2. Proper Use of Cineangiographic Equipment and Contrast Agents Grossman ’ s cardiac catheterization, angiography, and intervention CV R5 陳儒逸 醫師 Supervisor: 劉秉彥醫師

3. The Angiography Room

4. Rotation left or right anterior oblique Skew cranial or caudal Biplane system Single plane system

5. Classic Image Chain A generator A generator A cine pulse system A cine pulse system An x-ray tube An x-ray tubex-ray tubex-ray tube An image intensifier (I.I.) An image intensifier (I.I.)image intensifier (I.I.)image intensifier (I.I.) An optical distributor An optical distributor A 35-mm cine camera A 35-mm cine camera A television camera and monitor A television camera and monitor Live fluoroscopy Cineangiography 47 m 2 and 3 m 1 mm of lead Lead-treated glass Filmless system DICOM

6. The X-Ray Tube

7. Image Intensifier (I.I.)

8. Radiation Safety Radiation exposure Radiation exposure The biologic effects of radiation The biologic effects of radiation Proper use of monitoring Proper use of monitoring The shielding equipment The shielding equipment

9. Units of Measurement Primary unit of radiation exposure: R: roentgen ( 侖琴 ) = 2.58x10 -4 coulombs ( C ) Quantitating tissue effects: rad (radiation absorbed dose) gray (1 Gy = 100 rad); soft tissue (1R = 0.9rad); bone (1R = 4rad) Different types of radiation may produce different degrees of damage rem (radiation equivalent in man) Sievert (1 Sv = 100 rem) NCRP (1987) : EDE ( effective dose equivalent) ( rem or Sv)

10. Biologic Effects of Radiation The maximal annual occupational dose at 5 rem or 50 mSv. Normal (5 mSv) Stochastic problems 1. genetic damage (birth defect); (5%) (1 Sv == doubling baseline risk of mutation) 2. neoplasm; 0.04% / rem exposure (10 mSv) Deterministic problems 1. Eye (cataract): 250 ~ 500 rem 2. Skin: redness (200 rem) ; temporary hair loss (300 rem)

11. Reducing Exposure Dose Minimizing the patient dose Keep the I.I. in near contact with the patient’s chest Reducing the amount of fluoroscopy time (FT) to the minimum required to position catheters The total FT should be well under 10 minutes for a diagnostic procedure Avoid “lead foot” syndrome Increasing distance or using shielding

12. Intravascular Contrast Agents HOCM 6 X BLOOD 1950s LOCM mid-1980s 2 X BLOOD late-1980s 2~3 X BLOOD 1 X BLOOD ˇ LOCM

13. Fewer episodes of bradycardia and hypotension Fewer episodes of bradycardia and hypotension Less angina Less angina Less nausea Less nausea Less heat sensation than traditional HOCM Less heat sensation than traditional HOCM Fewer allergic effect Fewer allergic effect Less nephrotoxicity Less nephrotoxicity Predisposing patients to thrombotic events??

15. ＄ 150~200 / 200 ml (non-ionic) == ＄ 36 ＄ 150~200 / 200 ml (non-ionic) == ＄ 36 ＄ 20 / 200 ml (ionic) ＄ 20 / 200 ml (ionic) Two or more characteristics Age > 65 y/o LVEDP > 15 mmHg NYHA class IV symptoms A history of previous reaction to contrast material Baseline Cr > 2.5 mg/dl