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Acute radiodermatitis after radiofrequency catheter ablation
Acute radiodermatitis after radiofrequency catheter ablation George T. Nahass, M D St. Louis, Missouri Radiofrequency (RF) catheter ablation is used in the treatment of a variety of arrhthymias. This report describes the development of acute radiodermatitis after two prolonged RF catheter ablation procedures for supraventricular tachycardia. It also reviews the characteristics and treatment of radiation-induced skin reactions. (J Am Acad Dermatol 1997;36:881-4.) Radiofrequency (RF) catheter ablation is used to treat a variety o f cardiac arrhythmias. 1-8 This technique involves the transvenous passage o f a cardiac catheter under fluoroscopic guidance to specific locations within the heart. RF electrical energy (100 K H z Io 1.5MHz) is then delivered from the specialized catheter tip to a cutaneous dispersion pad on the thorax. The risks o f RF catheter ablation include cardiac perforation, vascular injury, valvular damage, thromboembolization, and interruption o f normal atrioventricular conduction. 2, 4, 5, 8 A potential noncardiovascular risk to both patients and personnel is radiation exposure from the fluoroscopic imaging required to guide catheter manipulation. The lifetime risk o f a fatal malignancy or a genetic defect from an hour of fluoroscopic imaging has been estimated to be 0.1% and 20 per 1 million biV_hs, respectively. 9 This report describes the development of acute radiodermatitis after RF catheter ablation and reviews the features o f fluoroscopy and how the potential complications o f radiodermatitis could be minimized.
CASE REPORTS Case 1 A patient with a supraventricular tachycardia underwent RF catheter ablation. The procedure was technically difficult and lasted several hours. One hundred and ninety
From the Department of Dermatology, St. Louis University Health Sciences Center. Reprint requests: George T. Nahass, MD, Department of Dermatology, St. Louis University Health Sciences Center, 1402 S. Grand Blvd. St. Louis, MO 63104. Copyright © 1997 by the American Academy of Dermatology, Inc. 0190-9622/97/$5.00 + 0 16/4/80727
cumulative minutes of fluoroscopic imaging time using a continuous fluoroscopic system with automatic brightness control (manufactured by General Electric) was required. Throughout the study a cutaneous electrical dispersion pad was kept on the left lower back, and defibrillator pads were placed on the anterior and posterior thorax.
Several days after the procedure an asymptomatic discoloration developed on the left upper back. During the next several weeks, the area became painfid and began to drain. Examination revealed a 7 x 14 cm tender erythematous rectangular plaque on the left upper back (Fig. 1). Several irregular ulcers were present within the plaque. A biopsy specimen showed hyperkeratosis, hypergranulosis, an occasional necrotic keratinocyte, and a sparse infiltrate of inflammatory cells within the dermis (Fig. 2). The patient was treated with silver sulfadiazine 1% cream and sterile dressings twice daily. There was gradual lessening of the tenderness with reepithelialization in 3 weeks leaving a mottled, slightly depressed plaque (Fig. 3).
Case 2 A patient with syncope and a supraventricular tachycardia underwent RF catheter ablation. The procedure was technically difficult and required 190 minutes of fluoroscopy time. Localized pruritus of the left upper back developed several days later. The skin in this area became red and peeled during the next several weeks. Approximately 3 weeks after the procedure, examination revealed a 9 x 17 cm rectangular pink plaque on the left upper back. The surface was covered with fine superflcial scale, but no ulcers or erosions were noted. The patient was treated with mupirocin ointment with sterile dressing changes twice daily. There was lessening of the erythema and scaling during the next 2 weeks. Five months after the procedure there was an asymptomatic faintly hyperpigmented patch remaining.
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Journal of the American Academy of Dermatology May 1997
Fig. 1. Inflammatory plaque with several irregular ulcers on left upper back, 7 weeks after radiofrequency catheter ablation. There is hyperpigmentation at periphery of plaque. White areas represent reepithelialization. Lesion is typical of second-degree acute radiation reaction.
