radiation exposure to during cardiac...

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We know of no reports of thyroid carcinoma beingassociated with cardiac catheterization. Awareness ofa potential association is desirable in all clinicians ex-amining such patients.

References1. Amiel M, Clermont A, Jocteur-Monrozier D, Moroni JP, Brun

P: Etude dosimetrique au course de l'angiographie cardiaquechez le jeune enfant. Ann Radiol 19: 623, 1975

2. Gustafsson M, Mortensson W: Irradiation to the thyroid glandat cardiac catheterization and angiocardiography in children.Br J Radiol 49: 686, 1976

3. Kaude J, Svahn G: Absorbed gonad and integral dose to the pa-tient and personnel from angiographic procedures. Acta Radio15: 454, 1974

4. Langmead WA, Wall BF: An assessment of lithium boratethermoluminescent dosimeters for the measurement of doses topatient in diagnostic radiology. Br J Radiol 49: 956, 1976

5. Martin EC, Olson A: Radiation exposure to the paediatric pa-tient from cardiac catheterization and angiocardiography. Br JRadiol 53: 100, 1980

6. Maripuu E: Measurement of radiation doses delivered to thepatient at urography and angiography. National Institute ofRadiation Protection (Sweden), report no. 017, 1974

7. Rowley KA: Patient exposure in cardiac catheterization andcinefluorography using the Eclair 16 mm camera at speeds up to200 frames per second. Br J Radiol 47: 169, 1974

8. Hempelmann L: Risk of thyroid neoplasms after irradiation inchildren. Science 169: 159, 1968

9. Modan B, Bardatz D, Mart H, Steinitz R, Levin SG: Radia-tion induced head and neck tumors. Lancet 1: 277, 1974

10. Grollman JH Jr, Klosterman H, Herman MW, Moler CL,Eber LM, MacAlpin RN: Dose reduction low pulse-rate fluoro-scopy. Radiology 105: 293, 1972

11. International Commission on Radiation Units and Meas-urements: Cameras for Image Intensifier Fluoroscopy. Reportno. 15, 1969

12. Hall E: Radiobiology for the Radiologist, 2nd ed. New York,Harper and Row, 1978, pp 371-372

Radiation Exposure to the ChildDuring Cardiac Catheterization

J. D. WALDMAN, M.D., P. S. RUMMERFIELD, SC.D., E. A. GILPIN, M.S.,AND S. E. KIRKPATRICK, M.D.

SUMMARY Few data are available regarding radiation exposure to children during cardiac catheter-ization. Using lithium fluoride thermoluminescent dosimeters, radiation exposure was measured duringprecatheterization chest roentgenography, fluoroscopy (hemodynamic assessment phase of catheterization)and cineangiography in 30 infants and children, ages 3 days to 21 years. Dosimeters were placed over the eyes,thyroid, anterior chest, posterior chest, anterior abdomen, posterior abdomen and gonads.

Average absorbed chest doses were 24.5 mR during chest roentgenography, 5810 mR during catheterizationfluoroscopy and 1592 mR during cineangiography. During the complete catheterization, average doses were 26mR to the eyes, 431 mR to the thyroid area, 150 mR to the abdomen and 11 mR to the gonads.

Radiation exposure during pediatric cardiac catheterization is low to the eyes and gonads but high to thechest and thyroid area. To decrease radiation dosage we suggest (1) low pulse-rate fluoroscopy; (2) substitu-tion of contrast echocardiography for cineangiography; (3) large-plate abdominal/gonadal shielding; (4) aselective shield for thyroid area; (5) a very small field during catheter manipulation. Minimum radiation con-sistent with accurate diagnosis is optimal; however, erroneous or incomplete diagnosis is more dangerous thanradiation-related hazards.

THIS STUDY was intended to answer four questionsrelating to cardiac catheterization in children: Howmuch radiation is the child exposed to during a routinestudy? What differences are there in exposure tovarious areas of the body? How much radiation isrelated to cineangiography compared with fluoros-copy? How might radiation exposure be reduced?

From the Pediatric Cardiology Medical Group, theSharp/Children's Cardiac Center, the Applied Radiation Protec-tion Services, and Research Cardiology, Data Management Proj-ect, University Hospital, University of California Medical Center,San Diego, California.

