1
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Schaefer TC, Greive S, Bierwisch C, Mohseni-Mofidi S, Heiland S, Kramer M, Möhlenbruch MA, Bendszus M, Vollherbst DF. Iatrogenic air embolism: influence of air bubble size on cerebral infarctions in an experimental in vivo and numerical simulation model. J Neurointerv Surg 2024; 16:1036-1041. [PMID: 37673679 PMCID: PMC11420717 DOI: 10.1136/jnis-2023-020739] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/10/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Cerebral infarctions resulting from iatrogenic air embolism (AE), mainly caused by small air bubbles, are a well-known and often overlooked event in endovascular interventions. Despite their significance, the underlying pathophysiology remains largely unclear. METHODS In 24 rats, AEs were induced using a microcatheter, positioned in the carotid artery via femoral access. Rats were divided into two study groups, based on the size of the bubbles (85 and 120 µm) and two sub-groups, differing in air volume (0.39 and 0.64 µl). Ultra-high-field magnetic resonance imaging (MRI) was performed 1.5 hours after intervention. MRI findings including the number, single volume and total volume of the infarctions were assessed. A software-based numerical simulation was performed to qualitatively assess the microvascular pathomechanisms. RESULTS In the study groups 22 of 24 rats (92%) revealed cerebral infarctions. The number of infarctions per rat was higher for the smaller bubbles, for the lower (medians: 5 vs 3; p=0.049) and higher air volume sub-groups (medians: 6 vs 4; p=0.012). Correspondingly, total infarction volume was higher for the smaller bubbles (1.67 vs 0.5 mm³; p=0.042). Simulations confirmed the results of the experiments and suggested that fusion of microbubbles to larger bubbles is the underlying pathomechanism of vascular occlusions. CONCLUSION In iatrogenic AE, the size of the bubbles can have a major impact on the number and total volume of cerebral infarctions. These findings can help to better understand the pathophysiology of this frequent, often underestimated adverse event in endovascular interventions.
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Affiliation(s)
- Tabea C Schaefer
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Veterinary Clinical Sciences, Small Animal Clinic, Justus-Liebig-University Giessen, Giessen, Germany
| | - Svenja Greive
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Sabine Heiland
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Kramer
- Department of Veterinary Clinical Sciences, Small Animal Clinic, Justus-Liebig-University Giessen, Giessen, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
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2
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Bouchez S, Gruenbaum BF, Van Vaerenbergh G, De Somer F. The evolving role of the modern perfusionist: Insights from processed electro-encephalography. Perfusion 2024:2676591241284864. [PMID: 39263861 DOI: 10.1177/02676591241284864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
Abstract
Introduction: Since its origin in the 1920s, electroencephalography (EEG) has become a viable option for anesthesia and perfusion teams to monitor anesthetic delivery, optimizing drug dosage and enhancing patient safety. Patients undergoing cardiopulmonary bypass (CPB) are at particular high risk for excessive or inadequate anesthetic doses. During CPB, traditional physiological indicators such as heart rate and blood pressure can be significantly altered. These abnormalities are compounded by rapid changes in anesthetic concentration from hemodilution, circuit absorption, and altered pharmacokinetics. Method: This narrative highlights the use of processed EEG with spectral analysis for anesthetic management during CPB. Conclusion: We emphasize that neuromonitoring using processed EEG during CPB can assess adequacy of anesthesia delivery and monitor for pathologic conditions that can compromise brain function such as inadequate cerebral blood flow, emboli, and seizures. This information is highly valuable for the clinical team including the perfusionist, who regularly diagnose and manage these pathological conditions.
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Affiliation(s)
- Stefaan Bouchez
- Department of Anesthesia, Intensive Care and Emergency Medicine, OLV Aalst, Aalst, Belgium
| | - Benjamin F Gruenbaum
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Filip De Somer
- Department of Cardiac Surgery, Ghent University Hospital, Ghent, Belgium
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3
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2024; 21:e31-e149. [PMID: 38597857 DOI: 10.1016/j.hrthm.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece.
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil; Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France; Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain; Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Case Western Reserve University, Cleveland, OH, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA; Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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4
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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Interv Card Electrophysiol 2024; 67:921-1072. [PMID: 38609733 DOI: 10.1007/s10840-024-01771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.
