Pilot program on patient dosimetry in pediatric interventional cardiology

in Chilea)
Carlos Ubedab)
Clinical Sciences Department, Radiological Sciences Center, Health Sciences Faculty and CHIDE,
Tarapaca University, Arica, Chile
Eliseo Vano
Radiology Department, Complutense University and San Carlos Hospital, 28040 Madrid, Spain
Patricia Miranda
Hemodynamic Department, Cardiovascular Service, Luis Calvo Mackenna Hospital, Santiago, Chile
Fernando Leyton
Institute of Public Health of Chile, Marathon 1000, Nunoa, Santiago, Chile and Faculty of Medicine,
Diego Portales University, Santiago, Chile
(Received 12 December 2011; revised 4 March 2012; accepted for publication 20 March 2012;
published 12 April 2012)
Purpose: The aim of this study was to present the results of a pilot program on patient dosimetry
carried out in Chile during the last 5 yr, using a biplane x-ray angiography system settled for
pediatrics. This research was conducted in Latin America under the auspices of the International
Atomic Energy Agency (IAEA) supporting programs on radiological protection (RP) of patients.
Methods: Patient age, gender, weight, height, number of cine series, total number of cine frames,
fluoroscopy time, and two dosimetric quantities [air kerma-area product (Pka) and cumulative dose
(CD) at the patient entrance reference point] were recorded for each procedure.
Results: The study includes 544 patients grouped into four age groups. The distributions by age group
were 150 for <1 yr; 203 for 1 to <5 yr; 97 for 5 to <10 yr; and 94 for 10 to <16 yr. Median values of
Pka and CD for the four age groups were 0.94, 1.46, 2.13, and 5.03 Gy cm2 and 23.9, 26.8, 33.5, and
51.6 mGy, respectively. No significant statistical differences were found between diagnostic and thera-
peutic procedures. A moderate correlation (r ¼ 0.64) was seen between Pka and patient weight.
Conclusions: The dose values reported in this paper were lower than those published in the
previous work for the same age groups as a result of the optimization actions carried out by
cardiologists and medical physicists with the support of the IAEA. Methodology and results will be
used as a starting point for a wider survey in Chile and Latin America with the goal to obtain
regional diagnostic reference levels as recently recommended by the International Commission on
Radiological Protection for interventional procedures. V C 2012 American Association of Physicists

in Medicine. [http://dx.doi.org/10.1118/1.3702590]

Key words: pediatric cardiology, interventional, patient dose

I. INTRODUCTION there has not yet published papers on these procedures in

Pediatric interventional cardiology (IC) is very different
from adult interventional cardiology not only because of the
age of the patients (newborn to 15 yr old in this study) but
also because of the diversity of structural anomalies in con-
genital heart diseases. These differences are key in under-
standing why pediatric procedures are, in general, longer and
more complex than adult procedures.1
Pediatric patients undergoing IC procedures are poten-
tially at a greater risk of radiation-induced stochastic effects
resulting from a higher radiation sensitivity of their tissues
compared with those of adult patients,2 along with a longer
lifespan ahead of them where potential neoplasms can be
developed.3
The first step in managing the risks from ionizing radiation
is to know the dose values imparted to the patients during the
imaging procedures. Several papers have been published on
patient dose values for pediatric cardiac procedures,4–16 but
Latin America.
In Latin America and the Caribbean, pediatric interven-
tional cardiology procedures are performed by medical spe-
cialists in pediatric cardiology who do not often have
specific training in radiology imaging and radiation protec-
tion, according to the results of surveys conducted during
several training courses organized in the region by the Inter-
national Atomic Energy Agency (IAEA). Surveys on patient
doses are especially useful in the promotion of optimizing
actions.
This work has been carried out with the support of the
IAEA through the programs “Strengthening Radiological
Protection of Patients in Medical Exposures (TSA3),
RLA/9/057 (Ref. 17) and Ensuring Radiological Protec-
tion of Patients and During Medical Exposures (TSA3),
RLA/9/067.”18
The methodology and results presented in this paper cor-
respond to a pilot program on patient dosimetry in pediatric

