The benefits of cardiac imaging are immense, and modern medicine requires the extensive and versatile use of a variety of cardiac imaging techniques. Cardiologists are responsible for a large part of the radiation exposures every person gets per year from all medical sources. Therefore, they have a particular responsibility to avoid unjustified and non-optimized use of radiation, but sometimes are imperfectly aware of the radiological dose of the examination they prescribe or practice. This position paper aims to summarize the current knowledge on radiation effective doses (and risks) related to cardiac imaging procedures. We have reviewed the literature on radiation doses, which can range from the equivalent of 1-60 milliSievert (mSv) around a reference dose average of 15 mSv (corresponding to 750 chest X-rays) for a percutaneous coronary intervention, a cardiac radiofrequency ablation, a multidetector coronary angiography, or a myocardial perfusion imaging scintigraphy. We provide a European perspective on the best way to play an active role in implementing into clinical practice the key principle of radiation protection that: 'each patient should get the right imaging exam, at the right time, with the right radiation dose'.

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The appropriate and justified use of medical radiation in cardiovascular imaging: a position document of the ESC Associations of Cardiovascular Imaging, Percutaneous Cardiovascular Interventions and Electrophysiology

Background— Orthopedic strain and radiation exposure are recognized risk factors in personnel staff performing fluoroscopically guided cardiovascular procedures. However, the potential occupational health effects are still unclear. The purpose of this study was to examine the prevalence of health problems among personnel staff working in interventional cardiology/cardiac electrophysiology and correlate them with the length of occupational radiation exposure.

Methods and Results— We used a self-administered questionnaire to collect demographic information, work-related information, lifestyle-confounding factors, all current medications, and health status. A total number of 746 questionnaires were properly filled comprising 466 exposed staff (281 males; 44±9 years) and 280 unexposed subjects (179 males; 43±7years). Exposed personnel included 218 interventional cardiologists and electrophysiologists (168 males; 46±9 years); 191 nurses (76 males; 42±7 years), and 57 technicians (37 males; 40±12 years) working for a median of 10 years (quartiles: 5–24 years). Skin lesions ( P =0.002), orthopedic illness ( P 16 years). In highly exposed physicians, adjusted odds ratio ranged from 1.7 for hypertension (95% confidence interval: 1–3; P =0.05), 2.9 for hypercholesterolemia (95% confidence interval: 1–5; P =0.004), 4.5 for cancer (95% confidence interval: 0.9–25; P =0.06), to 9 for cataract (95% confidence interval: 2–41; P =0.004).

Conclusions— Health problems are more frequently observed in workers performing fluoroscopically guided cardiovascular procedures than in unexposed controls, raising the need to spread the culture of safety in the cath laboratory.

Occupational Health Risks in Cardiac Catheterization Laboratory Workers

Aims Aim of this study was to compare a minimally fluoroscopic radiofrequency catheter ablation with conventional fluoroscopy-guided ablation for supraventricular tachycardias (SVTs) in terms of ionizing radiation exposure for patient and operator and to estimate patients' lifetime attributable risks associated with such exposure.

Methods and results We performed a prospective, multicentre, randomized controlled trial in six electrophysiology (EP) laboratories in Italy. A total of 262 patients undergoing EP studies for SVT were randomized to perform a minimally fluoroscopic approach (MFA) procedure with the EnSiteTMNavXTM navigation system or a conventional approach (ConvA) procedure. The MFA was associated with a significant reduction in patients' radiation dose (0 mSv, iqr 0–0.08 vs. 8.87 mSv, iqr 3.67–22.01; P < 0.00001), total fluoroscopy time (0 s, iqr 0–12 vs. 859 s, iqr 545–1346; P < 0.00001), and operator radiation dose (1.55 vs. 25.33 µS per procedure; P < 0.001). In the MFA group, X-ray was not used at all in 72% (96/134) of cases. The acute success and complication rates were not different between the two groups ( P = ns). The reduction in patients' exposure shows a 96% reduction in the estimated risks of cancer incidence and mortality and an important reduction in estimated years of life lost and years of life affected. Based on economic considerations, the benefits of MFA for patients and professionals are likely to justify its additional costs.

Conclusion This is the first multicentre randomized trial showing that a MFA in the ablation of SVTs dramatically reduces patients' exposure, risks of cancer incidence and mortality, and years of life affected and lost, keeping safety and efficacy.

Trial registration clinicaltrials.gov Identifier: [NCT01132274][1].

 [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01132274&atom=%2Feuropace%2Fearly%2F2015%2F11%2F10%2Feuropace.euv344.atom

/pdf/near-zero-fluoroscopic-exposure-during-catheter-ablation-of-2dgpatiojc.pdf

Near zerO fluoroscopic exPosure during catheter ablAtion of supRavenTricular arrhYthmias: the NO-PARTY multicentre randomized trial.

JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias.

An increasing number of patients with implantable cardiac rhythm devices undergo radiotherapy (RT) for cancer and are thereby exposed to the risk of device failure. Current safety recommendations seem to have limitations by not accounting for the risk of pacemakers and implantable cardioverter defibrillators malfunctioning at low radiation doses. Besides scant knowledge about optimal safety measures, only little is known about the exact prevalence of patients with devices undergoing RT. In this review, we provide a short overview of the principles of RT and present the current evidence on the predictors and mechanisms of device malfunctions during RT. We also summarize practical recommendations from recent publications and from the industry. Strongly associated with beam energy of photon RT, device malfunctions occur at ∼3% of RT courses, posing a substantial issue in clinical practice. Malfunctions described in the literature typically consist of transient software disturbances and only seldom manifest as a permanent damage of the device. Through close cooperation between cardiologists and oncologists, a tailored individualized approach might be necessary in this patient group in waiting time for updated international guidelines in the field.

Radiotherapy in patients with pacemakers and implantable cardioverter defibrillators: a literature review.

Despite the advent of non-fluoroscopic technology, fluoroscopy remains the cornerstone of imaging in most interventional electrophysiological procedures, from diagnostic studies over ablation interventions to device implantation. Moreover, many patients receive additional X-ray imaging, such as cardiac computed tomography and others. More and more complex procedures have the risk to increase the radiation exposure, both for the patients and the operators. The professional lifetime attributable excess cancer risk may be around 1 in 100 for the operators, the same as for a patient undergoing repetitive complex procedures. Moreover, recent reports have also hinted at an excess risk of brain tumours among interventional cardiologists. Apart from evaluating the need for and justifying the use of radiation to assist their procedures, physicians have to continuously explore ways to reduce the radiation exposure. After an introduction on how to quantify the radiation exposure and defining its current magnitude in electrophysiology compared with the other sources of radiation, this position paper wants to offer some very practical advice on how to reduce exposure to patients and staff. The text describes how customization of the X-ray system, workflow adaptations, and shielding measures can be implemented in the cath lab. The potential and the pitfalls of different non-fluoroscopic guiding technologies are discussed. Finally, we suggest further improvements that can be implemented by both the physicians and the industry in the future. We are confident that these suggestions are able to reduce patient and operator exposure by more than an order of magnitude, and therefore think that these recommendations are worth reading and implementing by any electrophysiological operator in the field.

Practical ways to reduce radiation dose for patients and staff during device implantations and electrophysiological procedures

https://onlinelibrary.wiley.com/doi/epdf/10.1002/joa3.12308

2019 APHRS expert consensus statement on three-dimensional mapping systems for tachycardia developed in collaboration with HRS, EHRA, and LAHRS

II Diretrizes Brasileiras de Fibrilação Atrial

CASE REPORT: This is a 49-year old female weighing 73 kg, 155 cm, and ASA II due to hypertension. The patient was monitored with a 12-lead ECG, pulse oximetry, heart rate, bispectral electroencephalography for BIS measurement, suppression rate (SR), and SEF95, and mean arterial pressure (MAP). Intravenous targetcontrolled infusion (TCI) of propofol with a target of 4 μg.mL-1, intravenous TCI of remifentanil with a target of 3 ng.mL-1, and intravenous bolus of rocuronium 0.2 mg.kg-1 were used for induction of anesthesia. The pharmacokinetic model of propofol described by Marsh was used and incorporated into the propofol PFS pump®. The pharmacokinetic model of remifentanil described by Minto was incorporated into the Alaris PK® infusion pump. Local effector, or biophase, concentrations corresponded to the information obtained from the infusion pumps and represented predictive measurements of the concentrations of both drugs on their sites of action. The concentrations of propofol and remifentanil were regulated according to BIS and MAP, respectively.

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Anestesia Venosa Total com Infusão Alvo-Controlada de Remifentanil e Propofol para Ablação de Fibrilação Atrial * Total Intravenous Anesthesia with Target-Controlled Infusion of Remifetanil and Propofol for Ablation of Atrial Fibrillation*

EB Saad

Papers

Practical ways to reduce radiation dose for patients and staff during device implantations and electrophysiological procedures

2019 APHRS expert consensus statement on three-dimensional mapping systems for tachycardia developed in collaboration with HRS, EHRA, and LAHRS

II Diretrizes Brasileiras de Fibrilação Atrial

Anestesia Venosa Total com Infusão Alvo-Controlada de Remifentanil e Propofol para Ablação de Fibrilação Atrial * Total Intravenous Anesthesia with Target-Controlled Infusion of Remifetanil and Propofol for Ablation of Atrial Fibrillation*