ALARA+: Summit on Radiation and Orthopedic Risks in Fluoroscopic Laboratories

March 24, 2026—The Heart Rhythm Society (HRS) co-published ALARA+: Summit on Radiation and Orthopedic Risks in Fluoroscopic Laboratories, a multisociety proceedings document led by the Society for Cardiovascular Angiography & Interventions (SCAI).

This document summarizes the findings of a multidisciplinary Think Tank focused on improving occupational safety in fluoroscopy-guided procedural environments. It brings together perspectives from physicians, allied health professionals, scientists, industry representatives, and health system leaders to address the dual risks of radiation exposure and musculoskeletal injury in the modern catheterization and electrophysiology laboratory.

Fluoroscopic procedures are essential to contemporary cardiovascular and interventional care, but they expose clinicians and staff to cumulative ionizing radiation and the physical strain of protective equipment. These risks have been associated with long-term health effects, including malignancy, cataracts, and chronic orthopedic injury, with disproportionate impacts on certain groups such as women, trainees, and support staff.

The document expands on the traditional ALARA (“as low as reasonably achievable”) principle by introducing ALARA+ (“as low and as light as reasonably achievable”), emphasizing the need to reduce both radiation exposure and the physical burden of protective equipment.

Key themes include:

• Recognition of radiation exposure and orthopedic injury as critical occupational health risks
• The need for improved ergonomics and safer procedural environments
• Adoption of enhanced radiation protection technologies that reduce reliance on heavy lead garments
• The importance of multidisciplinary team safety, including physicians, nurses, technologists, anesthesiologists, and imaging specialists
• Workforce implications, including recruitment, retention, and career sustainability

The document highlights emerging solutions, including advanced shielding systems, real-time dosimetry, improved imaging technologies, and ergonomic workflow design. It also addresses persistent barriers to implementation, such as cost, infrastructure limitations, and variability in regulatory standards.

Importantly, the proceedings emphasize that occupational safety is not solely an individual responsibility but requires coordinated action across institutions, industry, and policymakers.

Key recommendations include:

• Broader adoption of enhanced radiation protection devices (ERPDs)
• Integration of ergonomic design principles into laboratory infrastructure
• Standardized education and training on radiation and orthopedic safety
• Institutional investment in safer technologies and work environments
• Advocacy for regulatory and policy changes to support long-term safety improvements

Overall, this document serves as a call to action to modernize safety standards in fluoroscopic laboratories, with the goal of creating a more sustainable, equitable, and safer environment for all members of the care team.