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Preda A, Bonvicini E, Coradello E, Testoni A, Gigli L, Baroni M, Carbonaro M, Vargiu S, Varrenti M, Colombo G, Paolucci M, Mazzone P, Guarracini F. The Fluoroless Future in Electrophysiology: A State-of-the-Art Review. Diagnostics (Basel) 2024; 14:182. [PMID: 38248058 PMCID: PMC10814721 DOI: 10.3390/diagnostics14020182] [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: 12/16/2023] [Revised: 01/07/2024] [Accepted: 01/11/2024] [Indexed: 01/23/2024] Open
Abstract
Fluoroscopy has always been the cornerstone imaging method of interventional cardiology procedures. However, radiation exposure is linked to an increased risk of malignancies and multiorgan diseases. The medical team is even more exposed to X-rays, and a higher incidence of malignancies was reported in this professional group. In the last years, X-ray exposure has increased rapidly, involving, above all, the medical team and young patients and forcing alternative fluoroless imaging methods. In cardiac electrophysiology (EP) and pacing, the advent of 3D electroanatomic mapping systems with dedicated catheters has allowed real-time, high-density reconstruction of both heart anatomy and electrical activity, significantly reducing the use of fluoroscopy. In addition, the diffusion of intracardiac echocardiography has provided high anatomical resolution of moving cardiac structures, providing intraprocedural guidance for more complex catheter ablation procedures. These methods have largely demonstrated safety and effectiveness, allowing for a dramatic reduction in X-ray delivery in most arrhythmias' ablations. However, some technical concerns, as well as higher costs, currently do not allow their spread out in EP labs and limit their use to only procedures that are considered highly complex and time-consuming and in young patients. In this review, we aim to update the current employment of fluoroless imaging in different EP procedures, focusing on its strengths and weaknesses.
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Affiliation(s)
- Alberto Preda
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Eleonora Bonvicini
- Division of Cardiology, Department of Medicine, Verona University Hospital, 37129 Verona, Italy
| | - Elena Coradello
- Division of Cardiology, Department of Medicine, Verona University Hospital, 37129 Verona, Italy
| | - Alessio Testoni
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Lorenzo Gigli
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Matteo Baroni
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Marco Carbonaro
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Sara Vargiu
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Marisa Varrenti
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Giulia Colombo
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Marco Paolucci
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Patrizio Mazzone
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Fabrizio Guarracini
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
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Anim-Sampong S, Antwi WK, Adomako JB, Botwe BO, Sarkodie BD, Brakohiapa EK. Patient radiation dose during diagnostic and interventional cardiology procedures: A study in a tertiary hospital. J Med Imaging Radiat Sci 2023; 54:298-305. [PMID: 36746713 DOI: 10.1016/j.jmir.2022.12.010] [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: 07/25/2022] [Revised: 12/14/2022] [Accepted: 12/20/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Fluoroscopy-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. METHODS The 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. RESULTS CA 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. CONCLUSION This study, therefore, concludes that there is a need for dose optimization of radiation exposures for IC procedures at the cardiothoracic center in Ghana.
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Affiliation(s)
- Samuel Anim-Sampong
- Department. of Radiography, University of Ghana School of Biomedical and Allied Health Sciences, P.O. Box KB 143, Korle Bu, Accra, Ghana
| | - William Kwadwo Antwi
- Department. of Radiography, University of Ghana School of Biomedical and Allied Health Sciences, P.O. Box KB 143, Korle Bu, Accra, Ghana.
| | - John Bright Adomako
- Department. of Radiography, University of Ghana School of Biomedical and Allied Health Sciences, P.O. Box KB 143, Korle Bu, Accra, Ghana
| | - Benard Ohene Botwe
- Department. of Radiography, University of Ghana School of Biomedical and Allied Health Sciences, P.O. Box KB 143, Korle Bu, Accra, Ghana; Department of Midwifery and Radiography Division School of Health & Psychological Sciences, City, University of London, Northampton Square, London EC1V 0HB, UK
| | - Benjamin Dabo Sarkodie
- Department of Radiology, University of Ghana School of Medical and Dental Science, Accra, Ghana
| | - Edmund K Brakohiapa
- Department of Radiology, University of Ghana School of Medical and Dental Science, Accra, Ghana
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Rose A, Rae WI, Sweetlove MA, Ngetu L, Benadjaoud MA, Marais W. Radiation induced cataracts in interventionalists occupationally exposed to ionising radiation. SA J Radiol 2022; 26:2495. [PMID: 36262829 PMCID: PMC9575381 DOI: 10.4102/sajr.v26i1.2495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/06/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Occupational exposure to ionising radiation may have detrimental health effects. Longer and more complex fluoroscopic procedures have placed interventionalists at increased occupational health risks especially for developing cataracts in the radiosensitive lenses of the eyes. OBJECTIVES This study aimed to determine the prevalence of occupational related cataracts and describe the risk factors for cataracts in occupationally exposed interventionalists compared with unexposed doctors. METHOD A cross-sectional study using multiple methods. A survey was conducted. The radiation workload was determined based on a self-administered questionnaire and dose area product values determined in previous studies. Both groups had slit lamp examinations. The data were analysed analytically using R software version 9.3. RESULTS The study included 98 interventionalists. The combined prevalence of posterior sub-capsular (PSC) and cortical cataracts was 18.8% in the exposed and 13.9% in the unexposed group. The prevalence of PSC cataracts in the exposed group was 5.9% and 2.8% in the unexposed group, with an odds ratio (OR) of 2.2 (95% confidence interval [CI]: 0.58; 8.61). Posterior sub-capsular cataracts were more common in the left eye. The increase in cataracts was not statistically significant in the exposed group but is of clinical significance. CONCLUSION The findings are important as they highlight the need for greater vigilance for protecting the radiation healthcare workforce in a developing country setting. CONTRIBUTION The research is the first of its kind in South Africa and Africa and contributes to determining the prevalence in this highly skilled and occupationally vulnerable group.
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Affiliation(s)
- André Rose
- Center for Health Systems Research and Development, Faculty of Humanities, University of the Free State, Bloemfontein, South Africa
| | - William I.D. Rae
- Prince of Wales Hospital, Faculty of Medical Imaging, University of Sydney, Sydney, Australia
| | - Margaret A. Sweetlove
- Department of Medical Physics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Lumko Ngetu
- Department of Ophthalmology, Faculty of Health, University of the Free State, Bloemfontein, South Africa
| | - Mohamed A. Benadjaoud
- Institute for Radiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France,Department of Radiobiology and Regenerative Medicine (SERAMED), Fontenay-aux-Roses, France
| | - Wayne Marais
- Department of Ophthalmology, Faculty of Health, University of the Free State, Bloemfontein, South Africa
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Cui X, Li R, Zhou W, Zhang X, Wang X, Zhang J. Safety and efficacy of zero-fluoroscopy catheter ablation for paroxysmal supraventricular tachycardia in Chinese children. Front Cardiovasc Med 2022; 9:979577. [PMID: 36158836 PMCID: PMC9500196 DOI: 10.3389/fcvm.2022.979577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/18/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives To compare the safety and efficacy of completely zero-fluoroscopy radiofrequency ablation (RFA) with that of conventional RFA guided by three-dimensional mapping in Chinese children with paroxysmal supraventricular tachycardia (PSVT). Methods The study had a single-center observational design and included 46 children aged 6–14 years who underwent RFA for PSVT at the Second Hospital of Hebei Medical University between March 2019 and September 2021. The children were divided according to whether they underwent zero-fluoroscopy RFA (zero-fluoroscopy group, n = 26) or routine RFA under X-ray guidance (conventional group, n = 20). Three-dimensional mapping was used in both groups. Baseline characteristics, total procedure time, RFA time, volume and duration of X-ray exposure, target mapping time, the immediate RFA success rate, incidence of complications, and recurrence rate were compared between the two groups. Results The children had a median age of 12 years (interquartile range 10, 13), 47.8% (22/46) were boys, and 52.2% (24/46) were girls. The mean body weight was 48.75 ± 15.26 kg. There was no significant between-group difference in the baseline data (P > 0.05). All children were followed up as outpatients at 1, 3, and 6 months postoperatively. The target mapping time was significantly longer in the zero-fluoroscopy group than in the conventional group (12.96 ± 2.24 min vs. 6.65 ± 2.56 min, P < 0.05); however, there was no significant between-group difference in the immediate success rate (100% vs. 100%), success rate at 6 months postoperatively (92.30% vs. 95.00%), complication rate (0% vs. 0.05%), recurrence rate (7.70% vs. 5.00%), RFA time (212.50 s vs. 214.00 s), or total procedure time (78.50 min vs. 74.00 min) (P > 0.05). Conclusion Zero-fluoroscopy catheter ablation can completely avoid fluoroscopy exposure in children without affecting the safety and efficacy of RFA.
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Affiliation(s)
- Xiaoran Cui
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ruibin Li
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wenli Zhou
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaohui Zhang
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaoning Wang
- Department of Pediatric Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jidong Zhang
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
- *Correspondence: Jidong Zhang,
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Mikail N, Rossi A, Bengs S, Haider A, Stähli BE, Portmann A, Imperiale A, Treyer V, Meisel A, Pazhenkottil AP, Messerli M, Regitz-Zagrosek V, Kaufmann PA, Buechel RR, Gebhard C. Imaging of heart disease in women: review and case presentation. Eur J Nucl Med Mol Imaging 2022; 50:130-159. [PMID: 35974185 PMCID: PMC9668806 DOI: 10.1007/s00259-022-05914-6] [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: 05/04/2022] [Accepted: 07/12/2022] [Indexed: 11/04/2022]
Abstract
Cardiovascular diseases (CVD) remain the leading cause of mortality worldwide. Although major diagnostic and therapeutic advances have significantly improved the prognosis of patients with CVD in the past decades, these advances have less benefited women than age-matched men. Noninvasive cardiac imaging plays a key role in the diagnosis of CVD. Despite shared imaging features and strategies between both sexes, there are critical sex disparities that warrant careful consideration, related to the selection of the most suited imaging techniques, to technical limitations, and to specific diseases that are overrepresented in the female population. Taking these sex disparities into consideration holds promise to improve management and alleviate the burden of CVD in women. In this review, we summarize the specific features of cardiac imaging in four of the most common presentations of CVD in the female population including coronary artery disease, heart failure, pregnancy complications, and heart disease in oncology, thereby highlighting contemporary strengths and limitations. We further propose diagnostic algorithms tailored to women that might help in selecting the most appropriate imaging modality.
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Affiliation(s)
- Nidaa Mikail
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Ahmed Haider
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland.,Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Barbara E Stähli
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Angela Portmann
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Alessio Imperiale
- Nuclear Medicine and Molecular Imaging - Institut de Cancérologie de Strasbourg Europe (ICANS), University of Strasbourg, Strasbourg, France.,Molecular Imaging - DRHIM, IPHC, UMR 7178, CNRS/Unistra, Strasbourg, France
| | - Valerie Treyer
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Alexander Meisel
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Vera Regitz-Zagrosek
- Charité, Universitätsmedizin, Berlin, Berlin, Germany.,University of Zurich, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Cathérine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland. .,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland. .,Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.