Presented in part at the World Congress of Pediatric Cardiology,June 1980, London, England.

Address for correspondence: J. D. Waldman, M.D., 7920 FrostStreet, Suite 304, San Diego, California 92123.

Circulation 64, No. 1, 1981.

Materials and MethodsThirty infants and children chosen randomly were

evaluated during clinically indicated cardiac catheter-ization studies between April and July 1979. Ageranged from 3 days to 21 years (table 1). Fourteen hadleft-to-right shunts, 10 had cyanotic congenital heartdisease, four had right- or left-heart obstruction, onehad Ebstein's anomaly, and one child had no signifi-cant heart disease. Balloon septostomy was performedin two neonates.

Lithium fluoride thermoluminescent dosimeters(TLDs) were applied to the body during precatheter-ization chest roentgenography, during the hemo-dynamic assessment (fluoroscopy) phase of cardiaccatheterization and during cineangiography. TheTLDs, 0.3 X 0.3 X 0.09-mm chips of high-sensitivity

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RADIATION DURING PEDIATRIC CATH/Waldman et al.

TABLE 1. Clinical and Dosimetry Data from 30 Children During Cardiac Catheterization

Radiation dosage (mR)

Contrast Absorbed chest Complete catheterizationWeight Time (min) _Angio given Chest Thy- Abdo-

Pt Diagnosis (kg) Age Cath Fluoro planes (ml) X-ray Pluoro Cine Nose roid men Gonads1 NSHD2 VSD3 VSD4 TOF5 ASD6 TOF,

po repair7 PS8 ASD, VSD9 PDA10 TOF11 TA, CoA;

BAS12 VSD13 PAPVR14 VSD, po

closure15 RCA-RV

fistula16 VSD17 SV, CoA18 AS19 D-Cor, PS20 AS21 TOF, PA22 ASD23 PDA24 TOF, PA25 VSD26 TA, BAS27 TGA,

po Baffes28 CoA29 Ebstein30 VSD

19.53.26.8

13.37.6

15.418.22.1

12.69.3

6y5m8m5y6m

6y5 y 5 m2m5y1 y

2.5 3d14.8 3 y21.6 10y

14.3 3y

11.2 3y4m9.2 4y2m

15.7 4y 7m36.2 12y13.2 4 y19.5 5y4m8.4 ly9m

13.9 4 y14.9 3y3m2.5 id3.3 6m2.3 4d

52.6 21 y18.2 4y2m44.9 12y5m5.4 4m

3852966456

12274532334

804496

514221913

2512

14

8.521.5

24656

72646

657

4212295529

5537103037

93570

77 15 6 58

4084545793110

4084396148149

1453883119

24169.59

2017.5

817

18

279

2014

664464662629

5466

4640486239262958208510

2064010120

- 2675 400- 1650 1917- 6818 2522- 4916 1646- 8877 2888

58181417

8066

4.-

113568

2770 -5278 -

6678 -

- 4- 4655 --

33 6280 -- -- 17590 -

- 4. 4237 ~

205128

18631715178

7

79204812

3211298232904-

448472942554701244302989

23595

3036

399814901373

13173 -

57880

3606419420547454

3412 -.

19775439 -

18141475

- 150 376 0- 470 66 851 490 80 2418 - - -

30 400 320 20

516

38

30

24

2422

2217275

1431

10171855

600172

995389

222390490

284497684

274280

96

2015

- 365 11

335486

33239415381041989557120709

2303634211019

116 14- 19

133 4101 10366 2113 4

120 8116 6

170104145129

1042

14.4 4 y 2 m 71.811.9 4ylm 33.2

15.8 5.15.9 1.7

41.6- 24.5 581037.8 20.8 5251

1592 25.9 4311340 14.5 244

Abbreviations: y = years; m = months; d = days; Cath = time from insertion to withdrawal of cardiac catheter; fluoro =fluoroscopy; angio = angiography; cine = cineangiography; NSHD = no significant heart disease; VSD = ventricular septaldefect; TOF = tetralogy of Fallot; ASD = atrial septal defect; po = postoperative; PS = pulmonary stenosis; PDA = patentductus arteriosus; TA = tricuspid atresia; CoA = coarctation of the aorta; BAS = balloon atrial septostomy; PAPVR = partialanomalous pulmonary venous return; RCA-RV = right coronary artery-to-right ventricle; SV = single ventricle; AS = aorticstenosis; D-Cor = dextrocardia; PA = pulmonary atresia; TGA = transposition of the great arteries. Arrows indicate com-bined dosage for cine and fluoro.

