Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC K9m8kpv6S84m3QhxZnrVSTx S0066-782X2019000400400 10.5935/abc.20190052 Short Editorial The Radiological Exposure from the Perspective of the Interventional Cardiologist 0000-0003-3511-7375 Andrade Pedro Beraldo de 1 2 Labrunie André 1 2 Santa Casa de Marília Marília SP Brazil Santa Casa de Marília, Marília, SP - Brazil Hospital do Coração de Londrina Londrina PR Brazil Hospital do Coração de Londrina, Londrina, PR - Brazil Mailing Address: André Labrunie, Rua Paes Leme, 1351. Postal Code 86010-610, Jd. Ipiranga, Londrina, PR - Brazil. E-mail: alabrunie@cardiol.br, alabrunie@hospcoracao.com.br 15 04 2019 04 2019 112 4 400 401 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited Keywords Cardiology, Interventional/trends Heart, Defects, Congenital Percutaneous Coronay Intervention Cardiovascular Diseases/prevention and control Radiation Exposure/adverse effects

The interventional cardiology represents an area in constant development and it has advanced considerably in the treatment of both congenital and acquired cardiovascular diseases. It has a safe and effective role in the correction of septal and shunt1 congenital abnormalities, valve diseases, especially the percutaneous treatment of the aortic stenosis in patients with high or intermediate2,3 surgical risk and, more recently, it has also moved towards the mitral and tricuspid apparatuses.4,5

The percutaneous coronary intervention has stood out in the treatment of lesions of the left main coronary artery and multivessel coronary artery disease, in the absence of high anatomical complexity,6 reaching now the frontier of chronic occlusions with consistent results.7

The technical challenges impose greater risks to the occupational health of those involved in the daily routine of a cardiac catheterization laboratory, especially the interventional cardiologists. Beyond musculoskeletal or orthopedic abnormalities, related to wearable plumbing aprons, current evidence suggests that the extended radiological exposure would cause a fourfold and a half greater risk of cancer and a nine fold greater risk of cataract among these professionals.8 Besides, chronic low doses of ionizing radiation could promote changes in the endothelial cellular biology, resulting in vascular damage, subclinical atherosclerosis and a greater prevalence of cardiovascular disease.9

In the present issue of the Arquivos Brasileiros de Cardiologia, Barbosa AHP et al.,10 describe, in a pioneering way, the deleterious effects of the radiological exposure in a voluntary sample of interventional cardiologists, with nationwide representativity. In the exposed group, the prevalence of subcapsular posterior cataract, the most frequent variant found in this scenario, was 13%, compared to 2% in the control group (p=0.0081), in consonance with the findings from the international literature. In an alarming way, the authors report a lower than the desired and recommended frequency of the use of adjustable positioning shields, such as suspended screen and lead strips positioned at the side of the examination table, as well as protective goggles. The implementation of such preventive actions has proved to reduce radiological exposure to the operators.11

The risks inherent in the chronic exposure to the ionizing radiation certainly characterize a topic of extreme relevance and it is necessary to take them into account in the professional quality standards that guide the speciality, as well as in the employment relations. Individually, how many professionals would abdicate this area of medicine because of this hazard? As an inference to this questioning, we have witnessed a recent paradigm shift in relation to the vascular access in the performance of coronary artery invasive procedures, with the preferential choice for the radial technique in lieu of the femoral one. This strategy has benefitted the patients, with the reduction of the complications regarding the site of the arterial puncture, the rate of major bleeding as well as morbidity and mortality, but at the cost of a greater and proved radiological exposure to the operator.12

May the interventional cardiologists have the last word.

Short Editorial related to the article: Prevalence of Lens Opacity in Interventional Cardiologists and Professional Working in the Hemodynamics in Brazil