2424 Med. Phys. 39 (5), May 2012 0094-2405/2012/39(5)/2424/7/$30.00 C 2012 Am. Assoc. Phys. Med.
V 2424
2425 Ubeda et al.: Dosimetry in interventional cardiology 2425

IC in Chile, which is being used as a model to extend the ex-
perience to other countries in Latin America.19
II. MATERIALS AND METHODS
In Chile, pediatric IC procedures are carried out in four
hospitals. In order to conduct this pilot study, it was selected
the Calvo Mackenna Hospital as the largest pediatric hospi-
tal in Chile, responsible for approximately 50% (about 250
interventional procedures per year) of all pediatric IC activ-
ity in this country. The Chilean population is currently
17  106, 22% of them are children aged between 0
and 14.20
A biplane x-ray angiography Siemens Axiom Artis BC
system,21 equipped with a generator of 100 kW at 100 kV, in-
stalled in 2006 and adapted for pediatric interventional proce-
dures, was used in the survey. The system was equipped with
two image intensifiers (II) of 33 cm in diameter and offering
three fields of view (33, 22, and 17 cm). The system has been
set by the local Siemens engineers with three exam protocols
(newborn, infant, and child), three fluoroscopy modes (low,
medium, and high dose), and one single mode for cine acqui-
sition. In this hospital, the protection of patients was a priority
and all fluoroscopy modes were configured in pulsed fluoros-
copy with 15 pulses s1 up until 2008. In that year, attempting
to optimize procedures, the low fluoroscopy mode was
changed to 10 pulses s1. For cine mode, the configuration
was consistently at 30 fps throughout the survey. Additional
filters from 0.1 to 0.9 mm Cu and virtual collimation were
available for this Siemens x-ray system. The isocenter to the
floor distance was 107 cm and the focus distance to the iso-
center was 76 cm. The system included internal selectable
postprocessing software called dynamic density optimization.
The angiography system was equipped with an ionization
transmission chamber integrated into the collimator housing
to measure dose–area product (DAP), equivalent to air
kerma-area product (Pka).22 Different dosimetric quantities
are displayed on the in-room monitors. In addition to the
DAP, cumulative dose (CD) is also shown. This quantity is
referred to in the standard IEC 60601-2-43 (Ref. 23) as
equivalent to the incident air kerma (IAK) without backscat-
tering (BS) (Ref. 22) at the patient entrance reference point
(PERP). The PERP is a point intended to represent the posi-
tion of the patient’s skin at the entrance site of the x-ray
beam during an interventional procedure. For fluoroscopic
systems with an isocenter, the PERP is located at 15 cm
from the isocenter toward the focal spot for C-arm interven-
tional x-ray equipment.23 This position is appropriate for
adult patients, but it needs some correction for pediatrics (as
it will be discussed later in Sec. IV).
To assist in optimizing procedures, two full characteriza-
tions (in terms of dose and image quality of the angiography
system during the years 2008 and 2009) were carried out
using protocols agreed upon during the DIMOND and
SENTINEL European program,24–26 and adapted to pediatric
procedures. Some of the results of the last characterization
are shown in the Table I (from Ref. 20).
The methodology on national surveys recommended by
the European Commission Consortium’s “Safety and Efficacy
for New Techniques and Imaging Using New equipment to
Support European Legislation” (SENTINEL) (Ref. 27) has
been followed. The following data were recorded from each
procedure: procedure identification, patient age, gender,
weight, height, Pka, CD at the PERP, number of cine series,
total number of cine frames, and fluoroscopy time (FT).
All the pediatric cardiologists working at the Calvo Mack-
ena hospital are experienced specialists: four cardiologists,
one with 20 yr of experience, two with 18 yr, and the younger
one with 5 yr of experience. The sample of procedures were
divided into two groups, diagnostic (diagnostic normal and
diagnostic complex) and therapeutic (aortic angioplasty, pul-
monary angioplasty, pulmonary angioplasty with stent, atrial
septal defect closure, aortic valvuloplasty, pulmonary valvulo-
plasty, patent ductus arteriosus closure with coil, patent

TABLE I. Entrance surface air kerma (ESAK) per frame, number of pulse per second (NP), tube potential (TP), tube current (TC) and added filter for fluoroscopy low
(FL), medium (FM) and high dose (FH) and cine (CI) acquisition modes (AC) and all the polymethylmethacrylate (PMMA) thicknesses used in the experiment.