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Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | - Gregory F Michaud
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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5
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Shen C, Jia Z, Yu Y, Feng M, Du X, Fu G, Yu L, Wu T, Jiang Y, Jin H, Zhuo W, Gao F, Wang B, Chen S, Dai J, Fang R, Chu H. Efficacy and safety of pulsed field ablation for accessory pathways: a pilot study. Europace 2024; 26:euae139. [PMID: 38801673 PMCID: PMC11218562 DOI: 10.1093/europace/euae139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 05/06/2024] [Accepted: 05/23/2024] [Indexed: 05/29/2024] Open
Abstract
AIMS Radiofrequency ablation is used as a first-line therapy for accessory pathways (APs). However, data regarding the effects of pulsed field ablation (PFA) on APs are limited. We sought to evaluate the acute procedural and 6-month success and safety of PFA in a cohort of patients with APs. METHODS AND RESULTS A focal contact force-sensing PFA catheter was used for patients with APs. Pulsed field ablation generator generated a bipolar and biphasic waveform (±1000 V) with a duration of 100 ms from the tip of the PFA catheter. A 100% acute procedural success was achieved in 10 conscious patients with APs (7 left anterolateral, 2 left inferolateral, and 1 right posteroseptal APs) including 6 (60%) patients after an initial application. The average total ablation time was 6.3 ± 4.9 s for 4.7 ± 1.8 ablation sites (ASs), including 3.1 ± 2.4 s at targets and 3.2 ± 2.9 s at 3.2 ± 2 bolus ASs. The mean skin-to-skin time was 59.3 ± 15.5 min, and PFA catheter dwell time was 29.4 ± 7.8 min. One patient encountered transient sinus arrest during PFA due to parasympathetic overexcitation. Sinus rhythm was restored in all patients without any significant adverse events during the short-term follow-up. CONCLUSION Pulsed field ablation of APs was feasible, effective, and safe. Its efficiency was remarkable for its ultrarapid termination of AP conduction. Further studies are warranted to prove whether utilization of PFA with current parameters can extend to manifold AP ablation.
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Affiliation(s)
- Caijie Shen
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, 59th Liuting Street, Haishu district, Ningbo 315000, China
| | - Zhenyu Jia
- Health Science Center, Ningbo University, Ningbo 315000, China
| | - Yibo Yu
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, 59th Liuting Street, Haishu district, Ningbo 315000, China
| | - Mingjun Feng
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, 59th Liuting Street, Haishu district, Ningbo 315000, China
| | - Xianfeng Du
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, 59th Liuting Street, Haishu district, Ningbo 315000, China
| | - Guohua Fu
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, 59th Liuting Street, Haishu district, Ningbo 315000, China
| | - Lipu Yu
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, 59th Liuting Street, Haishu district, Ningbo 315000, China
| | - Tao Wu
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, 59th Liuting Street, Haishu district, Ningbo 315000, China
| | - Yongxing Jiang
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, 59th Liuting Street, Haishu district, Ningbo 315000, China
| | - He Jin
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, 59th Liuting Street, Haishu district, Ningbo 315000, China
| | - Weidong Zhuo
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, 59th Liuting Street, Haishu district, Ningbo 315000, China
| | - Fang Gao
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, 59th Liuting Street, Haishu district, Ningbo 315000, China
| | - Binhao Wang
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, 59th Liuting Street, Haishu district, Ningbo 315000, China
| | - Si Chen
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, 59th Liuting Street, Haishu district, Ningbo 315000, China
| | - Jiating Dai
- Health Science Center, Ningbo University, Ningbo 315000, China
| | - Renyuan Fang
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, 59th Liuting Street, Haishu district, Ningbo 315000, China
| | - Huimin Chu
- Cardiac Arrhythmia Center, The First Affiliated Hospital of Ningbo University, 59th Liuting Street, Haishu district, Ningbo 315000, China
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6
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Beisteiner R, Lozano A, Di Lazzaro V, George MS, Hallett M. Clinical recommendations for non-invasive ultrasound neuromodulation. Brain Stimul 2024; 17:890-895. [PMID: 39084519 DOI: 10.1016/j.brs.2024.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 07/16/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024] Open
Abstract
Non-invasive ultrasound neuromodulation has experienced exponential growth in the neuroscientific literature, recently also including clinical studies and applications. However, clinical recommendations for the secure and effective application of ultrasound neuromodulation in pathological brains are currently lacking. Here, clinical experts with neuroscientific expertise in clinical brain stimulation and ultrasound neuromodulation present initial clinical recommendations for ultrasound neuromodulation with relevance for all ultrasound neuromodulation techniques. The recommendations start with methodological safety issues focusing on technical issues to avoid harm to the brain. This is followed by clinical safety issues focusing on important factors concerning pathological situations.
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Affiliation(s)
- Roland Beisteiner
- Department of Neurology, Functional Brain Diagnostics and Therapy, High Field MR Center, Medical University of Vienna, Vienna, Austria.
| | - Andres Lozano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, M5T 2S8, Canada
| | - Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Mark S George
- Brain Stimulation Division, Psychiatry, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Mark Hallett
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, USA
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7
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O’Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2024; 26:euae043. [PMID: 38587017 PMCID: PMC11000153 DOI: 10.1093/europace/euae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 04/09/2024] Open
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología ‘Ignacio Chávez’, Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O’Neill
- Cardiovascular Directorate, St. Thomas’ Hospital and King’s College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Puthettu M, Vandenberghe S, Balafas S, Di Serio C, Singjeli G, Pagnamenta A, Demertzis S. Optimizing CO2 field flooding during sternotomy: In vitro confirmation of the Karolinska studies. PLoS One 2024; 19:e0292669. [PMID: 38194426 PMCID: PMC10775975 DOI: 10.1371/journal.pone.0292669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 09/26/2023] [Indexed: 01/11/2024] Open
Abstract
Although CO2 field-flooding was first used during cardiac surgery more than 60 years ago, its efficacy is still disputed. The invisible nature of the gas and the difficulty in determining the "safe" quantity to protect the patient are two of the main obstacles to overcome for its validation. Moreover, CO2 concentration in the chest cavity is highly sensitive to procedural aspects, such suction and hand movements. Based on our review of the existing literature, we identified four major factors that influence the intra-cavity CO2 concentration during open-heart surgery: type of delivery device (diffuser), delivery CO2 flow rate, diffuser position around the wound cavity, and its orientation inside the cavity. In this initial study, only steady state conditions were considered to establish a basic understanding on the effect of the four above-mentioned factors. Transient factors, such as suction or hand movements, will be reported separately.