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de Oliveira Marreiros DJ, Tomšič A, van Brakel TJ, Hamming JF, Scholte AJHA, Hjortnaes J, Klautz RJM. Computed tomography follow-up after elective proximal aortic surgery: Less is more? Am Heart J 2022; 249:66-75. [PMID: 35436505 DOI: 10.1016/j.ahj.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 03/16/2022] [Accepted: 04/07/2022] [Indexed: 06/14/2023]
Abstract
STUDY OBJECTIVE The added value of computed tomography (CT) follow-up after elective proximal aortic surgery is unclear. We evaluated the benefit of CT follow-up by assessing the incidence of aorta-related complications and reinterventions detected during routine CT follow-up. METHODS Data on 314 patients undergoing first time elective proximal aortic surgery between 2000 and 2015 were collected. The primary study end points were aorta-related complications and reinterventions, detected during routine CT follow-up. Secondary study endpoints included all aorta-related complications and reinterventions, irrespective of the mode of detection and survival. RESULTS Median CT follow-up time was 6.8 (IQR 4.1-9.8) years, during which a total of 1303 routine follow-up CT-scans (median 4, IQR 3-5) were performed. During CT follow-up, aorta-related complications were detected in 18 (5.7%) patients, of which 6 (1.6%) underwent reintervention. In total, 28 aorta-related complications were observed in 23 (7.3%) patients, of which 9 led to reintervention. In order to detect 1 aorta-related complication leading to reintervention, 218 routine follow-up CT-scans were required. The unadjusted and EuroSCORE II adjusted hazard ratios of not undergoing CT follow-up on mortality were 1.260 (95% CI 0.705-2.251) and 0.830 (95% CI 0.430-1.605), respectively. CONCLUSIONS Following first time elective proximal aortic surgery, aorta-related complications are uncommon, are not always detected during CT follow-up and, if detected, often do not result in reintervention. Therefore, a more conservative CT follow-up protocol could be considered in selected patients to reduce lifetime radiation burden and health care costs.
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Affiliation(s)
| | - Anton Tomšič
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas J van Brakel
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jaap F Hamming
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Arthur J H A Scholte
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jesper Hjortnaes
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert J M Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Bullock-Palmer RP, Peix A, Aggarwal NR. Nuclear Cardiology in Women and Underrepresented Minority Populations. Curr Cardiol Rep 2022; 24:553-566. [PMID: 35262873 DOI: 10.1007/s11886-022-01673-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW To outline sex-specific features of coronary artery disease (CAD) that should be considered in the assessment of women, including those from ethnic minority populations with suspected stable ischemic heart disease (IHD). Second, to determine the latest nuclear imaging tools available to assess microvascular CAD. RECENT FINDINGS Latest studies indicate that women are more likely to have ischemia with no obstructive coronary arteries (INOCA) and paradoxically have worse outcomes. Therefore, the evaluation of women with suspected IHD should include assessing microvascular and epicardial coronary circulation. The prevalence of CAD is increasing in younger women due to the increased cardiovascular disease (CVD) risk burden. CAD is often underrecognized in these patients. There is increasing recognition that INOCA is not benign and should be accurately diagnosed and managed. Nuclear imaging assesses the full spectrum of CAD from microvascular CAD to multivessel obstructive epicardial CAD. Further research on myocardial blood flow (MBF) assessment with PET MPI is needed.
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Affiliation(s)
- Renee P Bullock-Palmer
- Department of Cardiology, Deborah Heart and Lung Center, Trenton Road, Browns Mills, NJ, 08015, USA.
| | - Amalia Peix
- Institute of Cardiology and Cardiovascular Surgery, La Habana, Havana, Cuba
| | - Niti R Aggarwal
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN, 55902, USA
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr 2022; 16:54-122. [PMID: 34955448 DOI: 10.1016/j.jcct.2021.11.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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Abstract
Environmental impact of medical imaging is ill-defined and poorly recognised but can vary by a factor of 100 or 1 000 between one test or the other. One echocardiogram produces 2 Kg and a 3 Tesla magnetic resonance imaging produces 200 to 300 kg of carbon dioxide (CO2) equivalent. For 2016, CO2 emissions for magnetic resonance imaging and computed tomography calculated in 120 countries accounted for 0.77% of global emissions. In imaging justification, we usually consider benefit, cost, and risk including long-term cancer risk. Environmental footprint should be included, since there is a fourth partner in the imaging deal: not only the patient, the physician, the payer, but also the planet. Medical imaging is an important source of carbon footprint in the global scale. Environmental impact of each imaging examination might be spelled-out and missing data provided to bridge the knowledge gap. Research may develop a catalogue of carbon footprints associated with specific test modalities, and provide an updated estimation of medical imaging impact on global carbon footprint, promoting new approaches towards a progressive de-carbonization of testing with climate-neutral choices.
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:e187-e285. [PMID: 34756653 DOI: 10.1016/j.jacc.2021.07.053] [Citation(s) in RCA: 301] [Impact Index Per Article: 100.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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11
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709879 DOI: 10.1161/cir.0000000000001029] [Citation(s) in RCA: 135] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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12
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Sharkey AR, Gambhir P, Saraskani S, Walker R, Hajilou A, Bassett P, Sandhu N, Croasdale P, Honey I, Diamantopoulos A, Goh V. Occupational radiation exposure in doctors: an analysis of exposure rates over 25 years. Br J Radiol 2021; 94:20210602. [PMID: 34538079 PMCID: PMC8553192 DOI: 10.1259/bjr.20210602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Healthcare professionals' occupational exposure to ionising radiation may be increasing due to increasing use of imaging and image-guided intervention. This study aims to assess the occupational exposure of doctors over a 25-year period at an NHS teaching hospital. METHODS Dosemeter measurements were collected prospectively from 1995 to 2019. Two retrospective analyses were performed over time (first including all measurements, second excluding "zero-dose" measurements), and by speciality. Group comparisons were undertaken using multilevel linear regression; a p-value <0.05 was deemed significant. RESULTS 8,892 measurements (3,983 body, 1,514 collar, 649 eye, 2,846 hand), of which 3,350 were non-zero measurements (1,541 body, 883 collar, 155 eye, 771 hand), were included. Whole dataset analysis found a significant decrease in exposure for radiologists and cardiologists, as measured by body, hand and collar dosemeters over the last 25 years (p < 0.01 for all). The non-zero readings reflect the whole cohort analysis except in the case of eye dosemeters, which showed a significant decrease in exposure for cardiologists (p < 0.01), but a significant increase for radiologists and surgeons/anaesthetists (p < 0.01 for both). CONCLUSIONS Whilst ionising radiation remains an occupational risk for doctors, the overall decreasing trend in occupational exposure is reassuring. However, a significant rise in eye dose for radiologists, surgeons and anaesthetists is concerning, and close monitoring is required to prevent future issues. ADVANCES IN KNOWLEDGE This paper is one of few evaluating the occupational radiation exposure to doctors over a 25-year period, showing that although most dosemeter measurements reflect decreasing exposure, the increase in eye exposure warrants caution.
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Affiliation(s)
- Amy R Sharkey
- Department of Radiology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom.,Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | | | | | - Ross Walker
- King's College London, London, United Kingdom
| | | | - Paul Bassett
- Statsconsultancy Ltd, Buckinghamshire, United Kingdom
| | - Navneet Sandhu
- Department of Medical Physics, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Peter Croasdale
- Department of Medical Physics, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Ian Honey
- Department of Medical Physics, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Vicky Goh
- Department of Radiology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom.,Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
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13
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Anselmino M, Ballatore A, Giaccardi M, Agresta A, Chieffo E, Floris R, Racheli M, Scaglione M, Casella M, Maines M, Marini M, De Ferrari GM, De Ponti R, Del Greco M. X-ray management in electrophysiology: a survey of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC). J Cardiovasc Med (Hagerstown) 2021; 22:751-758. [PMID: 34009182 DOI: 10.2459/jcm.0000000000001210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Radiation use in medicine has significantly increased over the last decade, and cardiologists are among the specialists most responsible for X-ray exposure. The present study investigates a broad range of aspects, from specific European Union directives to general practical principles, related to radiation management among a national cohort of cardiologists. METHODS AND RESULTS A voluntary 31-question survey was run on the Italian Arrhythmology and Pacing Society (AIAC) website. From June 2019 to January 2020, 125 cardiologists, routinely performing interventional electrophysiology, participated in the survey. Eighty-seven (70.2%) participants are aware of the recent European Directive (Euratom 2013/59), although only 35 (28.2%) declare to have read the document in detail. Ninety-six (77.4%) participants register the dose delivered to the patient in each procedure, in 66.1% of the cases both as fluoroscopy time and dose area product. Years of exposition (P = 0.009) and working in centers performing pediatric procedures (P = 0.021) related to greater degree of X-ray equipment optimization. The majority of participants (72, 58.1%) did not recently attend radioprotection courses. The latter is related to increased awareness of techniques to reduce radiation exposure (96% vs. 81%, P = 0.022), registration of the delivered dose in each procedure (92% vs. 67%, P = 0.009), and X-ray equipment optimization (50% vs. 36%, P = 0.006). CONCLUSION Italian interventional cardiologists show an acceptable level of radiation awareness and knowledge of updated European directives. However, there is clear space for improvement. Comparison to other health professionals, both at national and international levels, is needed to pursue proper X-ray management and protect public health.
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Affiliation(s)
- Matteo Anselmino
- Division of Cardiology, 'Città della Salute e della Scienza di Torino' Hospital, Department of Medical Sciences, University of Turin
| | - Andrea Ballatore
- Division of Cardiology, 'Città della Salute e della Scienza di Torino' Hospital, Department of Medical Sciences, University of Turin
| | - Marzia Giaccardi
- Cardiology and Electrophysiology Unit, Department of Medicine, 'Santa Maria Nuova' Hospital, Florence
| | | | | | - Roberto Floris
- Ospedale di Nostra Signora di Bonaria, San Gavino Monreale
| | | | - Marco Scaglione
- Division of Cardiology, 'Cardinal Massaia' Hospital, Asti, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital, Ancona
| | | | | | - Gaetano Maria De Ferrari
- Division of Cardiology, 'Città della Salute e della Scienza di Torino' Hospital, Department of Medical Sciences, University of Turin
| | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo-University of Insubria, Varese, Italy
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14
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Arida-Moody L, Moody JB, Renaud JM, Poitrasson-Rivière A, Hagio T, Smith AM, Ficaro EP, Murthy VL. Effects of two patient-specific dosing protocols on measurement of myocardial blood flow with 3D 82Rb cardiac PET. Eur J Nucl Med Mol Imaging 2021; 48:3835-3846. [PMID: 33982174 DOI: 10.1007/s00259-021-05385-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 04/25/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Clinical measurement of myocardial blood flow (MBF) has emerged as an important component of routine PET-CT assessment of myocardial perfusion in patients with known or suspected coronary artery disease. Although multiple society guidelines recommend patient-specific dosing, there is a lack of studies evaluating the efficacy of patient-specific dosing for quantitative MBF accuracy. METHODS Two patient-specific dosing protocols (weight- and BMI-adjusted) were retrospectively evaluated in 435 consecutive clinical patients referred for PET myocardial perfusion assessment. MBF was estimated at rest and after regadenoson-induced hyperemia. The effect of dosing protocol on dose reduction, PET scanner saturation, relative perfusion, and image quality was compared. The effect of PET saturation on the accuracy of MBF and myocardial flow reserve (MFR) in remote myocardium was assessed with multivariable linear regression. RESULTS BMI-adjusted dosing was associated with lower administered 82Rb activities (1036.0 ± 274 vs. 1147 ± 274 MBq, p = 0.003) and lower PET scanner saturation incidence (28 vs. 38%, p = 0.006) and severity (median saturation severity index 0.219 ± 0.33 vs. 0.397 ± 0.59%, p = 0.018) compared to weight-adjusted dosing. PET saturation that occurred with either dosing protocol was moderate and resulted in modest remote MBF and MFR biases ranging from 2 to 9% after adjusting for patient age, sex, BMI, rate-pressure product, and LV ejection fraction. No adverse effects of BMI dose adjustment were observed in relative perfusion assessment or image quality. CONCLUSIONS Patient-specific dosing according to BMI is an effective method for guideline-directed dose reduction while maintaining image quality and accuracy for routine MBF and MFR quantification.