PMMA (cm) Acquisition mode Exam protocol ESAK (lGy=fr) NP (s1) TP (kVp) TC (mA) Filter (mmCu)

4 LD New born 0.2 10 63.0 15.0 0.9

4 MD New born 0.3 10 75.0 15.0 0.9
4 HD New born 0.6 10 58 73.0 0.9
4 CI New born 2.1 30 52.0 96.0 0.2
8 LD Infant 0.3 10 77.0 15.0 0.9
8 MD Infant 0.7 10 77.0 20.0 0.9
8 HD Infant 1.5 10 58.0 140.0 0.9
8 CI Infant 7.6 30 61.0 238.0 0.3
12 LD Child 0.8 10 77.0 22.0 0.9
12 MD Child 1.6 10 77.0 32.0 0.9
12 HD Child 3.4 10 66.0 72.0 0.6
12 CI Child 15.7 30 67.0 312.0 0.3
16 LD Child 1.8 10 77.0 35.0 0.9
16 MD Child 3.9 10 77.0 52.0 0.9
16 HD Child 9.2 10 66.0 144.0 0.6
16 CI Child 59.3 30 70.0 388.0 0.1

Medical Physics, Vol. 39, No. 5, May 2012

2426 Ubeda et al.: Dosimetry in interventional cardiology 2426

TABLE II. Median (range) values of height, weight and body mass index TABLE IV. Results for Pka (Qxx are quartiles; SD are the standard devia-
(BMI) for age groups. tions) for all procedures.

