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Leth-Olsen M, Døhlen G, Torp H, Nyrnes SA. Detection of Cerebral High-Intensity Transient Signals by NeoDoppler during Cardiac Catheterization and Cardiac Surgery in Infants. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:1256-1267. [PMID: 35410742 DOI: 10.1016/j.ultrasmedbio.2022.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 06/14/2023]
Abstract
There is a risk of gaseous and solid micro-embolus formation during transcatheter cardiac interventions and surgery in children with congenital heart disease (CHD). Our aim was to study the burden of high-intensity transient signals (HITS) during these procedures in infants. We used a novel color M-mode Doppler (CMD) technique by NeoDoppler, a non-invasive ultrasound system based on plane wave transmissions for transfontanellar continuous monitoring of cerebral blood flow in infants. The system displays CMD with 24 sample volumes and a Doppler spectrogram. Infants with CHD undergoing transcatheter interventions (n = 15) and surgery (n = 13) were included. HITS were manually detected based on an "embolic signature" in the CMD with corresponding intensity increase in the Doppler spectrogram. Embolus-to-blood ratio (EBR) defined HITS size. A total of 1169 HITS with a median EBR of 9.74 dB (interquartile range [IQR]: 5.10-15.80 dB) were detected. The median number of HITS in the surgery group was 45 (IQR: 11-150), while in the transcatheter group the median number was 12 (IQR: 7-24). During cardiac surgery, the highest number of HITS per hour was seen from initiation of cardiopulmonary bypass to aortic X-clamp. In this study we detected frequent HITS and determined the feasibility of using NeoDoppler monitoring for HITS detection.
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Affiliation(s)
- Martin Leth-Olsen
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Children's Clinic, St. Olav's University Hospital, Trondheim, Norway.
| | - Gaute Døhlen
- Department of Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Hans Torp
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Siri Ann Nyrnes
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Children's Clinic, St. Olav's University Hospital, Trondheim, Norway
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2
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Kussman BD, Imaduddin SM, Gharedaghi MH, Heldt T, LaRovere K. Cerebral Emboli Monitoring Using Transcranial Doppler Ultrasonography in Adults and Children: A Review of the Current Technology and Clinical Applications in the Perioperative and Intensive Care Setting. Anesth Analg 2021; 133:379-392. [PMID: 33764341 DOI: 10.1213/ane.0000000000005417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Transcranial Doppler (TCD) ultrasonography is the only noninvasive bedside technology for the detection and monitoring of cerebral embolism. TCD may identify patients at risk of acute and chronic neurologic injury from gaseous or solid emboli. Importantly, a window of opportunity for intervention-to eliminate the source of the emboli and thereby prevent subsequent development of a clinical or subclinical stroke-may be identified using TCD. In this review, we discuss the application of TCD sonography in the perioperative and intensive care setting in adults and children known to be at increased risk of cerebral embolism. The major challenge for evaluation of emboli, especially in children, is the need to establish the ground truth and define true emboli identified by TCD. This requires the development and validation of a predictive TCD emboli monitoring technique so that appropriately designed clinical studies intended to identify specific modifiable factors and develop potential strategies to reduce pathologic cerebral embolic burden can be performed.
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Affiliation(s)
- Barry D Kussman
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Syed M Imaduddin
- Department of Electrical Engineering and Computer Science, the Institute for Medical Engineering and Science, and the Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Mohammad Hadi Gharedaghi
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Thomas Heldt
- Department of Electrical Engineering and Computer Science, the Institute for Medical Engineering and Science, and the Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Kerri LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts.,Department of Neurology, Harvard Medical School, Boston, Massachusetts
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Clark JB. After the Clamp Comes Off: A Golden Opportunity to Decrease Cerebral Air Embolization. World J Pediatr Congenit Heart Surg 2020; 11:409-410. [PMID: 32645774 DOI: 10.1177/2150135120913862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Joseph B Clark
- Department of Pediatrics, Penn State Children's Hospital, Hershey, PA, USA.,Department of Surgery, Penn State Children's Hospital, Hershey, PA, USA
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Twedt MH, Hage BD, Hammel JM, Ibrahimye AN, Shukry M, Qadeer A, Eskridge KM, Truemper EJ, Bashford GR. Most High-Intensity Transient Signals Are Not Associated With Specific Surgical Maneuvers. World J Pediatr Congenit Heart Surg 2020; 11:401-408. [DOI: 10.1177/2150135120909761] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Mortality after congenital heart defect surgery has dropped dramatically in the last few decades. Current research on long-term outcomes has focused on preventing secondary neurological sequelae, for which embolic burden is suspected. In children, little is known of the correlation between specific surgical maneuvers and embolic burden. Transcranial Doppler ultrasound is highly useful for detecting emboli but has not been widely used with infants and children. Methods: Bilateral middle cerebral artery blood flow was continuously monitored from sternal incision to chest closure in 20 infants undergoing congenital heart defect repair or palliative surgery. Embolus counts for specific maneuvers were recorded using widely accepted criteria for identifying emboli via high-intensity transient signals (HITS). Results: An average of only 13% of all HITS detected during an operation were correlated with any of the surgical maneuvers of interest. The highest mean number of HITS associated with a specific maneuver occurred during cross-clamp removal. Cross-clamp placement also had elevated HITS counts that significantly differed from other maneuvers. Conclusions: In this study of infants undergoing cardiac surgery with cardiopulmonary bypass, the great majority of HITS detected are not definitively associated with a specific subset of surgical maneuvers. Among the measured maneuvers, removal of the aortic cross-clamp was associated with the greatest occurrence of HITS. Future recommended research efforts include identifying and confirming other sources for emboli and longitudinal outcome studies to determine if limiting embolic burden affects long-term neurological outcomes.
