Occupational radiation exposure can also be reduced by the use of a bismuth-containing, sterile disposable shield. When positioned just caudal and lateral to the intended device pocket region, these radiation-absorbing shields can decrease absorbed radiation to the operator by up to 80%.8 Widespread use of this device may be hampered by cost considerations.
Recent data suggest that radiation (some from scatter) to the brain (particularly the left side of the brain for right-sided implant procedures and vice versa) may be detrimental. Head caps of flexible barium sulfate and bismuth oxide strips, constructed with lightweight cloth, can attenuate radiation to the brain equivalent to a lead that is 0.5 mm thick.9 Full radiation protection cabins have been shown to reduce exposure to the operator by over 90%, without increasing procedure time or complication rates.10 Despite this finding, they remain costly and somewhat cumbersome, limiting their overall use. Standing behind another individual in closer proximity to the radiation field may offer no protection. Instead, perhaps through scatter and more favorable positioning of protective devices toward the primary operator, radiation exposure may actually be higher for a second operator.11 This has important implications for those in a position of instruction and emphasizes the need for optimal use of shielding protective for both the primary and secondary operators.
Bismuth radiation pads used to reduce x-radiation exposure to a patient’s breasts and eyes for computed tomography scans have been proposed and are controversial but to date have not been used for cardiac implantable electronic device (CIED) implantation.
Careful use of fluoroscopy can reduce the amount needed and not affect the ability to perform the implantation and not adversely affect the safety to the patient. Experienced implanters can routinely implant single- and dual-chamber pacemakers and implantable defibrillators with less than 1 to 2 minutes of fluoroscopy, and in some cases only a few seconds. Table 5.3 provides recommendations for CIED implantation to reduce radiation exposure.