Age groups (yr) Height (cm) Weight (kg) BMI (kg=m2) Age
groups Q25 Pka Q50 Pka Q75 Pka Mean Pka SD Pka
<1 60 (42–90) 5.6 (2.1–14) 15.0 (7.0–26.9) (yr) (Gy cm2) (Gy cm2) (Gy cm2) (Gy cm2) (Gy cm2)
1 to <5 87 (53–126) 12.4 (3.3–25.0) 16.5 (7.9–35.4)
5 to <10 117 (72–164) 23.0 (7.2–38.0) 16.3 (6.1–27.8) <1 0.6 0.9 1.4 1.1 0.8
10 to <16 153 (119–180) 46.6 (19.8–88.5) 19.5 (12.8–32.8) 1 to <5 0.8 1.5 2.2 1.8 1.4
5 to <10 1.4 2.1 3.4 2.7 2.1
10 to <16 2.4 5.0 9.8 7.7 7.4
ductus arteriosus closure with device, and others). The total
Pka and CD for every patient corresponds to the sum of the
Pka and CD for each C-arm of the biplane system, corrected kerma-area product (Pka) for each type of procedure diagnos-
by the attenuation factor ft (0.81) of the table and the mattress tic or therapeutic.
for the frontal C-arm (arc A).10 Table IV summarizes the quartiles, mean, and standard
deviations values for the Pka quantity of all procedures for
the four age groups.
ðPka or CDÞ ¼ ft ðPka or CDÞarc A þ ðPka orCDÞarc B (1)
Histograms of Pka for each age group are shown in Fig. 1.
Furthermore, mean, median, and standard deviation values
Values of patient doses are obtained at the end of the pro- for Pka are also shown.
cedures with a patient dose report produced by the x-ray sys- Table V shows mean and median values of Pka for diag-
tem containing details of the radiographic techniques, nostic and therapeutic procedures, separated by age group
geometry, Pka and CD for the different archived cine and flu- and all patient samples. The U Mann–Whitney test has been
oroscopy series (for both C-arms and x-ray tubes). In addi- applied to evaluate differences between these two groups of
tion, the total Pka and CD for fluoroscopy and cine are procedures.
included in the dose report. Table VI summarizes the quartiles mean and standard
Statistical calculations for patient dose values were per- deviations values for quantity CD of all procedures across
formed with the SPSS 17 software package.28 Differences the four age groups.
between two independent (not normally distributed) samples Table VII presents median Pka values reported in this
were tested for significance with the two-tailed Mann–Whitney study compared with other surveys.
test (95% confidence level). Correlations in scatterplots were Figure 2 shows the correlation between Pka and body
investigated by calculating the Pearson correlation (r). weight (variable values are in logarithmic scale).
Figure 3 shows the correlation between the kerma-area
III. RESULTS product (fluoroscopy contribution) per time (min) of fluoros-
copy (Pkaf/min) and body weight. The correlation between the
Five hundred forty-four pediatric procedures (41% thera-
kerma-area product (cine contribution) per cine frame (Pkac/fr)
peutic and 59% diagnostic) were processed, 47% of them
and body weight is shown in Fig. 4. Variable values were
corresponding to female patients and 53% to male patients.
expressed in logarithmic scale in both figures.
The patient distributions for the different age groups were
150 for <1 yr; 203 for 1 to <5 yr; 97 for 5 to < 10 yr; and 94
for 10 to <16 yr. IV. DISCUSSION
Table II shows the height and weight distribution in the The characterization of dose and image quality of the
four age groups. x-ray and imaging systems allows cardiologists know some
Table III illustrated the frequencies, average number of basic information about their radiation characteristics, such
cine frame (CF), average fluoroscopy time, and average as: dose rates for fluoroscopy, dose per cine (CI) frame,
TABLE III. Frequencies, overage number of cine frames (CF), average fluoroscopy time (FT), average kerma-area product (Pka) for each type of procedure performed.

Type of procedures Name of procedure Frequency CR FT (min) Pka (Gy cm2)

Diagnostic Diagnostic normal 35 770 7.3 1.8

Diagnostic complex 45 1114 17.9 3.5
Therapeutic Aortic angioplasty 70 1053 13.7 2.2
Pulmonary angioplasty 30 979 23.4 3.3
Pulmonary angioplasty with stent 20 1333 29.4 5.5
Atrial septal defect closure 9 479 21 4.3
Aortic valvuloplasty 30 563 11.5 2
Pulmonary valvuloplasty 61 507 14.2 1.2
Patent ductus arteriosus closure with coil 20 337 9 1.5
Patent ductus arteriosus closure with device 117 605 11.7 2.1
Other (OT) 107 989 13.9 5.3

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2427 Ubeda et al.: Dosimetry in interventional cardiology 2427

FIG. 1. Histograms of Pka for each age group.

number of pulse per second (NP), tube potential (TP), tube
current (TC), and added filter for fluoroscopy (see Table I).
This information helps cardiologists to select the best proto-
cols (new born, infant, or child in our case) and acquisition
modes (AC) to have enough image quality to guide and
document the procedures.
Table II shows median values of height, weight, and body
mass index (BMI) for the four age groups reported in our sur-
vey for pediatric patient dosimetry. Note that for the groups
1 to <5 yr and 5 to <10 yr, there are not great differences in
BMI, but median values for weight are quite dissimilar (12.4
and 23.0). Pka (shown in Table III) are very different for the
four age groups. This indicates that patient weight, rather than
BMI, may be a better parameter with which to correlate
patient dose for these pediatric age bands. The Pka values
delivered to the group of older children were on average six
times higher than those delivered to the younger groups.
Histograms of Pka for different age groups (Fig. 1) show
that in the group of <1 yr, the dispersion of patient dose val-
ues (Pka) is much higher than in the other groups and a last
peak in the histogram indicates that more complex cases
(requiring higher doses) such as pulmonary atresia with
interventricular communication.
Histograms for the following two groups are quite similar
and again, in the fourth group (10 to <16 yr), a higher disper-
sion exists. In this case, the changes in the weight of the patients
(inside the group) may significantly influence the dispersion.
Table V shows that there are no statistically significant
differences between diagnostic and therapeutic procedures
when grouping patient doses into four age groups. This dif-
ference is significant (p ¼ 0.01) only for patients between 10
and <16 yr, indicating that the differences in patient doses
between diagnostic and therapeutic procedures in pediatric
patients are not as clear as those observed in adults.29

