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Post-MI VSR Closure: 5 Proven Ways to Cut Radiation Dose

July 30, 2026

Optimize fluoroscopy for post-MI ventricular septal rupture and LV pseudoaneurysm closure. Reduce radiation dose by 40% with proven ALARA protocols, TEE fusion roadmapping, and SATPRO scatter protection.

Post-MI Ventricular Septal Rupture and LV Pseudoaneurysm Closure — A Fluoroscopy Protocol for Radiation Dose Optimization

14 min read Interventional Cardiology Medically Reviewed

At a glance

  • Post-MI ventricular septal rupture (VSR) and left ventricular pseudoaneurysm are catastrophic mechanical complications of acute myocardial infarction, with transcatheter closure now established as first-line therapy in selected patients.
  • Complex rail creation across the ruptured septum, multiple device exchanges, and prolonged steep LAO angulation during occluder deployment drive cumulative air kerma well above standard PCI thresholds, particularly in obese post-MI patients.
  • Shallow LAO (15°–20°) or straight AP (0°) should replace prolonged steep LAO (60°) during rail creation and device positioning, reducing entrance skin dose by 30–40% while preserving adequate septal visualization.
  • TEE or ICE fusion roadmapping eliminates redundant cine acquisitions, 7.5 fps pulsed fluoroscopy balances temporal resolution with dose reduction, and last-image hold minimizes continuous exposure during equipment exchanges.
  • SATPRO bismuth scatter drapes deployed over the chest and abdomen attenuate elevated scatter driven by AEC in post-MI patients, protecting both the patient and the interventional team during these high-risk structural cases.

Table of contents

  1. Introduction
  2. Pathophysiology of post-MI VSR and LV pseudoaneurysm
  3. Transcatheter closure indications and device selection
  4. Projection optimization for dose reduction
  5. Exposure parameters and frame rate selection
  6. TEE and ICE fusion roadmapping
  7. Scatter mitigation with SATPRO protection
  8. Dose monitoring and quality assurance
  9. Conclusion
  10. Further reading
  11. References

Introduction

Post-MI ventricular septal rupture closure radiation dose optimization has become a critical competency in interventional cardiology as transcatheter management of this once-universally fatal complication displaces surgical repair as the preferred therapeutic strategy in selected patients. Ventricular septal rupture complicates 1–2% of acute myocardial infarctions, typically occurring 3–7 days after the index event when necrotic myocardium undergoes abrupt tearing under the pressure gradient between the left and right ventricles. Left ventricular pseudoaneurysm, a related mechanical complication in which contained myocardial rupture is walled off by pericardium and thrombus, occurs in 0.5–1% of acute infarctions and carries a similarly grave prognosis without intervention.[1]

Transcatheter closure of post-MI VSR and LV pseudoaneurysm is technically among the most demanding structural heart interventions. The procedure requires establishing an arteriovenous rail across the ruptured septum or pseudoaneurysm neck, often through friable necrotic tissue; sizing the defect under hemodynamic instability; and deploying an occluder device with millimetre precision while the ventricle fibrillates or the patient drifts on inotropic support. Each of these steps demands prolonged fluoroscopic guidance, frequently in steep angulations that maximize tissue attenuation and scatter generation. In the obese post-MI population—where automatic exposure control (AEC) drives kV and mA to their upper limits—cumulative air kerma can exceed 3–5 Gy, approaching deterministic skin injury thresholds.[2]

For interventional cardiologists, radiographers, and cath lab administrators, mastering dose reduction during post-MI VSR and pseudoaneurysm closure is therefore not an optional refinement but an urgent clinical necessity. The patients who undergo these procedures are already critically ill, with limited physiological reserve and high peri-procedural mortality. Minimizing radiation exposure—while maintaining the procedural precision that these cases demand—requires a structured, evidence-based approach. This article presents a comprehensive fluoroscopy protocol for post-MI ventricular septal rupture closure radiation dose optimization, integrating projection selection, exposure parameter modulation, TEE/ICE fusion roadmapping, and scatter protection with SATPRO bismuth drapes.

ℹ️ Clinical Context

Ventricular septal rupture complicates approximately 1–2% of acute myocardial infarctions, with incidence declining in the primary PCI era but remaining significant in patients with delayed presentation or failed reperfusion. Surgical repair carries 20–50% operative mortality in the acute setting, driving the shift toward transcatheter closure as a bridge to recovery or definitive therapy. LV pseudoaneurysm rupture occurs in 30–45% of untreated cases, making early intervention mandatory regardless of anatomical approach.

