Efficacy of the RADPAD Protection Drape in Reducing Operators’ Radiation Exposure in the Catheterization Laboratory

The impact of the RADPAD in reducing radiation exposure in a contemporary cardiac Cath Lab: Rationale and design of the ATTENUATE trial

BACKGROUND

Despite recent improvements in radiation safety, interventionalists are increasingly exposed to radiation during cardiac catheterization laboratory (CCL) procedures. The RADPAD was designed as a protective scatter-radiation absorbing shield with the goal of reducing scatter radiation. Early studies demonstrated between a 20 and 62 % relative reduction in scatter radiation. The purpose of this study was to examine the impact of the RADPAD through a randomized controlled trial in a large contemporary CCL.

DESIGN

The ATTENUATE (v) Trial is an investigator-initiated, prospective, randomized controlled trial which will randomize 1000 CCL procedures 1:1 to use of the RADPAD vs. no use of the RADPAD. The primary outcome of interest is the most proximal operator's dose-area product (DAP)-normalized operator dose (E) defined as E divided by DAP. Additional subgroup analysis comparing types of procedure will also be performed. Every case will utilize contemporary radiation safety equipment.

SUMMARY

The ATTENUATE Trial is the largest randomized controlled trial to evaluate the utility of the RADPAD in reducing relative operator exposure in a contemporary CCL including coronary and structural interventions.

Implementing a 'Lead [Apron]-Free' Cardiac Catheterization: Current Status

PURPOSE OF REVIEW

In this review, we discuss the status of novel radiation shielding and other methods to reduce radiation exposure and its associated health risks within the CCL.

RECENT FINDINGS

There are many devices on the market each with its unique advantages and inherent flaws. Several are available for widespread use with promising data, while others still in development. The field of percutaneous transcatheter interventions includes complex procedures often involving significant radiation exposure. Increased radiation exposes the proceduralist and CCL staff to potential harm from both direct effects of radiation but also from the ergonomic consequences of daily use of heavy personal protective equipment. Here we discuss several innovative efforts to reduce both radiation exposure and orthopedic injury within the CCL that are available, leading to a safer daily routine in a "lead [apron]-free" environment.

RAdiation Dose Attenuation using RADPAD in CATH lab for primary and secondary operators - RADAR-CATH STUDY

Background

Radiation injury is an important concern for interventional cardiologists and needs to be addressed. RADPAD is a radiation protection drape that has been shown to reduce the radiation exposure of the primary operator (PO). While Indian data on radiation exposure of the PO in the cath lab are scarce, the exposure of the secondary operator (SO) is even less well studied.

Aims

The aim of this study was to evaluate the efficacy of RADPAD drapes in reducing radiation doses in the cath lab for the primary as well as the secondary operator.

Methods

A total of 160 patients (40 patients each with single vessel disease [SVD], double vessel disease [DVD] and triple vessel disease [TVD] undergoing coronary angioplasty, and 40 patients undergoing balloon mitral valvuloplasty [BMV]) were randomised in a 1:1 pattern to undergo a procedure with or without the use of RADPAD.

Results

For patients with SVD, DVD and TVD undergoing percutaneous coronary intervention (PCI) and those undergoing BMV, the % reduction with the use of RADPAD reduced the PO's received dose (in mrem) by 65%, 54%, 28% and 67%, respectively, as compared to without RADPAD. The % reduction in relative operator exposure for the PO for the 4 groups was 55%, 34%, 18% and 75%, respectively, with the use of RADPAD. The corresponding % reduction for the SO's received dose (in mrem) was 80%, 63%, 33% and 69% and for relative operator exposure was 74%, 46%, 23% and 76% in the 4 groups, respectively.

Conclusions

RADPAD significantly reduces the radiation exposure of the primary and secondary operator during prolonged complex PCI and BMV procedures.

Assessing the Efficacy of RADPAD Protection Drape in Reducing Radiation Exposure to Operators in the Cardiac Catheterization Laboratory: A Systematic Review and Meta-Analysis

One of the leading environmental hazards, ionizing radiation, is linked to several detrimental health consequences in the body. RADPAD (Worldwide Innovations & Technologies, Inc., Kansas City, Kansas) is a sterile, lead-free, lightweight, disposable radiation protection shield. We conducted a systematic review and meta-analysis to determine the effectiveness of RADPAD protection drapes in the cardiac catheterization lab and how they can aid interventional cardiologists in becoming subjected to less scatter radiation. PubMed, Embase, and Google Scholar were searched for studies discussing the efficacy of RADPAD protection drapes in reducing radiation exposure to operators in the cardiac catheterization laboratory. A random-effects model was used to pool odds ratios (ORs) and 95% confidence intervals (CIs) for endpoints: primary operator exposure dose, dose area product (DAP), relative exposure, and screening time. Our analysis included 892 patients from six studies. Compared to the No-RADPAD group, primary operator exposure dose (E) was significantly lower in the RADPAD group (OR: -0.9, 95% CI: -1.36 to -0.43, I2 = 80.5%, p = 0.0001). DAP was comparable between both groups (OR: 0.008, 95% CI: -0.12 to -0.14, I2 = 0%, p = 0.9066). There was no difference in the relative exposure (E/DAP) (OR: -0.47, 95% CI: -0.96 to 0.02, I2 = 0%, p = 0.90) and screening time (OR: 0.13, 95% CI: 0.08 to 0.35, I2 = 0%, p = 0.22) between the two groups. The interventional cardiology laboratory is exposed to significantly less scatter radiation during procedures owing to the RADPAD protective drape. Consequently, all catheterization laboratories could be advised to employ RADPAD protective drapes.

