Exposure reduction by optimization of the imaging toolchain in pulmonary vein isolation

Purpose: We implemented a strategy of cumulative dose rate savings in the setting of pulmonary vein isolation (PVI) and report on its effectiveness and impact on image quality. Methods: All patients that underwent PVI with 3D rotation angiography (3DRA) were included over 18 months. Dose per frame of the 3DRA acquisition was reduced by 50% and dose per frame of standard fluoroscopy acquisition was lowered. Results: In 133 patients (84 male, mean age 61.3±10.9 years, mean BMI 27.2), baseline procedure duration was 155.1±37.9 minutes and mean total dose area product (DAP) 34.73±16.85 Gy.cm2. The use of 3DRA accounted for 52.8% of total DAP (17.05±9.39 Gy.cm2). After 3DRA optimization, cine DAP was 10.06±4.30 Gy.cm2 (59.0% reduction). Image quality was unaffected in all patients. After fluoro optimization, fluoro DAP dropped to 5.64±7.01 Gy.cm2 (70.6% reduction). Average DAP rate dropped from 81 Gy.cm2/h to 31 Gy.cm2/h with the new protocol (p < 0.05). Image quality was sufficient for catheter manipulation in all patients. Mean total DAP using combined optimizations was 13.96±9.43 Gy.cm2 (estimated effective exposure of 2.8 mSv). Conclusion: Impressive exposure reduction is possible by optimizing X-ray acquisition parameters. In specific electrophysiological procedures, further gains are expected to be possible by compromising on image quality