The Society for Cardiovascular Angiography and Intervention (SCAI) is a non-profit professional association representing over 4,000 invasive and interventional cardiologists. SCAI promotes excellence in cardiac catheterization, angiography and interventional cardiology through physician education and representation, and quality initiatives to enhance patient care.
SCAI appreciates the opportunity to provide comments on the International Commission on Radiological Protection’s Draft Report titled “Patient and Staff Radiological Protection in Cardiology.”
Comments
1. The draft frequently fails to include electrophysiology procedures when discussing fluoroscopically directed interventional procedures and it should be noted that many interventional and electrophysiology procedures are performed in tandem.
2. The training section of the document needs to differentiate between physicians treating patients with potentially high dose procedures and those performing procedures with less radiation risk. Clearly, interventional cardiologists and electrophysiologists need this additional training, but that may not be true for physicians performing procedures with lower radiation risks.
3. Medical physicists should be active in the cardiology programs where high doses are administered: teaching/training, purchasing equipment and especially assuring proper functioning of equipment.
4. The detailed case studies of deterministic effect in Chapter 3 are over-done and needlessly gruesome. We believe a scientific document should focus on data that balances risks and benefits of procedures involving radiation. Millions of these procedures are done safely each year and the risks should be balanced with some information of the benefits of these medical procedures.
5. In Chapter five the last bullet in the Main Points section (lines 2230 – 2233) recommends two follow-up visits when one may be all that is necessary. It should be noted that radiation dosage concerns are sometimes a good reason for staging procedures.
6. In Chapter 6 under eye protection, the emphasis should be on high volume operators who are at greater risk and that they have proper eye wear that fits and with shielding on the sides is appropriate when ceiling shielding is not adequate. Recommending eye wear for all operators, including low volume operators, is unproven and may dilute the issue here. The high volume operator needs them, they must be the right kind, and they must fit.
7. Chapter 6 focuses on interventional fluoroscopy but does not focus on fluoroscopy equipment. It should consider the potential benefit of dose alarms with total exposure rather than fluoroscopy time in the equipment. This may provide better feedback to the operator during the procedure, preferably combined with institutional guidelines on termination of procedures with a certain total dose cut-off, to prevent administration of potentially injurious radiation doses.
8. Another way to lower radiation dose would be the systematic promotion by professional societies to acquire left ventriculograms, aortograms, balloon/stent inflation shots on "fluoro-save" when available, rather than cineangiography. For an individual patient the difference in dose may not be large but it may make a significant difference in the cumulative operator dose.
9. Also in Chapter 6, while two personal dosimeters are best, one at the collar can be used and we suggest focusing on complete compliance with at least one dosimeter should be the current goal. Having everyone wear at least one dosimeter should be the primary goal and insisting on two may lessen compliance.
10. In Chapter 9 on training, testing is not as important as formal training, with documentation of participation. Individuals may manage to pass the tests and not go to the sessions. Required attendance at sessions is more likely to result in greater retention of the knowledge. Documentation of training during fellowship is essential. Board certification with test questions on radiation physicists should be required for all who use significant amounts of radiation, not just interventional cardiologists. This does not have to be a separate section on the boards.
11. In Chapter 9 under the Main Points section a sentence should be included stating that physicists should be active in cardiology departments where high dose radiation is used and they should work with the cardiologists to assure that proper equipment is purchased and utilized. Physicists can guide cardiologist in making the proper balance of dose and image quality, and oversees the training of all involved.
I wish to express my appreciation to Charles Chambers, MD, FSCAI and SCAI Secretary for his role in drafting this response as well as Dr. Samir B. Pancholy, MD, FSCAI who also participated in drafting these comments. Please contact Wayne Powell at (202) 741-9869 or wpowell@scai.org in regards to scheduling this proposed meeting.
Sincerely,
/s/
Christopher J. White, M.D., FSCAI
President