 References 1 Turner DR, Owada CY, Sang CJ Jr, Khan M, Lim DS. Closure of secundum atrial septal defects with the AMPLATZER septal occluder: a prospective, multicenter, post-approval study. Circ Cardiovasc Interv. 2017;10(8). pii:e004212. Turner DR Owada CY Sang CJ Jr Khan M Lim DS Closure of secundum atrial septal defects with the AMPLATZER septal occluder: a prospective, multicenter, post-approval study Circ Cardiovasc Interv 2017 10 8 e004212 2 Gleason TG, Reardon MJ, Popma JJ, Deeb GM, Yakubov SJ, Lee JS, et al. 5-Year outcomes of self-expanding transcatheter versus surgical aortic valve replacement in high-risk patients. J Am Coll Cardiol. 2018;72(22):2687-96. Gleason TG Reardon MJ Popma JJ Deeb GM Yakubov SJ Lee JS 5-Year outcomes of self-expanding transcatheter versus surgical aortic valve replacement in high-risk patients J Am Coll Cardiol 2018 72 22 2687 2696 3 Reardon MJ, Van Mieghem NM, Popma JJ, Kleiman NS, Søndergaard L, Mumtaz M, et al. Surgical or transcatheter aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2017;376(14):1321-31. Reardon MJ Van Mieghem NM Popma JJ Kleiman NS Søndergaard L Mumtaz M Surgical or transcatheter aortic-valve replacement in intermediate-risk patients N Engl J Med 2017 376 14 1321 1331 4 Bapat V, Rajagopal V, Meduri C, Farivar RS, Walton A, Duffy SJ, et al. Early experience with new transcatheter mitral valve replacement. J Am Coll Cardiol. 2018;71(1):12-21. Bapat V Rajagopal V Meduri C Farivar RS Walton A Duffy SJ Early experience with new transcatheter mitral valve replacement J Am Coll Cardiol 2018 71 1 12 21 5 Taramasso M, Hahn RT, Alessandrini H, Latib A, Attinger-Toller A, Braun D, et al. The international multicenter TriValve Registry: which patients are undergoing transcatheter tricuspid repair? JACC Cardiovasc Interv. 2017;10(19):1982-90. Taramasso M Hahn RT Alessandrini H Latib A Attinger-Toller A Braun D The international multicenter TriValve Registry: which patients are undergoing transcatheter tricuspid repair? JACC Cardiovasc Interv 2017 10 19 1982 1990 6 Stone GW, Sabik JF, Serruys PW, Simonton CA, Généreux P, Puskas J, et al. Everolimus-eluting stents or bypass surgery for left main coronary artery disease. N Engl J Med. 2016;375(23):2223-35. Stone GW Sabik JF Serruys PW Simonton CA Généreux P Puskas J Everolimus-eluting stents or bypass surgery for left main coronary artery disease N Engl J Med 2016 375 23 2223 2235 7 Tajti P, Karmpaliotis D, Alaswad K, Jaffer FA, Yeh RW, Patel M, et al. The hybrid approach to chronic total occlusion percutaneous coronary intervention: update from the PROGRESS CTO Registry. JACC Cardiovasc Interv. 2018;11(14):1325-35. Tajti P Karmpaliotis D Alaswad K Jaffer FA Yeh RW Patel M The hybrid approach to chronic total occlusion percutaneous coronary intervention: update from the PROGRESS CTO Registry JACC Cardiovasc Interv 2018 11 14 1325 1335 8 Andreassi MG, Piccaluga E, Guagliumi G, Del Greco M, Gaita F, Picano E. Occupational health risks in cardiac catheterization laboratory workers. Circ Cardiovasc Interv. 2016;9(4):e003273. Andreassi MG Piccaluga E Guagliumi G Del Greco M Gaita F Picano E Occupational health risks in cardiac catheterization laboratory workers Circ Cardiovasc Interv 2016 9 4 e003273 9 Andreassi MG, Piccaluga E, Gargani L, Sabatino L, Borghini A, Faita F, et al. Subclinical carotid atherosclerosis and early vascular aging from long-term low-dose ionizing radiation exposure: a genetic, telomere, and vascular ultrasound study in cardiac catheterization laboratory staff. JACC Cardiovasc Interv. 2015;8(4):616-27. Andreassi MG Piccaluga E Gargani L Sabatino L Borghini A Faita F Subclinical carotid atherosclerosis and early vascular aging from long-term low-dose ionizing radiation exposure: a genetic, telomere, and vascular ultrasound study in cardiac catheterization laboratory staff JACC Cardiovasc Interv 2015 8 4 616 627 10 Barbosa AHP, Medeiros RB, Corpa AMR, Souza MT, Barbosa PL, et al. Prevalência de opacidades do cristalino m cardiologistas intervencionistas e profissionais atuantes na área de hemodinâmica no Brasil. Arq Bras Cardiol. 2019; 112(4):392-399. Barbosa AHP Medeiros RB Corpa AMR Souza MT Barbosa PL Prevalência de opacidades do cristalino m cardiologistas intervencionistas e profissionais atuantes na área de hemodinâmica no Brasil Arq Bras Cardiol 2019 112 4 392 399 11 Sciahbasi A, Frigoli E, Sarandrea A, Calabrò P, Rubartelli P, Cortese B, et al. Determinants of radiation dose during right transradial access: insights from the RAD-MATRIX study. Am Heart J. 2018 Feb;196:113-8. Sciahbasi A Frigoli E Sarandrea A Calabrò P Rubartelli P Cortese B Determinants of radiation dose during right transradial access: insights from the RAD-MATRIX study Am Heart J 2018 02 196 113 118 12 Plourde G, Pancholy SB, Nolan J, Jolly S, Rao SV, Amhed I, et al. Radiation exposure in relation to the arterial access site used for diagnostic coronary angiography and percutaneous coronary intervention: a systematic review and meta-analysis. Lancet. 2015;386(10009):2192-203. Plourde G Pancholy SB Nolan J Jolly S Rao SV Amhed I Radiation exposure in relation to the arterial access site used for diagnostic coronary angiography and percutaneous coronary intervention: a systematic review and meta-analysis Lancet 2015 386 10009 2192 2203 Minieditorial A Exposição Radiológica sob a "Óptica" do Cardiologista Intervencionista 0000-0003-3511-7375 Andrade Pedro Beraldo de 1 2 Labrunie André 1 2 Santa Casa de Marília, Marília, SP - Brasil Hospital do Coração de Londrina, Londrina, PR - Brasil Correspondência: André Labrunie, Rua Paes Leme, 1351. CEP 86010-610, Jd. Ipiranga, Londrina, PR - Brasil. E-mail: alabrunie@cardiol.br, alabrunie@hospcoracao.com.br Palavras-chave Cardiologia Intervencionista/tendências Cardiopatias Congênitas Intervenção Coronária Percutânea Doenças Cardiovasculares/prevenção e controle Exposição à Radiação/efeitos adversos