Reduction in Primary Operator Radiation Dose Exposure During Coronary Angioplasty Using Radiation Absorbing Drape

Background Percutaneous coronary intervention (PCI) involves the use of ionizing radiation and is a common procedure in a cardiac catheterization suite. The RADPAD® surgical drape (Worldwide Innovations & Technologies, Inc., Lenexa, KS) has been developed to reduce scatter radiation exposure to primary operators during routine PCI procedures. This study aims to assess the efficacy of RADPAD drapes in reducing radiation dose in the catheterization laboratory. Methods This was a single-center, prospective, observational study that aimed to compare the primary operator dose received with and without the use of a commercially available shield (RADPAD) during PCI. A total of 53 consecutive patients undergoing PCI were randomized in a 1:1 pattern to receive either the RADPAD (study group) or no RADPAD (control group). Standard shielding and personal protective equipment were used. Radiation exposure to the primary operator, total fluoroscopy time, number of cine acquisitions, and air kerma were recorded for each procedure. A one-way ANOVA calculator, including the Tukey honestly significant difference (HSD) test, was used to compare the mean values of radiation exposure. Scatterplot analysis and linear regression slopes of dose relative to air kerma were performed. All shields were reused once only. Results The study compared radiation exposure during PCI procedures between patients who received radiation attenuation devices (RADPAD) and those who did not. The RADPAD group had 30 patients, while the NO RADPAD group had 23 patients. There was a significant difference in the number of coronary angiography and single/multi-vessel PCI procedures between the two groups. There was no significant difference in procedural time or air kerma dose between the groups, but the RADPAD group had a significantly lower radiation dose (mean dose of 3.679 mrem) compared to the NO RADPAD group (mean dose of 8.12 mrem) (p < 0.00001). The primary operator dose per unit of air kerma was also significantly lower in the RADPAD group. Overall, the use of RADPAD resulted in a significant reduction in radiation exposure during PCI procedures. Conclusion The present study provides further evidence for the efficacy of using radiation-absorbing drapes (RADPAD) in reducing primary operator radiation dose exposure during coronary angioplasty. The equipment for radiation dose reduction of patients also reduces the radiation dose of medical staff. Therefore, the use of RADPAD is recommended as a safe and effective measure for reducing operator radiation dose exposure during coronary angioplasty.

Update on Radiation Safety in the Cath Lab - Moving Toward a "Lead-Free" Environment

Radiation exposure in the cardiac catheterization laboratory (CCL) is an occupational hazard that predisposes health care workers to the development of adverse health effects such as cataracts, cancer, and orthopedic injury. To mitigate radiation exposure, personal protective shielding as well as permanently installed shields reduces these adverse effects. Yet, heavy protective lead aprons and poor ergonomics required for positioning movable shields remain barriers to a safer environment. Recent innovations to enhance personal protective equipment and revolutionize fixed shielding systems will permit the CCL team to work in a personal "lead-free" environment, markedly reducing occupational hazards. The purpose of this review is to update the status and future of radiation protection in the CCL.

Effectiveness of radiation protection systems in the cardiac catheterization laboratory: a comparative study

BACKGROUND

As numbers and complexity of percutaneous coronary interventions are constantly increasing, optimal radiation protection is required to ensure operator safety. Suspended radiation protection systems (SRPS) and protective scatter-radiation absorbing drapes (PAD) are novel methods to mitigate fluoroscopic scattered radiation exposure. The aim of the study was to investigate the effectiveness regarding radiation protection of a SRPS and a PAD in comparison with conventional protection.

METHODS

A total of 229 cardiac catheterization procedures with SRPS (N = 73), PAD (N = 82) and standard radiation protection (N = 74) were prospectively included. Real-time dosimeter data were collected from the first operator and the assistant. Endpoints were the cumulative operator exposure relative to the dose area product [standardized operator exposure (SOE)] for the first operator and the assistant.

RESULTS

For the first operator, the SRPS and the PAD significantly decreased the overall SOE compared to conventional shielding by 93.9% and 66.4%, respectively (P < 0.001). The protective effect of the SRPS was significantly higher compared to the PAD (P < 0.001). For the assistant, the SRPS and the PAD provided a not statistically significant reduction compared to conventional shielding in the overall SOE by 38.0% and 30.6%, respectively.

CONCLUSIONS

The SRPS and the PAD enhance radiation protection significantly compared to conventional protection. In most clinical scenarios, the protective effect of SRPS is significantly higher than the additional protection provided by the PAD. Comparison of the additional radiation protection provided by protective scatter-radiation absorbing drapes (PAD) and the suspended radiation protection system (SRPS) system over standard protection with lead aprons.

Effect of an optimized X-ray blanket design on operator radiation dose in cardiac catheterization based on real-world angiography

Background

There is increasing concern and focus in the interventional cardiology community on potential long term health issues related to radiation exposure and heavy wearable protection. Optimized shielding measures may reduce operator dose to levels where lighter radioprotective garments can safely be used, or even omitted. X-ray blankets (XRB) are commercially available but suffer from small size and lack of stability. A larger XRB may reduce operator dose but could hamper vascular access and visualization. The aim of this study is to assess shielding effect of an optimized XRB during cardiac catheterization and estimate the potential reduction in annual operator dose based on DICOM Radiation Dose Structured Report (RDSR) data reflecting everyday clinical practice.

Methods

Data accumulated from 7681 procedures over three years in our RDSR repository was used to identify projection angles and radiation doses during cardiac catheterization. Using an anthropomorphic phantom and a scatter radiation detector, radiation dose to the operator (mSv) and patient (dose area product—DAP) was measured for each angiographic projection for three different shielding setups. Relative operator dose (mSv/DAP) was calculated and multiplied by DAP per projection to estimate effect on operator dose.

Results

Adding an optimized XRB to a standard shielding setup comprising a table- and ceiling-mounted shield resulted in a 94.9% reduction in estimated operator dose. The largest shielding effect was observed in left and cranial projections where the ceiling-mounted shield offered less protection.

Conclusions

An optimized XRB is a simple shielding measure that has the potential to reduce operator dose.

Efficacy of a Protective Sheet for Reducing Ocular Radiation Exposure During Transcatheter Aortic Valve Implantation

BACKGROUND

The use of hybrid operating rooms (HOR) for transcatheter aortic valve implantation (TAVI) has increased, so radiation exposure during procedures that use X-ray fluoroscopy is a fundamental problem not only for patients but also for surgeons and interventional cardiologists, increasing the risk of cataracts among operators. We investigated the efficacy of leaded glasses and protective sheets for ocular radiation protection.

METHODS AND RESULTS

Between January 2020 and February 2021 we enrolled 54 TAVI procedures using the transfemoral approach. The subjects were divided into a curtain protection group (Group C, n=20), glass protection group (Group G, n=17), and sheet protection group (Group S, n=17). The cumulative dose (CD) of the operators showed a decreasing trend in Group S compared with the other two groups. The CD normalized by dose area product (CD/DAP) of the operators was significantly reduced in Group S compared with Group C. However, Group G showed no significant difference compared with Group C. Regarding the distribution of CD/DAP, Group S had a significantly lower distribution than that in groups C and G.

CONCLUSIONS

Protective sheets provide more stable radiation protection than conventional curtains or leaded glasses.