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Affiliation(s)
- Liliana Arida-Moody
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | | | | | | | | | - Edward P Ficaro
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- INVIA, LLC, Ann Arbor, MI, USA
| | - Venkatesh L Murthy
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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15
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Cauti FM, Rossi P, La Greca C, Piro A, Di Belardino N, Battaglia A, Ferraris F, Pecora D, Lavalle C, Scalone A, Rossi L, Di Cori A, Solimene F, Mantovan R, Pedretti S, Iaia L, Bianchi S, Anselmino M. Minimal fluoroscopy approach for right-sided supraventricular tachycardia ablation with a novel ablation technology: Insights from the multicenter CHARISMA clinical registry. J Cardiovasc Electrophysiol 2021; 32:1296-1304. [PMID: 33783875 DOI: 10.1111/jce.15023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/25/2021] [Accepted: 03/16/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND No data exist on the ability of the novel Rhythmia 3-D mapping system to minimize fluoroscopy exposure during transcatheter ablation of arrhythmias. We report data on the feasibility and safety of a minimal fluoroscopic approach using this system in supraventricular tachycardia (SVT) procedures. METHODS Consecutive patients were enrolled in the CHARISMA registry at 12 centers. All right-sided procedures performed with the Rhythmia mapping system were analyzed. The acquired electroanatomic information was used to reconstruct 3-D cardiac geometry; fluoroscopic confirmation was used whenever deemed necessary. RESULTS Three hundred twenty-five patients (mean age = 56 ± 17 years, 57% male) were included: 152 atrioventricular nodal reentrant tachycardia, 116 atrial flutter, 41 and 16 right-sided accessory pathway and atrial tachycardia, respectively. Overall, 27 481 s of fluoroscopy were used (84.6 ± 224 s per procedure, equivalent effective dose = 1.1 ± 3.7 mSv per patient). One hundred ninety-two procedures (59.1%) were completed without the use of fluoroscopy (zero fluoroscopy, ZF). In multivariate analysis, the presence of a fellow in training (OR = 0.15, 95% CI: 0.05-0.46; p = .0008), radiofrequency application (0.99, 0.99-1.00; p = .0002), and mapping times (0.99, 0.99-1.00; p = .042) were all inversely associated with ZF approach. Acute procedural success was achieved in 97.8% of the cases (98.4 vs. 97% in the ZF vs. non-ZF group; p = .4503). During a mean of 290.7 ± 169.6 days follow-up, no major adverse events were reported, and recurrence of the primary arrhythmia was 2.5% (2.1 vs. 3% in the ZF vs. non-ZF group; p = .7206). CONCLUSIONS The Rhythmia mapping system permits transcatheter ablation of right-sided SVT with minimal fluoroscopy exposure. Even more, in most cases, the system enables a ZF approach, without affecting safety and efficacy.
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Affiliation(s)
- Filippo M Cauti
- Arrhythmology Unit, S. Giovanni Calibita Hospital, Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Pietro Rossi
- Arrhythmology Unit, S. Giovanni Calibita Hospital, Fatebenefratelli Isola Tiberina, Rome, Italy
| | | | | | | | | | - Federico Ferraris
- Department of Medical Sciences, "Città della Salute e della Scienza di Torino" Hospital, University of Turin, Turin, Italy
| | | | | | | | - Luca Rossi
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | | | | | | | | | - Luigi Iaia
- Arrhythmology Unit, S. Giovanni Calibita Hospital, Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Stefano Bianchi
- Arrhythmology Unit, S. Giovanni Calibita Hospital, Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Matteo Anselmino
- Department of Medical Sciences, "Città della Salute e della Scienza di Torino" Hospital, University of Turin, Turin, Italy
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16
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Subedi P, Gomolka M, Moertl S, Dietz A. Ionizing Radiation Protein Biomarkers in Normal Tissue and Their Correlation to Radiosensitivity: A Systematic Review. J Pers Med 2021; 11:jpm11020140. [PMID: 33669522 PMCID: PMC7922485 DOI: 10.3390/jpm11020140] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/05/2021] [Accepted: 02/14/2021] [Indexed: 12/16/2022] Open
Abstract
Background and objectives: Exposure to ionizing radiation (IR) has increased immensely over the past years, owing to diagnostic and therapeutic reasons. However, certain radiosensitive individuals show toxic enhanced reaction to IR, and it is necessary to specifically protect them from unwanted exposure. Although predicting radiosensitivity is the way forward in the field of personalised medicine, there is limited information on the potential biomarkers. The aim of this systematic review is to identify evidence from a range of literature in order to present the status quo of our knowledge of IR-induced changes in protein expression in normal tissues, which can be correlated to radiosensitivity. Methods: Studies were searched in NCBI Pubmed and in ISI Web of Science databases and field experts were consulted for relevant studies. Primary peer-reviewed studies in English language within the time-frame of 2011 to 2020 were considered. Human non-tumour tissues and human-derived non-tumour model systems that have been exposed to IR were considered if they reported changes in protein levels, which could be correlated to radiosensitivity. At least two reviewers screened the titles, keywords, and abstracts of the studies against the eligibility criteria at the first phase and full texts of potential studies at the second phase. Similarly, at least two reviewers manually extracted the data and accessed the risk of bias (National Toxicology Program/Office for Health Assessment and Translation—NTP/OHAT) for the included studies. Finally, the data were synthesised narratively in accordance to synthesis without meta analyses (SWiM) method. Results: In total, 28 studies were included in this review. Most of the records (16) demonstrated increased residual DNA damage in radiosensitive individuals compared to normo-sensitive individuals based on γH2AX and TP53BP1. Overall, 15 studies included proteins other than DNA repair foci, of which five proteins were selected, Vascular endothelial growth factor (VEGF), Caspase 3, p16INK4A (Cyclin-dependent kinase inhibitor 2A, CDKN2A), Interleukin-6, and Interleukin-1β, that were connected to radiosensitivity in normal tissue and were reported at least in two independent studies. Conclusions and implication of key findings: A majority of studies used repair foci as a tool to predict radiosensitivity. However, its correlation to outcome parameters such as repair deficient cell lines and patients, as well as an association to moderate and severe clinical radiation reactions, still remain contradictory. When IR-induced proteins reported in at least two studies were considered, a protein network was discovered, which provides a direction for further studies to elucidate the mechanisms of radiosensitivity. Although the identification of only a few of the commonly reported proteins might raise a concern, this could be because (i) our eligibility criteria were strict and (ii) radiosensitivity is influenced by multiple factors. Registration: PROSPERO (CRD42020220064).
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17
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Sáenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Europace 2020; 21:1143-1144. [PMID: 31075787 DOI: 10.1093/europace/euz132] [Citation(s) in RCA: 218] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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18
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Kosiuk J, Fiedler L, Ernst S, Duncker D, Pavlović N, Guarguagli S, Stegmann C, Miskowiec D, Garcia R, Russo V, Yakushev A, Szegedi N, De Potter T. Fluoroscopy usage in contemporary interventional electrophysiology: Insights from a European registry. Clin Cardiol 2020; 44:36-42. [PMID: 33220000 PMCID: PMC7803367 DOI: 10.1002/clc.23411] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/10/2020] [Indexed: 11/24/2022] Open
Abstract
Background Fluoroscopy has been an essential part of every electrophysiological procedure since its inception. However, till now no clear standards regarding acceptable x‐ray exposure nor recommendation how to achieve them have been proposed. Hypothesis Current norms and quality markers required for optimal clinical routine can be identified. Methods Centers participating in this Europe‐wide multicenter, prospective registry were requested to provide characteristics of the center, operators, technical equipment as well as procedural settings of consecutive cases. Results Twenty‐five centers (72% university clinics, with a mean volume of 526 ± 348 procedures yearly) from 14 European countries provided data on 1788 cases [9% diagnostic procedures (DP), 38% atrial fibrillation (AF) ablations, 44% other supraventricular (SVT) ablations, and 9% ventricular ablations (VT)] conducted by 95 operators (89% male, 41 ± 7 years old). Mean dose area product (DAP) and time was 304 ± 608 cGy*cm2, 3.6 ± 4.8 minutes, 1937 ± 608 cGy*cm2, 15.3 ± 15.5 minutes, 805 ± 1442 cGy*cm2, 10.6 ± 10.7 minutes, and 1277 ± 1931 cGy*cm2, 10.4 ± 12.3 minutes for DP, AF, SVT, and VT ablations, respectively. Seven percent of all procedures were conducted without any use of fluoroscopy. Procedures in the lower quartile of DAP were performed more frequently by female operators (OR 1.707, 95%CI 1.257‐2.318, P = .001), in higher‐volume center (OR 1.001 per one additional procedure, 95%CI 1.000‐1.001, P = .002), with the use of 3D‐mapping system (OR 2.622, 95%CI 2.053‐3.347, P < .001) and monoplane x‐ray system (OR 2.945, 95%CI 2.149‐4.037, P < .001). Conclusion Exposure to ionizing radiation varies widely in daily practice for all procedure. Significant opportunities for harmonization of exposure toward the lower range has been identified.
