Quantifying radiation exposure in cardiologists performing cardiac device implantation: training implications and safety considerations

Background

The increasing prevalence of fluoroscopy-guided procedures in cardiology results in continuous occupational radiation exposure for operators. In electrophysiology training, there is a heightened risk of increased exposure due to longer fluoroscopy times and less optimized working techniques. The aim of this study was to systematically quantify radiation exposure for physicians during cardiac rhythm device implantation and to evaluate the impact of training level, imaging technology, and individual protective measures.

Methods

A retrospective, single-center analysis was conducted of 534 cardiac device implantations (PM, ICD, CRT) performed between 2018 and 2023 by two operators during their transition from the training phase to full electrophysiology certification. Patient-related radiation parameters — dose–area product (DAP) and fluoroscopy time (FT) — were recorded along with operator-related occupational exposure measured by two dosimeters: a whole-body dosimeter worn beneath the lead apron and a ring dosimeter on the dominant hand. The influence of the X-ray system used and the use of a 3D electroanatomical mapping system in all CRT implantations were included in the analysis. Statistical evaluation was performed using t-tests, Mann–Whitney U tests, ANOVA, and multivariate analyses.

Results

During the training phase, DAP values were significantly higher than after certification (1,965.3 ± 489.2 vs. 1,243.6 ± 372.5 cGy·cm²; p < 0.001). Mean FT was also significantly reduced from 8.4 ± 3.1 min to 5.9 ± 2.6 min (p = 0.005). Use of the newer fluoroscopy system was associated with significantly lower patient radiation exposure (1,117.8 ± 384.4 vs. 2,104.2 ± 521.7 cGy·cm²; p = 0.001), with no difference in FT between systems (p = 0.772).

Cumulative hand dose over the observation period was 25 mSv for one operator, while the other recorded no measurable hand dose. Differences were independent of training level, suggesting individual variation in technique and radiation protection behavior. In all CRT implantations performed with 3D mapping, no hand dose peaks were observed. Mean per-procedure whole-body dose was 0.000711 mSv for Operator 1 and 0.000319 mSv for Operator 2 (no significant difference; p = 0.126). Stratified by experience level, trainees had significantly higher values (0.000774 mSv) than experts, who recorded 0.000 mSv in all cases (p = 0.0017).

Conclusions

Training level is a key determinant of radiation exposure in cardiac device implantation. Modern imaging systems and 3D mapping technologies can significantly reduce exposure without prolonging procedure duration. The complete elimination of measurable whole-body dose among experienced operators underscores the potential of consistently applied radiation protection strategies. This study provides practical recommendations for training concepts in interventional cardiology aimed at sustainably reducing both patient and operator dose.Fluoroscopy systemOperator experience