Cardiac Cath Lab &

Radiation Safety
Arwin Saleh Mangkuanom, MD

Department of Cardiology and Vascular Medicine

Faculty of Medicine, Universitas Indonesia
National Cardiovascular Center Harapan Kita Hospital Jakarta, Indonesia
Past
History of Cardiac
Catheterization
 History of Cardiac Catheterization

1711-Hales conducts the first cardiac

catheterization of a horse using brass pipes, a
glass tube and the trachea of a goose.

History Center (ptca.org).

 Werner Forssman (1904-1979)

Anesthetized his own elbow, inserted a catheter in

his antecubital vein and, catheter dangling from his
arm, proceeded to a basement x-ray room, where
he documented the catheter’s position in his right
atrium- proving that a catheter could be inserted
safely into a human heart.

History Center (ptca.org).

 The Work of the Predecessors
1929 Werner Forssmann Death-defying experiments

1958 Mason Sones « To open a door is to find other doors W. Forssmann

which are waiting to be opened. »

1964 Charles Dotter No respect for boundaries

Dotter’s catheter

1968 Eberhard Zeitler Development of Dotter’s approach in Europe

M. Sones C. Dotter E. Zeitler

Andreas Grüntzig
The Original Balloon Idea
1972-76

For 4 years the Grüntzig’s kitchen table

was used to produce and test the
prototypes which, one day, would lead to
coronary artery dilatation

First idea

DG 20-30

Grüntzig’s kitchen table

« Just stop me! »
 Andreas Grüntzig - Friday, September 16, 1977

It was not an accident or an unexpected incident. This

event came after intensive work over seven years

before distal test balloon after

Modern CathLab
 Coronary suite
Transforming complex PCI
procedures into confident care

Coronary suite offers you cutting-edge

innovations including Philips exclusive and
proven iFR/FFR co-registration technologies that
move physiology from justification to physiology
guidance.

* Philips.
©2021 Koninklijke Philips N.V. All rights reserved.
 Unlimited imaging flexibility empowered by 8-
axis movements (FlexArm)
Very flexible gantry
• Innovative design rotates on no less than 8 axes to help
enhance positioning of the c-arm for more imaging
positions
Ease of use
• Table-side control of gantry with a single intuitive
joystick with Axsys technology for predictable
movements
High image quality
• Stable gantry and high flexibility to select the best
imaging projections

©2021 Koninklijke Philips N.V. All rights reserved.

 Interventional tools in Coronary suite
Transforming complex PCI procedures into confident care

• Dynamic Coronary Roadmap, a Philips-exclusive
technology, creates a motion-compensated, real-time
view of coronary arteries that provides continuous visual
feedback on the position of wires and catheters.
* Philips.
• StentBoost Live provides instantaneous enhanced visualization of
positioning and deployment in real-time, eliminating the need to wait
on new images before you reposition the device. It quickly helps you
verify positioning before and after deploying balloons, stents, and
intracoronary devices to display underdeployment and confirm full
expansion.
 iFR: instant wave-Free Ratio

Helps assess lesion significance without

hyperemic agents
• iFR is the only resting indice supported by clinical trials
• iFR Co-registration maps pressure drops right onto the
angiogram, making it easy to:
❖ Identify the precise locations causing ischemia, each
yellow dot signifies a 0.01 drop
❖ Plan your treatment, before a stent is even placed,
with a virtual stent
❖ Determine lesion lengths without need for a
pullback device
❖ Predict physiologic gain with iFR Estimate
©2021 Koninklijke Philips N.V. All rights reserved.
 iFR Scout pullback technology vs FFR

Normalize Advance wire Select ‘Record’

Procure Hyperemic Administer

Agents Normalize Advance wire Select ‘Record’
Hyperemic Agent

Benefits of iFR Scout pullback technology Limitations of FFR pullback

• No hyperemic agent required • Requires IV hyperemia
• Simple graphical display of iFR values through the vessel • Can be difficult to interpret
• Maps the ischemic contribution of each lesion without the confounding • There is an interdependency of pressure gradients in serial lesions
effects observed with FFR pullback • Requires a second FFR pullback after treating the first lesion to assess the
• Easily bookmark areas of interest “updated” severities of the remaining lesions

©2021 Koninklijke Philips N.V. All rights reserved.

 Intravascular Ultrasound (IVUS)
Eagle Eye Platinum
Digital IVUS
Exceptional deliverability from hydrophilic coating with low entry profile
Radiopaque markers allow quick and convenient length estimation with radiopaque markers
Eagle Eye Platinum ST (Short Tip) Fast, plug-and-play simplicity for Ease of use
ChromaFlo allows easy image interpretation

Rotational IVUS
Refinity ST
45 MHz high frequency rotational IVUS generates sharp, crisp images
for reliable vessel interpretation and assessment

Revolution Polished, atraumatic radius tip Facilitates distal access

Variable stiffness catheter shaft provides strength and pushability to

negotiate tortuous vasculature

©2021 Koninklijke Philips N.V. All rights reserved.

 Intracoronary Optical Coherence Tomography
(OCT) Imaging

• is an intravascular imaging modality that uses near-infrared light to provide high-definition, cross-
sectional and three-dimensional images of the vessel microstructure.

* Abbott.
Radiation Safety in The Cath Lab
Chambers CE, et al.
Catheterization and
Cardiovascular Interventions
2011; 77:546-56
•`

Chambers CE, et al.

Catheterization and
Cardiovascular
Interventions 2011
 Concept of Radiation Protection
ALARA (As Low As Reasonably Achievable)

Reduce Exposure Time Keep optimal distance from Wear optimal amount of
(Pulsed Fluoro; the radiation source shielding
Exposed as needed) (inverse square law) (Personal radiation protection)
 Positioning & X-Ray Angulation

Low Subject-Image Distance A lower table setting Elevation of the image

without changing the intensifier results in higher
The patient should be
source-intensifier dose owing to geometric
placed away from the
distance results in magnification by the
radiation source and close
higher dose due to intensifier
to the image intensifier
proximity of the patient
to the radiation source
Christopoulos G, et al. Cathetherization and Cardiovascular Interventions 2016
 Positioning & X-Ray Angulation

Hendry JH. Ann ICRP 2012

Radiation Protection
Wear optimal amount of shielding

Vertical profile with undertable shielding

Vertical profile without shielding
Radiation Protection
Stand on the right place
tube

tube

Operator stands next to tube Operator stands opposite to tube

 Reducing Radiation Use

Do not step on fluoroscopy pedal

when not looking at screen

Fluoroscopy: 40%-
66% of AK

Decrease Cine Use

Fetterly KA, et al. JACC:Cardiovascular Interventions 2012

 Reducing Radiation Use
Benefits from using collimation
Optimal collimation on the area of interest allows significant dose reduction

Fetterly KA, et al. JACC:Cardiovascular Interventions 2012

Radiation Monitoring
.
 Radiation Monitoring
.

Christopoulos G, et al. Cathetherization and Cardiovascular Interventions 2016

 SUMMARY

• There are so many features that could optimized PCI

procedure using low radiation in modern cathlab.
• Reducing radiation exposure to the patient and staff by
education, shielding, and improving techniques is of the
utmost importance in maximizing the benefits and minimizing
the risk of radiation.

.
Thank You