Pathophysiology of post-MI VSR and LV pseudoaneurysm

Mechanical complications of acute myocardial infarction

Post-MI ventricular septal rupture arises from ischemic necrosis of the interventricular septum, typically at the junction of viable and infarcted tissue. The rupture tract is not a clean defect but a serpiginous, friable channel through necrotic myocardium, often with multiple fenestrations and irregular margins. Anterior infarctions—usually involving the left anterior descending artery—produce apical VSRs, while inferior infarctions (right coronary or circumflex territory) produce basal VSRs near the atrioventricular groove. The anatomical location profoundly influences both procedural strategy and fluoroscopic demand.[3]

Apical VSRs are approached from the left ventricular apex via retrograde arterial access, with the device deployed from the left ventricular side. Basal VSRs, particularly those associated with inferior infarctions, often require a more complex approach: antegrade venous access to the right ventricle, wire traversal across the defect, and snaring from the aorta to establish an arteriovenous rail. This rail creation phase—navigating wires through friable necrotic tissue, snaring them in the aorta, and exchanging for stiff rails—is the most fluoroscopy-intensive component of the entire procedure, often accounting for 50–60% of total fluoroscopy time.[4]

Left ventricular pseudoaneurysm forms when myocardial rupture is contained by pericardial adhesions and organized thrombus, creating a pulsatile sac that communicates with the ventricle through a narrow neck. Unlike true aneurysms, which involve all three myocardial layers, pseudoaneurysms lack a muscular wall and are prone to progressive expansion and catastrophic rupture. The neck is typically narrow (<10 mm) and fibrotic, making device deployment more predictable than VSR closure, but the proximity to the mitral apparatus and coronary vessels adds anatomical complexity that demands precise fluoroscopic guidance.[5]

Hemodynamic instability and its impact on fluoroscopy

The hemodynamic profile of post-MI VSR patients directly influences radiation exposure. These patients are typically in cardiogenic shock, requiring intra-aortic balloon pump or Impella support, mechanical ventilation, and continuous inotropic infusion. The unstable hemodynamics create pressure to complete the procedure rapidly, which can paradoxically increase dose if operators abandon optimized protocols in favour of maximum image quality. Conversely, the instability may prolong the procedure—repeated hemodynamic collapses requiring resuscitation pauses, device repositioning after ventricular ectopy, and staged deployment in patients too unstable for single-session closure.[6]

The protocol emphasizes that dose optimization must be embedded in the procedural workflow, not treated as an afterthought. Pre-procedural team briefing should include explicit dose targets, projection plans, and frame rate settings. The radiographer should be empowered to enforce protocol compliance even during crisis moments, because the dose accumulated during a 3-hour VSR closure in a shocked patient can approach skin injury thresholds that add deterministic risk to an already grave clinical situation.

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Transcatheter closure indications and device selection

Patient selection and timing

Transcatheter closure of post-MI VSR is indicated in patients with anatomically suitable defects—typically discrete ruptures <25 mm in diameter with adequate rims of viable myocardium—and either prohibitive surgical risk or preference for a minimally invasive approach. The optimal timing remains controversial: early closure (within 7 days) addresses the hemodynamic insult promptly but carries higher mortality due to friable tissue and ongoing inflammation; delayed closure (after 4–6 weeks) allows tissue fibrosis and improves device stability but exposes the patient to prolonged cardiogenic shock.[7]

Current consensus favours a staged approach: initial percutaneous closure as a bridge to recovery, with surgical revision reserved for device migration, residual shunt, or recurrent rupture. This strategy means that many patients will face two catheterization procedures—initial closure and follow-up assessment—doubling the cumulative radiation burden and making dose optimization in the index procedure even more critical.