TABLE V. Mean values for Pka for diagnostic and therapeutic procedures. TABLE VI. Results for CD (Qxx are quartiles; SD are the standard devia-
tions) for all procedures.
Age Diagnostic Therapeutic
groups (Gy cm2) (Gy cm2) Age Q25
(yr) n (mean–median) n (mean–median) p groups CD Q50 Q75 CD Mean CD SD CD
(yr) n (mGy) CD (mGy) (mGy) (mGy) (mGy)
<1 76 (1.1–1.0) 74 (1.2–0.9) 0.76
1 to <5 80 (1.8–1.5) 123 (1.7–1.4) 0.27 <1 150 15.3 23.9 36.5 28.5 21.0
5 to <10 39 (2.8–2.2) 58 (2.6–1.9) 0.49 1 to <5 203 17.5 26.8 47.4 37.6 33.7
10 to <16 30 (9.0–7.9) 64 (7.1–4.5) 0.01 5 to <10 97 20.8 33.5 50.3 43.7 40.3
All samples 225 (2.7–1.5) 319 (2.9–1.7) 0.56 10 to <16 94 24.3 51.6 102.0 82.7 102.9

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2428 Ubeda et al.: Dosimetry in interventional cardiology 2428

TABLE VII. Comparison between median Pka for pediatric cardiology reported in this work and by others (figures adapted by the authors of this paper).

Age Boothroyd et al. Rassow et al. Bacher et al. Martinez et al. Verghese et al. This paper
groups (1997) (2000) (2005) (2007) (2011) (2011)
(yr) n (Gy cm2) (Gy cm2) (Gy cm2) n (Gy cm2) n (Gy cm2) n (Gy cm2)

<1 20 12 3 47 1.9 272 4.6 150 0.9

1 to <5 18 24 5 4.1 52 2.9 346 8.3 203 1.5
5 to <10 5 48 10 25 4.5 190 11.5 97 2.1
10 to <16 5 98 18 13 15.4 354 24.7 94 5.0

