Dipartiment Cardio Toracico e Vasculare Univesita

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Dipartiment Cardio Toracico e Vasculare
Univesita
di Pisa Dottorato di Ricerca in Fisiopatologia
e Clinica dell Apparato
Cardiovascolare e
Respiratorio
Presidente prof, Alfredo Mussi Radiological
Professional Exposure in Contemporary
Interventional Cardiologist
Ahmed
Emad Tutor ., Prof., L Abbate
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RADIORISIKOil rischio dei cardiologi
interventisti
SUIT (Stop Useless Imaging Testing)

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• Lo tsunami
• Lesposizione
• La protezione
• Il danno possibile

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Coronary Angiography
Coronary procedure in Europe
Millions of procedures
PCI
Stent coronarico
1992
2001
1992
2001
1992
2001
Togni M et al. Eur Heart J 2004 25 1208-1213

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• Lo tsunami
• Lesposizione
• La protezione
• Il danno possibile

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Friendly fire on interventional cardiologists

Vano E et al. Radiation exposure to medical staff
in interventional and cardiac radiology. Br J
Radiol. 1998 71954-60.
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10-year exposure in cath lab (n21 out of 27 with
2006 expo gt2 mSv)
60
10-year exposure (mSv/subject)
0
Cath lab nurses and technicians (n 3 )
Interventional cardiologists (n10)
Cardiac electrophysiologists (n 8 )
Vennery, Emad ESC et.al (2007)
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Tuscany (Florence-Pisa) Health Physics data
bankRADIOLOGICAL YEAR 2006
No threshold (n5509)
10
31
gt1 mSv/year (n360)
gt2 mSv/year (n54)
56
gt3 mSv/year (n38)
45
gt6 mSv/year (n 6)
66
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Limitation Dosimeter is the witness
Legally mandatory to establish a probability
causation beyond 50 at 90 Confidence intervals
between organ dose and observed disease (NIOSH
2005 and Circolare ministeriale 2003)

Indispensable to have an idea of your own risk
and a marker of technological and professional
quality of your lab
When do you wear dosimeter?
Kottou S et al. Radiat Prot Dosimetry.
200194121-4.
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• Lo tsunami
• Lesposizione
• La protezione
• Il danno possibile

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Radiomachismo

• Increasingly, we have become causal regarding
  our exposure. We forget to wear the dosimeters.
  We pay little heed to monthly or cumulative
  reports of radiation exposure. While some
  institutions require a course in radiation safety
  prior to issuing the radiation dosimetry badges
  to new fellows, they represent the exception. Not
  infrequently, there is a machismo disregard for
  radiation protection
• Rita Watson, Sayonara ALARA, Cath Cardiov Diagn,
  1997

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Cath lab we dont need another hero

• A reduction of the effective dose by a factor of
  10 has been achieved. The most successful action
  to reduce occupational doses has been training in
  radiation protection.
• Vano E et al, Br J Radiol 2006

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• Lo tsunami
• Lesposizione
• La protezione
• Il danno possibile

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Lifetime attributable risk (LAR) for cancer in
most-exposed cardiac cath lab staff (BEIR VII
estimates)
1 in 50
1 in 100
LAR of cancer
1 in 200
1 in 20,000
5
50
100
150
Dose (mSv))
10-year exposure
1-year exposure
Lifetime (11-26 years) exposure
Venneri L, Emad A.et al. ESC 2007
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Somatic DNA damage in chronically exposed
cardiologists
vs

• Case-control
• Prospective
• Blinded

Andreassi MG ,Cioppa A, et al. Somatic DNA damage
in interventional cardiologists a case-control
study. FASEB J. 2005 19 998-9
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Environmental exposure (fertile female)
Environmental exposure (fertile male)
(Germline mutations, unrepaired DNA damage,
epigenetic and protein damage)
Affected ova
Affected sperm
Affected offspring
Low birth weight
Major genetic defects
Multisystem developmental abnormalities
Cancer in childhood
Multifactorial chronic disease in adults
Adapted from..chapionER et..al environment204
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Experimental data
Biological model in man
Fetus
Lowest
Highest
RADIATION SENSITIVITY
All in all, the sperm is much more susceptibile
to damage than an egg because of its prolonged
solitary existence and relative lack of
protective , repair and self-destruct mechanisms.
Nomura. T. (2006) J.Radial Res
Aitken et al. Reprod Biomed Online. 2003
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Mounting evidence, indicates that events
occurring in the earliest stage of human
development even before birth may influence
the occurrence of diabetes, cardiovascular
disease, asthma, cancers, osteoporosis, and
neuropsychiatric disorders.
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Antepartum Radiography and Infant Low Birth
Weight
Hypophysis?
Thyroid?
Hypothalamus?
Hujoel et al., JAMA. 20042911987-1993.
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Father radiation exposure in the 30 weeks before
conceptions
(All ionizing exposures at work, usually when the
father was working as an X-ray technician,
physician or dentist at diagnostic X-ray
facilities)
Rel Risk
Atrio-Ventricular Septal Defect with Down
Muscular Interventricular Defect
Aortic Coartation
Correa-Villasenor A et al. J Expo Annal
Environment Epidemiol 1993
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Reproduction physiology and anecdotes
90 exposed and 90 non-exposed physicians
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So, Papa exposure to ionizing radiation before my
conception could be a risk factor for me?!
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Relative risk
4.5
1.8
Shakhatreh FM. Saudi Med J. 2001 Feb 22150-2.
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Gli effetti riproduttivi di dosi basse e
protratte di radiazioni ionizzanti The
Interventional Cardiologist Reproductive Study
Subproject Radiological Professional Exposure
in Contemporary Interventional Cardiologists
InterCardioReproStudy


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InterCardioReproStudy Conoscere è Ricordare

END POINT PRIMARIO
POPOLAZIONE
(Hujoel et al., JAMA. 2004)
Peso alla nascita lt2500 (predittore di CAD,
diabete, ipertensione, ecc)

END POINT SECONDARIO

Aborti Nati morti Infertilità -Difetti
congeniti alla nascita- Eventi in età 26 anni
(Shakhatreh FM. Saudi Med J. 2001)


N250 Medici/Tecnici/Infermieri
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Miscarriage
Low birth weight
Infertility
Congenital abnormalities
Exposed (n125)
Non-exposed (n125)
Emad Survey Egypt
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Brenner DJ,2005
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The sons of alcohol
In Carthago and Sparta, laws prohibited the use
of alcohol by newlyweds (Wamer RH, J Studies
Alc, 1975)
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Responsibility in the cath lab

• Responsibility on all physicians to minimize the
  radiation injury hazard to their patients,
• to their professional staff, and to themselves
• Hirschfeld JW et al, ACC/AHA Guidelines,
  Circulation 2005