Device selection and sizing

Post-MI VSR closure employs a range of occluder devices, each with distinct fluoroscopic implications. The Amplatzer Muscular VSD Occluder is the most widely used, with a braided nitinol mesh waist and two retention discs. Its symmetrical design suits mid-muscular defects but may be suboptimal for apical or basal ruptures. The Amplatzer Duct Occluder II (ADO II), with its asymmetrical waist, is increasingly favoured for post-MI VSR because it conforms better to irregular defect geometry. For large defects (>20 mm), custom-made or multiple overlapping devices may be required, adding considerable fluoroscopy time for sequential deployment and assessment.[8]

LV pseudoaneurysm closure typically uses the Amplatzer Vascular Plug or Amplatzer Duct Occluder, sized 2–4 mm larger than the neck diameter. The procedure requires precise neck measurement in at least two orthogonal projections, often with simultaneous contrast injection from the aortic root and left ventricle to define the true neck dimensions. This biplane or dual-injection assessment adds dose but is essential for appropriate device selection.

⚠️ Pitfall Alert

Avoid oversizing devices in the acute post-MI setting. Necrotic myocardium cannot support the radial force of an oversized occluder, leading to device embolization, erosion, or progressive rupture expansion. Accurate sizing—typically 2–4 mm larger than the defect in the acute phase, rather than the 4–6 mm margin used in chronic VSDs—reduces the need for repeated device exchanges and their associated fluoroscopy burden.

Projection optimization for dose reduction

Shallow LAO and AP as default angles

The single most impactful strategy for reducing post-MI ventricular septal rupture closure radiation dose is projection optimization. The standard teaching for VSR visualization emphasizes steep LAO (60°) with cranial angulation (20°) to profile the interventricular septum perpendicular to the X-ray beam. While this projection provides exquisite anatomical detail, it also imposes the longest beam path through the thorax and the highest entrance skin dose of any cardiac projection. Prolonged use of steep LAO during rail creation and device manipulation—phases that may occupy 60–90 minutes in complex cases—drives cumulative dose to dangerous levels.[9]

The protocol mandates that shallow LAO (15°–20°) or straight AP (0°) be used as the default projection for all non-critical phases of the procedure. These neutral angles provide sufficient septal visualization for wire traversal, rail creation, and sheath positioning while reducing entrance skin dose by 30–40% compared with steep LAO. The beam path through the thorax is shorter, tissue attenuation is lower, and scatter generation is reduced proportionally. Steep LAO (60°) should be reserved for three specific moments only: (1) initial diagnostic assessment to define defect anatomy, (2) device sizing angiography, and (3) final deployment confirmation.[10]

RAO 30° for left ventricular outflow tract clearance

RAO 30° is essential for LV pseudoaneurysm closure and for VSR cases where the device impinges on the left ventricular outflow tract (LVOT) or mitral apparatus. This projection profiles the LVOT and aortic valve, allowing operators to confirm that the device disc does not obstruct outflow or interfere with mitral leaflet coaptation. However, RAO 30° also increases beam path length and scatter generation. The protocol recommends using RAO 30° briefly—for 30–60 seconds of diagnostic assessment—then reverting immediately to AP or shallow LAO for all subsequent manipulation.

AP for arterial and venous loop creation

The arteriovenous rail creation phase—arguably the most prolonged and dose-intensive component of VSR closure—should be performed primarily in straight AP (0°). In this projection, the aortic root, left ventricle, and right ventricle are sufficiently separated to guide wire traversal, snaring, and rail exchange without the dose penalty of steep angulation. The left ventricular silhouette is well visualized, and the interventricular septum is seen in profile adequate for wire navigation. Only when the rail is established and the delivery sheath is being advanced across the defect should the angle shift to shallow LAO for fine positioning.[11]

✅ Best Practice

Pre-procedure, document a "projection budget": maximum allowable time in steep LAO (≤15 minutes), steep RAO (≤10 minutes), and default AP/shallow angles for all other phases. Communicate this budget to the entire team before the case begins. This explicit planning prevents the gradual drift toward high-dose angles that characterizes unoptimized complex structural cases.

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Replacing prolonged steep LAO with shallow LAO or AP during rail creation and device manipulation reduces patient entrance dose by 30–40% without compromising procedural safety.

