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The Growing Culture of a Minimally Fluoroscopic Approach in Electrophysiology Lab

As the first imaging modality of the living human body, X-ray fluoroscopic imaging has been the most important technical tool in modern medicine (Roentgen). It allowed one to see the inside of the body and, after contrast injection, even of soft tissues like the beating heart. To date, most of interventional procedures in cardiology are carried out under fluoroscopic imaging guidance. Besides other peri-interventional risks, radiation exposure should be considered for its stochastic (inducing malignancy) and deterministic effects on health (tissue reactions like erythema, hair loss and cataracts).

Due to increased interventional procedures and imaging studies in the last decades, patients are being exposed to a substantial amount of radiation over their lifetime. Some procedures like catheter ablation of atrial fibrillation frequently requires cardiac computed tomography (CT) scan before the intervention and more than one ablation procedure, thereby adding a substantial amount of radiation.

On an average, a complex cardiac radiofrequency ablation corresponds to 750 chest X-rays (range 100–2850). Recently, attention has been applied to the radiation exposure of the catheter lab staff who expose themselves professionally. Being close to the patient during an interventional procedure, the first hand operator is exposed to scattered radiation, whilst other health care professionals are better protected by their position at a greater distance to the radiation source and the patient itself.

Besides the associated X-ray exposure, the main limitation of fluoroscopy is that in complex arrhythmias fluoroscopy only provides two-dimensional (2D) representations of three dimensional (3D) anatomical structures as potentials targets for ablation. With the evolution of technology, new non fluoroscopic 3D mapping systems from the late 1990s have been an alternative to fluoroscopy alone in electrophysiology world. Infact constructing a virtual real time 3D map, catheter navigation is facilitated while minimizing or eliminating fluoroscopy exposure. New software upgrades to non fluoroscopic 3D mapping have resulted in very detailed cardiac chambers, potentially eliminating pre-procedure CT imaging.

In this article we analized the radiation risk from cardiovascular imaging to both patients and medical staff and discusses how customize the X-ray system and how to implement shielding measures in the cath lab. Finally, we reviewed the most recent developments and the latest findings in catheter navigation and 3D electronatomical mapping systems that may help to reduce patient and operator exposure.

Credits: Michela Casella; Eleonora Russo; Francesca Pizzamiglio; Sergio Conti; Ghaliah Al-Mohani; Daniele Colombo; Victor Casula; Yuri D’Alessandra; Viviana Biagioli; Corrado Carbucicchio; Stefania Riva; Gaetano Fassini; Massimo Moltrasio; Fabrizio Tundo; Martina Zucchetti; Benedetta Majocchi; Vittoria Marino; Giovanni Forleo; Pasquale Santangeli; Luigi Di Biase; Antonio Dello Russo; Andrea Natale; Claudio Tondo

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