lithium fluoride, were sealed in 5 X 3-mm plastic bagsto avoid contamination. For chest roentgenography,the TLDs were placed over the left nipple and the leftscapula; during fluoroscopy, TLDs were located onthe glabella, sternal notch, left nipple, left scapula,umbilicus, sacral spine and on testicles (males) or in-

side the rectum (females) within an IVAC disposableplastic thermoprobe; during cineangiography, unex-posed TLDs were added to those already present onthe left nipple and left scapula and all of the otherTLDs remained in place.

After irradiation, the TLDs were prepared and read

Mean± SD

150110

11

10

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(at 257°C) in a Victoreen 2800 TLD reader equippedwith dry nitrogen gas flow. To calibrate dosage to theTLDs, an MDH model 1015 x-ray monitor (itselfcalibrated on 3/18/79) was used. The TLDs subse-quently passed all test phases in category III, NationalBureau of Standards, Technique L-G.

Cardiac catheterization was performed in the stan-dard fashion; no change in technique was introduced.Angiograms were performed as clinically indicatedusing the Philips three-phase Rotalix 350 biplane cine-angiography system. Focal spot was 0.6 mm in eachplane. The milliamperage was stabilized (maximum300 mA) with variable kilovolts (maximum 125 kVp).Filming was performed at 60 frames/sec and meas-ured to be 23 ,tR/frame.

ResultsCatheterization time (from insertion to withdrawal

of catheter) ranged from 23-149 minutes (mean 71.8minutes) (Table 1) and mean fluoroscopy time (thesum of the anteroposterior and lateral planes) was15.8 minutes (range 5-27 minutes). Volume of con-trast administered varied with patient size; when in-dexed to weight (ml/kg body weight) the average was3.16 ml/kg (range 1.33-4.76 ml/kg). The number ofangiograms performed varied with the complexity ofthe lesion. The number of angiograms was tabulatedas the number of planes of cineangiography per-formed; one biplane cineangiogram was tabulated astwo angiograms (table 1). Most children had two orthree biplane cineangiograms.

Precatheterization chest roentgenography was per-formed in all children; dosimetry was measured in 20.Average absorbed dose to the chest was 24.5 ± 20.8mR. Absorbed dose was defined as the differencebetween entrance and exit doses. Absorbed chest doseduring fluoroscopy (hemodynamic assessment) was anaverage of 5810 ± 5251 mR (table 1) and during cine-angiography was 1592 ± 1340 mR.As a means of comparison, radiation exposure was

expressed as chest x-ray equivalents, defined as ratioof total catheterization dose to chest roentgenogramdose. When so expressed (table 2), the fluoroscopyphase of the study was equal to an average of 428.2chest x-rays and the cineangiography was equivalentto an average of 99.9 chest x-rays (fig. 1). From thecomplete cardiac catheterization, the average thyroiddose was equivalent to 35 chest x-rays.

Average target doses during the complete catheter-ization study (fluoroscopy plus cineangiography)were: nose (25.9 mR) thyroid (431 mR) and gonads(11 mR); absorbed dose to the abdomen averaged150 ± 110 mR. Even though the TLDs were placed in-ternally in females and externally in males, there wasno significant difference in gonadal dose betweenmales and females. Thyroid dose did not correlatesignificantly with age, weight or body surface area.

Chest dose did not correlate well with fluoroscopytime (r = 0.52) but did correlate with body surfacearea when controlling for fluoroscopy time (partial

TABLE 2. Chest X-ray Equivalents of Cardiac Catheter-ization

EquivalentAverage # of chestdose (mR) x-rays

Absorbed by chest duringRegular anteroposteriorroentgenogram 24 1

Cardiac fluoroscopy 5810 428Cineangiography 1592 100

Doses during completecatheterization

Eyes 26 0.4Thyroid 431 35Abdomen 150 3Gonads 12 0.8

r = 0.84). A regression equation (r = 0.92, SEE± 2.54) was developed, based on fluoroscopy time(fluoro time) (minutes) and body surface area (BSA)(cm2): chest dose (R) = 0.3 (fluoro time) + 13.5 (BSA)- 7.2.