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Affiliation(s)
- Jedrzej Kosiuk
- Rhythmology Department, Helios Clinic Koethen, Koethen, Germany
| | - Lucas Fiedler
- Department of Internal Medicine II, General Hospital Wiener Neustadt, Wiener Neustadt, Austria
| | | | - David Duncker
- Rhythmology and Electrophysiology, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Nikola Pavlović
- Department of Cardiology, Univeristy Hospital Center Sestre Milosrdnice, Zagreb, Croatia
| | | | - Clara Stegmann
- Department of Electrophysiology, Heart Center Leipzig, Leipzig, Germany
| | - Dawid Miskowiec
- Department of Cardiology, Medical University of Lodz, Lodz, Poland
| | | | - Vincenzo Russo
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Andriy Yakushev
- Amosov National Institute of Cardiovascular Surgery, Kyiv, Ukraine
| | - Nándor Szegedi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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19
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Bella PD, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. J Interv Card Electrophysiol 2020; 59:145-298. [PMID: 31984466 PMCID: PMC7223859 DOI: 10.1007/s10840-019-00663-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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20
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Predictors of zero X ray procedures in supraventricular arrhythmias ablation. Int J Cardiovasc Imaging 2020; 36:1599-1607. [PMID: 32447632 DOI: 10.1007/s10554-020-01884-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 05/14/2020] [Indexed: 01/01/2023]
Abstract
To evaluate predictors of zero-X ray procedures for supraventricular arrhythmias (SVT) using minimally fluoroscopic approach (MFA). Patients referred for RF catheter ablation of SVT were admitted for a MFA with an electro-anatomical navigation system or a conventional fluoroscopic approach (ConvA). Exclusion criterion was the need to perform a transseptal puncture. 206 patients (98 men, age 53 ± 19 years) underwent an EP study, 93 (45%) with an MFA and 113 (55%) with a ConvA. Fifty-five had no inducible arrhythmias (EPS). Fifty-four had AV nodal reentrant tachycardia (AVNRT), 49 patients had typical atrial flutter (AFL), 37 had AV reciprocating tachycardia (AVRT/WPW), 11 had focal atrial tachycardia (AT), and underwent a RF ablation. X-ray was not used at all in 51/93 (58%) procedures (zero X ray). MFA was associated with a significant reduction in total fluoroscopy time (5.5 ± 10 vs 13 ± 18 min, P = 0.01) and operator radiation dose (0.8 ± 2.5 vs 3 ± 8.2 mSV, P < 0.05). The greatest absolute dose reduction was observed in AVNRT (0.1 ± 0.3 vs 5.1 ± 10 mSV, P = 0.01, 98% relative dose reduction) and in AFL (1.3 ± 3.6 vs 11 ± 16 mSV, P = 0.003, 88% relative dose reduction) groups. Both AVNRT or AFL resulted the only statistically significant predictors of zero x ray at multivariate analysis (OR 4.5, 95% CI 1.5-13 and OR 5, 95% CI 1.7-15, P < 0.001, respectively). Success and complication rate was comparable between groups (P = NS). Using MFA for SVT ablation, radiological exposure is significantly reduced. Type of arrhythmia is the strongest predictor of zero X ray procedure.
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Nappi C, Acampa W, Nicolai E, Daniele S, Zampella E, Assante R, Gaudieri V, Mannarino T, Petretta M, Cuocolo A. Long-term prognostic value of low-dose normal stress-only myocardial perfusion imaging by wide beam reconstruction: A competing risk analysis. J Nucl Cardiol 2020; 27:547-557. [PMID: 30027504 DOI: 10.1007/s12350-018-1373-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/10/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND A normal stress myocardial perfusion single-photon emission computed tomography (MPS) is associated with a good clinical outcome. New iterative algorithms, such as wide beam reconstruction (WBR), which improve image interpretation with half-dose or half-time acquisition, have been proposed for cardiac MPS. The aim of this study was to assess the long-term predictive value of a low-dose normal stress-only MPS with WBR using conventional Anger camera in patients with known or suspected coronary artery disease (CAD). METHODS AND RESULTS A total of 2106 patients with known or suspected CAD and normal perfusion at half-dose stress-only MPS protocol were followed for a mean of 6.6 ± 2.7 years. MPS data were reconstructed with WBR iterative algorithm. End-point events were cardiac death or nonfatal myocardial infarction. Noncardiac death was considered the competing event. During follow-up, 149 cardiac events occurred with an annualized event rate of 1.2%. Independent predictors of cardiac events at Cox analysis were age, male gender, diabetes mellitus, previous myocardial infarction and the need for pharmacologic stress testing. At Fine-Gray analysis the cumulative incidence of cardiac events progressively increases with age and in the presence of diabetes for any combination of gender and stress type. Survival tree analysis confirmed that long-term prognosis considerably varies according of risk factors profile. CONCLUSIONS Low-dose normal stress-only WBR MPS has a reliable long-term prognostic value in patients with suspected or known CAD. This finding supports the introduction of such a method into clinical practice with a consistent dose optimization in the interest of patients and exposed staff.
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Affiliation(s)
- Carmela Nappi
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Wanda Acampa
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
- Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy
| | | | - Stefania Daniele
- Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy
| | - Emilia Zampella
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Roberta Assante
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Valeria Gaudieri
- Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy
| | - Teresa Mannarino
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Mario Petretta
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy.
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22
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Stopsack KH, Cerhan JR. Cumulative Doses of Ionizing Radiation From Computed Tomography: A Population-Based Study. Mayo Clin Proc 2019; 94:2011-2021. [PMID: 31248696 PMCID: PMC6778511 DOI: 10.1016/j.mayocp.2019.05.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 05/20/2019] [Accepted: 05/21/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To assess cumulative radiation doses from computed tomography (CT), patient characteristics, and clinical indications for CT in a population-based sample. PATIENTS AND METHODS A cohort study using medical records linkage through the Rochester Epidemiology Project was conducted to ascertain all CT examinations in Olmsted County, Minnesota, performed between January 1, 2004, and December 31, 2013, among all adults who were alive for 3 or more years after the end of follow-up (to exclude exposures preceding death). Ten-year cumulative effective ionizing radiation doses were estimated on the basis of typical doses per CT modality. Among patients with high doses (≥100 mSv/10 years), CT scans were reviewed for clinical setting, indications, and results. RESULTS Of 54,447 adults (median age, 44.0 years at inclusion), 26,377 (48.4%) underwent at least one CT. Ten-year radiation doses from CT were 0.1 to 9.9 mSv in 15.8% of the population (8593 patients), 10 to 24.9 mSv in 16.9% (9502), 25 to 99.9 mSv in 13.8% (7492), and 100 mSv or greater in 1.9% (1041). Computed tomography of the abdomen and pelvis accounted for 67.2% of the estimated dose. In multivariable models, doses differed 1.21-fold to 2.16-fold between extreme categories of age, body mass index, education level, smoking status, and by race. Of 600 CTs in 200 patients with high doses, 70.5% were obtained for restaging of solid cancers and lymphoma, abdominal pain, infection, kidney stones, follow-up of nodules or masses, and chest pain/evaluation for pulmonary embolism. CONCLUSION Exposure to ionizing radiation from CT occurred disproportionally in specific subgroups of the population. A limited number of clinical indications contributed the majority of radiation among adults with high doses.
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Affiliation(s)
- Konrad H Stopsack
- Department of Internal Medicine, Mayo Clinic, Rochester, MN; Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
| | - James R Cerhan
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
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23
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Eichenlaub M, Astheimer K, Minners J, Blum T, Restle C, Maring C, Schweitzer S, Thiel U, Neumann FJ, Arentz T, Lehrmann H. Evaluation of a new ultralow-dose radiation protocol for electrophysiological device implantation: A near-zero fluoroscopy approach for device implantation. Heart Rhythm 2019; 17:90-97. [PMID: 31494091 DOI: 10.1016/j.hrthm.2019.07.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Radiation is one of the main hazards of electrophysiological device implantation, and insertion of cardiac resynchronization therapy (CRT) devices in particular is associated with high radiation doses. OBJECTIVE The purpose of this study was to evaluate the impact of a new ultralow-dose radiation protocol on radiation doses, success rate, and safety of electrophysiological device implantations. METHODS In 2018, we established a new ultralow-dose radiation protocol (reduced pulse width, increased thickness of minimum copper filters, reduced detector entrance dose, reduced pulse rate, optimized image postprocessing settings) for de novo device implantation at our hospital. A total of 1173 patients (11% single-chamber devices, 69% dual-chamber devices, 20% CRT devices) were analyzed. Five hundred twelve patients (44%) in the ultralow-dose group were compared to 661 patients (66%) treated during 2017 with a conventional low-dose protocol. RESULTS With the ultralow-dose radiation protocol, effective doses could be reduced by 59% (median 0.25 [interquartile range: 0.11-0.63] vs median 0.10 [interquartile range: 0.03-0.28] mSv; P <.0001) per procedure without a significant change in procedure time (P = .5). This dose reduction could be achieved without decreasing procedure success (P = 1) or increasing complication rate (P = .8). Male gender, higher body mass index, increased procedure and fluoroscopy times, and use of the conventional radiation protocol were independent predictors of higher radiation doses in multivariate regression analysis. CONCLUSION By establishing a new ultralow-dose radiation protocol, we could significantly decrease radiation exposure, reaching the lowest radiation doses for electrophysiological device implantation reported to date.
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Affiliation(s)
- Martin Eichenlaub
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany.
| | - Klaus Astheimer
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Jan Minners
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Thomas Blum
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Christian Restle
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Christian Maring
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Saskia Schweitzer
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Ulrike Thiel
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Franz-Josef Neumann
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Thomas Arentz
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Heiko Lehrmann
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
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24
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Banerjee I, McNulty JP, Catania D, Maccagni D, Masterson L, Portelli JL, Rainford L. An Investigation of Procedural Radiation Dose Level Awareness and Personal Training Experience in Communicating Ionizing Radiation Examinations Benefits and Risks to Patients in Two European Cardiac Centers. HEALTH PHYSICS 2019; 117:76-83. [PMID: 31136364 DOI: 10.1097/hp.0000000000001049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE Cardiac interventional practitioners need to be appropriately informed regarding radiation dose quantities and risks. Communicating benefit-risk information to patients requires attention as specified in Basic Safety Standards Directive 2013/59/Eurotom. This study investigated the awareness of procedural radiation dose levels and the impact of personal training experience in communicating ionizing radiation benefit-risks to patients. METHODOLOGY A questionnaire, consisting of 28 questions, was distributed directly to adult and pediatric interventional cardiology specialists at specialized cardiovascular imaging centers in Dublin, Ireland and Milan, Italy. RESULTS A total of 18 interventional cardiologists (senior registrar to consultant grades with between 2 y to over 21 y experience in cardiac imaging) participated. The majority of participants (n = 17) stated that parents of pediatric and adult patients should be informed of the potential benefits and risk. All participants indicated they had radiation safety training; however, 50% had not received training in radiation examination benefit-risk communication. Despite this, 77.8% (n = 14) participants indicated a high confidence level in successfully explaining risks and/or benefits of cardiac imaging procedures. When asked to estimate effective dose (ED) values for common cardiac imaging procedures less than 50% identified appropriate dose ranges. All participants underestimated procedural dose values based on recent European data. 50% (n = 9) participants answered all questions correctly for a number of true or false radiation risk statements. CONCLUSION Benefit-risk communication training deficits and inaccurate understanding of radiation dose levels was identified. Further research and training to support clinicians using radiation on a daily basis is required.
