Lead Suits Cut Physician Radiation Exposure for Interventional Cardiology Cases

Use of suspended lead suits during percutaneous left atrial appendage occlusion (LAAO) was associated with significant reductions in echocardiographers’ radiation exposure to the head as compared with conventional lead aprons, a prospective comparison showed.

Median radiation exposure decreased from 10.6 microsieverts (µSv) with lead aprons to 0 with the suspended lead suits. In 60% of LAAO procedures involving the suits, interventional echocardiographers had undetectable radiation exposure, and no interventionist had exposure ≥20 µSv versus almost a third of procedures involving lead aprons. Similar associations emerged from exploratory analyses adjusted for radiation doses for procedural dose area product (DAP).

The findings have major implications for occupational radiation exposure risk and use of shielding mechanisms during structural heart interventions, reported David A. McNamara, MD, MPH, of Frederik Meijer Heart & Vascular Institute, Corewell Health West in Grand Rapids, Michigan, and colleagues in JAMA Network Open.

“The interventional echocardiographers are at a particularly high risk [for radiation exposure], even compared with other groups in the cath lab,” McNamara told MedPage Today. “Additionally, there are some issues with what’s used [for shielding]. Nationally and worldwide, greater than 90% of interventional echocardiographers use the traditional lead aprons. [Suspended lead suits] are a new tool in our toolkit, and they’re widely underutilized. I think this is demonstrating that we have this new technology for a particularly high-risk group.”

Interventional echocardiographers’ radiation exposure has attracted little research interest, resulting in a knowledge gap about the risk and the potential for suspended lead suits to reduce the risk, he added. Additionally, the lead suits are more expensive than aprons, although the study was not designed to assess cost-effectiveness, and the added cost definitely is a factor in the lack of use.

LAAO procedures frequently are performed with an interventional echocardiographer near the patient and radiation source, increasing the risk for occupational exposure to radiation. No consensus exists about the optimal radiation shielding methods, the authors noted in their introduction.

A study conducted almost a decade ago showed that use of robotics and suspended lead suits could limit radiation exposure to the head and chest of operators during percutaneous coronary interventions. Another study by the same group showed that use of accessory lead shields reduced radiation exposure by two-thirds to various personnel during cardiac catheterization.

More recently, McNamara and colleagues reported that interventional echocardiographers were exposed to substantially higher radiation doses than interventional cardiologists and sonographers during percutaneous structural heart interventions. McNamara also was part of a group that showed suspended lead suits significantly reduced head-level radiation exposure to physicians during coronary angiography.

In the current study, investigators examined interventional echocardiographers’ radiation exposure during LAAO procedures with two types of shielding: suspended lead suits and lead aprons. The lead suits consist of a 1.0-mm-thick lead apron and a 0.5-mm lead-equivalent transparent head and neck shield with overhead support to eliminate weight on the operator.

The authors prospectively collected data on all LAAO procedures performed at a single center from Feb. 21 to Aug. 22, 2023. The primary objective was to assess radiation exposure to interventional echocardiographers with use of a suspended lead suit or a traditional lead apron.

Data analysis included 125 patients who had a mean age of 78, and men accounted for 62% of the cases. In 95 of the cases, interventional echocardiographers used the suspended lead suits, and lead aprons were used in the remaining 30 cases. Six interventional echocardiographers participated in the study. They had an average of 6.6 years of post-fellowship clinical experience.

Procedural radiation characteristics included a median fluoroscopy time of 7.0 minutes, air kerma of 81 mGy, and DAP of 8.1 Gy x cm². All three values were significantly lower (P<0.001) during cases involving lead suits. To account for differences in procedural radiation, physician radiation doses were normalized to DAP.

Whether assessed by radiation dose (µSv) or dose normalized to DAP, interventional echocardiographers had significantly less radiation exposure with the lead suit compared with the apron (P<0.001).

Looking ahead to potential next steps, McNamara said implementation and cost-effectiveness analyses need to be performed. More work is required to understand variability in use of radiation shielding by interventional echocardiographers and the protection afforded for different types of interventional cardiology procedures.

“I think this is setting the foundation for future studies,” he said. “Right now, there are no multicenter trials looking at radiation reduction techniques for interventional echocardiographers. From an advocacy standpoint, I think it’s important for interventional echocardiographers to have this information to help with discussions with hospital administrators.”

Issues involving radiation exposure and use of different types of shielding could be pertinent to clinical areas outside of cardiology, McNamara acknowledged. The findings could apply to other procedures that involve fluoroscopy or continuous imaging. Interventional radiology approaches to invasive gastrointestinal procedures and conventional pulmonology offer additional examples.

“I think radiation exposure, as a whole, is becoming more of a hot-topic issue, and I think this work could be extrapolated,” he said.