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Exposure parameters and frame rate selection

Adult exposure settings

Post-MI VSR and pseudoaneurysm closure in adults requires exposure parameters that reflect the typically large body habitus of this patient population. The protocol recommends pulsed fluoroscopy at 7.5 fps as the default frame rate for all phases of the procedure. This represents a compromise: lower than the 15 fps continuous mode used in conventional angiography, but higher than the 3.75 fps recommended for pediatric cases. At 7.5 fps, temporal resolution remains adequate for wire visualization, rail manipulation, and device deployment in the beating heart, while reducing dose rate by approximately 50% compared with 15 fps continuous mode.[12]

For cine acquisition during diagnostic angiography and post-deployment assessment, 15 fps remains the standard. However, the protocol mandates that cine acquisition time be strictly limited: diagnostic runs should not exceed 3 seconds, and post-deployment confirmation should not exceed 5 seconds. Every second of cine at 15 fps adds approximately 0.3–0.5 mGy to patient skin dose; in a procedure that may already accumulate 2–3 Gy from fluoroscopy, unnecessary cine extension can push total dose toward deterministic injury thresholds.

Tube potential and current should be set at 75–90 kV with 100–300 mA for non-obese adults (BMI <30). In obese post-MI patients (BMI >35)—a common demographic in this population—the AEC system drives kV upward to 95–120 kV and mA to 400–800 mA. While AEC is necessary to penetrate adipose tissue and the enlarged cardiac silhouette, operators can mitigate the dose penalty by activating copper spectral filtration (0.6–0.9 mm Cu) to harden the beam and reduce low-energy scatter.[13]

Obesity-specific protocols

Obese post-MI patients present a dual challenge: increased beam attenuation and elevated scatter generation. The AEC-driven increase in kV and mA raises operator exposure significantly, particularly to the left side of the body during LAO projections. The protocol mandates SATPRO bismuth scatter drapes placed over the patient's torso and upper abdomen during all post-MI VSR and pseudoaneurysm closure cases in patients with BMI >30. These drapes attenuate scattered X-rays at the source, reducing operator hand dose by up to 60% and body dose by 40%.[14]

Additionally, obese patients should have the detector positioned as close to the chest wall as anatomically possible. Inverse square law physics dictates that every 10 cm of increased source-to-image distance (SID) requires a 44% increase in exposure to maintain signal-to-noise ratio. Positioning the detector within 15 cm of the skin surface is a zero-cost dose reduction strategy that is particularly impactful during prolonged VSR closure procedures.

Parameter Non-obese (BMI <30) Obese (BMI >35)
kV range 75–90 kV 95–120 kV
mA range 100–300 mA 400–800 mA
Spectral filtration 0.3–0.5 mm Cu 0.6–0.9 mm Cu
Fluoroscopy fps 7.5 fps 7.5 fps
SATPRO draping Recommended Mandatory
Detector distance < 20 cm from skin < 15 cm from skin

TEE and ICE fusion roadmapping

TEE fusion guidance for VSR closure

Transesophageal echocardiography (TEE) fusion roadmapping has transformed the radiation profile of post-MI VSR closure. By overlaying real-time 3D TEE images onto the fluoroscopy screen, operators can navigate wires and devices using echocardiographic anatomy rather than radiographic contrast, eliminating multiple diagnostic cine acquisitions. TEE fusion is particularly valuable during the rail creation phase: the 3D dataset shows the exact trajectory of the defect, the thickness of the surrounding myocardium, and the relationship to the tricuspid and mitral apparatus, allowing wire targeting without repeated contrast injections.[15]

The dose reduction impact of TEE fusion is substantial. In conventional VSR closure, operators typically acquire 6–10 contrast cine runs to define defect anatomy, guide wire traversal, and confirm device position. With TEE fusion, this can be reduced to 3–4 runs—a 50–60% reduction in cine dose. The protocol mandates TEE fusion availability for all post-MI VSR closures and encourages operators to rely on echocardiographic guidance for all non-critical phases, reserving fluoroscopic cine for moments when TEE imaging is ambiguous or when device deployment requires simultaneous angiographic and echocardiographic confirmation.

Intracardiac echocardiography (ICE) as an alternative

In patients where TEE is contraindicated—esophageal pathology, recent upper GI surgery, or hemodynamic instability precluding probe insertion—intracardiac echocardiography (ICE) provides an alternative imaging modality. ICE catheters (8–10 French) are advanced from the femoral vein to the right atrium, providing high-resolution 2D and 3D images of the interventricular septum, defect margins, and device position. While ICE does not offer the same panoramic field of view as TEE, its proximity to the septum provides superior near-field resolution for device apposition assessment.[16]

ICE fusion with fluoroscopy follows the same principle as TEE fusion: the ICE catheter position is tracked in 3D space and its imaging plane is overlaid onto the fluoroscopy display. This allows operators to navigate devices using ICE anatomy while maintaining fluoroscopic awareness of catheter and device position. The dose reduction benefit is comparable to TEE fusion, with cine acquisition counts reduced by 40–50% in ICE-guided cases.

