Cardiac Rhythm Management
Articles Articles 2011 November

COMMENTARY FROM THE SECTION EDITOR

DOI: 10.19102/icrm.2011.021202

George F. Van Hare, MD

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Editor-in-Chief

Dr. George McDaniel provides a comprehensive review of the use of nonfluoroscopic systems in pediatric electrophysiology practice. I think it is accurate to say that the current standard of care in pediatric ablation practice is to have the capability for electroanatomic mapping, and that this capability can, but does not always, lead to decreases in fluoroscopy exposure for both patient and operator.

Of course, everyone is in favor of less radiation in everything that we do. However, the focus of this paper is a little different: the prospect of the complete elimination of the use of fluoroscopy within these cases. There are certainly clinicians who promote this approach as an obvious virtue. I am, in fact, a big fan of those clinicians and laboratories who have taken the lead in developing protocols and techniques to accomplish this goal. It is a big undertaking, and a fundamental shift in thinking, and I admire the effort! It could be considered an extremist position, however. It is a little like the space program; we went to the moon and as a result we now have integrated circuits, Tang and Velcro. Also, Pampers. Everyone benefits, but not everyone has to go to the moon.

It seems to me that we can agree with the idea that less radiation is better, but some believe that no radiation is far superior to a little bit of radiation. Let's examine that. If it were possible for someone to go through life with no radiation exposure whatsoever, then I would agree with this view (ignoring, of course, the important role of ionizing radiation in evolution, if you believe in it).

However, everyone is exposed to radiation on a daily basis. This exposure increases when we fly in airliners, get a chest X-ray, submit to TSA backscatter imaging, etc. So, it seems to me that the incremental risk, real as it may be, of 10 or 15 minutes of fluoroscopy is likely to be small when compared with a lifetime's worth of other exposures.

The risks on the other side, however, have not been well delineated. This includes the primary risk of not having fluoroscopy at our disposal to keep us out of trouble, when we need to do things such as passing guide wires. In particular, I am a bit mystified by the enthusiasm expressed by some for transseptal puncture without fluoroscopy. Can it be done? Sure. Is it safe? Perhaps we need a report of more than 10 cases before so concluding. Safety, in general, is harder to prove than feasibility.

So, I will continue to enthusiastically learn from my colleagues who are pushing the limits of what we do, but will likely continue to use a little bit of fluoroscopy here and there.

George F. Van Hare, MD
VanHare@kids.wustl.edu
Director, Pediatric Cardiology
Washington University
St. Louis Children’s Hospital One Children’s Place
Campus Box 8116 - NWT
St. Louis, MO

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