What are useful methods to reduce occupational radiation exposure among radiological medical workers, especially for interventional radiology personnel?

Protection against occupational radiation exposure in clinical settings is important. This paper clarifies the present status of medical occupational exposure protection and possible additional safety measures. Radiation injuries, such as cataracts, have been reported in physicians and staff who perform interventional radiology (IVR), thus, it is important that they use shielding devices (e.g., lead glasses and ceiling-suspended shields). Currently, there is no single perfect radiation shield; combinations of radiation shields are required. Radiological medical workers must be appropriately educated in terms of reducing radiation exposure among both patients and staff. They also need to be aware of the various methods available for estimating/reducing patient dose and occupational exposure. When the optimizing the dose to the patient, such as eliminating a patient dose that is higher than necessary, is applied, exposure of radiological medical workers also decreases without any loss of diagnostic benefit. Thus, decreasing the patient dose also reduces occupational exposure. We propose a novel four-point policy for protecting medical staff from radiation: patient dose Optimization, Distance, Shielding, and Time (pdO-DST). Patient dose optimization means that the patient never receives a higher dose than is necessary, which also reduces the dose received by the staff. The patient dose must be optimized: shielding is critical, but it is only one component of protection from radiation used in medical procedures. Here, we review the radiation protection/reduction basics for radiological medical workers, especially for IVR staff.

DOES RADIOLOGICAL PROTECTION TRAINING OR A REAL-TIME STAFF DOSEMETER DISPLAY REDUCE STAFF DOSES DURING X-RAY-GUIDED PULMONARY BRONCHOSCOPY?

X-ray-guided interventions have increased in number and complexity. Mandatory radiological protection training includes both theoretical and practical training sessions. A recent additional training tool is real-time display dosemeters that give direct feedback to staff on their individual dose rates. Ten staff members who regularly perform pulmonary bronchoscopy wore an extra dosemeter during four 2-month periods. We controlled for the patient air kerma area product and the number of procedures in each period. Between periods 1 and 2, radiological training sessions were held and during period 3 the staff used the real-time display system. Focus-group interviews with the staff were held to obtain their opinion about learning radiological protection. We hypothesised that neither training nor the additional real-time dose rate display alters the personal dose equivalent, Hp(d); d = 0.07 and 10 mm. Useful experiences from radiological protection training were obtained, and median staff doses did decrease, however not significantly.

Reduction of Occupational Radiation Exposure During Endovascular Treatment of Peripheral Artery Disease Using Radiation Absorbing Drapes

BACKGROUND

A chronic exposure to low dose radiation, as encountered in endovascular procedures, may impact the health of surgeons and radiologists over a timespan of several months to a lifetime. This study evaluates the feasibility and efficacy of a radiation absorbing sterile drape (RADPAD) to reduce operator exposure during the endovascular treatment of obstructive peripheral artery disease (PAD).

METHODS

Between February 2016 and September 2017, patients with PAD who received percutaneous transluminal angioplasty, stent placement, remote endarterectomy, or a combination thereof were included in this nonrandomized study. Patients were equally divided over a study cohort (with RADPAD) and a control cohort (without RADPAD). The unshielded body dose (E) of the staff was measured via electronic dosimeters placed at a chest height of the first operator (FO), second operator (SO), and sterile nurse (SN). A virtual maximum operator (MO) dose was constructed, yielding the highest dose per fluoroscopy run for either of the operators. Simultaneously, the dose area product (DAP) and C-arm settings for each fluoroscopy run were extracted. Staff exposures of the study cohort and control cohort were compared in terms of relative exposure (E/DAP). A secondary analysis involved an analysis of the individual fluoroscopy runs using a multivariate generalized linear mixed effect model.

RESULTS

In total, 49 patients were included in this study. The use of RADPAD was technically feasible. Significant reductions of relative exposure were observed when comparing the study cohort with the control cohort. The relative exposure of the FO was reduced with 66.5% (1.82 vs. 0.61 μSv/Gycm², P < 0.001), the relative exposure of the SO with 68.3% (0.55 vs. 0.17 μSv/Gycm², P = 0.02), and the relative exposure of the MO with 65.8% (2.06 vs. 0.71 μSv/Gycm², P < 0.001). Dose levels of SN were too low to draw conclusions under the current sample size. The multivariate generalized linear mixed effect model showed a significant correlation between absolute exposure of the MO and the use of the RADPAD (odds: 0.51, P < 0.001).

CONCLUSIONS

Usage of a radiation absorbing drape (RADPAD) during endovascular treatment of PAD results in statistically significant reduction in a relative operator dose while presenting no drawbacks. The use of these drapes is advised in future peripheral endovascular procedures.

Radiation protection for the interventional cardiologist: Practical approach and innovations

Use of ionizing radiation during cardiac catheterization interventions adversely impacts both the patients and medical staff. In recent years, radiation dose in cardiac catheterization interventions has become a topic of increasing interest in interventional cardiology and there is a strong interest in reducing radiation exposure during the procedures. This review presents the current status of radiation protection in the cardiac catheterization laboratory and summarizes a practical approach for radiation dose management for minimizing radiation exposure. This review also presents recent innovations that have clinical potential for reducing radiation during cardiac interventions.

Efficacy of MAVIG X-Ray Protective Drapes in Reducing CTO Operator Radiation

Background

The MAVIG X-ray protective drape (MXPD) has been shown to reduce operator radiation dose during percutaneous coronary interventions (PCI). Whether MXPDs are also effective in reducing operator radiation during chronic total occlusion (CTO) PCI, often with dual access, is unknown.

Methods

We performed a prospective, randomized-controlled study comparing operator radiation dose during CTO PCI (n = 60) with or without pelvic MXPDs. The primary outcomes were the difference in first operator radiation dose (μSv) and relative dose of the first operator (radiation dose normalized for dose area product) at the level of the chest in the two groups. The effectiveness of MXPD in CTO PCI was compared with non-CTO PCI using a patient-level pooled analysis with a previously published non-CTO PCI randomized study.

Results

The use of the MXPD was associated with a 37% reduction in operator dose (weighted median dose 26.0 (IQR 10.00–29.47) μSv in the drape group versus 41.8 (IQR 30.82–60.59) μSv in the no drape group; P < 0.001) and a 60% reduction in relative operator dose (median dose 3.5 (IQR 2.5–5.4) E/DAPx10⁻³ in the drape group versus 8.6 (IQR 4.2–12.5) E/DAPx10⁻³ in the no drape group; P=0.001). MXPD was equally effective in reducing operator dose in CTO PCI compared with non-CTO PCI (P value for interaction 0.963).

