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Sanchez RM, Siiskonen T, Vano E. Current status of diagnostic reference levels in interventional cardiology. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2022; 42:041002. [PMID: 36379055 DOI: 10.1088/1361-6498/aca2b3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/15/2022] [Indexed: 06/16/2023]
Abstract
Interventional cardiology provides indisputable benefits for patients but uses a substantial amount of ionising radiation. The diagnostic reference level (DRL) is the tool recommended by the International Commission on Radiological Protection to optimise imaging procedures. In this work, a review of studies dealing with radiation dose or recommending DRL values for interventional cardiology since 2010 is presented, providing quantitative and qualitative results. There are many published papers on coronary angiography (CA) and percutaneous coronary intervention. The DRL values compiled for different continental regions are different: the DRL for CA is about 35 Gy cm2for Europe and 83 Gy cm2for North America. These differences emphasise the need to establish national DRLs considering different social and/or economic factors and the harmonisation of the survey methodology. Surveys with a large amount of data collected with the help of dose management systems provide more reliable information with less chance of statistical bias than those with a small amount of data. The complexity of procedures and improvements in technology are important factors that affect the radiation dose delivered to patients. There is a need for additional data on structural and electrophysiological procedures. The analysis of paediatric procedures is especially difficult because some studies present results split into age bands and others into weight bands. Diagnostic procedures are better described, but there is a great variety of therapeutic procedures with different DRL values (up to a factor of nine) and these require a dedicated review.
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Affiliation(s)
- Roberto M Sanchez
- Hospital Clinico Universitario San Carlos, Medical Physics, Madrid, Spain
| | - Teemu Siiskonen
- Radiation and Nuclear Safety Authority-STUK, Helsinki, Finland
| | - Eliseo Vano
- Radiology Department, Universidad Complutense de Madrid, Madrid, Spain
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Azizmohammadi F, Castellanos IN, Miró J, Segars P, Samei E, Duong L. Generative learning approach for radiation dose reduction in X-ray guided cardiac interventions. Med Phys 2022; 49:4071-4081. [PMID: 35383946 DOI: 10.1002/mp.15654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 03/23/2022] [Accepted: 03/27/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Navigation guidance in cardiac interventions is provided by X-ray angiography. Cumulative radiation exposure is a serious concern for pediatric cardiac interventions. PURPOSE A generative learning-based approach is proposed to predict X-ray angiography frames to reduce the radiation exposure for pediatric cardiac interventions while preserving the image quality. METHODS Frame predictions are based on a model-free motion estimation approach using a Long Short Term Memory (LSTM) architecture and a content predictor using a Convolutional Neural Network (CNN) structure. The presented model thus estimates contrast-enhanced vascular structures such as the coronary arteries and their motion in X-ray sequences in an end-to-end system. This work was validated with 56 simulated and 52 patients' X-ray angiography sequences. RESULTS Using the predicted images can reduce the number of pulses by up to 3 new frames without affecting the image quality. The average required acquisition can drop by 30% per second for a 15 frame per second acquisition. The average Structural Similarity Index Measurement (SSIM) was 97% for the simulated dataset and 82% for the patients' dataset. CONCLUSIONS Frame prediction using a learning-based method is promising for minimizing radiation dose exposure. The required pulse rate is reduced while preserving the frame rate and the image quality. With proper integration in X-ray angiography systems, this method can pave the way for improved dose management. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Fariba Azizmohammadi
- Interventional Imaging Lab, Department of software and IT engineering, École de technologie supérieure, 1100 Notre-Dame West, Montreal, H3C 1K3, Canada
| | | | - Joaquim Miró
- Department of Pediatrics, CHU Sainte-Justine, Montreal, H3T 1C5, Canada
| | - Paul Segars
- Department of Radiology, Carl E. Ravin Advanced Imaging Laboratories, Duke University Medical Center, Durham, NC, USA
| | - Ehsan Samei
- Department of Radiology, Carl E. Ravin Advanced Imaging Laboratories, Duke University Medical Center, Durham, NC, USA
| | - Luc Duong
- Interventional Imaging Lab, Department of software and IT engineering, École de technologie supérieure, 1100 Notre-Dame West, Montreal, H3C 1K3, Canada