Fig. 2. Biopsy specimen showing hyperkeratosis and hypergranulosis, consistent with healing phase of acute radiodermatitis. (Hematoxylin-eosin stain; original magnification x200).
DISCUSSION
Cardiovascular complications associated with catheter ablation techniques are the most common. Cutaneous side effects have been reported infrequently. Hematomas from vascular injury 1° and a mild chest wall burn at the ground patch site s have been described. Recently, radiation-induced skin injuries from
prolonged fluoroscopic exposure during interventional cardiac procedures have been reported. TM12 Inflammation of the skin, adnexal structures, and subcutaneous tissues after radiation exposure are features of radiodermatitis. 13 Acute radiodermatitis is characterized by erythema, epilation, moist desquamarion, and dermal necrosis in severe cases. These reactions generally begin 7 to 14 days after exposure
Journal of the American Academy of Dermatology Volume 36, Number 5, Part 2
Nahass
883
Fig. 3. Three weeks later. Marked improvement with almost complete reepithelialization leaving mottled hyper- and hypopigmented slightly depressed atrophic plaque.
T a b l e I. Fluoroscopy times for radiofrequency catheter ablation procedures Duration of fluoroscopy Study
(rain.)
Kuck1 and Schlute~3 Calkins et al.4 Lesh et al.5 Gursoy, Schluter, and Kuck6
22.8 __ 20.4 47 --- 33 66 _+ 8.9 43.4* 20.9"~ 53.7:) 23.4 44 +--40 50 -+ 31
Kay et al. 7 Calkins et al. 9 Lindsay et aL15
Range (rain)
1.6 to 148.2 5 to 150 5 to 180 NS NS 5 tO 150 >90 in 7%
NS, Not: stated.
*Accessory an-ioventticular connections. tLeft-sided pathways single catheter. :)Left-sided pathways multiple catheters.
and correspond to different doses of absorbed radiation. Specifically, the threshold doses for the development of erythema, permanent epilation, moist desquamation, and necrosis are 3 to 10, 7 to 10, 12 to 25 and 25 Gy, respectively. 14 Chronic radiodermatitis and squamous and basal cell carcinomas may develop months to years later. The presentation in the two cases described in this report indicate the cutaneous changes were secondary to ionizing radiation. The localization of the lesions to the left upper back correspond to the left anterior oblique projection, a view that is frequently used to verify catheter location during RF ablation procedures. 15
The dose of radiation obtained during RF catheter ablation depends on the duration of fluoroscopy, body site, and the type of fluoroscopic equipment. The amount of fluoroscopic imaging time required during the procedure can be quite variable (Table I). With more experience lengthy procedures have become much less common. 10 The amount of fluoroscopy time should be carefully logged for all procedures to help prevent excessive radiation exposure. 16 Radiation exposure also varies substantially by anatomic location during RF ablation procedures; the largest average radiation dose is given to the posterior ninth thoracic vertebral body. 9 Different regions of the skin also exhibit different degrees of
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Nahass
radiosensitivity. For example, the neck is the least radiosensitive; the chest, abdomen, thigh, back, and face are progressively m o r e sensitive. 17 Because the b a c k is particularly radiosensitive and receives the greatest amount of exposure during this procedure, every effort should b e taken to reduce fluoroscopy time and limit excessive exposure in one projection. Radiation exposure can also be significantly reduced for both patients and medical personnel through the use o f pulse fluoroscopic imaging systerns. H o l m e s et al.18 demonstrated a 37% reduction in radiation exposure for physicians with pulsed fluoroscopy c o m p a r e d with conventional systems. 18 Collimating the radiographic b e a m to the smallest field size necessary for each procedure also minimizes the radiation risk. 9 T h e treatment o f acute radiodermatitis is directed at stimulating w o u n d healing, treating infection, and alleviating discomfort. Occlusive dressings m a y speed healing and can reduce the pain associated with radiation-induced skin reactions. 19 Topical Nacetylcysteine 2° and sucralfate c r e a m 21 h a v e been reported to minimize the severity o f acute radiationinduced skin reactions w h e n applied during treatment. Because these agents are used prophylactically, they would have limited application after radiation overexposure has occurred. Because the signs o f acute radiodermatitis clear spontaneously, cases with mild s y m p t o m s m a y go unrecognized. Therefore, the true incidence o f this complication is unknown. Patients w h o h a v e been exposed to lengthy fluoroscopic procedures should be examined periodically because the long-term consequences o f radiation overexposure appear months to years later. Within the skirl, special attention should be directed at detecting squamous and basal cell carcinomas. Because the left and right anterior oblique projections are used m o s t frequently in R F catheter ablation procedures, the left and right upper b a c k would theoretically be at greatest risk. REFERENCES 1. Langberg JL, Chin MC, Rosenqvist M, et al. Catheter ablation of the atrioventricular junction with radiofrequency energy. Circulation 1989;80:1527-35. 2. Jackman WM, Wang X, Friday KJ, et al. Catheter ablation of accessory atrioventricular pathways 0Nolff-ParkinsonWhite syndrome) by radiofrequency current. N Engl J Med 1991 ;324:1605-11.