Conclusions

The pelvic MAVIG X-ray protective drape significantly reduced CTO operator radiation dose. This trial is clinically registered with https://www.clinicaltrials.gov (unique identifier: NCT04285944).

Effectiveness of a Real-Time X-ray Dosimetry Monitor in Reducing Radiation Exposure in Coronary Procedures: The ESPRESSO-Raysafe Randomized Trial

Background—Several methods to reduce radiation exposure in the setting of coronary procedures are available on the market, and we previously showed that additional radiation shields reduce operator exposure during radial interventions. We set out to examine the efficacy of real-time personal dosimetry monitoring in a real-world setting of radial artery catheterization. Methods and Results—In an all-comer prospective, parallel study, consecutive coronary diagnostic and intervention procedures were performed with the use of standard radiation shield alone (control group) or with the addition of a real-time dosimetry monitoring system (Raysafe, Billdal, Sweden, monitoring group). The primary outcome was the difference in exposure of the primary operator among groups. Additional endpoints included patient, nurse, second operator exposure and fluoroscopy time. A total of 700 procedures were included in the analysis (n = 369 in the monitoring group). There were no differences among groups in patients’ body mass index (p = 0.232), type of procedure (intervention vs. diagnostic, p = 0.172), and patient sex (p = 0.784). Fluoroscopy time was shorter in the monitoring group (5.6 (5.1–6.2) min vs. 7.0 (6.1–7.7) min, p = 0.023). Radiation exposure was significantly lower in the monitoring group for the patient (135 (115–151) µSv vs. 208 (176–245) µSv, p < 0.0001) but not for the first operator (9 (7–11) µSv vs. 10 (8–11), p = 0.70) and the assistant (2 (1–2) µSv vs. 2 (1–2) µSv, p = 0.121). Conclusions—In clinical daily practice, the use of a real-time dosimetry monitoring device reduces patient radiation exposure and fluoroscopy time without an effect on operator radiation exposure.

Impact of radiation to the eye of operators during endo-cardiovascular surgery and the importance of protection

OBJECTIVE

To verify the amount of radiation exposure to the eye of operators during endocardiovascular surgery (ECVS) in hybrid operating room (HOR), which increases the risk of cataracts in surgeons.

METHODS

Fifty cases of ECVS (including 36 transcatheter aortic valve implantation and 14 thoracic endovascular repair) using the transfemoral approach performed from February 2020 to July 2020 were included. A measurement device was attached to the left side of the head of the operators and their assistants to measure the cumulative dose (CD) of intraoperative radiation exposure. The subjects were divided into the control group (Group C, n = 26), received conventional protection using the protective curtain in HOR and the protected group (Group R, n = 24), received conventional protection and protection sheet. The normalized CD by dose area product (CD/DAP) was evaluated.

RESULTS

The CD/DAP of the surgeons was significantly decreased in Group R, averaging at 5.97 μSV/Gy cm² in Group C group and 4.40 μSV/Gy cm² in Group R (p < 0.01). Moreover, CD/DAP of the assistant was significantly reduced in the Group R, with an average of 1.87 μSV/Gy cm² in the Group C and 1.01 μSV/Gy cm² in Group R (p < 0.01).

CONCLUSIONS

The radiation exposure to the surgeon's eye could be significantly reduced by protection sheet.

Self-reported radiation safety behaviors among veterinary specialists and residents performing fluoroscopic procedures on small animals

OBJECTIVE

To describe the radiation safety behaviors of veterinary specialists performing small animal fluoroscopic procedures and examine potential risk factors for these behaviors, including knowledge of radiation risk and training regarding machine operating parameters.

SAMPLE

197 veterinary specialists and residents in training.

PROCEDURES

An electronic questionnaire was distributed to members of the American Colleges of Veterinary Internal Medicine (subspecialties of cardiology and small animal internal medicine), Veterinary Radiology, and Veterinary Surgery.

RESULTS

The overall survey response rate was 6% (240/4,274 email recipients). Of the 240 respondents, 197 (82%) had operated an x-ray unit for a small animal fluoroscopic procedure in the preceding year and fully completed the questionnaire. More than 95% of respondents believed that radiation causes cancer, yet approximately 60% of respondents never wore hand or eye protection during fluoroscopic procedures, and 28% never adjusted the fluoroscopy machine operating parameters for the purpose of reducing their radiation dose. The most common reasons for not wearing eye shielding included no requirement to wear eyeglasses, poor fit, discomfort, and interference of eyeglasses with task performance. Respondents who had received training regarding machine operating parameters adjusted those parameters to reduce their radiation dose during procedures significantly more frequently than did respondents who had not received training.

CONCLUSIONS AND CLINICAL RELEVANCE

On the basis of the self-reported suboptimal radiation safety practices among veterinary fluoroscopy users, we recommend formal incorporation of radiation safety education into residency training programs. All fluoroscopy machine operators should be trained regarding the machine operating parameters that can be adjusted to reduce occupational radiation exposure.

The radioprotective effect of the Cathpax® AIR cabin during interventional cardiology procedures

BACKGROUND

The use of ionizing radiation during cardiac catheterization interventions adversely impacts the medical staff. Traditional radiation protection equipment is only partially effective. The Cathpax® radiation protection cabin (RPC) has proven to significantly reduce radiation exposure in electrophysiological and neuroradiology interventions. Our objective was to analyze whether the Cathpax® RPC reduces radiation dose in coronary and cardiac structural interventions in unselected real-world procedures.

METHODS AND RESULTS

In this nonrandomized all-comers prospective study, 119 consecutive cardiac interventional procedures were alternatively divided into two groups: the RPC group (n = 59) and the non-RPC group (n = 60). No significant changes in the characteristics of patients and procedures, average contrast volume, air kerma (AK), dose area-product (DAP) and fluoroscopy time between both groups were apparent. In the RPC group, the first-operator relative radiation exposure was reduced by 78% at the chest and by 70% at the wrist. This effect was consistent during different types of procedures including complex percutaneous interventions and structural procedures.

CONCLUSIONS

Our study demonstrates, for the first time, that the Cathpax® cabin significantly and efficiently reduces relative operator radiation exposure during different types of interventional procedures, confirming its feasibility in a real-world setting.

