Occupational radiation exposure remains one of the key hazards of interventional cardiology procedures. Despite recent advances in technology, including improved fluoroscopy systems and novel radiation protection devices, these hazards persist. Cumulative radiation exposure can lead to premature cataracts and malignancy among operators, while radiation protection aprons can result in orthopedic injuries, disability, and forced early retirement.1,2 These risks exacerbate an existing national physician shortage, ultimately impacting patient access to cardiovascular care. Solutions to date have largely focused on education and adoption of enhanced radiation protection devices (ERPDs); however, cost and workflow inefficiencies have limited their implementation.
In this issue of JSCAI, Madder et al3 offer a new perspective on radiation risk by evaluating the contribution of high-dose outlier cases to cumulative occupational radiation burden. In a single-center prospective study, they report findings from 363 coronary cases performed by 26 physicians, of which ∼1 in 4 included a right heart catheterization (RHC) and ∼1 in 3 included percutaneous coronary intervention (PCI). Radiation exposure was measured using real-time dosimetry, to which staff were blinded. The authors identify several important findings. First, the top 10% of cases based on radiation exposure accounted for ∼60% of cumulative radiation exposure, whereas the bottom 50% accounted for only 5% of exposure. Second, these findings were consistent across all members of the catheterization laboratory staff (coronary and structural interventional cardiologists, structural echocardiographers, nurses, and technologists). Third, predictors of outlier (top 10%) radiation exposure included ST-elevation myocardial infarction (STEMI), PCI, RHC, and male patients.
Traditionally, assessments of radiation exposure rely on average and median operator doses. This study challenges the status quo by suggesting that outlier exposures are a critical metric of overall radiation dose, given their disproportionate contribution to annual radiation exposure. To explore mechanisms for these findings, the authors found several predictors of outlier exposures. The strongest predictor—STEMI—may be counterintuitive at first glance. In contrast to procedures typically considered high radiation risk to patients, such as complex PCIs and chronic total occlusions, STEMI cases may, in fact, pose a disproportionate risk to operators for reasons beyond case complexity.
Given the emergency nature of STEMI cases, including the pressures of achieving door-to-balloon time goals, staff may be distracted from best practices for radiation safety and place themselves at higher risk than they may be aware. This underscores the need for real-time radiation dose monitoring for operators, which may diverge from the real-time radiation doses routinely tracked for patients. The second strongest predictor was PCI, which may be attributable to the increased length of these cases as well as the rare but higher risk of procedural complications that may hinder optimal radiation protection (eg, chest compressions). RHC was also found to be a predictor, with likely multifactorial etiologies. Ergonomic limitations during RHC that require accessing the internal jugular veins in close proximity to the radiation source can lead to high radiation despite the brevity of these procedures. Additionally, patients (eg, those with cardiogenic shock) undergoing RHC procedures may require higher acuity, such that staff may be more likely to neglect radiation safety while they focus on delivering timely, complex care. These predictors should serve as an alert to operators to remain vigilant in complex and time-pressure cases, even if the risk of radiation exposure to patients is low.
The focus on outlier cases comes at an opportune time. Recent advances in radiation protection have led to the development of a host of new ERPDs that enable substantial reductions in median operator dose while improving ergonomics by reducing the need for lead aprons.4 However, limitations to broad uptake include increased setup times that may impact use during emergent procedures, as well as practical limitations of certain device designs that limit full anatomic access. The fact that high-risk outlier case types map directly to ERPD limitations highlight future targets for industry advancements to support universal implementation.
The implications of this work stand to affect the field of interventional cardiology as a whole. As strong efforts continue to recruit and retain women in interventional cardiology, this study provides new opportunities to reduce radiation-related barriers to career entry that have been identified as particularly important deterrents for female trainees.5 Increasing our understanding of case types that pose the greatest risks can also provide pregnant operators and staff, as well as supervising attendings who oversee protections of all trainees, with actionable insights to stay within recommended radiation limits.
By reframing radiation risk, this study reveals important areas for further research. First, more detailed understanding of patient and case-level details as they relate to outliers will further elucidate mechanisms of findings. For example, although patient sex was identified as a predictor of outlier events, it is not clear whether this is due to confounding with increased use of PCI, case complexity, anatomic differences, body size impacting scatter radiation, or other causes. Analysis of variation in practices at the provider level may yield additional insights. This study did not incorporate use of ERDPs, for which real-world patterns of use may differ. Additional studies are needed to determine whether focusing protection on outlier cases, including risk stratification to guide use of limited ERDP resources, will effectively yield greater cumulative reductions than existing practices. Expanding findings beyond this single-center study will also support broad adoption of standardized practices, including integration of radiation dose analytics into hospital safety metrics and much-needed regulatory consistency across states.6
The hypothesis-generating findings from this study push us to consider radiation exposure from a new lens. With more research, future prediction of outlier cases may build upon an important new pillar of an evidence-guided framework to reduce occupational risk for all members of the cardiac catheterization laboratory (Figure 1).
Figure 1.
A new framework to guide interventions at the case, institutional, and systems levels to reduce radiation exposure and improve safety for all cardiac catheterization laboratory physicians and staff. PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction.
Declaration of competing interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Acknowledgments
Funding sources
This work was not supported by funding agencies in the public, commercial, or not-for-profit sectors.
References
- 1.Klein L.W., Goldstein J.A., Haines D., et al. SCAI multi-society position statement on occupational health hazards of the catheterization laboratory: shifting the paradigm for healthcare workers’ protection. J Am Coll Cardiol. 2020;75(14):1718–1724. doi: 10.1016/j.jacc.2020.02.015. [DOI] [PubMed] [Google Scholar]
- 2.Abudayyeh I., Dupont A.G., Hermiller J.B., et al. Occupational health hazards in the cardiac catheterization laboratory: results of the 2023 SCAI survey. J Soc Cardiovasc Angiogr Interv. 2025;4(4) doi: 10.1016/j.jscai.2024.102493. [DOI] [Google Scholar]
- 3.Madder R.D., Abiragi M., Madanat L., et al. Relative contribution of high-dose outliers to cumulative occupational radiation dose in the catheterization laboratory. J Soc Cardiovasc Angiogr Interv. 2026;5(1):104054. doi: 10.1016/j.jscai.2025.104054. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Lisko J.C., Shekiladze N., Chamoun J., et al. Radiation exposure using Rampart vs standard lead aprons and shields during invasive cardiovascular procedures. J Soc Cardiovasc Angiogr Interv. 2023;3(1) doi: 10.1016/j.jscai.2023.101184. [DOI] [Google Scholar]
- 5.Yong C.M., Abnousi F., Rzeszut A.K., et al. Sex differences in the pursuit of interventional cardiology as a subspecialty among cardiovascular fellows-in-training. JACC Cardiovasc Interv. 2019;12(3):219–228. doi: 10.1016/j.jcin.2018.09.036. [DOI] [PubMed] [Google Scholar]
- 6.Vora A.N., Hermiller J.B., Gupta R., et al. Variability in state-level regulations regarding occupational radiation exposure. J Soc Cardiovasc Angiogr Interv. 2025;4(6) doi: 10.1016/j.jscai.2025.103597. [DOI] [Google Scholar]