Influence of Fluoroscopy Technology and Operator Training on Radiation Exposure in Cardiac Implantations: Should Training Centers Upgrade Qualification Requirements?

Background: This study investigates the impact of fluoroscopy system technology and operator experience on radiation exposure during dual chamber pacemaker implantations. Data were retrospectively collected from 2018 to 2023 at Klinikum Fürth, focusing on two fellows in electrophysiology. Currently there is still limited data on radiation exposure during device implantation as most research focuses on experienced physicians and often considers fluoroscopy time rather than dose area product (DAP).

Methods: All data were retrospectively collected at Klinikum Fürth (Fürth, Bavaria, Germany) between the years 2018 to 2023. The operators conducted implantations in two settings: an operating room equipped with a Siemens Arcadis Varic X-ray generator (permitting to operate at 8 to 15 frames/second) and a catheterization lab with a Siemens Artis Zee system (permitting to operate up to 0,5 frame/second). The Siemens Artis Zee system enabled advanced dose-reduction techniques (virtual collimation, low dose per frame, adjustments of C-arm movements, image reviews etc.). The data were analyzed by categorizing the operators' procedures as trainees and as experienced operators after either obtaining the DGK/EHRA qualification for implantology or completing the required logbook procedures. The data were analyzed with IBM SPSS Statistics Data Editor version 29.0.2.0(20).

Results: Between 2018 and 2023, 318 dual chamber pacemaker (DDD) implantations were performed by the two operators (Operator 1: 131 procedures, Operator 2: 187 procedures, p= 0,24). DAP, expressed in microgray per square meter (µGy/m²), were available for 306 procedures. Of these, 182 devices were implanted in the catheterization lab and 124 in the operating room. The mean DAP in the cath lab was 23.95 µGy/m² (SD 24.29) and in the operating room 521.08 µGy/m² (SD 473.98). A t-test for independent samples of all implantations over the years showed a significant difference in DAP between the two rooms (p < 0.001), attributable to the type of C-arm used. Multivariate analysis demonstrated a significant reduction in DAP over the years, reflecting the growing experience of the operators (p < 0.001), and a significant interaction between room type and year (p < 0.001). There was no significant difference when analyzing the interaction of operator and year of implantation (p = 0.197) and between operator and type of room (p = 0.619). The lack of significant differences between operators suggests that individual differences did not significantly impact radiation exposure. The effect of the type of room on DAP was consistent across both operators. Both showed similar pattern of improvement in minimizing radiation exposure over the years.

Conclusion: The findings highlight the influence of advanced fluoroscopy technology and the learning curve of operators on radiation exposure. The significant reduction in DAP with increased experience underscores the importance of appropriate training environments and advanced technologies to minimize radiation exposure. Given that physicians in training are typically younger, they are at a higher risk of radiation exposure-related harm. Cardiology centers should consider equipping their facilities with advanced fluoroscopy systems to reduce radiation risks. We recommend an upgrade of qualification requirements, including a detailed description of fluoroscopy and C-arm technology, to ensure safer operating conditions.