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CLINICAL RESEARCH: SAFETY ISSUE

Fluoroscopically Guided Implantation of Modern Cardiac Resynchronization Devices

Radiation Burden to the Patient and Associated Risks

Kostas Perisinakis, PhD^_*,_*, Nicholas Theocharopoulos, MSc^_*,, John Damilakis, PhD^_*, Emmanouel Manios, MD, Panayiotis Vardas, MD, PhD, FESC, FACC and Nicholas Gourtsoyiannis, MD, PhD

^_* Department of Medical Physics, Faculty of Medicine, University of Crete, Iraklion, Greece
Department of Cardiology, Faculty of Medicine, University of Crete, Iraklion, Greece
Department of Radiology, Faculty of Medicine, University of Crete, Iraklion, Greece
Department of Natural Sciences, Technical Education Institute of Crete, Iraklion, Greece

Manuscript received August 5, 2004; revised manuscript received January 13, 2005, accepted January 17, 2005.

^_* Reprint requests and correspondence: Dr. Kostas Perisinakis, Medical Physics Department, Faculty of Medicine, University of Crete, P.O. Box 2208, 71003 Iraklion, Crete, Greece (Email: perisina{at}med.uoc.gr).

OBJECTIVES: To establish radiation risks for patients undergoing fluoroscopically guided cardiac resynchronization device implantation.

BACKGROUND: Cardiac resynchonization therapy (CRT) may be associated with extended fluoroscopic exposure.

METHODS: The fluoroscopy time, dose-area product (DAP), exposure parameters, and percentage contribution of the fluoroscopic projections commonly used were recorded in a series of 14 consecutive patients referred for cardiac resynchronization device implantation and compared to corresponding data obtained from a control group of 20 patients who underwent a conventional rhythm device implantation operation. The DAP to peak skin dose, DAP to effective dose, and DAP to gonadal dose conversion factors were determined for biventricular pacing and conventional rhythm device implantation using a humanoid phantom and thermoluminescence dosimetry.

RESULTS: The mean total fluoroscopy time and DAP values were 35.2 min and 4,765 cGy cm², respectively, for biventricular pacing and 8.2 min and 1,106 cGy cm², respectively, for conventional rhythm device implantation. Patient skin dose from biventricular pacing procedures requiring extended fluoroscopic exposure may exceed threshold dose for the induction of skin effects only if X-ray source-to-skin distance is kept low. The risk values for fatal cancer and severe hereditary disorders, respectively, associated with a typical CRT procedure were 273 per million and 0.2 per million treated patients.

CONCLUSIONS: Radiation risks associated with fluoroscopically guided CRT procedures may be considerable. Present data may be used for the estimation of patient radiation risks from CRT procedures performed in other institutions.

Abbreviations and Acronyms   cGy cm2 = centigray x centimeter2   CRT = cardiac resynchronization therapy   DAP = dose-area product   ICD = implantable cardioverter-defibrillator   ICRP = International Commission on Radiological Protection   LAO = left-anterior oblique   PA = posteroanterior   RAO = right-anterior oblique   SSD = source-to-skin distance   TLD = thermoluminescence dosimeter   Sv–1 = sievert–1   Gy–1 = gray–1

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