DiscussionIn 1906, Bergonie and Tribondeau reported that

younger, more immature organisms have greater sen-sitivity to radiation effects.' Experience with child-hood irradiation of the head and neck2 has confirmedthis. Extrapolating from California Children's Ser-vices data,2 over 37,000 cardiac catheterizations wereperformed in children in the United States in 1978.Despite the extensive use of cardiac catheterizationand the demonstrated sensitivity of children, data arefragmentary regarding radiation exposure to thepatient during cardiac catheterization.Adams et al.4 emphasized the importance of radia-

tion exposure data. Evaluating blood samples taken

0 CHEST X-RAY(24 mR)

CARDIACCATHETERIZATION

(7402 mR)

FIGURE 1. Pediatric radiation exposure to the thoraxchest roentgenogram vs cardiac catheterization. Area incircles reflects relative absorbed dosage to the chest.Relative contributions of the fluoroscopy (F) andangiography (A) phases of catheterization are indicated.

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before and after catheterization with cineangiographyin 20 children, chromosomal damage was found in allpost-study specimens. In a subsequent study, the doseeffect was shown to be enhanced by the use of contrastagent for angiography.5 Differences between pediatricand adult cardiac catheterization are relevant: averagevolume of contrast administered in children was 3.16ml/kg body weight; in adults, the average volume was2.08 ml/kg body weight (unpublished data).

In adults, Gough et al.6 Ardran et al.7 and Malskyet al.8 estimated exposure based on radiologic equip-ment settings and field size. Calculation of total ex-posure ranged from 3-lOOR. Malsky suggested thatthe ideal setting would be to obtain dosimetry infor-mation of the performance of the actual procedure.

Thermoluminescent dosimetry has been applied toadults9 and children'0'4 during cardiac catheteriza-tion, usually to measure gonadal or thyroidal dosage.Mean exposure to the pubic region was 12.1 mR inadults,9 a figure almost identical to ours, and rangedfrom 9-300 mrad in children,'10-2 apparently reducedin the presence of gonadal shielding, according toKaude and Svahn.'0 A wide diversity of thyroidaldosage has been reported. Martin and Olson13reported an exceedingly high thyroidal exposure(average of 7.7 rad) in a catheterization laboratory inwhich the serial film changer technique was used in allstudies. In children from early infancy to 13 years ofage, Gustaffson and Mortensson'4 reported a total me-dian absorbed thyroidal dose of 261-369 mrad, basedon a single soft-tissue conversion factor of 0.92 radR-'. Reuter, in 12 adults, reported a similar level of ex-posure (243-278 mR).9

While it is preferable to discuss human dosimetry inradiation-absorbed dose (rad), the conversion factorfrom roentgen (a unit of exposure) to rad is basedprimarily on size, location and mass density of varioustissues, derived from phantom studies. Such studieshave not been reported in children of various ages andsizes. Because of the wide range of patient size in ourseries and the likelihood of introducing error using asingle roentgen-to-rad conversion factor, our dosim-etry data are reported in roentgens.Our results indicate a very low radiation exposure

to patients' eye region; the level found is consistentwith the forehead exposure to the physician found byWold et al.16 and is probably- related to scatter. Theaverage gonadal dose we found, 11 mR (equivalent toless than one-half of the exposure to the chest from achest roentgenogram), is reassuring, especially con-sidering the work of Adams et al.4 The application ofcommercially available gonadal shields would be oflittle use in cardiac catheterization because the radia-tion source is posterior and the device is appliedanteriorly.Our data indicate an average exposure of 431 mR to

the thyroid region. Gustaffson and Mortensson" feltthat absorbed dose to the thyroid comes almost ex-clusively from scattered radiation. Martin and Olsonstated that thyroid exposure is directly related to the

degree of collimation, at least during serial radiog-raphy.'3 We believe that both scatter and collimationare significant factors. Collimation close to the heartis critical to prevent directing the primary beam on in-cidental structures, e.g., the thyroid. However, insmall infants, it may be difficult to "cone" the field soas to completely avoid thyroid exposure and stillvisualize the aortic arch.