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Werner GS, Yaginuma K, Koch M, Tischer K, Silber M, Werner J, Keuser T, Moehlis H. Reducing fluoroscopic and cineangiographic contribution to radiation exposure for chronic total coronary occlusion interventions. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 36:58-64. [PMID: 33931375 DOI: 10.1016/j.carrev.2021.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 04/17/2021] [Accepted: 04/19/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The treatment of chronic total coronary occlusions (CTO) carries the highest radiation exposure among percutaneous coronary interventions (PCI). In order to minimize radiation damage, we need to understand and optimize the contribution of all components of radiation exposure. METHODS A total of 1000 CTO procedures performed between 2011 and 2020 were compared according to implemented radiation modifications. Group 1 used the original set-up of the X-ray equipment (Artis Zee, Siemens). In group 2 a modified protocol aimed at reducing the fluoroscopy exposure, in group 3 further modifications aimed at reducing cineangiographic exposure. RESULTS Despite an increased lesion complexity, Air Kerma (AK) was reduced from 2619 mGy (1653-4574) in group 1 to 2178 mGy (1332-3500; p < 0.001) in group 2 by mainly reducing fluoroscopic contribution by 54.1%, the cineangiographic contribution was lowered by only 6.6%. In group 3 AK dropped drastically to 746 mGy (480-1225; p < 0.001) mainly by reducing the cineangiographic contribution by 53.4%, still there was a further reduction of fluoroscopy contribution of 8.2%. This also led to a reduction of the skin entry dose from 1038 mGy (690-1589) in group 2 to 359 mGy (204-591; p < 0.001) in group 3. This was achieved both in normal weight and obese patients, and both in antegrade and retrograde procedures. CONCLUSIONS The present study demonstrates that by modifying both the fluoroscopic and cineangiographic contribution to radiation exposure a drastic reduction of radiation risk can be achieved, even in obese patients. Currently accepted radiation thresholds may no longer be a limit for CTO PCI.
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Affiliation(s)
- Gerald S Werner
- Medizinische Klinik I, Klinikum Darmstadt GmbH, Darmstadt, Germany.
| | - Kenji Yaginuma
- Department of Cardiology, Juntendo University Urayasu Hospital, Tokyo, Japan
| | - Matthias Koch
- Medizinische Klinik I, Klinikum Darmstadt GmbH, Darmstadt, Germany
| | | | - Martin Silber
- Institut für Radioonkologie und Strahlentherapie, Klinikum Darmstadt GmbH, Darmstadt, Germany
| | - Juliane Werner
- Medizinische Klinik I, Klinikum Darmstadt GmbH, Darmstadt, Germany
| | - Thomas Keuser
- Medizinische Klinik I, Klinikum Darmstadt GmbH, Darmstadt, Germany
| | - Hiller Moehlis
- Medizinische Klinik I, Klinikum Darmstadt GmbH, Darmstadt, Germany
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Sanchez RM, Vano E, Salinas P, Gonzalo N, Escaned J, Fernández JM. High filtration in interventional practices reduces patient radiation doses but not always scatter radiation doses. Br J Radiol 2020; 94:20200774. [PMID: 33180554 DOI: 10.1259/bjr.20200774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES In fluoroscopy-guided interventional practices, new dose reduction systems have proved to be efficient in the reduction of patient doses. However, it is not clear whether this reduction in patient dose is proportionally transferred to operators' doses. This work investigates the secondary radiation fields produced by two kinds of interventional cardiology units from the same manufacturer with and without dose reduction systems.Methods:Data collected from a large sample of clinical procedures over a 2-year period (more than 5000 procedures and 340,000 radiation events) and the DICOM radiation dose structured reports were analysed. RESULTS The average cumulative Hp(10) per procedure measured at the C-arm was similar for the standard and the dose reduction systems (452 vs 476 μSv respectively). The events analysis showed that the ratio Hp(10)/KAP at the C-arm was (mean ± SD) 5 ± 2, 10 ± 4, 14 ± 4 and 14 ± 6 μSv·Gy-1·cm-2 for the beams with no added filtration, 0.1, 0.4 and 0.9 mm Cu respectively and suggested that the main cause for the increment of the ratio Hp(10)/KAP vs the "standard system" is the use of higher beam filtration in the "dose reduction" system. CONCLUSION Dose reduction systems are beneficial to reduce KAP in patients and their use should be encouraged, but they may not be equally effective to reduce occupational doses. Interventionalists should not overlook their own personal protection when using new technologies with dose reduction systems. ADVANCES IN KNOWLEDGE Dose reduction technology in interventional systems may increase scatter dose for operators. Personal protection should not be overlooked with dose reduction systems.