Journal of the American Academy of Dermatology May 1997
3. Kuck KH, Schluter M. Single-catheter approach to radiofrequency current ablation of left-sided accessory pathways in patients with Wolff-Parkinson-White syndrome. Circulation 1991;84:2366-75. 4. Calkins H, Langberg J, Sousa J, et al. Radiofrequency catheter ablation of accessory atrioventricular connections in 250 patients abbreviated therapeutic approach to WolffParkinson-White syndrome. Circulation 1992;85:1337-46. 5. Lesh MD, Van Hare GF, Schamp DJ, et al. Curative percutaneous catheter ablation using radiofrequency energy for accessory pathways in all locations: results in 100 consecutive patients. J Am Coil Cardiol 1992;19:1303-9. 6. Gursoy S, Schluter M, Kuck KH. Radiofrequency current catheter ablation for control of supraventricular arrhythrajas. J Cardiovasc Electrophysiol 1993;4:194-205. 7. Kay GN, Epstein A.E, Dailey SM, et al. Role of radiofrequency ablation in the management of supraventricular arrhythmias. J Cardiovasc Electrophysiol 1993;4:371-89. 8. Van Hare GF, Witherell CL, Lesh MD. Follow-up of radiofrequency catheter ablation in children: results in 100 consecutive patients. J Am Coll Cardiol 1994;23: 1651-9. 9. Calkins H, Niklason L, Sousa J, et al. Radiation exposure during radiofrequency catheter ablation of accessory atrioventricular connections. Circulation 1991;84:2376-82. 10. Scheinman MM. Radiofrequency catheter ablation for patients with supraventricular tachycardia. PACE Pacing Clin Electrophysiol 1993;16:671-9. 11. Radiation-induced skin injuries from fluoroscopy. FDA Med Bull 1994;24:6. 12. Lichenstein DA, Klapholz L, Vardy DA, et al. Chronic radiodermatitis following cardiac catheterization. Arch Dermatol 1996;132:663-7. 13. Goldschmidt H, Sherwin WK. Reactions to ionizing radiation. J Am Acad Dermatol 1980;3:551-79. 14. Nenot JC. Medical and surgical management for localized radiation injuries, hat J Radiat Biol 1990;57:783-95. 15. Lindsay BD, Eichling JO, Ambos HD, et al. Radiation exposure to patients and medical personnel during radiofrequency catheter ablation for supraventricular tachycardias. Am J Cardiol 1992;70:218-23. 16. Fisher JD, Cain ME, Ferdinand KC, et al. ACC position statement. Catheter ablation for cardiac arrhythmSas: clinical applications, personnel, and facilities. J Am Coll Cardiol 1994;24:828-33. 17. Grosch DS, Hopwood LE. Biological effects of radiations, second edition. New York: Academic Press, 1979:191-5. 18. Holmes DR, Wondrow MA, Gray JE, et al. Effect of pulsed progressive fluoroscopy on reduction of radiation dose in the cardiac catheterization laboratory. J Am Coll Cardiol 1990;15:159-62. 19. Shell JA, Stanntz F, Grimm J. Comparison of moisture vapor permeable di~essings to conventional dressings for management of radiation skin reactions. Oncol Nurs Forum 1986;13:11-6. 20. Kim JA, Baker DG, Hahn SS, et al. Topical N-acetylcysteine for reduction of skin reaction to radiation therapy. Semin Oncol 1983;10:86-8. 21. Maiche A, Isokangas OP, Grohrl P. Skin protection by sucralfate cream during electron beam therapy. Acta Oncologica 1994;33:201-3.