Childhood irradiation of the thyroid gland has beenassociated with the induction of thyroid tumors andhypothyroidism.2' 16-18 In thyroid carcinoma, tumorincidence is proportional to thyroidal dose.'7 A latentperiod of longer than 40 years has been found betweenirradiation and clinical presentation."' It is difficult tocompare our thyroid dosage with head-and-neckradiation given to children in the 1950s because theearly dosage data were estimated rather than meas-ured, and the 1950s exposure was repetitive, whereascardiac catheterization is a single-dose event. The dataof Beach and Dolphin'8 and Silverman and Hoffman2citing doses of 6-1225 rads is several orders ofmagnitude different from our measured thyroid ex-posure of 431 mR. However, both from recent'6 andearly reports, children are clearly more radiosensitivethan adults. The optimal dose is the lowest possibledose that produces complete, clinically relevant infor-mation.

While some abdominal structures are not highlyradiosensitive, the gastrointestinal tract may bedamaged by ionizing radiation. The abdominal ex-posure found during cardiac catheterization is highenough (average 150 mR) to merit efforts at reduc-tion. Placement of a lead shield (0.5 mm or thicker)under the buttocks should be standard; the shieldshould be positioned so that its most cephalad edge isjust below the level of the diaphragm.

Radiosensitivity is proportional to cell reproduc-tion rate and thus, the hematopoetic bone marrowareas are highly radiosensitive. In a 1974 study,Seidlitz and Margulis'9 estimated x-ray dosimetry tothe vertebral bone marrow based on measured skin en-trance dose and phantom experiments to correlate en-trance dose with intravertebral exposure. Althoughthe internal mass relationships found in the adulthuman differ significantly from those in the child, wehave applied our skin entrance dosimetry to the for-mula developed by Seidlitz to calculate an averageabdominal vertebral bone marrow exposure of40.5 ± 20.4 mR during the complete cardiac catheter-ization. Dose to the thoracic vertebral bone marrow asan average of 460 ± 267 mR for the complete cardiaccatheterization study. Until long-term (20-40 years)studies indicate the absence of increased incidence ofleukemia in patients who had cardiac catheterizationsin childhood, continued vigilance and periodic check-ups must be applied.The target organ of cardiac catheterization is, of

course, the heart. The resultant x-ray dosage to thechest is large, an average of 7.4 R, expressed as thedifference between entrance and exit exposures. (If

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one considers only the entrance readings, the meanchest exposure was 8.1 R.) There is no accepted limitfor maximum diagnostic radiation dosage to thethorax. The guidelines for maximum radiation to thewhole body ("occupational dose") for those under 18years of age limit the yearly exposure to 500 mrem."Certainly, occupational repetitive incremental ex-posure is physiologically different from single-eventirradiation. Nonetheless, it is of concern that anaverage pediatric cardiac catheterization produces anabsorbed thoracic x-ray dosage 14.8 times the yearlyallowable whole body occupational dosage.Damage to thoracic organs has been well

documented after therapeutic levels of radiation, in-cluding cardiac inflammation,21-2' constrictive peri-carditis28 and myocardial fibrosis.25 Though thera-peutic dosage is in rads and diagnostic exposureis usually in mrads, a single average pediatric cardiaccatheterization produces an absorbed thoracic dosageof 7.4 rads (fig. 1). Many children require multiplecardiac catheterizations, with resulting accumulationof radiation effects,24 and subclinical damage maybecome evident only after years or decades.17' 18 Inview of the potentially longer life span of children, itseems imperative to perform long-term, follow-upstudies of patients who have had cardiac catheteriza-tions in childhood.

Clinical ImplicationsThe regression equation based on our data cor-

relates well with the observed chest dosage in ourlaboratory. However, it is unlikely that the same for-mula would yield reliable predictions in otherlaboratories, owing to differences in radiographicsystems, geometry, table composition and filtration.We believe that the same factors (fluoroscopy timeand body surface area) are likely to be the relevantvariables. To have a useful regression equation, eachlaboratory must generate its own exposure data andanalysis.

