utilize transcatheter stent placement in a vertical vein and patent ductus arteriosus to delay and stage cardiac surgeries in an infant born with obstructed total anomalous pulmonary venous return, unbalanced atrioventricular septal defect with pulmonary atresia and heterotaxy, thus reducing the morbidity and mortality associated with this diagnosis.

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.

Three years of interventional pediatric cardiology experience in a newly built city hospital

Aim: The importance of interventional methods in the treatment of congenital heart disease (CHD) is increasing. In this article, we retrospectively evaluated our angiography experience for the diagnosis and treatment of congenital heart diseases in the newly built Kayseri City Hospital for 3 years.&#x0D; Material and Method: The demographic data of the patients, their diagnoses and information about interventions were evaluated retrospectively.&#x0D; Results: In our center, 291 interventional procedures were performed in a 36-month period. 71 (24%) procedures were for diagnostic evaluation and 220 (76%) procedures were for treatment. 74 (25%) atrial septal defect (ASD) closure procedures, 9 (3%) ventricular septal defect (VSD) closure procedures and 62 (21.3%) patent ductus arteriosus (PDA) closure procedures were performed via percutaneous technique. Eleven of the patients who underwent PDA closure were

Pediatric and Congenital Interventional Cardiology Training

Pediatric and Congenital Interventional Cardiology Training

Contribution of the fluoroscopy and cine modes to patient exposure in paediatric interventional cardiology procedures

IntroductionPaediatric interventional cardiology procedures have grown in recent years. The main disadvantage of these procedures is the high dose of radiation that patients receive. Such methods include the fluoroscopy mode, which allows real-time visualization, and the cine mode, which allows the documentation of images. The dosimetric quantities recommended currently for these procedures are: kerma-area product (PKA), air kerma at the patient entrance reference point (Ka,r), fluoroscopy time (tFl) and number of acquired images (IN). While PKA and Ka,r characterize total irradiation during the examination, IN and tFl describe the contribution of fluoroscopy and cine modes separately. These characteristics are indirect and presume that the radiation exposure is proportional to them. Such a choice is made because most of the equipment do not supply information about the contribution of fluoroscopy and cine modes to the PKA or Ka,r separately. ObjectivesThe primary objective of this work is to evaluate the contribution of the fluoroscopy and cine modes to the total exposure; we study to what extent these contributions can be characterized by fluoroscopy and cine time and number of acquired images. We also propose local diagnostic reference levels for quantities that separately describe the contribution of fluoroscopy and cine modes. MethodsIn a period of 3 years (2019–2021), data on 135 procedures were evaluated; the study included 53% of male patients (72) and 47% of female patients (63). Cardiac catheterization procedures were considered for diagnostic (59%) and therapeutic (41%) purposes. The average weight of patients was 21.4 ± 1.7 kg (2.0–112.0 kg), and the average age was 5.3 ± 0.4 years (0.0–17.1 years). Interventional cardiology procedures were performed using a GE Innova IGS 530 equipment (GE Healthcare, Milwaukee, WI, USA), manufactured in 2016 and installed in 2017, dedicated to the paediatric population. The necessary data on each procedure was extracted from the Radiation Dose Structure Reports, generated by the equipment at the end of the procedure. This report presents the PKA values for the fluoroscopy mode and the cine mode, total PKA, the fluoroscopy time, the cine time, and IN, as well as other data related to the procedure. The diagnostic reference levels (DRLs) proposed in this study were calculated as the 3-rd quartile of the corresponding distribution. ResultsThe contribution of the cine mode to the total kerma-area product is, on average, 50% though this mode lasted about 4% of the procedure time. Only the fluoroscopy time may be used among the indirect quantities to characterize the contribution of the fluoroscopy and cine modes. ConclusionsThe following local DRLs values are proposed: 2.0 Gy⋅cm2 for kerma-area product in fluoroscopy mode, 1.9 Gy⋅cm2 for kerma-area product in cine mode and 22 min (26 min for therapeutic procedures) for fluoroscopy time. For diagnostic and therapeutic procedures, the local DRLs values may be chosen as 1.5 Gy⋅cm2 and 2.5 Gy⋅cm2 correspondingly in both modes.

B-38 | Decannulation of Percutaneously Placed Veno-Arterial ECMO Cannulas in Children by the Pediatric Interventional Cardiologist

Decannulation from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the pediatric population has historically been performed by surgeons. We have previously described techniques for successful percutaneous VA-ECMO cannulation at our institution by pediatric interventional cardiologists (PIC) in children. The goal of this study is to describe the safety and feasibility for VA-ECMO decannulation by PIC.

Local Diagnostic Reference Levels in Paediatric Interventional Cardiology Procedures in Brazil

Local Diagnostic Reference Levels in Paediatric Interventional Cardiology Procedures in Brazil