Adult Congenital Heart Disease and Radiation Exposure: The Malignant Price of Cardiac Care

Article, see p 1334 Survival for patients with congenital heart disease (CHD) has improved dramatically over recent decades, and >85% of people born with a heart defect are now expected to survive to adulthood.1 Although surgical intervention has provided increasingly durable anatomic and physiological correction or repair, these interventions rarely achieve a cure. The subsequent clinical challenge involves careful consideration of the correct time to reintervene. Intervening too early exposes patients to unnecessary risks from procedural complications and is an unwarranted burden to the healthcare system. On the other hand, intervening too late poses the risk of irreversible ventricular impairment or recalcitrant arrhythmia. With so much at stake, a more intensive imaging follow-up has been an unsurprising correlate of progress. Imaging techniques involving ionizing radiation still account for a substantial proportion of these assessments and between 1990 and 2005 there was an almost 3-fold increase in the use of low-dose ionizing radiation (LDIR) procedures in patients with CHD.2 Technological advances in percutaneous structural intervention, usually under fluoroscopy guidance, have allowed patients to avoid redo surgery or, in some cases, to avoid any conventional surgical intervention whatsoever. As transcatheter technology and experience improve, the threshold for performing these procedures continues to fall, and coupled with the prevailing objective of ventricular preservation, intervention now takes place at progressively lower thresholds3,4 The “as low as reasonably achievable” principle for the use of ionizing radiation is by no means new, but it might be argued that we need to be reminded of its importance on a regular basis and in the context of the patient in front of us. Indeed, the success story of survivorship of patients with CHD demands better clarity of thought and justification of the use of radiation as concerns for subsequent malignancy increase.5 During …