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Affiliation(s)
- Max H. Twedt
- Department of Biological Systems Engineering, University of Nebraska–Lincoln, Lincoln, NE, USA
| | - Benjamin D. Hage
- Department of Biological Systems Engineering, University of Nebraska–Lincoln, Lincoln, NE, USA
| | - James M. Hammel
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ali N. Ibrahimye
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Mohanad Shukry
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ahsan Qadeer
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kent M. Eskridge
- Department of Statistics, University of Nebraska–Lincoln, Lincoln, NE, USA
| | - Edward J. Truemper
- Department of Biological Systems Engineering, University of Nebraska–Lincoln, Lincoln, NE, USA
| | - Gregory R. Bashford
- Department of Biological Systems Engineering, University of Nebraska–Lincoln, Lincoln, NE, USA
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Caneo LF, Matte GS, Guimarães DP, Viotto G, Mazzeto M, Cestari I, Neirotti RA, Jatene MB, Wang S, Ündar A, Chang Junior J, Jatene FB. Functional Performance of Different Venous Limb Options in Simulated Neonatal/Pediatric Cardiopulmonary Bypass Circuits. Braz J Cardiovasc Surg 2018; 33:224-232. [PMID: 30043914 PMCID: PMC6089135 DOI: 10.21470/1678-9741-2018-0074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 03/09/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Hemodilution is a concern in cardiopulmonary bypass (CPB). Using a smaller dual tubing rather than a single larger inner diameter (ID) tubing in the venous limb to decrease prime volume has been a standard practice. The purpose of this study is to evaluate these tubing options. METHODS Four different CPB circuits primed with blood (hematocrit 30%) were investigated. Two setups were used with two circuits for each one. In Setup I, a neonatal oxygenator was connected to dual 3/16" ID venous limbs (Circuit A) or to a single 1/4" ID venous limb (Circuit B); and in Setup II, a pediatric oxygenator was connected to dual 1/4" ID venous limbs (Circuit C) or a single 3/8" ID venous limb (Circuit D). Trials were conducted at arterial flow rates of 500 ml/min up to 1500 ml/min (Setup I) and up to 3000 ml/min (Setup II), at 36°C and 28°C. RESULTS Circuit B exhibited a higher venous flow rate than Circuit A, and Circuit D exhibited a higher venous flow rate than Circuit C, at both temperatures. Flow resistance was significantly higher in Circuits A and C than in Circuits B (P<0.001) and D (P<0.001), respectively. CONCLUSION A single 1/4" venous limb is better than dual 3/16" venous limbs at all flow rates, up to 1500 ml/min. Moreover, a single 3/8" venous limb is better than dual 1/4" venous limbs, up to 3000 ml/min. Our findings strongly suggest a revision of perfusion practice to include single venous limb circuits for CPB.
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Affiliation(s)
- Luiz Fernando Caneo
- Cardiovascular Surgery Division, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Gregory S Matte
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Daniel Peres Guimarães
- Cardiovascular Surgery Division, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Guilherme Viotto
- Cardiovascular Surgery Division, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Marcelo Mazzeto
- Cardiovascular Surgery Division, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Idagene Cestari
- Cardiovascular Surgery Division, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Rodolfo A Neirotti
- Clinical Professor of Surgery and Pediatrics, Emeritus Michigan State University, MI, USA
| | - Marcelo B Jatene
- Cardiovascular Surgery Division, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Shigang Wang
- Pediatric Cardiovascular Research Center, Department of Pediatrics; Public Health Sciences; Surgery and Bioengineering, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Akif Ündar
- Pediatric Cardiovascular Research Center, Department of Pediatrics; Public Health Sciences; Surgery and Bioengineering, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - João Chang Junior
- Department of Industrial Engineering, FEI University Center, São Paulo, Brazil
| | - Fabio B Jatene
- Cardiovascular Surgery Division, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
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Matte GS, Neirotti RA. Translational Research: Comparing Oxygenators From Different International Markets. Artif Organs 2018; 42:100-102. [PMID: 29314114 DOI: 10.1111/aor.12996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 06/26/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Gregory S Matte
- Chief Perfusionist and Manager, Boston Children's Hospital, Boston, MA, USA
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LaRovere KL, Kapur K, McElhinney DB, Razumovsky A, Kussman BD. Cerebral High-Intensity Transient Signals during Pediatric Cardiac Catheterization: A Pilot Study Using Transcranial Doppler Ultrasonography. J Neuroimaging 2017; 27:381-387. [DOI: 10.1111/jon.12426] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 12/30/2016] [Indexed: 11/29/2022] Open
Affiliation(s)
- Kerri L. LaRovere
- Department of Neurology; Boston Children's Hospital and Harvard Medical School; Boston MA
| | - Kush Kapur
- Department of Neurology; Boston Children's Hospital and Harvard Medical School; Boston MA
| | - Doff B. McElhinney
- Department of Cardiothoracic Surgery; Boston Children's Hospital and Harvard Medical School; Boston MA
| | - Alexander Razumovsky
- Sentient NeuroCare Services, Inc.; Boston Children's Hospital and Harvard Medical School; Boston MA
| | - Barry D. Kussman
- Department of Anesthesiology; Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School; Boston MA
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