A large-scale multicentre study of patient skin doses in interventional cardiology: dose-area product action levels and dose reference levels.

For 318 patients in 8 different Belgian hospitals, the entire skin-dose distribution was mapped using a grid of 70 thermoluminescence dosimeters per patient, allowing an accurate determination of the maximum skin dose (MSD). Dose-area product (DAP) values, exposure parameters and geometry, together with procedure, patient and cardiologist characteristics, were also registered. Procedures were divided into two groups: diagnostic procedures (coronary angiography) and therapeutic procedures (dilatation, stent, combined procedures (e.g. coronary angiography + dilatation + stent)). The mean value of the MSD was 0.310 Gy for diagnostic and 0.699 Gy for therapeutic procedures. The most critical projection for receiving the MSD is the LAO90 (left anterior oblique) geometry. In 3% of cases, the MSD exceeded the 2 Gy dose threshold for deterministic effects. Action levels in terms of DAP values as the basis for a strategy for follow-up of patients for deterministic radiation skin effects were derived from measured MSD and cumulative DAP values. Two DAP action levels are proposed. A first DAP action level of 125 Gy cm(2) corresponding to the dose threshold of 2 Gy would imply an optional radiopathological follow-up depending on the cardiologist's decision. A second DAP action level of 250 Gy cm(2) corresponding to the 3 Gy skin dose would imply a systematic follow-up. Dose reference levels - 71.3 Gy cm(2) for diagnostic and 106.0 Gy cm(2) for therapeutic procedures - were derived from the 75 percentile of the DAP distributions. As a conclusion, we propose that total DAP is registered in patient's record file, as it can serve to improve the follow-up of patients for radiation-induced skin injuries.

Torsades de pointes and aborted sudden death after implantation of a cardioverter defibrillator.

Recent publications have demonstrated that the implantable cardioverter defibrillator (ICD) improves survival in patients with ventricular tachycardia (VT) or fibrillation (VF) by reducing arrhythmic death. We report the case of a patient with a history of an old myocardial infarction and a left ventricular dysfunction, who presented four episodes of syncope associated with a hemodynamically not well tolerated sustained VT, who had easy inductible clinical VT during electrophysiologic study and required an ICD. After a follow-up of 2 months, the patient presents a complete AV block and multiple episodes of torsades de pointes that sometimes degenerate into VF. The ICD delivered 64 adequate and well-tolerated shocks during 10 hours before and during the hospital admission. We programmed a VVI pacing rate at 65 bpm and no more arrhythmia was observed. The left ventricular ejection fraction was not altered afterwards. In conclusion, we experienced the temporary efficacy of the ICD in the treatment of incessant torsades de pointes, without myocardial injury.

Cigarette smoking and chronic polyclonal B-cell lymphocytosis.

A syndrome associating a polyclonal increase of B-cells with binucleate lymphocytes in peripheral blood and a polyclonal increase of serum IgM, accompanied or not by splenomegaly and lymphadenopathy, has been reported in young to middle-aged women who are cigarette smokers. The majority of patients were HLA-DR7 positive and their clinical course remained stable over periods of years. We report four cases of this syndrome. In all patients, DNA analysis provided additional evidence that the lymphocytosis was polyclonal, while in one patient who met all other symptomatic criteria the total lymphocyte count was normal. This would suggest that unless careful attention is paid to the morphology of the lymphocytes, the syndrome may go undiagnosed.