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Affiliation(s)
- I Banerjee
- Radiography and Diagnostic Imaging, School of Medicine, University College Dublin, Ireland
| | - J P McNulty
- Radiography and Diagnostic Imaging, School of Medicine, University College Dublin, Ireland
| | - D Catania
- AITRI, Association of Italian Interventional Radiographers, Milan, Italy
| | | | - L Masterson
- Our Lady's University Children's Hospital, Crumlin, Dublin, Ireland
| | - J L Portelli
- Department of Radiography, Faculty of Health Sciences, University of Malta
| | - L Rainford
- Radiography and Diagnostic Imaging, School of Medicine, University College Dublin, Ireland
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25
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Heart Rhythm 2019; 17:e2-e154. [PMID: 31085023 PMCID: PMC8453449 DOI: 10.1016/j.hrthm.2019.03.002] [Citation(s) in RCA: 179] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 01/10/2023]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Chetrit M, Verma BR, Xu B. Choosing the Appropriate Stress Test for Myocardial Perfusion Imaging. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019. [DOI: 10.1007/s12410-019-9488-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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27
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Affiliation(s)
| | - Christina Stewart
- Department of Medical Physics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nicholas W Weir
- Department of Medical Physics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David E Newby
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
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28
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Plank F, Stowasser B, Till D, Schgör W, Dichtl W, Hintringer F, Weiss G, Stühlinger M. Reduction of fluoroscopy dose for cardiac electrophysiology procedures: A feasibility and safety study. Eur J Radiol 2019; 110:105-111. [DOI: 10.1016/j.ejrad.2018.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/14/2018] [Accepted: 11/19/2018] [Indexed: 10/27/2022]
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29
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Vano E, Sanchez RM, Fernandez JM. Strategies to optimise occupational radiation protection in interventional cardiology using simultaneous registration of patient and staff doses. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2018; 38:1077-1088. [PMID: 30019690 DOI: 10.1088/1361-6498/aad429] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The International Commission on Radiological Protection recommends that occupational protection and patient protection be managed in an integrated approach. This paper describes the experience and the initial results of a system able to register and to process simultaneously staff and patient doses in interventional cardiology and the practical use of this system in the optimisation of occupational exposure. The system used simultaneously collects and manages patient and staff doses for all radiation events. The personal electronic dosimeters worn over the protective apron of health professionals working inside catheterisation laboratories can send (wireless) doses and dose rate values to an X-hub and provide the operators inside the catheterisation rooms with real-time information. Individual and global reports for all the health professionals may be periodically obtained from the system to help with the optimisation. The results for eight cardiologists, one fellow and four nurses for a total of 2468 interventional cardiology procedures and 3207 occupational dose values collected over one year are presented here. Annual doses Hp(10) measured over the apron for cardiologists ranged from 0.3 to 6.3 mSv. For the cardiologist, the ratio between occupational doses (over the apron) and patient doses ranged from 0.05 to 0.23 μSv Gy-1 cm-2, with a mean value of 0.12 μSv Gy-1 cm-2. The system allows defining optimisation strategies by comparing the results between the different operators while considering the workload and complexity of the procedures (based on the total Kerma Area Product managed by the different operators). The registration of the date and time of the occupational radiation doses allows auditing the use of the personal dosimeters worn by the various operators.
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Affiliation(s)
- Eliseo Vano
- Radiology Department, Faculty of Medicine. Complutense University, E-28040 Madrid, Spain. IdISSC and Medical Physics Service, Hospital Clínico San Carlos, Martin Lagos s.n., E-28040 Madrid, Spain
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30
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Gomez J, Golzar Y, Fughhi I, Olusanya A, Doukky R. The significance of post-stress decrease in left ventricular ejection fraction in patients undergoing regadenoson stress gated SPECT myocardial perfusion imaging. J Nucl Cardiol 2018; 25:1313-1323. [PMID: 28181156 DOI: 10.1007/s12350-017-0802-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 01/20/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND The significance of post-stress decrease in left ventricular ejection fraction (LVEF) with regadenoson stress gated SPECT (GSPECT) myocardial perfusion imaging (MPI) has not been studied. METHODS AND RESULTS Consecutive patients who underwent rest/regadenoson stress GSPECT-MPI followed by coronary angiography within 6 months were analyzed. Change in LVEF by GSPECT-MPI was calculated as stress LVEF minus rest LVEF; a significant decrease was tested at 5% and 10% thresholds. In a diagnostic cohort of 793 subjects, LVEF change was not predictive of severe/extensive coronary artery disease (area under the curve, 0.50; 95% confidence interval, 0.44-0.57; P = 0.946). There was no significant difference in the rates of severe/extensive coronary artery disease in patients with or without a decrease in LVEF, irrespective of MPI findings. In an outcome cohort of the 929 subjects followed for 30 ± 16 months, post-regadenoson stress decrease in LVEF was not associated with increased risk of the composite endpoint of cardiac death or myocardial infarction or in the risk of coronary revascularization. CONCLUSIONS In patients selected to undergo coronary angiography following regadenoson stress GSPECT-MPI, a decrease in LVEF after regadenoson stress is not predictive of severe/extensive CAD or adverse clinical outcomes, irrespective of MPI findings.
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Affiliation(s)
- Javier Gomez
- Division of Cardiology, John H. Stroger, Jr. Hospital of Cook County, 1901 W. Harrison St., Suite # 3620, Chicago, IL, 60612, USA
| | - Yasmeen Golzar
- Division of Cardiology, John H. Stroger, Jr. Hospital of Cook County, 1901 W. Harrison St., Suite # 3620, Chicago, IL, 60612, USA
| | - Ibtihaj Fughhi
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Adebayo Olusanya
- Division of Cardiology, John H. Stroger, Jr. Hospital of Cook County, 1901 W. Harrison St., Suite # 3620, Chicago, IL, 60612, USA
- Division of Cardiology, Rutgers, New Jersey Medical School, Newark, NJ, USA
| | - Rami Doukky
- Division of Cardiology, John H. Stroger, Jr. Hospital of Cook County, 1901 W. Harrison St., Suite # 3620, Chicago, IL, 60612, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
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31
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Casella M, Dello Russo A, Russo E, Catto V, Pizzamiglio F, Zucchetti M, Majocchi B, Riva S, Vettor G, Dessanai MA, Fassini G, Moltrasio M, Tundo F, Vignati C, Conti S, Bonomi A, Carbucicchio C, Di Biase L, Natale A, Tondo C. X-Ray Exposure in Cardiac Electrophysiology: A Retrospective Analysis in 8150 Patients Over 7 Years of Activity in a Modern, Large-Volume Laboratory. J Am Heart Assoc 2018; 7:JAHA.117.008233. [PMID: 29789334 PMCID: PMC6015357 DOI: 10.1161/jaha.117.008233] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Only a few studies have systematically evaluated fluoroscopy data of electrophysiological and device implantation procedures. Aims of this study were to quantify ionizing radiation exposure for electrophysiological/device implantation procedures in a large series of patients and to analyze the x‐ray exposure trend over years and radiation exposure in patients undergoing atrial fibrillation ablation considering different technical aspects. Methods and Results We performed a retrospective analysis of all electrophysiological/device implantation procedures performed during the past 7 years in a modern, large‐volume laboratory. We reported complete fluoroscopy data on 8150 electrophysiological/device implantation procedures (6095 electrophysiological and 2055 device implantation procedures); for each type of procedure, effective dose and lifetime attributable risk of cancer incidence and mortality were calculated. Over the 7‐year period, we observed a significant trend reduction in fluoroscopy time, dose area product, and effective dose for all electrophysiological procedures (P<0.001) and a not statistically significant trend reduction for device implantation procedures. Analyzing 2416 atrial fibrillation ablations, we observed a significant variability of fluoroscopy time, dose area product and effective dose among 7 different experienced operators (P<0.0001) and a significant reduction of fluoroscopy use over time (P<0.0001) for all of them. Considering atrial fibrillation ablation techniques, fluoroscopy time was not different (P = 0.74) for radiofrequency catheter ablation in comparison with cryoablation, though cryoablation was still associated with higher dose area product and effective dose values (P<0.001). Conclusions Electrophysiological procedures involve a nonnegligible x‐ray use, leading to an increased risk of malignancy. Awareness of radiation‐related risk, together with technological advances, can successfully optimize fluoroscopy use.
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Affiliation(s)
- Michela Casella
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | | | - Eleonora Russo
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Valentina Catto
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | | | - Martina Zucchetti
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | | | - Stefania Riva
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Giulia Vettor
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | | | - Gaetano Fassini
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Massimo Moltrasio
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Fabrizio Tundo
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Carlo Vignati
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Sergio Conti
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Alice Bonomi
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | | | - Luigi Di Biase
- Albert Einstein College of Medicine, Montefiore Hospital, Bronx, NY.,Texas Cardiac Arrhythmia Institute, St Davis Medical Center, Austin, TX.,Department of Biomedical Engineering, University of Texas at Austin, TX.,Department of Cardiology, University of Foggia, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St Davis Medical Center, Austin, TX.,Department of Biomedical Engineering, University of Texas at Austin, TX.,Dell Medical School, University of Texas at Austin, TX.,California Pacific Medical Center, San Francisco, CA
| | - Claudio Tondo
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan, Italy.,Department of Clinical Science and Community Health, University of Milan, Italy
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Hayes SN, Kim ESH, Saw J, Adlam D, Arslanian-Engoren C, Economy KE, Ganesh SK, Gulati R, Lindsay ME, Mieres JH, Naderi S, Shah S, Thaler DE, Tweet MS, Wood MJ. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e523-e557. [PMID: 29472380 PMCID: PMC5957087 DOI: 10.1161/cir.0000000000000564] [Citation(s) in RCA: 680] [Impact Index Per Article: 113.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. Patient-initiated research has spurred increased awareness of SCAD, and improved diagnostic capabilities and findings from large case series have led to changes in approaches to initial and long-term management and increasing evidence that SCAD not only is more common than previously believed but also must be evaluated and treated differently from atherosclerotic myocardial infarction. High rates of recurrent SCAD; its association with female sex, pregnancy, and physical and emotional stress triggers; and concurrent systemic arteriopathies, particularly fibromuscular dysplasia, highlight the differences in clinical characteristics of SCAD compared with atherosclerotic disease. Recent insights into the causes of, clinical course of, treatment options for, outcomes of, and associated conditions of SCAD and the many persistent knowledge gaps are presented.