Pregnancy in the Cardiac Catheterization Laboratory: A Safe and Feasible Endeavor

Concerns over radiation exposure are ubiquitous to all interventional cardiologists; however, fear of exposure during childbearing years disproportionately deters women from entering the field. This review summarizes the available data on occupational radiation exposure during pregnancy with an emphasis on radiation quantification, the impact of exposure at various stages of fetal development, societal recommendations for safe levels of exposure during gestation, threshold levels necessary to induce fetal harm, and safe practices for the pregnant interventionalist. Reconciling the available information, we conclude that pregnancy in the cardiac catheterization laboratory is both safe and feasible. This review also highlights new technologies that may augment standard radiation safety techniques and are of particular interest to the pregnant interventional cardiologist. Finally, we propose steps to improve female representation in this field, underscoring the importance of a sex-balanced workforce.

Clinical Issues-April 2021

Scrubbed team members leaving the OR while x-rays are taken Key words: radiation source exposure, x-ray, distance and shielding, radiation protection devices, inverse square law. Cleaning radiation protection garments and devices Key words: radiation protection, cleaning reusable garments, eyewear, lead aprons, shielding devices. Implementing radiation precautions for pregnant health care workers Key words: scatter radiation, shielding, dosimeter, pregnant health care worker, protective garment. Protecting patients from radiation exposure Key words: scatter radiation, radiation protection devices, radiation shielding, radiation protection drapes, patient exposure. Wearing x-ray aprons that fit correctly Key words: body size, radiation protection garment sizing, x-ray, lead aprons, anthropomorphic phantom.

THE EFFICACY OF RADPAD AS A RADIATION PROTECTION TOOL IN CT FLUOROSCOPY GUIDED LUNG BIOPSIES

Computed tomography fluoroscopy is now the preferred technique for percutaneous lung biopsies. However, concern regarding operator and patient radiation dose remains, which warrants further exploration into dose optimisation tools. This phantom-study aims to assess the dose reduction capabilities of RADPAD, a single-use patient drape designed to decrease staff exposure to scattered radiation. Dosemeters at the waist and eye levels were used to determine the whole-body and lens exposure during simulated lung biopsy procedures while using RADPAD and other combinations of personal protective equipment. RADPAD resulted in a 36% and 38% dose reduction for whole-body and eye exposure, respectively. However, when used in combination with radioprotective eyewear and aprons, RADPAD did not reduce the radiation dose further. Consequently, the use of standard personal protective equipment is a more cost-effective option for staff dose reduction. RADPAD is useful in the reduction of radiation dose to unprotected regions.

Patient Body Mass Index and Occupational Radiation Doses to Circulating Nurses During Coronary Angiography

BACKGROUND

Patient BMI is associated with radiation doses received by interventional cardiologists, yet the association between patient BMI and nurse radiation doses is unknown. This study evaluated the association between patient body mass index (BMI) and nurse radiation doses during coronary angiography.

METHODS

Nurse radiation doses were collected by real-time dosimeters during consecutive coronary angiography procedures and are reported as the personal dose equivalent (H_p10). Patient radiation doses were estimated using dose area product (DAP). Patient BMI was categorized in kg/m² as <25.0, 25.0-29.9, 30.0-34.9, 35.0-39.9, and ≥40. Multiple regression analysis determined procedural factors independently association with nurse radiation doses.

RESULTS

In 643 consecutive coronary angiography procedures, patient radiation doses increased significantly across increasing patient BMI categories (p < 0.001). Compared to a patient BMI <25, a patient BMI ≥40 was associated with a 2.3-fold increase in DAP (p < 0.001). Significant differences were also observed in nurse radiation doses across patient BMI categories (p = 0.036). Compared to a patient BMI <25, a patient BMI ≥40 was associated with a 4.0-fold increase in nurse radiation dose (BMI < 25: 0.3 [0.1, 1.3] μSv; BMI ≥ 40: 1.2 [0.2, 2.9] μSv; p = 0.003). By multiple regression analysis, each 1-unit kg/m² increase in patient BMI was associated with a 3.3% increase in nurse radiation dose (p = 0.002).

CONCLUSIONS

Patient BMI was significantly associated with nurse radiation doses during coronary angiography. These observations may have important implications on nurse radiation safety, especially in the setting of the ongoing obesity epidemic.

Efficacy of MAVIG X-Ray Protective Drapes in Reducing Operator Radiation Dose in the Cardiac Catheterization Laboratory: A Randomized Controlled Trial

BACKGROUND

Interventional cardiologists are occupationally exposed to high doses of ionizing radiation. The MAVIG X-ray protective drape (MXPD) is a commercially available light weight, lead-free shield placed over the pelvic area of patients to minimize operator radiation dose. The aim of this study was to examine the efficacy of the MXPD during routine cardiac catheterization, including percutaneous coronary interventions.

METHODS

We performed a prospective, randomized controlled study comparing operator radiation dose during cardiac catheterization and percutaneous coronary intervention (n=632) with or without pelvic MXPD. We measured operator radiation dose at 4 sites: left eye, chest, left ring finger, and right ring finger. The primary outcomes were the difference in first operator radiation dose (µSv) and relative dose of the first operator (radiation dose normalized for dose area product) at the level of the chest in the 2 groups.

RESULTS

The use of the MXPD was associated with a 50% reduction in operator radiation dose (median dose 30.5 [interquartile range, 23.0-39.7] µSv in no drape group versus 15.3 [interquartile range, 11.1-20.0] µSv in the drape group; P<0.001) and a 57% reduction in relative operator dose (P<0.001). The largest absolute reduction in dose was observed at the left finger (median left finger dose for the no drape group was 104.9 [75.7-137.4] µSv versus 41.9 [32.6-70.6] µSv in the drape group; P<0.001).

CONCLUSIONS

The pelvic MXPD significantly reduces first operator radiation dose during routine cardiac catheterization and percutaneous coronary intervention. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT04285944.

Effectiveness of additional X-ray protection devices in reducing scattered radiation in radial intervention: the ESPRESSO randomised trial

AIMS

We aimed to examine the impact of three different radiation protection devices in a real-world setting of radial artery catheterisation.

