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Pulmonary Vein Antral Isolation (PVAI) of atrial fibrillation (AF) is a curative treatment of AF and involves prolonged procedure times and fluoroscopy use. The risks associated with radiation exposure are well known and radiation safety guidelines have been put forth by the regulatory commission. However, physicians may fail to observe these radiation safety measures strictly. A study performed by Lakkireddy et al. published in JICE (2009)24:105-112, attempts to assess the effect of a strict enforcement of a comprehensive radiation safety program.
The comprehensive safety program consisted of simple operator practices that are known to reduce radiation exposure and included
1. Verbal reinforcement where the operator is reminded prior to a procedure about the fluoroscopy times of the previous 5 procedures,
2. Effective collimation to reduce fluoroscopy exposure
3. Minimising source – intensifier distance to operational comfort
4. Effective lead shield use.
In this study, informed consent was obtained from 41 AF patients undergoing PVAI and were divided into two groups, group 1 and group 2. Operators in group 1 were examined and radiation and fluoroscopic exposure times were recorded. Operators were unaware that their fluoroscopic practices were being evaluated. They did not receive any radiation safety reminders. For group 2 patients, the operators were detailed about the radiation safety program as mentioned above. All the above safety measures are standard practices that reduce radiation exposures that operators fail to follow. There were 3 operators in both groups. Group 1 patients were ablated first and no instructions were given to the operators. Nursing staff recorded whether the operators followed the radiation safety procedures. All operators wore lead apron and thyroid shield. Mean operator exposure was the average of primary and secondary operator exposures. Operator exposure was measured with a dosimeter placed outside the thyroid collar and the patient exposure was measured with 4 chips placed on the torso along the four edges of the cardiac silhouette.
There were no differences in the 2 groups in terms of demographics, procedure times and operator experiences. In group 1, the operators minimized the source intensifier distance in only 2 patients (9%) and lead shield was used effectively in only 57% of patients. No collimation was used in any of the patients in group 1. Mean operator, primary operator and secondary operator radiation exposure were significantly reduced in group 2. It has in fact reduced the operator exposure by two times and also reduced the peak skin exposure in group 2 patients by 3 three to ten times. Importantly, there was no difference in operators on exposure level within each group, but there was a difference when compared at group 1 and group 2 which explains that the implemented radiation safety program contributed to the difference. Use of 3D computerized non fluoroscopic mapping system significantly reduced the operator and the patient radiation exposure in both group I and group 2. No radiation skin injuries were noticed in the patients over the follow-up period of one year.
This study reiterates that adherence to basic safety procedures reduces radiation exposure significantly. Procedure times for AF ablation are significantly higher than other supraventricular arrhythmia ablation and thus paying attention to techniques that reduce radiation exposure are invaluable. Use of 3 D mapping system also significantly reduces radiation exposure. Although this is a small study, it captures the real world practices of electrophysiologists.
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