Radioprotection for Interventional Echocardiographers: A Consensus Statement of the Italian Society of Echocardiography and Cardiovascular Imaging

The interventional echocardiographer (IE) plays a crucial role in structural heart interventions, yet faces significant risks from ionizing radiation, often greater than those encountered by the primary interventional cardiologist (IC). This elevated exposure is due to the IE's close proximity to the patient's head and, consequently, to the X-ray source, combined with a general lack of dedicated protective equipment designed for their position. Despite growing awareness of radiation safety in the catheterization lab, the specific protection needs of IEs remain under-recognized. Recent studies have shown that IEs can receive up to 11 times more radiation than ICs during procedures guided by transesophageal echocardiography (TEE), such as transcatheter edge-to-edge repair or left atrial appendage closure. These findings, together with the recent reduction in recommended dose thresholds for deterministic effects like cataract formation, emphasize the urgent need to implement effective protective measures. Radiation exposure can be significantly reduced by following the core principles of radiation safety: time, distance, and shielding. Key strategies include optimizing the IE's position based on expected fluoroscopic projections, using dedicated mobile or ceiling-mounted shields, adopting lightweight personal protective equipment, and encouraging the use of low-dose imaging protocols. Ongoing education and training, targeted not only at IEs but also at ICs, is essential to reinforce safe practices and promote a culture of radiation awareness. Technological innovations offer promising solutions. New shielding systems like the Eggnest® and Rampart^® have demonstrated effective protection for staff near the patient's head. Disposable radiation-reducing drapes and the development of robotic systems for remote TEE manipulation may further enhance safety without compromising workflow or image quality. Advances in imaging hardware and software also support dose reduction without sacrificing clinical effectiveness. Finally, computational dosimetry methods may soon allow for more accurate and individualized exposure monitoring, overcoming the limitations of conventional dosimeters. In summary, improving radiation protection for IE must become a priority. A combination of strategies is necessary to ensure long-term safety and sustainability in this rapidly evolving field.