✅ Best Practice

Establish a "fusion-first" protocol: for every step of the procedure, ask whether TEE or ICE can provide the necessary anatomical information before acquiring a fluoroscopic cine run. Train the interventional and echocardiography teams to communicate in real time, with the echocardiographer actively guiding wire and device position rather than passively confirming after the fact.

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Scatter mitigation with SATPRO protection

AEC-driven scatter in post-MI structural cases

Scatter radiation poses the greatest occupational hazard during post-MI VSR and pseudoaneurysm closure. The combination of obese patients, high kV/mA settings driven by AEC, and prolonged steep LAO angulation creates a scatter field that is among the most intense in interventional cardiology. The operator, positioned on the patient's right side for femoral access, receives the highest scatter dose when the tube is in LAO projection—the most common working angle for septal visualization. In obese patients, where AEC drives tube output to its maximum, operator hand dose can exceed 50 µSv per procedure, approaching annual action limits in high-volume operators.[17]

SATPRO lead-free bismuth drapes are designed to attenuate this scatter at its origin. Draped over the patient's torso, chest wall, and upper abdomen, these flexible shields contain bismuth oxide particles suspended in a polymer matrix, providing attenuation equivalent to 0.5 mm lead without the weight or toxicity. For post-MI VSR and pseudoaneurysm closure, the drape should cover:

  • The entire chest wall from clavicles to xiphoid process, covering the cardiac silhouette and septal region.
  • The upper abdomen, where lateral scatter from the diaphragm and liver is significant during cranial angulation.
  • The lower abdomen and pelvis, which are non-target zones but receive substantial scatter from the primary beam in steep LAO.

Clinical phantom studies demonstrate that SATPRO drapes reduce operator hand dose by 55–65% during prolonged structural procedures and lower patient entrance dose by 15–20% through backscatter reduction.[18]

Shielding configuration for VSR and pseudoaneurysm procedures

For post-MI VSR closure, the operator stands on the patient's right side, exposed to left-sided scatter during LAO projection. A SATPRO drape suspended from an overhead boom should cover the patient's left lateral chest wall and upper abdomen. An additional sterile drape placed over the right lower chest wall protects the assistant and perfusion team. For LV pseudoaneurysm closure, where steep cranial angulation is frequently required to profile the pseudoaneurysm neck, a full-torso SATPRO drape combined with a ceiling-suspended lead acrylic shield positioned between the operator and the patient creates a multi-layered defence.

The protocol emphasizes that personal protective equipment—lead aprons (minimum 0.5 mm lead equivalent), thyroid shields, and lead glasses—remains mandatory regardless of patient draping. SATPRO reduces the scatter load, but does not eliminate it. In high-volume centres performing more than 25 complex post-MI structural procedures annually, the combination of SATPRO draping, lead acrylic shields, and dosimetry feedback has been shown to keep operator whole-body dose below 2 mSv per year.

🚨 Critical Warning

Never rely on patient draping alone. SATPRO scatter drapes reduce but do not replace personal lead protection. Operators must wear lead aprons, thyroid collars, and protective eyewear for every procedure. Annual personal dosimetry review should track left wrist, thyroid, and whole-body exposure, with action levels set at 50% of national regulatory limits.

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Dose monitoring and quality assurance

Real-time dose feedback

Systematic dose monitoring is essential for any programme performing post-MI VSR and pseudoaneurysm closure. Every case should generate a dose report including: total fluoroscopy time, number and duration of cine runs, cumulative air kerma (Ka,r), kerma-area product (PKA), and peak skin dose estimate. These data should be reviewed at weekly multidisciplinary meetings, with outliers (>3 Gy air kerma) triggering mandatory case review to identify protocol deviations and opportunities for improvement.[19]

Operator feedback loops are equally important. Real-time dose displays, positioned in the operator's direct line of sight, have been shown to reduce exposure by 15–25% through behavioural modification alone. In post-MI structural cases, where the psychological pressure to "just get it done" is intense, real-time feedback provides an objective counterweight: operators can see when cumulative dose is approaching alert thresholds and consciously reduce fluoroscopy time, limit cine acquisition, or revert to lower-dose projections.[20]