Radiation exposure can be decreased during stan-dard catheterization procedure in many ways. (1)Field size during catheter manipulation should be verysmall. (2) Real-time echocardiographic visualizationof size and location of cardiac structures provides im-portant precatheterization information especially incomplex malformations, which may shorten cathetermanipulation time and thus indirectly decrease radia-tion exposure. (3) Angiography is usually performedafter completion of all hemodynamic studies due tothe large osmotic load and toxic effects of contrastagents. However, in extremely complex anomalies,even with preparatory echocardiographic studies, un-certainty regarding anatomy or blood flow patternsmay lengthen the procedure and increase the risk. Insuch cases, consideration may be given to an initialangiogram before extensive catheter probing/manipulation. (4) Though radiation exposure of theabdomnen and gonads during cardiac catheterization islow, a large-plate abdominal/gonadal shield mayfurther decrease exposure. (5) In small children, fre-quently it is not possible to narrow the field to exclubde

the thyroid area and still visualize the aortic archstructures. A small, malleable lead shield should beplaced between the primary beam and the neck toprotect selectively the lower nuchal region. (6) Thoughbiplane filming provides more information thansingle-plane mode, there are occasions in which onlyone plane is of interest, e.g., the four-chamber view ofthe atrial septum. In such situations, single-plane film-ing may be used to decrease radiation. (7) Thecustomary filming speed of 60 frames/sec generallyprovides excellent line resolution and detail. How-ever, in some situations, e.g., spot cines for cathetercourse, left superior vena cava injection for visualiza-tion of the brachiocephalic anastomosis, slower rates(15 or 30 frames/sec) allow reduction in radiationwithout loss of crucial data.

Alternatives to current practice might also be con-sidered to reduce radiation exposure. Low-pulse-ratefluoroscopy26' 27 should be operationally and dose-tested in children; if an appreciable decrease in ex-posure is achieved, the system should be recom-mended for all pediatric catheterization laboratories.Selective chamber/great artery contrast echocardiog-raphy can provide considerable information formerlyavailable only by angiography. This is especially truewhen using two-dimensional echocardiographic equip-ment. Increasing utilization of this technique shoulddecrease the numnber of angiograms and volume of dyeadministered.

Long-term follow-up studies decades after cardiaccatheterization in childhood will provide a morerealistic appraisal of the possible dangers of catheter-ization-related x-ray exposure.

Potentially hazardous tests are often performed(i.e., cardiac catheterization) when the disease processposes a greater danger to the patient than the test. Theneed for cardiac catheterization usually indicates thepossibility of surgical intervention. Thus, the childwith heart disease is at risk from the heart defect aswell as the surgery that may be required. Erroneous orincomplete diagnosis poses a much greater danger tothe patient than any potential hazard from catheter-ization-related irradiation. Thus, while radiation ex-posure should be minimized, this must not be done atthe expense of diagnostic accuracy.

AcknowledgmentOur gratitude is expressed to Drs. George Kaplan, Sidney C.

Smnith, Jr., Kenneth Miller and to George Cowman and CharlesKoch for support and encouragement in this project.

AddendumAfter acceptance of this paper, a low-pulse rate fluoroscopy

system using a video-disc memory (VAS) was installed and inter-faced with the Phillips radiographic system. Flicker rate was main-tained at 10 pulses/second. The effect on absorbed thoracic radia-tion during fluoroscopy was assessed in 12 consecutive childrenduring cardiac catheterization and the results in these children werecompared with those in the original study group. The original (con-tinuous fluoroscopy) and the new (pulsed fluoroscopy) study groupsare comparable in age, body surface area and fluoroscopy time(table Al). An 88% reduction in absorbed thoracic radiation wasachieved with use of pulsed fluoroscopy.

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TABLE Al. Effect of Pulsed Fluoroscopy on Absorbed Chest Dose

Mean Mean absorbedMean fluoroscopy chest dose

n Mean age BSA (M2) time (min) (mR)

Continuous fluoroscopy 30 4 y 2 m 0.58 15.8 5810Pulsed fluoroscopy 12 4 y 7m 0.66 15.2 705

Abbreviations: BSA = body surface area; y = years; m = months.

