Division of Cardiology, Department of Pediatrics, Pediatric Cardiac Catheterization Laboratory, Children's Hospital at Montefiore Albert Einstein College of Medicine, Yeshiva University, Bronx, New York.
Catheter Cardiovasc Interv. 2014 Jan 1;83(1):80-3. doi: 10.1002/ccd.25058. Epub 2013 Aug 17.
Surveillance endomyocardial biopsy (EMB) with right heart catheterization (RHC) is the standard of care for the assessment of post cardiac transplantation rejection. This procedure has traditionally relied upon fluoroscopy, which exposes both patient and staff to the risks of ionizing radiation. These risks may be of particular concern in the transplant patient who must undergo many such procedures lifelong. We present data on a new "ALARA - As Low As Reasonably Achievable" protocol to reduce radiation exposure during the performance of RHC with EMB.
All cardiac transplantation patients < 21 years of age who underwent RHC with EMB at The Children's Hospital at Montefiore from 6/11-12/11 were included. EMB was performed after all right heart pressures including wedge pressure and thermodilution cardiac output were measured. A novel ALARA protocol consisting of multiple features including ultra-low frame rates (2-3 fps), low fluoro dose/frame (10-18 nGy/frame), use of the "air-gap" technique for patients < 20 kg, and multiple other techniques aimed at minimizing use of fluoroscopy were employed in all cases. Demographics, procedural data and patient radiation exposure levels were collected and analyzed.
18 patients underwent 45 surveillance RHC with EMB in the study period and were the subject of this analysis. The mean age was 5.9 ± 6.1 years, weight was 20.4 kg ± 16.6 kg, and BSA was 0.75 ± 45 m(2) . PA fluoroscopy was used exclusively in 45/45. Vascular access was RFV (21/45; 47%), RIJV (17/45; 38%), LFV (4/45; 9%) and LIJV (3/45; 7%). The median number of EMB specimens obtained was 5 (range, 4-7). The median fluoroscopy time was 3.7 min (range, 1.2-9). The median air Kerma product (K) was 1.4 mGy (range, 0.4-14), and dose area product (DAP) was 15.8 uGym(2) (range, 3.5-144.5). The K and DAP are substantially lower than any prior published data for RHC/EMB in this patient group. There were no procedural complications.
The use of a novel ALARA protocol for RHC and EMB in pediatric cardiac transplantation patients markedly reduced radiation exposure to levels far below any previously reported values without negatively affecting the safety or efficacy of these procedures.
在心脏移植术后，监测心内膜心肌活检（EMB）与右心导管术（RHC）是评估排斥反应的标准方法。该程序传统上依赖于荧光透视术，这会使患者和医务人员都面临电离辐射的风险。对于必须终身接受多次此类手术的移植患者来说，这些风险可能特别令人担忧。我们提出了一种新的“ALARA - 尽可能低的合理可达”协议的数据，以减少在进行 RHC 与 EMB 期间的辐射暴露。
所有年龄小于 21 岁的在 Montefiore 儿童医院接受 RHC 与 EMB 的心脏移植患者均被纳入研究。在测量所有右心压力（包括楔压和热稀释心输出量）后进行 EMB。在所有情况下，都采用了一种新的 ALARA 协议，包括超低帧率（2-3 fps）、低荧光剂量/帧（10-18 nGy/帧）、对于体重小于 20 公斤的患者使用“空气间隙”技术，以及其他多种旨在最大限度减少荧光透视术使用的技术。收集并分析了患者的人口统计学、程序数据和辐射暴露水平。
在研究期间，18 名患者接受了 45 次监测性 RHC 与 EMB，这是本分析的对象。平均年龄为 5.9 ± 6.1 岁，体重为 20.4 kg ± 16.6 kg，BSA 为 0.75 ± 45 m²。PA 荧光透视术在 45/45 例中均有使用。血管通路为 RFV（21/45；47%）、RIJV（17/45；38%）、LFV（4/45；9%）和 LIJV（3/45；7%）。获得的 EMB 标本中位数为 5（范围 4-7）。荧光透视时间中位数为 3.7 分钟（范围 1.2-9）。空气比释动能乘积（K）中位数为 1.4 mGy（范围 0.4-14），剂量面积乘积（DAP）中位数为 15.8 uGym²（范围 3.5-144.5）。K 和 DAP 明显低于任何以前在该患者群体中发表的 RHC/EMB 数据。没有发生程序并发症。
在儿科心脏移植患者中，使用一种新的 ALARA 协议进行 RHC 和 EMB 可显著降低辐射暴露水平，远低于以往任何报告的值，而不会影响这些程序的安全性或疗效。