CASE REPORTS Case 1 A patient with a supraventricular tachycardia underwent RF catheter ablation. The procedure was technically difficult and lasted several hours. One hundred and ninety
From the Department of Dermatology, St. Louis University Health Sciences Center. Reprint requests: George T. Nahass, MD, Department of Dermatology, St. Louis University Health Sciences Center, 1402 S. Grand Blvd. St. Louis, MO 63104. Copyright © 1997 by the American Academy of Dermatology, Inc. 0190-9622/97/$5.00 + 0 16/4/80727
cumulative minutes of fluoroscopic imaging time using a continuous fluoroscopic system with automatic brightness control (manufactured by General Electric) was required. Throughout the study a cutaneous electrical dispersion pad was kept on the left lower back, and defibrillator pads were placed on the anterior and posterior thorax.
Several days after the procedure an asymptomatic discoloration developed on the left upper back. During the next several weeks, the area became painfid and began to drain. Examination revealed a 7 x 14 cm tender erythematous rectangular plaque on the left upper back (Fig. 1). Several irregular ulcers were present within the plaque. A biopsy specimen showed hyperkeratosis, hypergranulosis, an occasional necrotic keratinocyte, and a sparse infiltrate of inflammatory cells within the dermis (Fig. 2). The patient was treated with silver sulfadiazine 1% cream and sterile dressings twice daily. There was gradual lessening of the tenderness with reepithelialization in 3 weeks leaving a mottled, slightly depressed plaque (Fig. 3).
Case 2 A patient with syncope and a supraventricular tachycardia underwent RF catheter ablation. The procedure was technically difficult and required 190 minutes of fluoroscopy time. Localized pruritus of the left upper back developed several days later. The skin in this area became red and peeled during the next several weeks. Approximately 3 weeks after the procedure, examination revealed a 9 x 17 cm rectangular pink plaque on the left upper back. The surface was covered with fine superflcial scale, but no ulcers or erosions were noted. The patient was treated with mupirocin ointment with sterile dressing changes twice daily. There was lessening of the erythema and scaling during the next 2 weeks. Five months after the procedure there was an asymptomatic faintly hyperpigmented patch remaining.
881
882
Nahass
Journal of the American Academy of Dermatology May 1997
Fig. 1. Inflammatory plaque with several irregular ulcers on left upper back, 7 weeks after radiofrequency catheter ablation. There is hyperpigmentation at periphery of plaque. White areas represent reepithelialization. Lesion is typical of second-degree acute radiation reaction.
Fig. 2. Biopsy specimen showing hyperkeratosis and hypergranulosis, consistent with healing phase of acute radiodermatitis. (Hematoxylin-eosin stain; original magnification x200).
DISCUSSION
Cardiovascular complications associated with catheter ablation techniques are the most common. Cutaneous side effects have been reported infrequently. Hematomas from vascular injury 1° and a mild chest wall burn at the ground patch site s have been described. Recently, radiation-induced skin injuries from
prolonged fluoroscopic exposure during interventional cardiac procedures have been reported. TM12 Inflammation of the skin, adnexal structures, and subcutaneous tissues after radiation exposure are features of radiodermatitis. 13 Acute radiodermatitis is characterized by erythema, epilation, moist desquamarion, and dermal necrosis in severe cases. These reactions generally begin 7 to 14 days after exposure
Journal of the American Academy of Dermatology Volume 36, Number 5, Part 2
Nahass
883
Fig. 3. Three weeks later. Marked improvement with almost complete reepithelialization leaving mottled hyper- and hypopigmented slightly depressed atrophic plaque.
