International Atomic Energy Agency Can cardiac procedures be graded in complexity and related with dose? L 8.3

Radiation Protection in Cardiology Lecture 8.3: Complexity2 Educational Objectives 1.Complexity related factors in cardiac interventions 2.Relationship of patient dose with technical and clinical factors 3.Development of complexity index and its utility

Radiation Protection in Cardiology Lecture 8.3: Complexity3 factors determining patient’s exposure adequacy of equipment fluoroscopy time cine-angiography time operator’s experience procedure complexity

Radiation Protection in Cardiology Lecture 8.3: Complexity4 fluoro time: 1 m’ 20 sec total DAP: 102 dGy simple case straightforward right

Radiation Protection in Cardiology Lecture 8.3: Complexity5 difficult case extreme vessel tortuosity fluoro time: 20 m’ total DAP: 1074 dGy

Radiation Protection in Cardiology Lecture 8.3: Complexity6 complexity related factors age number of vessels treated occluded vessels previous CABG poor Ejection Fraction quantification never proposed

Radiation Protection in Cardiology Lecture 8.3: Complexity7 Clinical and technical determinants of the complexity of PTCA procedures. Analysis in relation to fluoroscopy time (Cathet Cardiovasc Intervent 2000; 51:1-9)

Radiation Protection in Cardiology Lecture 8.3: Complexity8 PTCA characteristics n 402, 21/06/96-08/05/98 (50% of tot) 76.3% 15.4% 8.2% Stenting 49% (x procedure) mean fluoro time 11,5’ ± 8,6’ success 96.5 %

Radiation Protection in Cardiology Lecture 8.3: Complexity9 patients’ characteristics n 402, M 72 % age 62± % 34.9% 31% 6% previous CABGmean EF 58% ± 10

Radiation Protection in Cardiology Lecture 8.3: Complexity10 clinical factors tested age sex single or multivessel disease EF previous CABG no significant correlation with fluoro time or exposure parameters

Radiation Protection in Cardiology Lecture 8.3: Complexity11 p< 0.001, p<0.01*, p<0.005°

Radiation Protection in Cardiology Lecture 8.3: Complexity12 r = P < complexity index/fluoro time correlation most significant & less operator-dependent variables Complexity Index Fluoro time (sec)

Radiation Protection in Cardiology Lecture 8.3: Complexity13 simple medium complex CI = 0 CI  1.5 CI > Fluoro time (sec) complexity index-based stratification fluoro time P <

Radiation Protection in Cardiology Lecture 8.3: Complexity14 simple medium complex CI = 0 CI  1.5 CI > Cine frames (n) complexity index-based stratification cine frames P = P = ns P = 0.001

Radiation Protection in Cardiology Lecture 8.3: Complexity15 Gy * cm 2 complexity index-based stratification total DAP P < P = simple medium complex CI = 0 CI  1.5 CI > 1.5

Radiation Protection in Cardiology Lecture 8.3: Complexity16 procedural success rate (402 cases, 50% of total activity) % P =

Radiation Protection in Cardiology Lecture 8.3: Complexity17 fluoro time in different diagnostic procedures (844) minutes 2.6±3.42.7± ± ± ±7.1 65%

Radiation Protection in Cardiology Lecture 8.3: Complexity18 In our experience, fluoroscopy time and total DAP were directly related to technical and not to clinical factors The weight of these factors can be quantified in order to anticipate the radiation dose needed to treat patients undergoing complex procedures conclusions (I)

Radiation Protection in Cardiology Lecture 8.3: Complexity19 Comparison of different centers and operators for quality control assessment, as well as the definition of appropriate fluoroscopy time and DAP doses, should take into account complexity indexes Further studies in different institutions are warranted to corroborate this data conclusions (II)