METHODS AND RESULTS

In an all-comer randomised trial, consecutive coronary radial diagnostic and intervention procedures were assigned in a 1:1:1 ratio to shield-only protection (shield group), shield and overlapping 0.5 mm Pb panel curtain (shield+curtain group) or shield, curtain and additional 75x40 cm, 0.5 mm Pb drape placed across the waist of the patient (shield+curtain+drape group). A total of 614 radial procedures were randomised (n=193 shield, n=220 shield+curtain, n=201 shield+curtain+drape). There were no differences among the groups in patient or procedural characteristics. The primary endpoint (relative exposure ratio between the operators' exposure in μSv and the patient's exposure, dose area product in cGy·cm2) was significantly lower in the shield+curtain+drape group for both the first operator (20% reduction vs shield, 16% vs shield+curtain, p=0.025) and the assistant (39% reduction vs shield, 25% vs shield+curtain, p=0.009).

CONCLUSIONS

The use of an additional drape reduced the radiation exposure of both the first operator and the second operator during routine radial procedures; a shield-attached curtain alone was only partially effective. ClinicalTrials.gov identifier: NCT03634657

Temporal Trends in X-Ray Exposure during Coronary Angiography and Percutaneous Coronary Intervention

Background

Percutaneous coronary intervention exposes patient and staff to ionizing radiation. Although staff only receive a small fraction of patient dose through scatter radiation, there are concerns about the potential health effects of repeated exposure. Minimizing both patient and occupational exposure is needed.

Objective

This article investigates patient and operator X-ray exposure over time in coronary intervention in relation to upgraded X-ray equipment, improved shielding, and enhanced operator awareness.

Materials and Methods

Data regarding irradiation time, patient dose, and patient characteristics were extracted from the Norwegian Registry for Invasive Cardiology (NORIC) for procedures performed from 2013 to mid-2019. Personal operator dosimetry records were provided by the Norwegian Radiation and Nuclear Safety Authority. Improved operator shielding and awareness measures were introduced in 2018.

Results

In the period 2013 through June 2019, 21499 procedures were recorded in our institution. Mean dose area product (DAP) for coronary angiography decreased 37% from 2981 μGy·m² in 2013 to 1891 μGy·m² in 2019 (p < 0.001). For coronary intervention, DAP decreased 39% from 8358 μGy·m² to 5055 μGy·m². Personal dosimetry data indicate a 70% reduction in operator dose per procedure in 2019 compared to 2013. The most pronounced reduction occurred after improved radiation protection measures were implemented in 2018 (−48%).

Conclusions

This study shows a temporal trend towards considerable reduction in X-ray doses received by the patient and operator during cardiac catheterization. Upgraded X-ray equipment, improved shielding, and enhanced operator awareness are likely contributors to this development.

Scatter radiation reduction with a radiation-absorbing pad in interventional radiology examinations

PURPOSE

Radiation-absorbing pads are an additional possibility to reduce scattered radiation at its source. The goal of this study is to investigate the efficacy of a new reusable radiation-absorbing pad at its origin in an experimental setup.

MATERIAL AND METHODS

All measurements were carried out using a clinical angiography system with a standardized fluoroscopy protocol, different C-arm angulations and an anthropomorphic torso phantom as a scattering body. An ionization chamber was used to measure the radiation exposure at five different heights of a simulated operator during a simulated transfemoral angiography intervention. Measurements were carried out with and without radiation-absorbing pads with lead equivalents of 0.25 and 0.5 mm placed onto the scattering body. For all measurements a mobile acrylic shield and an under-table lead curtain was used.

RESULTS

At all operator heights from 100 to 165 cm a significant radiation dose reduction of up to 80.6 % (p < 0.01) using the radiation-absorbing pad was measured, when compared to no radiation-absorbing pad. At the height of 165 cm the radiation-absorbing pad with a lead equivalence of 0.5 mm showed a significant radiation dose reduction (51.4 %, p < 0.01) in comparison to a lead equivalence of 0.25 mm.

CONCLUSION

The addition of a radiation-absorbing pad to the standard protection means results in a significant dose reduction for the operator, particularly for upper body parts.

Reduction of Occupational Exposure Using a Novel Tungsten-Containing Rubber Shield in Interventional Radiology

This study investigates whether a novel tungsten-containing rubber shield could be used as substitute shielding material in interventional radiology to reduce the occupational exposure of operators to scattered radiation from a patient. The tungsten-containing rubber is a lead-free radiation-shielding material that contains as much as 90% tungsten powder by weight. Air kerma rates of scattered radiation from solid-plate phantoms, simulating a patient, were measured with a semiconductor dosimeter at the height of the operator's eye (1,600 mm from the floor), chest (1,300 mm), waist (1,000 mm), and knee (600 mm) with and without tungsten-containing rubber shielding (1-5 mm thickness). The tungsten-containing rubber and a commercial shielding material (RADPAD) were affixed onto the phantom on the operator's side, and reductions in air kerma rates were compared. Reduction rates for tungsten-containing rubber shielding with thicknesses of 1, 2, 3, 4, and 5 mm at each height level were as follows: 70.37 ± 0.40%, 72.17 ± 0.29%, 72.95 ± 0.31%, 72.58 ± 0.35%, and 73.63 ± 0.63% at eye level; 76.36 ± 0.19%, 77.13 ± 0.10%, 77.36 ± 0.14%, 77.62 ± 0.25%, and 77.66 ± 0.14% at chest level; 67.78 ± 0.31%, 68.12 ± 0.19%, 68.88 ± 0.28%, 68.97 ± 0.14%, and 68.85 ± 0.45% at waist level; and 0.14 ± 0.94%, 0.72 ± 0.56%, 1.08 ± 0.74%, 1.77 ± 0.80%, and 1.79 ± 1.82% at knee level, respectively. Reduction rates with RADPAD were 61.80 ± 0.67%, 60.33 ± 0.61%, 64.70 ± 0.25%, and 0.14 ± 0.66% at eye, chest, waist, and knee levels, respectively. The shielding ability of the 1 mm tungsten-containing rubber was superior to that of RADPAD. The tungsten-containing rubber could be employed to minimize an operator's radiation exposure instead of the commercial shielding material in interventional radiology.