T a b l e I. Fluoroscopy times for radiofrequency catheter ablation procedures Duration of fluoroscopy Study
(rain.)
Kuck1 and Schlute~3 Calkins et al.4 Lesh et al.5 Gursoy, Schluter, and Kuck6
22.8 __ 20.4 47 --- 33 66 _+ 8.9 43.4* 20.9"~ 53.7:) 23.4 44 +--40 50 -+ 31
Kay et al. 7 Calkins et al. 9 Lindsay et aL15
Range (rain)
1.6 to 148.2 5 to 150 5 to 180 NS NS 5 tO 150 >90 in 7%
NS, Not: stated.
*Accessory an-ioventticular connections. tLeft-sided pathways single catheter. :)Left-sided pathways multiple catheters.
and correspond to different doses of absorbed radiation. Specifically, the threshold doses for the development of erythema, permanent epilation, moist desquamation, and necrosis are 3 to 10, 7 to 10, 12 to 25 and 25 Gy, respectively. 14 Chronic radiodermatitis and squamous and basal cell carcinomas may develop months to years later. The presentation in the two cases described in this report indicate the cutaneous changes were secondary to ionizing radiation. The localization of the lesions to the left upper back correspond to the left anterior oblique projection, a view that is frequently used to verify catheter location during RF ablation procedures. 15
The dose of radiation obtained during RF catheter ablation depends on the duration of fluoroscopy, body site, and the type of fluoroscopic equipment. The amount of fluoroscopic imaging time required during the procedure can be quite variable (Table I). With more experience lengthy procedures have become much less common. 10 The amount of fluoroscopy time should be carefully logged for all procedures to help prevent excessive radiation exposure. 16 Radiation exposure also varies substantially by anatomic location during RF ablation procedures; the largest average radiation dose is given to the posterior ninth thoracic vertebral body. 9 Different regions of the skin also exhibit different degrees of
884
Nahass
radiosensitivity. For example, the neck is the least radiosensitive; the chest, abdomen, thigh, back, and face are progressively m o r e sensitive. 17 Because the b a c k is particularly radiosensitive and receives the greatest amount of exposure during this procedure, every effort should b e taken to reduce fluoroscopy time and limit excessive exposure in one projection. Radiation exposure can also be significantly reduced for both patients and medical personnel through the use o f pulse fluoroscopic imaging systerns. H o l m e s et al.18 demonstrated a 37% reduction in radiation exposure for physicians with pulsed fluoroscopy c o m p a r e d with conventional systems. 18 Collimating the radiographic b e a m to the smallest field size necessary for each procedure also minimizes the radiation risk. 9 T h e treatment o f acute radiodermatitis is directed at stimulating w o u n d healing, treating infection, and alleviating discomfort. Occlusive dressings m a y speed healing and can reduce the pain associated with radiation-induced skin reactions. 19 Topical Nacetylcysteine 2° and sucralfate c r e a m 21 h a v e been reported to minimize the severity o f acute radiationinduced skin reactions w h e n applied during treatment. Because these agents are used prophylactically, they would have limited application after radiation overexposure has occurred. Because the signs o f acute radiodermatitis clear spontaneously, cases with mild s y m p t o m s m a y go unrecognized. Therefore, the true incidence o f this complication is unknown. Patients w h o h a v e been exposed to lengthy fluoroscopic procedures should be examined periodically because the long-term consequences o f radiation overexposure appear months to years later. Within the skirl, special attention should be directed at detecting squamous and basal cell carcinomas. Because the left and right anterior oblique projections are used m o s t frequently in R F catheter ablation procedures, the left and right upper b a c k would theoretically be at greatest risk. REFERENCES 1. Langberg JL, Chin MC, Rosenqvist M, et al. Catheter ablation of the atrioventricular junction with radiofrequency energy. Circulation 1989;80:1527-35. 2. Jackman WM, Wang X, Friday KJ, et al. Catheter ablation of accessory atrioventricular pathways 0Nolff-ParkinsonWhite syndrome) by radiofrequency current. N Engl J Med 1991 ;324:1605-11.