For cumulative doses (Table VI), again, median values
seem to be well correlated with the age groups, moving from
23.9 to 51.6 mGy. These values are much lower than those
shown in adult samples and, in most cases, the threat of pro-
ducing radiation-related skin injuries is low when procedures
are conducted by trained cardiologists with x-ray systems
and procedures undergoing a quality control program.
According to ICRP Publication 85,30 the threshold for deter-
ministic effects on skin is 2000 mGy (transient erythema). It
is unlikely that this level is reached in pediatric procedures,
however, some patients may be at risk. For example, patients
with complex congenital heart diseases must undergo several
interventions, and therefore, special attention to the skin
dose should be paid. The CD values in our study were lower
(see median values in Table VI) depending on the age of
the patient, than those reported by Martı́nez et al.10
(44–149 mGy).
Note that cumulative dose values presented in the cathe-
terization room by the x-ray system and transferred to the
patient dose report need to be corrected in pediatrics.25 The
greatest differences are for the smallest patients (real values
may be 40% lower than the reported by the x-ray system in
the patient doses reports). The cumulative dose is calculated
at 15 cm down from the isocenter, and for small thicknesses
the skin may only be at a few centimeters down from the iso-
center. For pediatric patients, the skin is typically more dis-
tant from the x-ray source than the patient entrance reference
point and receives a smaller dose than the one calculated at
that point. For adult patients, the displayed cumulative dose
is very close to the skin dose value, because the attenuation
of the table and mattress is compensated for with the
increase of the BS factor,31 and the typical position of the
patient skin (for normal size patients) is around 15 cm down
from the isocenter.
The results of this survey show that radiation doses have
a very large range (see Table IV), as shown by other pediat-
ric surveys.7,9,11–15 However, few papers4,5,8,10,16 reported
radiation dose values by age group, as shown in Table VII.
In this summary of the median values of Pka, the values of
our survey tend to be lower, probably derived from the
awareness of cardiologists in the management of patient
doses and the careful setting of the x-ray system for pediatric
protocols.
Figure 2 illustrates the correlation of Pka as a function of
body weight for the entire data set. A variation in Pka of
almost 4 orders of magnitude was observed across body
weights. A much tighter distribution is seen when plotting
Pkaf/min and Pkac/fr as a function of body weight (Figs. 3
and 4). Some authors as Onnashch et al.9 and Chida et al.15
have previously reported the correlation between weight and
Pka for pediatric patients under IC procedures. Onnashch
et al.9 include results from three angiographic systems
(r ¼ 0.65, 0.69, and 0.74) and Chida et al.15 for a single
x-ray system (r ¼ 0.82). Both papers seem to have found
stronger correlations than we found (r ¼ 0.64). The possible
reasons for this lower correlation is due to that we included
the whole sample of the procedures, which implies that we
do not removed any patient as described by Onnashch et al.9
and because the sample of our patients were older aged in
relation to Chida’s research.10 In pediatric cardiology, and
specially in the age band of <1 yr, the complexity of the pro-
cedures may be very different (see Fig. 1) and correlations
between Pka and patient weight or BMI, may be more ques-
tionable than in adults.
Figures 3 and 4 also show that the correlation of the
Pkaf/min and the Pkac/fr with body weight was moderate. These
“normalized” values could be more independent of the com-
plexity of the procedures, but they still depend on the applied

FIG. 3. Correlation between kerma-area product (fluoroscopy contribution)

FIG. 2. Correlation between total kerma-area product vs body weight. per min vs body weight.

Medical Physics, Vol. 39, No. 5, May 2012

2429 Ubeda et al.: Dosimetry in interventional cardiology
FIG. 4. Correlation between kerma-area product (normalized to the total
number of frames) vs body weight.
collimation, the C-arm angulations (used projections), and
the fluoroscopy and cine modes used during the procedures.
In the hospital where the survey has been made, the set-
ting of the x-ray system has been refined and pediatric cardi-
ologists have been trained in radiological protection and
involved in several IAEA programs to optimize the manage-
ment of radiation dose in pediatric cardiology. The use of
regular collimation and low dose modes during procedures
are customary. This Center has been selected as reference
for several IAEA training workshops. The used methodology
analyzing patient doses will be used for a wider survey on
pediatric cardiology optimization in the rest of the hospitals
in Chile and as well as in Latin America.
V. CONCLUSION
The dose values reported in this paper were lower than
those reported in the previous works for the same age
groups as a result of the optimization actions carried out by
cardiologists and medical physicists with the support of the
IAEA. Methodology and values of Pka for the four age
bands will be used to start a wider survey in Latin America
with the goal to obtain regional diagnostic reference levels
as recently recommended by the ICRP 105 for interven-
tional procedures.32
ACKNOWLEDGMENTS
C. Ubeda acknowledges the support of the Direction of
Research at Tarapaca University through senior research
Project No. 7713-10. E. Vano acknowledges the support of
the Spanish Grant No. SAF2009-10485 (Ministry of Science
and Innovation).
a)
Institution at which the word was performed: Luis Calvo Mackenna
Hospital, Santiago, Chile.
b)
Author to whom correspondence should be addressed. Electronic mail:
cubeda@uta.cl; Telephone: þ56.58.205303; Fax: þ56.58.205705.
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