Vascular access and radiation exposure during percutaneous coronary procedures

In the cardiology community, the use of transradial access for percutaneous coronary procedures is progressively increasing all around the world overtaking the use of transfemoral access. The advantages of the transradial access are based on a significant reduction in bleeding and vascular events compared to the femoral access and on a reduction in mortality in the setting of acute coronary syndromes. However, in recent years a slight but significant increase in radiation exposure for patients and operators associated with the radial approach has been detected, increasing concerns about possible long term increased stochastic risk. In particular interventional cardiologists are among physicians performing interventional procedures using X-rays, those exposed to the highest radiation dose during their activity and this exposure is not without possible long-term clinical consequences in term of deterministic and stochastic effects. All the operators should be aware of these risks and manage to reduce their radiation exposure. In this review we analysed the differences in term of radiation exposure comparing the radial and the femoral access for percutaneous coronary procedures. Then, we discussed the possible clinical consequences of these differences and finally we showed the available tools aimed to reduce the operator radiation exposure. In particular the use of adjunctive protective drapes placed on the patient might reduce operator radiation exposure in up to 81% of the dose.

Optimizing Transradial Access: Radiation, Contrast, Access Site Crossover, and Ergonomics

This article summarizes the data comparing radiation exposure and contrast use between transradial and transfemoral cardiac catheterizations. It also reviews the important features that may predict access site failure and crossover. In addition, it reviews the concept of ergonomics in the catheterization laboratory and how clinicians can improve the transradial approach.

Reduced radiation exposure in the cardiac catheterization laboratory with a novel vertical radiation shield

Objectives

Investigation of novel vertical radiation shield (VRS) in reducing operator radiation exposure.

Background

Radiation exposure to the operator remains an occupational health hazard in the cardiac catheterization laboratory (CCL).

Methods

A mannequin simulating an operator was placed near a computational phantom, simulating a patient. Measurement of dose equivalent and Air Kerma located the angle with the highest radiation, followed by a common magnification (8 in.) and comparison of horizontal radiation absorbing pads (HRAP) with or without VRS with two different: CCL, phantoms, and dosimeters. Physician exposure was subsequently measured prospectively with or without VRS during clinical procedures.

Results

Dose equivalent and Air Kerma to the mannequin was highest at left anterior oblique (LAO)‐caudal angle (p < .005). Eight‐inch magnification increased mGray by 86.5% and μSv/min by 12.2% compared to 10‐in. (p < .005). Moving 40 cm from the access site lowered μSv/min by 30% (p < .005). With LAO‐caudal angle and 8‐in. magnification, VRS reduced μSv/min by 59%, (p < .005) in one CCL and μSv by 100% (p = .016) in second CCL in addition to HRAP. Prospective study of 177 procedures with HRAP, found VRS lowered μSv by 41.9% (μSv: 15.2 ± 13.4 vs. 26.2 ± 31.4, p = .001) with no difference in mGray. The difference was significant after multivariate adjustment for specified variables (p < .001).

Conclusions

Operator radiation exposure is significantly reduced utilizing a novel VRS, HRAP, and distance from the X‐ray tube, and consideration of lower magnification and avoiding LAO‐caudal angles to lower radiation for both operator and patient.

Effectiveness of additional X-ray protection devices in reducing Scattered radiation in radial interventions: protocol of the ESPRESSO randomised trial

BACKGROUND

A number of devices have been developed to minimise operator radiation exposure in the setting of cardiac catheterisation. The effectiveness of these devices has traditionally been explored in transfemoral coronary procedures; however, less is known for the transradial approach. We set out to examine the impact of three different radiation protection devices in a real-world setting.

METHODS AND DESIGN

Consecutive coronary diagnostic and intervention procedures are randomised in a 1:1:1 ratio to a shield-only protection (shield group), shield and overlapping 0.5 mm Pb panel curtain (curtain group) or shield, curtain and additional 75×40 cm, 0.5 mm Pb drape placed across the waist of the patient (drape group).The primary outcome is the difference in relative exposure of the primary operator among groups. Relative exposure is defined as the ratio between operator's exposure (E in μSv) and patient exposure (dose area product in cGy·cm²).

ETHICS AND DISSEMINATION

The protocol complies with good clinical practice and the ethical principles described in the Declaration of Helsinki and is approved by the local ethics committee. The results of the trial will be published as original article(s) in medical journals and/or as presentation at congresses.

TRIAL REGISTRATION NUMBER

NCT03634657.

Strategies for Minimizing Occupational Radiation Exposure in Cardiac Imaging

PURPOSE OF REVIEW

Radiation safety has been at the center of interest of both researchers and healthcare institutions. This review will summarize and shed light on the various techniques adapted to reduce staff exposure to ionizing radiation (IR) in the field of cardiac imaging.

RECENT FINDINGS

In the last years, with the advance of awareness and the development of new technologies, there have been several tools and techniques adapted. The breakthrough of several technologies to lower radiation dose and shorten the duration of diagnostic tests associated with IR, the use of protection devices by staff members, and mostly the awareness of exposure to IR are the hallmark of these advances. Using all these measures has led to a significant decrease in staff exposure to IR. Reducing staff exposure to meet the "As Low As Reasonably Achievable" principle is feasible. This review introduces the most important strategies applied in cardiac imaging.

A randomized controlled trial to assess operator radiation exposure from cardiac catheterization procedures using RAD BOARD® with standard pelvic shielding versus standard pelvic shielding alone

OBJECTIVE

To study radiation exposure to the primary operator during diagnostic cardiac catheterizations using a radio-dense RAD BOARD® radial access arm board.

BACKGROUND

The use of radial access for catheterization in the United States has increased from 1% in 2007 to 41% in 2018. Compared to femoral access, operator radiation exposure from radial access is similar or higher. The RAD BOARD radio-dense radial access arm board has been marketed as reducing radiation to operators by 44%.

MATERIALS AND METHODS

We randomized 265 patients undergoing catheterization via right radial access to standard pelvic lead drape shielding (nonboard group) versus RAD BOARD in addition to pelvic drape (board group). Operator radiation exposure was measured using Landauer Microstar nanoDot™ badges worn by the operator.

RESULTS

Board and nonboard groups were similar with respect to demographic and procedural variables. Mean operator dose per case was higher in the board group (.65mSieverts) than in the nonboard group (.56mSieverts, P < 0.0001). In sub-group analyses, radiation doses were higher in the board group compared to the nonboard group in patients across all body mass index groups (P < 0.03). In multivariate analysis, operator dose correlated with use of the RAD BOARD more closely than any other variable (P < 0.001). Post hoc analysis of the table setup with RAD BOARD revealed that use of RAD BOARD prevented placement of a shield normally inserted into the top of the standard below-table shield.

CONCLUSION

RAD BOARD with the pelvic shield was associated with higher radiation exposure to the operator compared with pelvic shield alone, likely due to inability to use standard radiation shielding along with the RAD BOARD.