Journal of the American Academy of Dermatology May 1997
3. Kuck KH, Schluter M. Single-catheter approach to radiofrequency current ablation of left-sided accessory pathways in patients with Wolff-Parkinson-White syndrome. Circulation 1991;84:2366-75. 4. Calkins H, Langberg J, Sousa J, et al. Radiofrequency catheter ablation of accessory atrioventricular connections in 250 patients abbreviated therapeutic approach to WolffParkinson-White syndrome. Circulation 1992;85:1337-46. 5. Lesh MD, Van Hare GF, Schamp DJ, et al. Curative percutaneous catheter ablation using radiofrequency energy for accessory pathways in all locations: results in 100 consecutive patients. J Am Coil Cardiol 1992;19:1303-9. 6. Gursoy S, Schluter M, Kuck KH. Radiofrequency current catheter ablation for control of supraventricular arrhythrajas. J Cardiovasc Electrophysiol 1993;4:194-205. 7. Kay GN, Epstein A.E, Dailey SM, et al. Role of radiofrequency ablation in the management of supraventricular arrhythmias. J Cardiovasc Electrophysiol 1993;4:371-89. 8. Van Hare GF, Witherell CL, Lesh MD. Follow-up of radiofrequency catheter ablation in children: results in 100 consecutive patients. J Am Coll Cardiol 1994;23: 1651-9. 9. Calkins H, Niklason L, Sousa J, et al. Radiation exposure during radiofrequency catheter ablation of accessory atrioventricular connections. Circulation 1991;84:2376-82. 10. Scheinman MM. Radiofrequency catheter ablation for patients with supraventricular tachycardia. PACE Pacing Clin Electrophysiol 1993;16:671-9. 11. Radiation-induced skin injuries from fluoroscopy. FDA Med Bull 1994;24:6. 12. Lichenstein DA, Klapholz L, Vardy DA, et al. Chronic radiodermatitis following cardiac catheterization. Arch Dermatol 1996;132:663-7. 13. Goldschmidt H, Sherwin WK. Reactions to ionizing radiation. J Am Acad Dermatol 1980;3:551-79. 14. Nenot JC. Medical and surgical management for localized radiation injuries, hat J Radiat Biol 1990;57:783-95. 15. Lindsay BD, Eichling JO, Ambos HD, et al. Radiation exposure to patients and medical personnel during radiofrequency catheter ablation for supraventricular tachycardias. Am J Cardiol 1992;70:218-23. 16. Fisher JD, Cain ME, Ferdinand KC, et al. ACC position statement. Catheter ablation for cardiac arrhythmSas: clinical applications, personnel, and facilities. J Am Coll Cardiol 1994;24:828-33. 17. Grosch DS, Hopwood LE. Biological effects of radiations, second edition. New York: Academic Press, 1979:191-5. 18. Holmes DR, Wondrow MA, Gray JE, et al. Effect of pulsed progressive fluoroscopy on reduction of radiation dose in the cardiac catheterization laboratory. J Am Coll Cardiol 1990;15:159-62. 19. Shell JA, Stanntz F, Grimm J. Comparison of moisture vapor permeable di~essings to conventional dressings for management of radiation skin reactions. Oncol Nurs Forum 1986;13:11-6. 20. Kim JA, Baker DG, Hahn SS, et al. Topical N-acetylcysteine for reduction of skin reaction to radiation therapy. Semin Oncol 1983;10:86-8. 21. Maiche A, Isokangas OP, Grohrl P. Skin protection by sucralfate cream during electron beam therapy. Acta Oncologica 1994;33:201-3.