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Badel AE, Rico-Mesa JS, Gaviria MC, Arango-Isaza D, Hernández Chica CA. Radiación ionizante: revisión de tema y recomendaciones para la práctica. REVISTA COLOMBIANA DE CARDIOLOGÍA 2018. [DOI: 10.1016/j.rccar.2017.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Picano E, Morrone D, Scali MC, Huqi A, Coviello K, Ciampi Q. Integrated quadruple stress echocardiography. Minerva Cardioangiol 2018; 67:330-339. [PMID: 29642694 DOI: 10.23736/s0026-4725.18.04691-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Stress echocardiography (SE) is an established diagnostic technique. For 40 years, the cornerstone of the technique has been the detection of regional wall motion abnormalities (RWMA), due to the underlying physiologically-relevant epicardial coronary artery stenosis. In the last decade, three new parameters (more objective than RWMA) have shown the potential to integrate and complement RWMA: 1) B-lines, also known as ultrasound lung comets, as a marker of extravascular lung water, measured using lung ultrasound with the 4-site simplified scan symmetrically of the antero-lateral thorax on the third intercostal space, from mid-axillary to anterior axillary and mid-clavicular line; 2) left ventricular contractile reserve (LVCR), assessed as the peak stress/rest ratio of left ventricular force, also known as elastance (systolic arterial pressure by cuff sphygmomanometer/end-systolic volume from 2D echocardiography); 3) coronary flow velocity reserve (CFVR) on left anterior descending coronary artery, calculated as peak stress/rest ratio of diastolic peak flow velocity assessed using pulsed-wave Doppler. The 4 parameters (RWMA, B-lines, LVCR and CFVR) now converge conceptually, logistically, and methodologically in the Integrated Quadruple (IQ)-SE. IQ-SE optimizes the versatility of SE to include in a one-stop shop the core "ABCD" (asynergy+B-lines+contractile reserve+Doppler flowmetry) protocol. It allows a synoptic assessment of parameters mirroring the epicardial artery stenosis (RWMA), interstitial lung water (B-lines), myocardial function (LVCR) and small coronary vessels (CFVR). Each variable has a clear clinical correlate, different and complementary to all others: RWMA identify an ischemic vs. non-ischemic heart; B-lines a wet vs. dry lung; LVCR a strong vs. weak heart; CFVR a warm vs. cold heart. IQ-SE is highly feasible, with minimal increase in the imaging and analysis time, and obvious diagnostic and prognostic impact also beyond coronary artery disease - especially in heart failure. Large scale effectiveness studies with IQ-SE are now under way with the Stress Echo 2020 Study, and will provide the necessary evidence base prior to large scale acceptance of the technique.
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Affiliation(s)
| | - Doralisa Morrone
- Section of Cardiovascular Disease, Department of Surgery, Medicine, Molecular and Critical Area, Pisa University, Pisa, Italy
| | | | - Alda Huqi
- Versilia Hospital, Viareggio, Lucca, Italy
| | - Katia Coviello
- Section of Cardiovascular Disease, Department of Surgery, Medicine, Molecular and Critical Area, Pisa University, Pisa, Italy
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Massalha S, Lugassi R, Raysberg E, Koskosi A, Lechtenberg G, Israel O, Kennedy JA. Evaluation of Staff Radiation Exposure during Transthoracic Echocardiography Close to Myocardial Perfusion Imaging. J Am Soc Echocardiogr 2018; 31:763-770. [PMID: 29625886 DOI: 10.1016/j.echo.2018.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Indexed: 10/17/2022]
Abstract
BACKGROUND Transthoracic echocardiography (TTE) and myocardial perfusion imaging (MPI) are used in cardiac patients. In this study the radiation exposure of sonographers performing TTE following MPI was evaluated. METHODS Of 40 study patients, 30 underwent same-day 99mTc sestamibi MPI and TTE, while another 10 underwent only TTE. Patients who underwent both studies were divided into three groups: right-handed TTE performed by an echocardiographer and right- and left-handed TTE performed by a cardiac sonographer. Seven thermoluminescent radiation dosimeter badges monitored the forehead, wrists, anterolateral right and left chest, sternal notch, and umbilical region of each examiner. Group characteristics were compared. Radiation exposures were deemed positive if >0.1 mSv. RESULTS There were no statistical differences in patient weight and body mass index. The left-handed approach group had higher residual radioactivity (979 ± 73 vs 884 ± 73 MBq [P < .01] and 906 ± 81 MBq [P < .04]), but no statistical difference in duration of TTE, compared with the other two MPI groups. Radiation exposure was positive in the right anterolateral chest and hand (0.45 and 1 mSv, respectively) for the echocardiographer, the right anterolateral chest and wrist and umbilical region (0.59, 1.06, and 0.15 mSv, respectively) for the right-handed sonographer, and the left chest and hand (0.12 and 0.34 mSv, respectively) for the left-handed sonographer. Dosimeters indicated no radiation exposure in the TTE-only group. CONCLUSIONS Staff members performing TTE after MPI are exposed to radiation that might warrant monitoring. Altering study sequence, adopting a left-handed approach, and using other radiation-reducing techniques can minimize the degree of exposure.
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Affiliation(s)
- Samia Massalha
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel; Department of Cardiology, Rambam Health Care Campus, Haifa, Israel.
| | - Rachel Lugassi
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Elyahu Raysberg
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Amjad Koskosi
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | | | - Ora Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - John A Kennedy
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel; Faculty of Biomedical Engineering, Technion - Israel Institute of Technology, Haifa, Israel
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Rose A, Uebel KE, Rae WI. Interventionalists' perceptions on a culture of radiation protection. SA J Radiol 2018; 22:1285. [PMID: 31754493 PMCID: PMC6837825 DOI: 10.4102/sajr.v22i1.1285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 11/21/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Occupational exposure to ionising radiation poses potential health risks to radiation workers unless adequate protection is in place. The catheterisation laboratory is a highly contextualised workplace with a distinctive organisational and workplace culture. OBJECTIVE This study was conducted to understand the culture of radiation protection (CRP). METHODS This study was a qualitative study and data were collected through 30 in-depth and 6 group interviews with 54 purposively selected South African interventionalists (interventional radiologists and cardiologists). The participants included a diversity of interventionalists who varied in sex, geographic location and years of experience with fluoroscopy. The transcribed data were analysed thematically using a deductive and inductive approach. RESULTS 'Culture of radiation protection' emerged as a complex theme that intersected with other themes: 'knowledge and awareness of radiation', 'radiation safety practice', 'personal protective equipment (PPE) utilisation' and 'education and training'. CONCLUSION Establishing and sustaining a CRP provides an opportunity to mitigate the potentially detrimental health effects of occupational radiation exposure. Education and training are pivotal to establishing a CRP. The time to establish a culture of radiation in the catheterisation laboratory is now.
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Affiliation(s)
- André Rose
- Department of Community Health, University of the Free State, South Africa
| | - Kerry E. Uebel
- Department of Internal Medicine, University of the Free State, South Africa
| | - William I. Rae
- Department of Medical Physics, University of the Free State, South Africa
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Kim DA, Farrell MB, Jerome SD. It's about time we think about lowering radiation dose in obese patients too. J Nucl Cardiol 2017; 24:1922-1925. [PMID: 27541046 DOI: 10.1007/s12350-016-0636-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 08/02/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Daniel A Kim
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Scott D Jerome
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Shaw LJ, Blankstein R, Jacobs JE, Leipsic JA, Kwong RY, Taqueti VR, Beanlands RSB, Mieres JH, Flamm SD, Gerber TC, Spertus J, Di Carli MF. Defining Quality in Cardiovascular Imaging: A Scientific Statement From the American Heart Association. Circ Cardiovasc Imaging 2017; 10:e000017. [PMID: 29242239 PMCID: PMC5926771 DOI: 10.1161/hci.0000000000000017] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aims of the current statement are to refine the definition of quality in cardiovascular imaging and to propose novel methodological approaches to inform the demonstration of quality in imaging in future clinical trials and registries. We propose defining quality in cardiovascular imaging using an analytical framework put forth by the Institute of Medicine whereby quality was defined as testing being safe, effective, patient-centered, timely, equitable, and efficient. The implications of each of these components of quality health care are as essential for cardiovascular imaging as they are for other areas within health care. Our proposed statement may serve as the foundation for integrating these quality indicators into establishing designations of quality laboratory practices and developing standards for value-based payment reform for imaging services. We also include recommendations for future clinical research to fulfill quality aims within cardiovascular imaging, including clinical hypotheses of improving patient outcomes, the importance of health status as an end point, and deferred testing options. Future research should evolve to define novel methods optimized for the role of cardiovascular imaging for detecting disease and guiding treatment and to demonstrate the role of cardiovascular imaging in facilitating healthcare quality.
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Stangenberg L, Shuja F, van der Bom IMJ, van Alfen MHG, Hamdan AD, Wyers MC, Guzman RJ, Schermerhorn ML. Modern Fixed Imaging Systems Reduce Radiation Exposure to Patients and Providers. Vasc Endovascular Surg 2017; 52:52-58. [DOI: 10.1177/1538574417742211] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
High-definition fluoroscopic imaging is required to perform endovascular procedures safely and precisely, especially in complex cases, resulting in longer procedures and increased radiation exposure. This is of importance for training institutions as trainees, even with sound instruction in as low as reasonably achievable (ALARA) principles, tend to have high radiation exposures. Recently, there was an upgrade in the imaging system allowing for comparison of radiation exposure to patients and providers. We performed an analysis of consecutive endovascular aneurysm repair (EVAR) and superficial femoral artery (SFA) interventions in the years 2013 to 2014. We recorded body mass index (BMI) and fluoroscopy time (FT) and subsequently matched 1:1 based on BMI, FT, or both. We determined radiation dose using air kerma (AK) and also recorded individual surgeons’ badge readings. Allura Xper FD20 was upgraded to AlluraClarity with ClarityIQ. We identified a total of 77 EVARs (52 pre and 25 post) and 134 SFA interventions (99 pre and 35 post). Unmatched results for EVAR were BMI pre 26.2 versus post 25.8 (kg/m2, P = .325), FT 28.1 versus 21.2 (minutes, P = .051), and AK 1178.5 versus 581 (mGy, P < .001), respectively. After matching, there was a 53.2% reduction in AK (846.1 vs 395.9 mGy; P = .004) for EVAR. Unmatched results for SFA interventions were BMI pre 28.1 versus post 26.6 ( P = .327), FT 18.7 versus 16.2 ( P = .282), and AK 285.6 versus 106.0 ( P < .001), respectively. After matching, there was a 57.0% reduction in AK (305.0 vs 131.3, P < .001). The total deep dose equivalent from surgeons’ badge readings decreased from 39.5 to 17 mrem ( P = .029). Aortic and peripheral endovascular interventions can be performed with reduced radiation exposure to patients and providers, employing modern fixed imaging systems with advanced dose reduction technology. This is of particular importance in the light of the increasing volume and complexity of endovascular and hybrid procedures as well as the prospect of decades of radiation exposure during training and practice.