Cardiology fellows-in-training are exposed to relatively high levels of radiation in the cath lab compared with staff interventional cardiologists-insights from the RECAP trial

Background

Interventional cardiologists are inevitably exposed to low-dose radiation, and consequently are at risk for radiation induced diseases like cataract and left-sided brain tumours. Operator behaviour may possibly be the largest influencer on radiation exposure. We hypothesised that awareness regarding radiation exposure grows as skill and the general experience in the catheterization laboratory increase.

Objectives

In this study we determined the difference in the relative radiation exposure of staff interventional cardiologists compared with cardiology fellows-in-training.

Methods

During this prospective trial the operator’s radiation exposure (E in µSv) was measured at chest height during 766 diagnostic catheterisations and percutaneous coronary interventions. Also, the patient exposure (DAP in mGy·cm²), representing the amount of radiation administered by the operator per procedure, was collected. The primary outcome of this study was the difference in relative exposure between staff interventional cardiologists versus cardiology fellows-in-training (E/DAP).

Results

From January to May 2017, staff interventional cardiologists performed 637 procedures and cardiology fellows-in-training 129 procedures. The performance of relatively complex procedures by staff interventional cardiologists resulted in a 74% higher use of radiation compared with fellows-in-training. Consequently, staff interventional cardiologists were exposed to 50% higher levels of actual radiation exposure. However, when correcting for the complexity of the procedure, by comparing the relative operator exposure (E/DAP), fellows-in-training were exposed to a 34% higher relative exposure compared with staff interventional cardiologists (p = 0.025).

Conclusions

In the current study, when corrected for complexity, cardiology fellows-in-training were exposed to significantly higher radiation levels than staff interventional cardiologists during catheterisation procedures.

Usefulness of Pelvic Radiation Protection Shields During Transfemoral Procedures-Operator and Patient Considerations

Interventional cardiologists are increasingly exposed to radiation-induced hazards. The MAVIG shield is a lead-free drape and the RADPAD is a sterile, disposable, and lead-free shield, placed on the patient with the aim to minimize operator-received scatter radiation. The objective of the trial was to examine their efficacy in a real-world situation. We randomized 125 patients who underwent coronary procedures from the right femoral artery into 3 groups: Control group (n = 48 [39%]) without additional protection, MAVIG lead shield (n = 38 [30%]) and RADPAD shield (n = 39 [31%]). Multiple radiation dosimeters were used in each case. All 3 groups were with similar baseline and procedural characteristics. Fluoroscopy time and number of views were similar in all 3 study groups. Compared with the standard (no shield) protection [3.5 ± 5.57 mSv], the scatter radiation was reduced by a factor of 5 for the MAVIG group [0.46 ± 1.6 mSv and p = 0.001] and a factor of 4 for the RADPAD group [1.16 ± 2.29 mSv and p = 0.01]. The physician's radiation decreased with the 2 shields, but only the MAVIG shield showed statistically significant lower radiation: 0.49 ± 0.42 mSv in the standard group versus 0.26 ± 0.3 mSv in the MAVIG and 0.35 ± 0.44 mSv in the RADPAD (p = 0.135 for RADPAD and p = 0.005 for MAVIG). Patient's exposure was statistically similar to the control group. Although numerically there was an increase in radiation with the RADPAD and decrease with the MAVIG.

CONCLUSIONS

Our study found no statistically increase in patient radiation while the operator's radiation exposure was reduced. Decreasing scatter radiation can be done effectively using simple measurements and is of major importance.

Shields and garb for decreasing radiation exposure in the cath lab

INTRODUCTION

Decreasing radiation exposure of the cardiac catheterization laboratory staff is critical for minimizing radiation-related adverse outcomes and can be accomplished by decreasing patient dose and by shielding. Areas covered: protection from ionizing radiation can be achieved with architectural, equipment-mounted, and disposable shields, as well as with personal protective equipment. Expert commentary: Radiation protective aprons are the most commonly used personal protective equipment and provide robust radiation protection but can cause musculoskeletal strain. Use of a thyroid collar is recommended, as is use of 'shin guards', lead glasses and radioprotective caps, although the efficacy of the latter is being debated. Alternatives to lead aprons include shielding suspended from the ceiling and robotic percutaneous coronary intervention. Radiation protective gloves and cream can be used to protect the hands, but the best protection is to not directly expose them to the radiation beam. Devices that provide real time operator radiation dose monitoring can enable real time adjustments in positioning and shield placement, reducing radiation dose. Shielding can be achieved with architectural, equipment-mounted, and disposable shields. Equipment-mounted shielding includes ceiling-suspended shields, table-suspended drapes, and radioabsorbent drapes. Personal protective equipment and shielding should be consistently and judiciously utilized by all catheterization laboratory personnel.

Advances in Clinical Cardiology 2017: A Summary of Key Clinical Trials

INTRODUCTION

Numerous important cardiology clinical trials have been published or presented at major international meetings during 2017. This paper aims to summarize these trials and place them in clinical context.

METHODS

The authors reviewed clinical trials presented at major cardiology conferences during 2017 including the American College of Cardiology, European Association for Percutaneous Cardiovascular Interventions, European Society of Cardiology, European Association for the Study of Diabetes, Transcatheter Cardiovascular Therapeutics, and the American Heart Association. Selection criteria were trials with a broad relevance to the cardiology community and those with potential to change current practice.

RESULTS

A total of 75 key cardiology clinical trials were identified for inclusion. New interventional and structural cardiology data include left main bifurcation treatment strategy, multivessel disease management in cardiogenic shock, drug-eluting balloons for in-stent restenosis, instantaneous wave-free physiological assessment, new-generation stents (COMBO, Orsiro), transcatheter aortic valve implantation, and closure devices. New preventative cardiology data include trials of liraglutide, empagliflozin, PCSK9 inhibitors (evolocumab and bococizumab), inclisiran, and anacetrapib. Antiplatelet data include the role of uninterrupted aspirin therapy during non-cardiac surgery and dual antiplatelet therapy following coronary artery bypass grafting. New data are also included from fields of heart failure (levosimendan, spironolactone), atrial fibrillation (apixaban in DC cardioversion), cardiac devices (closed loop stimulation pacing for neuromediated syncope), and electrophysiology (catheter ablation for atrial fibrillation).

CONCLUSION

This paper presents a summary of key clinical cardiology trials during the past year and should be of practical value to both clinicians and cardiology researchers.