GUEST COMMENTARY
Gautam Kumar, MD, and Syed Tanveer Rab, MBBS
Editor’s Note: This commentary also appeared in the January/
February 2016 issue of CardioSource WorldNews: Interventions,
the sister publication of CardioSource WorldNews.
Radiation Safety for the
Interventional Cardiologist
A Practical Approach to Protecting Ourselves from the
Dangers of Ionizing Radiation
R
adiation safety is the concern of all health
care providers who perform procedures
associated with radiation imaging, whether
for diagnostic purposes or t herapeutic procedures.
Appropriately, there has been increasing public
and societal interest in limiting patient radiation.
Likewise, laboratory personnel are at risk for radiation compounded by long procedures and multiyear
careers using radiation procedures.
Over the years, there have been various equipment
modifications. The initial focus was to improve image
quality by increasing radiation intensity. However, there
is now a greater focus on limiting patient
exposure in the setting of often prolonged
procedures, such as complex multivessel
and chronic total occlusion (CTO) revascularization procedures. X-ray systems
Gautam Kumar, MD
are able to provide excellent image quality
with lower X-ray exposure.
However, despite these improvements, radiation remains a risk for procedure personnel. Unfortunately, the
focus on the complexity and intensity
Syed Tanveer
of the procedure itself often overshadRab, MBBS
ows attention to personal optimal
“self-radiation” protection. The following article not only describes these risks but also,
importantly, enumerates the specific operator and
personnel approaches to minimize radiation risk. A
review of these preventive strategies is important
to re-emphasize the personnel opportunities and
responsibilities for radiation protection. Finally, the
authors describe some of the evolving opportunities
to more dramatically reduce radiation exposure.
This article is an excellent refocus on an important
issue for the interventional community.
Ionizing radiation in the form of X-rays is used
extensively in the modern cardiac catheterization
40 CardioSource WorldNews
laboratory. Unlike patients who receive a dose of
ionizing radiation during their procedure, interventional cardiologists and cardiac catheterization
laboratory personnel are repeatedly exposed to
ionizing radiation in the course of their duties.
This issue has been magnified with increased
exposure in the long duration of structural or complex adult congenital heart disease intervention
and CTO cases. Personnel not previously exposed
to ionizing radiation such as echocardiographers,
ultrasound technologists, cardiac surgeons, and
anesthesiologists are frequently close to the X-ray
field. Therefore, minimizing radiation exposure is
of utmost importance.
UNDERSTANDING THE HAZARDS
Significant radiation exposure has the potential to
impact the health and well-being of interventional
cardiologists in the following ways:
• Brain Tumors: A case report of brain tumors
in two Canadian interventional cardiologists1
first raised this concern. There were three additional cases identified in a study from Sweden
in physicians who had worked with fluoroscopy.2
The left-sided predisposition of these tumors
raised further alarm when four additional cases
were reported from France and Israel.3 Active
case findings from this group highlighted this
concern further when they identified that 22 of
26 cases (85%) had a left-sided distribution of
brain tumors, which is a phenomenon that is not
noted in the general population.4 In a study of 11
cardiologists performing invasive (diagnostic and
interventional) procedures, radiation exposure
to the outside left side and outside center of the
head was significantly greater than the outside
right side of the head (106.1 ± 33.6 and 83.1 ±
18.9 vs. 50.2 ± 16.2 mrad, p < 0.001). This was
significantly attenuated by the usage of a radiation protection cap (42.3 ± 3.5 and 42.0 ± 3.0 vs.
41.8 ± 2.9 mrad) and only slightly higher than
ambient control (38.3 ± 1.2 mrad, p = 0.046).5
• Cataracts: Higher incidence of cataracts (specifically posterior subcapsular) has been reported in interventional cardiologists in a large French multicenter
observational study.6 Similar results were also noted
in a separate study of both interventional cardiologists and CCL nurses and technicians. Fortunately,
this risk appeared to be mitigated in those who
wore lead-lined glasses.7
• Thyroid Disease: Structural and functional changes
as a result of radiation exposure have been reported in the thyroid gland. The degree of exposure
has been correlated with a linear increase in the
development of both benign and malignant thyroid
neoplasms.8,9
• Cardiovascular Effects: Exposure to radiation
has been associated with both macrovascular and
microvascular abnormalities. The occupational
significance of this is not well-identified presently.10
• Reproductive System Effects: Although exposure to ionizing radiation reduces both sperm
count and quality, the occupational effects of
this have not been determined.11 A study of
56,436 female radiology technicians in the
United States revealed 1,050 cases of breast
cancer and concluded that daily low-dose radiation exposure over several years may increase
the risk of developing breast cancer.12 It is
concerning that in the small series reported by
Continued on page 42
February 2016