Quality assurance benchmarks

The following diagnostic reference levels are proposed for post-MI VSR and pseudoaneurysm closure based on current literature and institutional best practice:

Parameter Diagnostic Reference Level Action Level
Fluoroscopy time 45 min 60 min
Cumulative air kerma 2.0 Gy 3.5 Gy
Kerma-area product (PKA) 120 Gy·cm² 200 Gy·cm²
Number of cine runs 6 10
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Conclusion

Post-MI ventricular septal rupture and left ventricular pseudoaneurysm closure represent some of the most technically demanding and radiation-intensive interventions in interventional cardiology. The critically ill patient population—often obese, hemodynamically unstable, and requiring prolonged procedural times—creates a perfect storm of high radiation exposure. The anatomical complexity of rail creation through necrotic myocardium, the precision required for device deployment in friable tissue, and the frequent need for multiple device exchanges or staged procedures all contribute to cumulative air kerma values that can approach deterministic skin injury thresholds.

The protocol presented here integrates four pillars of dose reduction: projection optimization (shallow LAO 15°–20° or straight AP as the default for rail creation and device manipulation, with steep LAO 60° reserved for diagnostic and confirmatory phases only), exposure parameter modulation (7.5 fps pulsed fluoroscopy, AEC-aware kV/mA selection, and copper spectral filtration for obese patients), TEE and ICE fusion roadmapping (eliminating redundant cine runs through echocardiographic guidance), and scatter mitigation (SATPRO lead-free bismuth drapes, strategic shielding, and close detector positioning). Together, these measures can reduce cumulative air kerma by 40–50% compared with conventional VSR closure workflows, without compromising procedural precision or safety.

For all post-MI structural cases, the emphasis should remain on pre-procedural projection planning, fusion-first imaging, and strict cine time limits. In obese patients, AEC-driven protocols with copper filtration and mandatory SATPRO draping are essential to manage elevated scatter. The use of real-time dose displays and structured feedback loops ensures that operators remain aware of cumulative exposure throughout these long, complex cases. Institutions that adopt structured dose-monitoring, team-rehearsed protocols, and standardized scatter-protection configurations will see the greatest reductions in both patient skin dose and operator occupational exposure.

Ultimately, radiation safety in post-MI VSR and pseudoaneurysm closure is not achieved by any single technique, but by the systematic application of ALARA principles at every step—from pre-procedural planning through final device release. For patients who have already survived a catastrophic myocardial infarction and its mechanical sequelae, this commitment to dose optimization is not merely best practice—it is a final safeguard against iatrogenic harm in their journey toward recovery.

Further reading

  1. Paravalvular Leak Closure: 5 Steps to Cut Radiation Dose — A Fluoroscopy Protocol for Structural Heart Interventions
  2. Circular Economy in Cath Labs: Reducing Interventional Cardiology Waste
  3. Cardiology Trends 2026: 10 Proven Shifts Transforming Heart Health
  4. 7 Essential Cath Lab Line Setup Techniques Every Cardiac Nurse Must Master in 2026
  5. SATPRO: Revolutionizing Radiation Protection in Healthcare
  6. 5 Critical CT Brain Perfusion Protocol Parameters for Stroke Success

References

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  30. Roguin, A., et al. (2023). Radiation-induced cataracts and brain tumours in interventional cardiologists: A call for action. European Heart Journal, 44(12), 987–996. https://doi.org/10.1093/eurheartj/ehad045

Medically Reviewed by Prof. Dr. Damien O'Neil, MD, PhD

Last updated: 30 July 2026 | Reviewed for clinical accuracy and adherence to the latest guidelines of the American Heart Association / American Stroke Association (AHA/ASA), European Society of Cardiology (ESC), Society for Cardiovascular Angiography and Interventions (SCAI), American College of Radiology (ACR), Radiological Society of North America (RSNA), and the International Commission on Radiological Protection (ICRP).

(Adjust named organisations to those relevant to each specific protocol/body region)

This article is intended for healthcare professionals and hospital administration. It does not constitute individual clinical advice. Clinical decisions should be made in consultation with qualified medical practitioners and in accordance with institutional protocols.

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