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Affiliation(s)
- Roberto M Sanchez
- Medical Physics Service and Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain.,Radiology Department, Medicine Faculty of the Universidad Complutense de Madrid, Madrid, Spain
| | - Eliseo Vano
- Medical Physics Service and Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain.,Radiology Department, Medicine Faculty of the Universidad Complutense de Madrid, Madrid, Spain
| | - Pablo Salinas
- Cardiology department and Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Nieves Gonzalo
- Cardiology department and Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Javier Escaned
- Cardiology department and Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Jose M Fernández
- Medical Physics Service and Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
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Subban V. Radiation doses during cardiac catheterisation procedures in India: a multicentre study: Radiation dose study. ASIAINTERVENTION 2020; 6:25-33. [PMID: 34912981 PMCID: PMC8525728 DOI: 10.4244/aij-d-18-00044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 03/04/2020] [Indexed: 10/25/2023]
Abstract
AIMS Established, evidence-based measures of radiation are required to minimise its hazards, while maintaining adequate image quality. The aim of this study is to evaluate radiation data and generate reference radiation levels for commonly performed coronary catheterisation procedures in India. METHODS AND RESULTS In this prospective, observational study, all procedures were performed in accordance with the established standards using Innova IGS 520/2100-IQ catheterisation laboratories. Demographic, procedural and radiation data were collected. Dose reference limits (DRL) were established as the 75th percentile of the total distribution. There were 2,906 coronary angiograms (CAG), 750 percutaneous coronary interventions (PCI) and 715 CAG+PCI. DRLs for dose area product were: 19.6 Gy·cm2 for CAG, 49.8 Gy·cm2 for PCI and 72.0 Gy·cm2 for CAG+PCI, respectively. Median cumulative air kerma levels were: 185 mGy for CAG, 533mGy for PCI, and 891 mGy for CAG+PCI. Male gender, higher BMI, combining CAG+PCI, fluoroscopy time, number of cine frames, and image acquisition settings were significant contributors to increased radiation dose. CONCLUSIONS This study established reference radiation dose levels for diagnostic and interventional coronary procedures in India, which were comparable to and in the lower range of international standards.
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Affiliation(s)
- Vijayakumar Subban
- Institute of Cardiovascular Diseases, The Madras Medical Mission, Chennai, India
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Sánchez R, Vañó E, Fernández Soto JM, Ten JI, Escaned J, Delgado C, García B, Carrera Magariño F, Fernández JFD, Luna RJM, Moreno MAR, Catalán A, Ojeda FB, Rosales Espizua FJ, Moreno JRS, Pifarré X, Goicolea J, Ordiales JM, Nogales JM, Martinez G, García P, Benedicto A, Castillo MFR, Torres LP, Font J, Bethencourt A, Cesteros MJ, Pérez A, Pinar E, Tobarra B. Updating national diagnostic reference levels for interventional cardiology and methodological aspects. Phys Med 2020; 70:169-175. [DOI: 10.1016/j.ejmp.2020.01.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 12/05/2019] [Accepted: 01/14/2020] [Indexed: 10/25/2022] Open
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Liu J, Al’Aref SJ, Singh G, Caprio A, Moghadam AAA, Jang SJ, Wong SC, Min JK, Dunham S, Mosadegh B. An augmented reality system for image guidance of transcatheter procedures for structural heart disease. PLoS One 2019; 14:e0219174. [PMID: 31260497 PMCID: PMC6602420 DOI: 10.1371/journal.pone.0219174] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/18/2019] [Indexed: 11/18/2022] Open
Abstract
The primary mode of visualization during transcatheter procedures for structrural heart disease is fluoroscopy, which suffers from low contrast and lacks any depth perception, thus limiting the ability of an interventionalist to position a catheter accurately. This paper describes a new image guidance system by utilizing augmented reality to provide a 3D visual environment and quantitative feedback of the catheter’s position within the heart of the patient. The real-time 3D position of the catheter is acquired via two fluoroscopic images taken at different angles, and a patient-specific 3D heart rendering is produced pre-operatively from a CT scan. The spine acts as a fiduciary land marker, allowing the position and orientation of the catheter within the heart to be fully registered. The automated registration method is based on Fourier transformation, and has a high success rate (100%), low registration error (0.42 mm), and clinically acceptable computational cost (1.22 second). The 3D renderings are displayed and updated on the augmented reality device (i.e., Microsoft HoloLens), which can provide pre-set views of various angles of the heart using voice-command. This new image-guidance system with augmented reality provides a better visualization to interventionalists and potentially assists them in understanding of complicated cases. Furthermore, this system coupled with the developed 3D printed models can serve as a training tool for the next generation of cardiac interventionalists.