A cardiologia intervencionista representa uma área de atuação em constante evolução, avançando a passos largos na abordagem terapêutica das doenças cardiovasculares congênitas ou adquiridas. Atua-se hoje com eficácia e segurança atestadas na correção das cardiopatias congênitas septais e de shunt,1 das doenças valvares, notadamente no tratamento percutâneo da estenose aórtica em pacientes de risco cirúrgico elevado ou intermediário,2,3 adentrando recentemente no aparato mitral e tricuspídeo.4,5

A intervenção coronária percutânea assumiu protagonismo em lesões de tronco de coronária esquerda e coronariopatia multiarterial, na ausência de complexidade anatômica elevada,6 ultrapassando agora com resultados consistentes a fronteria das oclusões crônicas.7

Os desafios técnicos conferem àqueles envolvidos na rotina de um laboratório de intervenção maiores riscos à saúde de natureza ocupacional, sobretudo aos cardiologistas intervencionistas. Além de patologias ortopédicas ou músculo-esqueléticas, relacionadas ao uso do avental plumbífero, evidências atuais sugerem que a exposição radiológica prolongada acarretaria um risco 4,5 vezes maior de câncer e 9 vezes maior de catarata entre estes profissionais.8 Além disso, doses baixas crônicas de radiação ionizante poderiam promover alterações na biologia celular endotelial, culminando com dano vascular, aterosclerose subclínica e consequentemente maior prevalência de doença cardiovascular.9

Na presente edição dos Aquivos Brasileiros de Cardiologia, Barbosa AHP et al.10 ilustram, de forma pioneira, os efeitos nocivos da exposição radiológica em uma amostra voluntária de cardiologistas intervencionistas, com representatividade nacional. No grupo exposto, a prevalência de catarata subcapsular posterior, variante mais frequentemente encontrada nesse cenário, foi de 13%, comparada a 2% no grupo controle (p = 0,0081), em consonância com os achados da literatura internacional. De forma alarmante, os autores reportam uma frequência aquém da desejada e recomendada de utilização de blindagens de posicionamento ajustáveis, como anteparo suspenso e faixas plumbíferas posicionadas na lateral da mesa de exames, assim como de óculos de proteção. A adoção dessas medidas preventivas, comprovadamente, reduz a exposição radiológica aos operadores.11

Os riscos inerentes à exposição crônica à radiação ionizante certamente configuram tópico de extrema relevância, a ser considerado nas normativas de qualidade profissional que norteiam a especialidade, bem como nas relações empregatícias. Individualmente, quantos profissionais abdicariam da escolha por essa área de atuação em virtude dessa constatação? Como inferência a esse questionamento, observamos uma recente mudança de paradigma em relação ao acesso vascular na realização de procedimentos coronários invasivos, com a adoção preferencial da técnica radial em detrimento à femoral, em prol dos pacientes, pela redução de complicações relacionadas ao sítio de punção arterial, da taxa de sangramento grave e da morbimortalidade, a despeito de uma maior e comprovada exposição radiológica ao operador.12

Com a palavra os cardiologistas intervencionistas.

Minieditorial referente ao artigo: Prevalência de Opacidades do Cristalino em Cardiologistas Intervencionistas e Profissionais Atuantes na Área de Hemodinâmica no Brasil