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Affiliation(s)
- Lars Stangenberg
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Division of Vascular and Endovascular Surgery, Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Allen D. Hamdan
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mark C. Wyers
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Raul J. Guzman
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Marc L. Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Thibault B, Macle L, Mondésert B, Dubuc M, Shohoudi A, Dyrda K, Guerra PG, Rivard L, Roy D, Talajic M, Khairy P. Reducing radiation exposure during procedures performed in the electrophysiology laboratory. J Cardiovasc Electrophysiol 2017; 29:308-315. [PMID: 29064134 DOI: 10.1111/jce.13373] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 09/22/2017] [Accepted: 10/16/2017] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Expert societies recently published strong recommendations to reduce the exposure of patients and staff to ionizing radiation (IR) during interventional and electrophysiology (EP) procedures. However, adherence to these guidelines remains difficult and the impact of implementing such recommendations is poorly characterized. METHODS AND RESULTS We conducted a single-center cohort study to quantify radiation exposure over time in three EP laboratories at the Montreal Heart Institute during 5,546 consecutive procedures from 2012 to 2015 by 11 primary operators. Overall, 2,618 (47.2%) procedures were catheter-based and 2,928 (52.8%) were device interventions. Interventions to reduce radiation exposure included educational initiatives to raise awareness (i.e., limiting cine acquisition, patient position, table height), slower frame rate, lower radiation dose per pulse, collimation, and integration with 3-D mapping systems and/or MediGuide technology. An 85% reduction in IR exposure was observed from 2012 to 2015, with the mean dose-area-product (DAP) decreasing from 7.65 ± 0.05 Gy·cm2 to 1.15 ± 0.04 Gy·cm2 (P < 0.001). This was true for catheter-based procedures (mean DAP 16.99 ± 0.08 to 2.00 ± 0.06 Gy·cm2 , P < 0.001) and device interventions (mean DAP 4.18 ± 0.06 to 0.64 ± 0.05 Gy·cm2 , P < 0.001). The median effective dose of IR recorded per quarter by 282 cervical dosimeters on EP staff decreased from 0.57 (IQR 0.18, 1.03) mSv in 2012 to 0.00 (IQR 0.00, 0.19) mSv in 2015, P < 0.001. CONCLUSION Enforcing good clinical practices with simple measures and low-dose fluoroscopy settings are highly effective in reducing IR exposure in the EP lab. These promising results should encourage other EP labs to adopt similar protective measures.
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Affiliation(s)
- Bernard Thibault
- Electrophysiology Service, Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montréal, Canada
| | - Laurent Macle
- Electrophysiology Service, Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montréal, Canada
| | - Blandine Mondésert
- Electrophysiology Service, Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montréal, Canada
| | - Marc Dubuc
- Electrophysiology Service, Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montréal, Canada
| | - Azadeh Shohoudi
- Montreal Health Innovations Coordinating Center, Montreal Heart Innovations Coordinating Center, Montrel Heart Institute, Université de Montréal, Montréal, Canada
| | - Katia Dyrda
- Electrophysiology Service, Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montréal, Canada
| | - Peter G Guerra
- Electrophysiology Service, Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montréal, Canada
| | - Léna Rivard
- Electrophysiology Service, Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montréal, Canada
| | - Denis Roy
- Electrophysiology Service, Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montréal, Canada
| | - Mario Talajic
- Electrophysiology Service, Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montréal, Canada
| | - Paul Khairy
- Electrophysiology Service, Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montréal, Canada
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Nakahara T, Iwabuchi Y, Katagiri M, Matsusaka Y, Itoh K, Ogata Y, Jinzaki M. RADIATION EXPOSURE TO OPERATORS PERFORMING PHARMACOLOGIC STRESS TESTING IN 99mTc MYOCARDIAL PERFUSION IMAGING: A PROSPECTIVE STUDY. RADIATION PROTECTION DOSIMETRY 2017; 176:235-241. [PMID: 28115658 DOI: 10.1093/rpd/ncx001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 01/05/2017] [Indexed: 06/06/2023]
Abstract
This prospective study investigated radiation exposure dose (RED) to main operator (MO) and supervisory operator (SO) performing dypiridamole stress testing in a 1-d rest/stress 99mTc tetrofosmin single-photon emission computed tomography (SPECT) of consecutive 42 patients. MO was instructed to be close to the patients during the entire procedures including the vasodilator and radiotracer injection. SO mainly recorded the data on the procedures apart from the patients. RED, procedure time (PT) and internal radioactivity (IR) of patients were measured before and after a secondary tracer injection for stress SPECT, respectively. RED was significantly greater to MO than to SO (6.2 ± 2.7 vs 2.5 ± 2.1 μSV per stress procedure, p < 0.0001). Multivariate analyses revealed that IR and PT were significantly independent factors to predict RED to both operators. Operators performing pharmacologic stress procedure should be aware that IR and PT are independent factors for RED in 99mTc myocardial perfusion imaging.
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Affiliation(s)
- Tadaki Nakahara
- Department of Diagnostic Radiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yu Iwabuchi
- Department of Diagnostic Radiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Mari Katagiri
- Department of Diagnostic Radiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yohji Matsusaka
- Department of Diagnostic Radiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Kazunari Itoh
- Department of Diagnostic Radiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yuji Ogata
- Department of Diagnostic Radiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Masahiro Jinzaki
- Department of Diagnostic Radiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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Abstract
The use of diagnostic medical imaging is becoming increasingly more commonplace in the pediatric setting. However, many medical imaging modalities expose pediatric patients to ionizing radiation, which has been shown to increase the risk of cancer development in later life. This review article provides a comprehensive overview of the available data regarding the risk of cancer development following exposure to ionizing radiation from diagnostic medical imaging. Attention is paid to modalities such as computed tomography scans and fluoroscopic procedures that can expose children to radiation doses orders of magnitude higher than standard diagnostic x-rays. Ongoing studies that seek to more precisely determine the relationship of diagnostic medical radiation in children and subsequent cancer development are discussed, as well as modern strategies to better quantify this risk. Finally, as cardiovascular imaging and intervention contribute substantially to medical radiation exposure, we discuss strategies to enhance radiation safety in these areas.
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Abstract
PURPOSE OF REVIEW Ionizing radiation poses important health risks. The per capita annual dose rate has increased in the United States and there is increasing concern for the risks posed by low-dose occupational exposure among workers in nuclear industries and healthcare. Recent nuclear accidents and concern for terrorism have heightened concern for catastrophic, high-dose ionizing radiation exposure. This review will highlight recent research into the risks to lung health posed by ionizing radiation exposure and into potential treatments. RECENT FINDINGS Angiotensin-converting enzyme inhibitors and some antioxidants have shown promise as mitigators, to decrease pneumonitis and fibrosis when given after exposure. Studies of survivors of nuclear catastrophes have shown increased risk for lung cancer, especially in nonsmokers. There is evidence for increased lung cancer risk in industrial radiation workers, especially those who process plutonium and may inhale radioactive particles. There does not seem to be an increased risk of lung cancer in healthcare workers who perform fluoroscopic procedures. SUMMARY High-dose ionizing radiation exposure causes pneumonitis and fibrosis, and more research is needed to develop mitigators to improve outcomes in nuclear catastrophes. Long-term, low-dose occupational radiation may increase lung cancer risk. More research to better define this risk could lead to improved safety protocols and screening programs.
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Healthcare Policy Statement on the Utility of Coronary Computed Tomography for Evaluation of Cardiovascular Conditions and Preventive Healthcare: From the Health Policy Working Group of the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2017; 11:404-414. [DOI: 10.1016/j.jcct.2017.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/14/2017] [Accepted: 08/14/2017] [Indexed: 12/14/2022]
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Taqueti VR, Dorbala S, Wolinsky D, Abbott B, Heller GV, Bateman TM, Mieres JH, Phillips LM, Wenger NK, Shaw LJ. Myocardial perfusion imaging in women for the evaluation of stable ischemic heart disease-state-of-the-evidence and clinical recommendations. J Nucl Cardiol 2017; 24:1402-1426. [PMID: 28585034 PMCID: PMC5942593 DOI: 10.1007/s12350-017-0926-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/15/2017] [Indexed: 12/21/2022]
Abstract
This document from the American Society of Nuclear Cardiology represents an updated consensus statement on the evidence base of stress myocardial perfusion imaging (MPI), emphasizing new developments in single-photon emission tomography (SPECT) and positron emission tomography (PET) in the clinical evaluation of women presenting with symptoms of stable ischemic heart disease (SIHD). The clinical evaluation of symptomatic women is challenging due to their varying clinical presentation, clinical risk factor burden, high degree of comorbidity, and increased risk of major ischemic heart disease events. Evidence is substantial that both SPECT and PET MPI effectively risk stratify women with SIHD. The addition of coronary flow reserve (CFR) with PET improves risk detection, including for women with nonobstructive coronary artery disease and coronary microvascular dysfunction. With the advent of PET with computed tomography (CT), multiparametric imaging approaches may enable integration of MPI and CFR with CT visualization of anatomical atherosclerotic plaque to uniquely identify at-risk women. Radiation dose-reduction strategies, including the use of ultra-low-dose protocols involving stress-only imaging, solid-state detector SPECT, and PET, should be uniformly applied whenever possible to all women undergoing MPI. Appropriate candidate selection for stress MPI and for post-MPI indications for guideline-directed medical therapy and/or invasive coronary angiography are discussed in this statement. The critical need for randomized and comparative trial data in female patients is also emphasized.
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Affiliation(s)
- Viviany R Taqueti
- Noninvasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, ASBI-L1 037-G, 75 Francis Street, Boston, MA, 02115, USA.
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Sharmila Dorbala
- Noninvasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, ASBI-L1 037-G, 75 Francis Street, Boston, MA, 02115, USA
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Wolinsky
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston, FL, USA
| | - Brian Abbott
- Warren Alpert Medical School, Brown University, Providence, RI, USA
- Cardiovascular Institute, The Miriam and Newport Hospitals, Providence, RI, USA
| | - Gary V Heller
- Gagnon Cardiovascular Center, Morristown Medical Center, Morristown, NJ, USA
| | - Timothy M Bateman
- Saint Luke's Health System, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | | | - Lawrence M Phillips
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York University School of Medicine, New York, NY, USA
| | - Nanette K Wenger
- Division of Cardiology, Department of Medicine, Emory University Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Leslee J Shaw
- Division of Cardiology, Department of Medicine, Emory University Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
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Moody JB, Hiller KM, Lee BC, Corbett JR, Ficaro EP, Murthy VL. Limitations of Rb-82 weight-adjusted dosing accuracy at low doses. J Nucl Cardiol 2017; 24:1395-1401. [PMID: 27184903 DOI: 10.1007/s12350-016-0531-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 04/28/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Weight-adjusted dosing is important to maintain accurate quantification for dynamic cardiac three-dimensional positron emission tomography (PET). However, the manufacturer of the only Food and Drug Administration approved rubidium-82 (Rb-82) generator (CardioGen-82, Bracco Diagnostics, Inc.) recommends recalibration after each change in dose which is inefficient in a busy clinical PET lab. The objective of this study was to evaluate the accuracy of Rb-82 dosing without this recalibration. METHODS After daily calibration to either 30 mCi (1110 MBq) or 12 mCi (444 MBq), Rb-82 doses between 6 and 45 mCi (222-1665 MBq) were eluted and measured on an external dose calibrator. This was repeated for four generators at weeks 1, 2, or 4 of the generator cycle. The measurements were compared with values reported by the infusion system. RESULTS For requested doses less than 30 mCi, the measured dose was consistently lower than the requested dose, ranging from -3.2 mCi at 25 mCi to -5.5 mCi at 10 mCi. The error exceeded 10% for doses less than or equal to 26 mCi for the 30 mCi calibration. Residual activity in the infusion system dead volume accounted for the discrepancy between requested and delivered doses for calibration to 30 mCi but not 12 mCi. CONCLUSIONS The CardioGen-82 infusion system is capable of accurate weight-adjusted doses without recalibration for Rb-82 doses as low as 26 mCi when calibrated to 30 mCi. For doses less than 26 mCi, the generator-reported residual activity within the infusion system can be used to correct the delivered dose.
