Radiation Exposure of TEE Operators During Structural Cardiac Interventions

Study Questions:

What is the radiation exposure for transesophageal echocardiography (TEE) operators (TEEOP) during structural cardiac interventional procedures?


This study compared radiation exposure for TEEOP, primary operators (OP1), secondary operators (OP2), and anesthesiologists (ANA) during percutaneous structural heart interventions during an initial 98 procedures, followed by 50 procedures utilizing additional TEEOP shielding. Personnel used an instantly downloadable dosimeter, and all wore standard lead apparel. OP1 and OP2 were also protected by a table mounted lower body lead shield and a ceiling mounted drop-down shield. The ANA was provided with a lead shield on wheels, and the TEEOP had access to use the lead shield on wheels. After the initial 98 procedures, the TEEOP was additionally protected by a ceiling mounted lead shield for 50 additional cases.


For the initial 98 procedures, median (interquartile range) effective dose was 2.6 µSv (1.0-4.8) for TEEOP, 1.9 µSv (0.5-3.8, p = 0.10 vs. TEEOP) for OP1, 0.5 µSv (0-1.9, p < 0.001 vs. TEEOP) for OP2, and 0.5 µSv (0-1.4, p < 0.001 vs. TEEOP) for ANA. There were significant differences in median radiation dose between types of procedures, with left atrial device implants associated with the highest dose (p < 0.001). In 50 additional cases with additional ceiling mounted lead shielding provided for TEEOP, the radiation dose for TEEOP was reduced by 82% to a median of 0.5 µSv (interquartile range 0-1.4, p < 0.001). Multivariate analysis demonstrated that this additional shielding reduced TEEOP radiation dose by 76% (95% confidence interval, 59-86%; p < 0.001).


During structural cardiac interventional procedures, the TEEOP is exposed to the highest median radiation dose, which is not significantly different from the OP1, but is significantly higher than other team members. Additional shielding can markedly reduce the radiation dose of the TEEOP.


The past decade has seen increasing awareness of the cancer risk from diagnostic tests using ionizing radiation, as well as dramatic growth in percutaneous cardiac procedures that utilize both TEE and fluoroscopy. While primary operators typically have access to additional shielding during procedures, TEE operators often do not, and this study demonstrates the consequences of this, with TEE operators having the highest median radiation exposure among the procedural team (although the difference from the primary operator was not statistically significant). From personal experience, this study may underestimate radiation exposure; while performing TEE in crowded procedural rooms, I have often had to stand much closer to the radiation source than depicted in the diagram, while squeezing between anesthesia equipment and a moving C-arm. While this study indicates that TEE operators initially had access to a shield on wheels, this is often not helpful, as it may interfere with manipulation of the TEE probe during procedures. This study demonstrates the potential risk associated with current practice, and should prompt TEE operators to require additional shielding for these procedures.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Anesthesia, Atrial Fibrillation, Cardiac Surgical Procedures, Cardiology Interventions, Diagnostic Tests, Routine, Echocardiography, Transesophageal, Fluoroscopy, Heart Valve Diseases, Neoplasms, Protective Devices, Radiation Dosage, Radiation Protection, Radiation, Ionizing

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