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Affiliation(s)
- Jun Liu
- Dalio Institute of Cardiovascular Imaging, New York Presbyterian Hospital and Weill Cornell Medicine, New York, United States of America
| | - Subhi J. Al’Aref
- Dalio Institute of Cardiovascular Imaging, New York Presbyterian Hospital and Weill Cornell Medicine, New York, United States of America
| | - Gurpreet Singh
- Dalio Institute of Cardiovascular Imaging, New York Presbyterian Hospital and Weill Cornell Medicine, New York, United States of America
| | - Alexandre Caprio
- Dalio Institute of Cardiovascular Imaging, New York Presbyterian Hospital and Weill Cornell Medicine, New York, United States of America
| | - Amir Ali Amiri Moghadam
- Dalio Institute of Cardiovascular Imaging, New York Presbyterian Hospital and Weill Cornell Medicine, New York, United States of America
| | - Sun-Joo Jang
- Dalio Institute of Cardiovascular Imaging, New York Presbyterian Hospital and Weill Cornell Medicine, New York, United States of America
| | - S. Chiu Wong
- Dalio Institute of Cardiovascular Imaging, New York Presbyterian Hospital and Weill Cornell Medicine, New York, United States of America
| | - James K. Min
- Dalio Institute of Cardiovascular Imaging, New York Presbyterian Hospital and Weill Cornell Medicine, New York, United States of America
| | - Simon Dunham
- Dalio Institute of Cardiovascular Imaging, New York Presbyterian Hospital and Weill Cornell Medicine, New York, United States of America
| | - Bobak Mosadegh
- Dalio Institute of Cardiovascular Imaging, New York Presbyterian Hospital and Weill Cornell Medicine, New York, United States of America
- * E-mail:
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Hoffmann R, Langenbrink L, Reimann D, Kastrati M, Becker M, Piatkowski M, Michaelsen J. Image noise reduction technology allows significant reduction of radiation dosage in cardiac device implantation procedures. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:1374-1379. [PMID: 29052249 DOI: 10.1111/pace.13222] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Revised: 09/24/2017] [Accepted: 10/08/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Novel x-ray systems with real-time image noise reduction technology (INRT) to reduce radiation dose during fluoroscopy and cine acquisition have become available. This study evaluated the reduction of radiation dose in device implantation with INRT. METHODS Radiation dose data from 132 consecutive new device implantation procedures (102 pacemaker [PM] or implantable cardioverter defibrillator [ICD] and 30 cardiac resynchronization therapy [CRT] devices) performed between January 2015 and December 2015 on an angiography system with INRT (Allura ClarityIQ) were collected. For comparison, radiation dose data from 147 consecutive device implantation procedures (121 PM/ICDs and 26 CRT devices) performed between June 2013 and September 2014 on a C-arm system with continuous and pulsed fluoroscopy option (4 frames/second) were evaluated. Total dose area product (DAP), fluoroscopy DAP, and cine DAP were evaluated. RESULTS Patient age, gender and body weight, procedure, and fluoroscopy times were similar between systems. In PM/ICD cases, DAP of INRT and C-arm system was similar (423 ± 381 cGycm2 vs 417 ± 517 cGycm) due to pulsed fluoroscopy with the C-arm system (78% of time) and sparse use of cine. In CRT procedures requiring higher image quality (82% use of continuous fluoroscopy with C-arm system), DAP of INRT was significantly lower (1,544 ± 834 cGycm vs 7,252 ± 6,431 cGycm, P < 0.001) due to less fluoroscopy DAP (1,414 ± 757 cGycm vs 5,854 ± 6,767 cGycm) and less cine DAP (130 ± 106 cGycm vs 1,399 ± 1,342 cGycm). Considering all procedures, total DAP was reduced by 60% using INRT. CONCLUSION Novel INRT results in a substantial lowering of radiation dose in device implantation, in particular, in complex CRT implantation procedures requiring high image quality.
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Affiliation(s)
- Rainer Hoffmann
- Department of Cardiology, Angiology and Sleep Medicine, Bonifatius Hospital Lingen, Lingen, Germany
| | - Lukas Langenbrink
- Department of Cardiology, Angiology and Sleep Medicine, Bonifatius Hospital Lingen, Lingen, Germany
| | - Doris Reimann
- Department of Cardiology, Angiology and Sleep Medicine, Bonifatius Hospital Lingen, Lingen, Germany
| | - Mirlind Kastrati
- Department of Cardiology, Angiology and Sleep Medicine, Bonifatius Hospital Lingen, Lingen, Germany
| | - Michael Becker
- Department of Cardiology, Medical Clinic I, University Clinic Aachen, Aachen, Germany
| | - Michal Piatkowski
- Department of Cardiology, Angiology and Sleep Medicine, Bonifatius Hospital Lingen, Lingen, Germany
| | - Jochen Michaelsen
- Department of Cardiology, Angiology and Sleep Medicine, Bonifatius Hospital Lingen, Lingen, Germany
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