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Affiliation(s)
| | - Kerri M Hiller
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, 1338 Cardiovascular Center, 1500 E. Medical Center Dr, SPC 5873, Ann Arbor, MI, 48109-5873, USA
| | | | - James R Corbett
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, 1338 Cardiovascular Center, 1500 E. Medical Center Dr, SPC 5873, Ann Arbor, MI, 48109-5873, USA
| | - Edward P Ficaro
- INVIA Medical Imaging Solutions, Ann Arbor, MI, USA
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, 1338 Cardiovascular Center, 1500 E. Medical Center Dr, SPC 5873, Ann Arbor, MI, 48109-5873, USA
| | - Venkatesh L Murthy
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, 1338 Cardiovascular Center, 1500 E. Medical Center Dr, SPC 5873, Ann Arbor, MI, 48109-5873, USA.
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Hill KD, Frush DP, Han BK, Abbott BG, Armstrong AK, DeKemp RA, Glatz AC, Greenberg SB, Herbert AS, Justino H, Mah D, Mahesh M, Rigsby CK, Slesnick TC, Strauss KJ, Trattner S, Viswanathan MN, Einstein AJ. Radiation Safety in Children With Congenital and Acquired Heart Disease: A Scientific Position Statement on Multimodality Dose Optimization From the Image Gently Alliance. JACC Cardiovasc Imaging 2017; 10:797-818. [PMID: 28514670 PMCID: PMC5542588 DOI: 10.1016/j.jcmg.2017.04.003] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 04/25/2017] [Accepted: 04/28/2017] [Indexed: 02/07/2023]
Abstract
There is a need for consensus recommendations for ionizing radiation dose optimization during multimodality medical imaging in children with congenital and acquired heart disease (CAHD). These children often have complex diseases and may be exposed to a relatively high cumulative burden of ionizing radiation from medical imaging procedures, including cardiac computed tomography, nuclear cardiology studies, and fluoroscopically guided diagnostic and interventional catheterization and electrophysiology procedures. Although these imaging procedures are all essential to the care of children with CAHD and have contributed to meaningfully improved outcomes in these patients, exposure to ionizing radiation is associated with potential risks, including an increased lifetime attributable risk of cancer. The goal of these recommendations is to encourage informed imaging to achieve appropriate study quality at the lowest achievable dose. Other strategies to improve care include a patient-centered approach to imaging, emphasizing education and informed decision making and programmatic approaches to ensure appropriate dose monitoring. Looking ahead, there is a need for standardization of dose metrics across imaging modalities, so as to encourage comparative effectiveness studies across the spectrum of CAHD in children.
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Affiliation(s)
- Kevin D Hill
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina (Image Gently Alliance representative)
| | - Donald P Frush
- Department of Radiology, Duke University Medical Center, Durham, North Carolina (Image Gently Alliance and SPR representative)
| | - B Kelly Han
- Department of Pediatric Cardiology, Children's Heart Clinic at The Children's Hospitals and Clinics of Minnesota and the Minneapolis Heart Institute, Minneapolis, Minnesota (SCCT representative)
| | - Brian G Abbott
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island (ASNC representative)
| | - Aimee K Armstrong
- Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio (ACC representative)
| | - Robert A DeKemp
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada (SNMMI representative)
| | - Andrew C Glatz
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania (Image Gently Alliance representative)
| | - S Bruce Greenberg
- Department of Radiology, Arkansas Children's Hospital, Little Rock, Arkansas (NASCI representative)
| | - Alexander Sheldon Herbert
- Department of Radiology, New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York (ASRT representative)
| | - Henri Justino
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas (SCAI representative)
| | - Douglas Mah
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts (PACES representative)
| | - Mahadevappa Mahesh
- Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland (AAPM representative)
| | - Cynthia K Rigsby
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois (ACR representative)
| | - Timothy C Slesnick
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia (AAP representative)
| | - Keith J Strauss
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (Image Gently Alliance Representative)
| | - Sigal Trattner
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York (Image Gently Alliance representative)
| | - Mohan N Viswanathan
- Department of Internal Medicine, Stanford University, Stanford, California (HRS representative)
| | - Andrew J Einstein
- Division of Cardiology, Department of Medicine, and Department of Radiology, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York (Image Gently Alliance representative).
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48
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Rose A, Rae WID, Chikobvu P, Marais W. A multiple methods approach: radiation associated cataracts and occupational radiation safety practices in interventionalists in South Africa. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2017; 37:329-339. [PMID: 28253201 DOI: 10.1088/1361-6498/aa5eee] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Ionising radiation is a modality used in diagnostic and therapeutic medicine. The technology has improved and resulted in lower dose exposure but there has been an escalation in the quantity of procedures, their duration and complexity. These factors have meant increased occupational radiation exposure for interventionalists. Ionising radiation exposure can have detrimental health effects and includes radiation skin burns, various carcinomas, genetic and chromosomal aberrations and cataractogenesis of the lenses of the eye. The lenses of the eye are of the most radiosensitive organs and the risk of cataracts is high despite low radiation dose exposures. The use of personal protective equipment (PPE) is a method that can be used to mitigate the risk for developing lens opacifications. The consistent and effective utilisation of PPE is marred by availability, proper fit and ease of use when performing procedures. Radiation safety training is imperative to enforce a culture of radiation safety among interventionalists. The aim of this study was to quantify and describe cataracts among South African interventionalists and to understand their radiation safety practices. For this purpose, a cross sectional study was designed using multiple methods. A survey was conducted to determine the demographics and the risk factors of doctors exposed to radiation to doctors not exposed. The radiation workload and radiation safety practices of interventionalists were explored. Both groups had slit lamp examinations. The data were analysed analytically and a regression model developed looking at the outcomes and the risk factors. Qualitative in-depth interviews and group interviews were conducted to explore the perceptions of interventionalists regarding radiation safety. Deductive and inductive thematic analysis was done. Interdisciplinary research is challenging but offers tremendous opportunity for exploring and tackling complex issues related to securing a safe radiation work environment.
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Affiliation(s)
- A Rose
- Department of Community Health, University of the Free State, South Africa
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Koh AS, Lye WK, Chia SY, Salunat-Flores J, Sim LL, Keng FY, Tan RS, Chua TS. Long-Term Prognostic Value of Appropriate Myocardial Perfusion Imaging. Am J Cardiol 2017; 119:1957-1962. [PMID: 28456317 DOI: 10.1016/j.amjcard.2017.03.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 03/10/2017] [Accepted: 03/10/2017] [Indexed: 10/19/2022]
Abstract
Appropriate use criteria (AUC) for single-photon emission computed tomography myocardial perfusion images (SPECT-MPIs) were developed to address the growth of cardiac imaging studies. Long-term prognostic value of AUC in SPECT-MPI has not been tested in existing cohorts. We sought to determine the long-term prognostic value of MPI classified as appropriate. AUC was evaluated in a prospectively designed cohort of patients who underwent clinically indicated MPI. MPI studies were classified based on 2009 AUC for SPECT-MPI. Data regarding downstream coronary angiography (cath), revascularization and all-cause mortality, cardiac death, and nonfatal myocardial infarction (MI) were collected from national registries. Among n = 1,129 MPI scans that received an appropriate grading, 148 all-cause deaths, 109 MIs, 58 cardiac deaths, 152 caths, 113 revascularization procedures occurred over a mean follow-up period of 5.4 ± 1.2 years (0.9% cardiac death rate per year, 1.8% MI rate per year). Most of the scans were low-risk normal MPI scans (summed stress score ≤3; 74.1%). An abnormal scan was associated with higher rates of MI (19.5% vs 6.2%, hazard ratio 1.72, p = 0.017) and cardiac death (13.4% vs 2.3%, hazard ratio 2.12, p = 0.016). In conclusion, MPI scans classified as appropriate have long-term prognostic value, despite a high proportion of low-risk scans. This provides support for clinicians to consider the use of appropriate grading in addition to MPI scan results in patient management.
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Jones T, Brennan PC, Mello-Thoms C, Ryan E. CONTEMPORARY AUSTRALIAN DOSE AREA PRODUCT LEVELS IN THE FLUOROSCOPIC INVESTIGATION OF PAEDIATRIC CONGENITAL HEART DISEASE. RADIATION PROTECTION DOSIMETRY 2017; 173:374-379. [PMID: 26908924 DOI: 10.1093/rpd/ncw012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 01/06/2016] [Indexed: 06/05/2023]
Abstract
This study examines radiation dose levels delivered to children from birth to 15 y of age in the investigation of congenital heart disease (CHD) at a major Sydney children's hospital. The aims are to compare values with those derived from similar studies, to provide a template for more consistent dose reporting, to establish local and national diagnostic reference levels and to contribute to the worldwide paediatric dosimetry database. A retrospective review of 1007 paediatric procedural records was undertaken. The cohort consisted of 795 patients over a period from January 2007 to December 2012 who have undergone cardiac catheterisation for the investigation of CHD. The age range included was from the day of birth to 15 y. Archived dose area product (DAP) and fluoroscopy time (FT) readings were retrieved and analysed. The mean, median, 25th and 75th percentile DAP levels were calculated for six specific age groupings. The 75th percentile DAP values for the specific age categories were as follows: 0-30 d-1.9 Gy cm2, 1-12 months-2.9 Gy cm2, 1-3 y-5.3 Gy cm2, 3-5 y-6.2 Gy cm2, 5-10 y-7.5 Gy cm2 and 10-15 y-17.3 Gy cm2. These levels were found to be lower than the values reported in comparable overseas studies. Individual year-specific levels were determined, and it is proposed that these are more useful than the common grouping method. The age-specific 75th percentile DAP levels outlined in this study can be used as baseline local diagnostic reference levels. The needs for the standardisation of DAP reporting and for a greater range of age-specific diagnostic reference levels have been highlighted. For the first time, Australian dose values for paediatric cardiac catheterisation are presented.
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Affiliation(s)
- T Jones
- Medical Imaging Optimisation and Perception Group (MIOPeG), Discipline of Medical Radiation Sciences, Faculty of Health Science, University of Sydney, 75 East Street, Room M208, Lidcombe, NSW 2141, Australia
| | - P C Brennan
- Medical Imaging Optimisation and Perception Group (MIOPeG), Discipline of Medical Radiation Sciences, Faculty of Health Science, University of Sydney, 75 East Street, Room M208, Lidcombe, NSW 2141, Australia
| | - C Mello-Thoms
- Medical Imaging Optimisation and Perception Group (MIOPeG), Discipline of Medical Radiation Sciences, Faculty of Health Science, University of Sydney, 75 East Street, Room M208, Lidcombe, NSW 2141, Australia
| | - E Ryan
- Medical Imaging Optimisation and Perception Group (MIOPeG), Discipline of Medical Radiation Sciences, Faculty of Health Science, University of Sydney, 75 East Street, Room M208, Lidcombe, NSW 2141, Australia
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