OPRIPALC program: a regional perspective on pediatric radiation protection in interventional cardiology

Fluoroscopy-guided interventional procedures (FGIP) are now an essential component of modern pediatric care, particularly in interventional cardiology, where they have progressively replaced more invasive surgical approaches for the diagnosis and treatment of congenital heart diseases (1). These procedures offer clear clinical benefits, but they may also involve relatively high radiation doses. This raises specific concerns in pediatric patients, who are more radiosensitive and have a longer life expectancy, thereby increasing the potential risk of radiation induced effects later in life (2)(3).From a radiological protection perspective, optimization of radiation protection exposure in pediatric interventional cardiology is therefore a priority. International organizations, including the International Commission on Radiological Protection (ICRP) (4), the World Health Organization (WHO), and the International Atomic Energy Agency (IAEA) (5), consistently emphasize the principles of justification and optimization in medical exposures. Within this framework, diagnostic reference levels (DRLs) are recognized as a key tool to support dose management while preserving clinical efficacy (6). In pediatric practice, DRLs are particularly important because they provide pragmatic benchmarks that help identify unusually high or low radiation doses and trigger local review and corrective actions. Despite these recommendations, the implementation of DRLs in pediatric interventional cardiology has historically been limited and heterogeneous, outside of developed countries (6). Most published DRL data originate from single center experiences and show substantial variability in methodology, patient categorization, and reported dose metrics. This lack of harmonization has hindered meaningful comparisons and delayed the development of national or regional DRLs, particularly in less developed regions of the world (7)(8)(9)(10). To address these gaps, the Optimization of Protection in Pediatric Interventional Radiology in Latin America and the Caribbean (OPRIPALC) program was launched in 2018 as a joint initiative of the WHO, the Pan American Health Organization (PAHO), and the IAEA. OPRIPALC was conceived as a regional response to the need for structured optimization strategies in pediatric FGIP, with a particular focus on interventional cardiology. Beyond the establishment of regional DRLs, the program explicitly aimed to promote a culture of radiological protection, strengthen quality assurance (QA) practices, and foster multidisciplinary collaboration among pediatric cardiologists, medical physicists, and radiographers (medical technologists) (11,12).Since its inception, OPRIPALC has evolved into a large multicenter and multinational collaborative network. It has generated preliminary and updated regional DRLs for pediatric interventional cardiology and stimulated the development of local and national DRL initiatives within participating countries (13)(14)(15)(16)(17). At the same time, the implementation of such a complex regional program has revealed important limitations related to resources, technology, human capital, and sustainability (12,18).The aim of this Opinion article is to provide a critical appraisal of the strengths, weaknesses, and future opportunities of the OPRIPALC program, based on published evidence and documented regional experience. By reflecting on lessons learned, this work seeks to contribute to constructive discussion on how regional initiatives can effectively support optimization, QA, and safety culture in pediatric interventional cardiology.One of the principal strengths of OPRIPALC is its conception as the first coordinated regional initiative specifically focused on optimizing radiation protection in pediatric FGIP, particularly in interventional cardiology for countries of Latin America and the Caribbean. Prior to OPRIPALC, DRL initiatives in this field were largely limited to isolated single center studies (19)(20)(21)(22). In contrast, OPRIPALC established a structured regional framework that enabled the derivation of harmonized regional DRLs across multiple countries in Latin America and the Caribbean. During the OPRIPALC program, 33 centers from 11 countries (Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, Ecuador, Mexico, Panama, Peru and Uruguay) participated. Of these, only 23 centers were able to send a total of 2906 interventional cardiology procedures to establish the regional DRLs between December 2020 and December 2023 (12,18).A key methodological strength lies in the program's close alignment with international radiological protection recommendations. The use of the third quartile of patient dose distributions, stratification by age and weight bands, and the selection of kerma-area product as the primary DRL quantity are fully consistent with ICRP guidance. This methodological coherence ensures that the DRLs derived through OPRIPALC are scientifically robust, clinically meaningful, and directly comparable with those reported in other regions (6).The most up-to-date regional DRLs, published in 2025 for different diagnostic and therapeutic procedures by age and weight groups for kerma-area product quantity, were 4.3-5.4 Gy cm 2 (