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2. Silverman C, Hoffman DA: Thyroid tumor risk from radiationduring childhood. Prev Med 4: 100, 1975

3. Report of Cardiac Centers, 1976-1977; California State Deptof Health Services, Sacramento, September 1978

4. Adams FH, Norman A, Bass D, Oku G: Chromosome damagein infants and children after cardiac catheterization and angiog-raphy. Pediatrics 62: 312, 1978

5. Callisen HH, Norman A, Adams FH: Absorbed dose in thepresence of contrast agents during pediatric cardiac catheter-ization. Med Phys 6: 504, 1979

6. Gough JH, David R, Stacey AJ: Radiation doses delivered tothe skin, bone marrow and gonads of patients during cardiaccatheterization and angiography. Br J Radiol 41: 508, 1968

7. Ardran GM, Hamill J, Emrys-Roberts E, Oliver E: Radiationdose to the patient in cardiac radiology. Br J Radiol 43: 391,1970

8. Malsky SJ, Haft J, Hoyt D, Gould L, Bratt C, Simon DF,Roswit B: Radiation exposure to staff cardiologist vs seniorresident cardiologist and patients during cardiac catheteriza-tion. Radiat Data Rep 387, 1972

9. Rueter FG: Physician and patient exposure during cardiaccatheterization. Circulation 58: 134, 1978

10. Kaude J, Svahn G: Absorbed gonad and integral doses to thepatient and personnel from angiographic procedures. ActaRadiol 15: 454, 1974

11. Amiel M, Clermont A, Jocteur-Monrozier D, Moroni JP, BrunP: £tude-dosimetrique au cours de l'angiographic cardiaquechez le jeune enfant. Ann Radiol 19: 623, 1976

12. Langmeed WA, Wall BF, Palmer KE: An assessment oflithium borate thermoluminescent dosimeters for the measure-ment of doses to patients in diagnostic radiology. Br J Radiol49: 956, 1976

13. Martin EC, Olson A: Radiation exposure to the pediatricpatient from cardiac catheterization and angiography. Br JRadiol 53: 100, 1980

14. Gustaffson M, Mortensson W: Irradiation to the thyroid glandat cardiac catheterization and angiocardiography in children.Br J Radiol 49: 686, 1976

15. Wold GJ, Scheele RV, Agarwal SK: Evaluation of physicianexposure during cardiac catheterization. Radiology 99: 188,1971

16. Maxon HR, Thomas SR, Saenger EL, Buncher CR, KereiakesJG: Ionizing irradiation and the induction of clinically signifi-cant disease in the human thyroid gland. Am J Med 63: 967,1977

17. Hempelmann LH, Hall WJ, Phillips M, Cooper RA, AmesWR: Neoplasms in persons treated with x-rays in infancy:fourth survey in twenty years. J Nat Cancer Inst 55: 519, 1975

18. Beach SA, Dolphin GW: A study of the relationship betweenx-ray dose delivered to the thyroid of children and the subse-quent development of malignant tumors. Phys Med Biol 6: 583,1961

19. Seidlitz L, Margulis AR: Doses to the vertebral marrow duringcommon x-ray examination in clinical situations. Invest Radiol9: 419, 1974

20. Title 17, California Administrative Code; chapter 5, sub-chapter 4; #30265-a

21. Stewart JR, Cohn KE, Fajardo LF, Hancock EW, Kaplan HS:Radiation-induced heart disease. Radiol 89: 302, 1967

22. Rubin E, Camara J, Grayzel DM, Zak FG: Radiation-inducedcardiac fibrosis. Am J Med 34: 71, 1963

23. Greenwood RD, Rosenthal A, Cassady R, Jaffe N, Nadas AS:Constrictive pericarditis in childhood due to mediastinalirradiation. Circulation 50: 1033, 1974

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25. Fajardo LF, Stewart JR: Capillary injury preceding radiation-induced myocardial fibrosis. Radiology 101: 429, 1971

26. Grollman JH: Radiation reduction by means of low pulse-ratefluoroscopy during cardiac catheterization and coronaryarteriography. Am J Roentgen Rad Ther Nucl Med 121: 636,1974

27. Dorph S, Mygind T, Northeved A, Okholm B, Petersen KO,Oigaard A: A dose-reducing fluoroscopy system: dose meas-urements and clinical evaluation. Radiol 97: 399, 1970

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J D Waldman, P S Rummerfield, E A Gilpin and S E KirkpatrickRadiation exposure to the child during cardiac catheterization.

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radiation exposure to during cardiac...

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