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Affiliation(s)
- Mira Puthettu
- Department of Cardiac Surgery, Istituto Cardiocentro Ticino, Lugano, Switzerland
- Laboratory of Cardiovascular Engineering, Laboratories for Translational Research EOC (LRT-EOC), Bellinzona, Switzerland
| | - Stijn Vandenberghe
- Department of Cardiac Surgery, Istituto Cardiocentro Ticino, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Spyros Balafas
- University Centre for Statistics in the Biomedical Sciences, Vita-Salute San Raffaele University, Milano, Italy
| | - Clelia Di Serio
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
- University Centre for Statistics in the Biomedical Sciences, Vita-Salute San Raffaele University, Milano, Italy
- Clinical Trial Unit (CTU), Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | - Geni Singjeli
- Department of Cardiac Surgery, Istituto Cardiocentro Ticino, Lugano, Switzerland
| | - Alberto Pagnamenta
- Clinical Trial Unit (CTU), Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
- Department of Intensive Care, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
- Division of Pneumology, University of Geneva, Geneva, Switzerland
| | - Stefanos Demertzis
- Department of Cardiac Surgery, Istituto Cardiocentro Ticino, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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9
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Ong SJ, Koh CH. Aeromedical Transportation of the Critically Ill Cardiac Patient: In-flight Considerations and Management. Curr Probl Cardiol 2023; 48:101855. [PMID: 37321282 DOI: 10.1016/j.cpcardiol.2023.101855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 06/04/2023] [Indexed: 06/17/2023]
Abstract
The aeromedical transportation (AMT) of critically ill cardiac patients can enable access to advanced specialized medical attention, or provide improved care for operational, psychosocial, political, or economic reasons. However, AMT is a complex undertaking necessitating extensive clinical, operational, administrative, and logistical planning to ensure that the patient receives an equivalent level of critical care monitoring and management in the air as on the ground. This paper is the second of a 2-part series. Part 1 focused on the preflight planning and preparation for critically ill cardiac patients during AMT aboard commercial platforms, while this current part aims to provide an overview of in-flight considerations for the same population.
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Affiliation(s)
- Siyu Jocelyn Ong
- Department of Anesthesiology, Singapore General Hospital, Singapore, Singapore
| | - Choong Hou Koh
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore; Duke-NUS School of Medicine, National University of Singapore, Singapore, Singapore; Changi Aviation Medical Centre, Changi General Hospital, Singapore, Singapore.
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10
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Ho R, McDonald C, Pauls JP, Li Z. Improving Trendelenburg position effectiveness by varying cardiopulmonary bypass flow. Perfusion 2023; 38:1213-1221. [PMID: 35703549 DOI: 10.1177/02676591221108810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Trendelenburg position (TP) is used to transport gaseous emboli away from the cerebral region during cardiac surgery. However, TP effectiveness has not been fully considered when combined with varying the cardiopulmonary bypass (CPB) flow. This study simulated the supine and TP at different pump flows and assessed the trapped emboli and embolic load entering the aortic arch branch arteries (AABA). METHODS A computational fluid dynamics (CFD) approach used a centrally cannulated adult patient-specific aorta model replicating a CPB circuit. Air emboli of 0.1 mm, 0.5 mm, and 1.0 mm (n = 700 each) were injected into the aorta placed in the supine position (0°) and the TP (-20°) at 2 L/min and 5 L/min. The number of emboli entering the AABA were compared. An aortic phantom flow experiment was performed to validate air bubble behaviour. RESULTS TP at 5 L/min had the lowest 0.1 mm mean (±SD) embolic load compared to the supine 2 L/min (55.3 ± 30.8 vs 64.3 ± 35.4). For both the supine and TP, the lower flow of 2 L/min had the highest number of simulated trapped emboli in higher elevated regions than at 5 L/min (541 ± 185 and 548 ± 191 vs 520 ± 159 and 512 ± 174), respectively. The flow experiment demonstrated that 2 L/min promoted bubble coalescence and high amounts of trapped emboli and 5 L/min transported air emboli away from the AABA. CONCLUSIONS TP effectiveness was improved by using CPB flow to manage air emboli. These results provide insights for predicting emboli behaviour and improving emboli de-airing procedures.
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Affiliation(s)
- Raymond Ho
- School of Mechanical, Medical and Process Engineering, Faculty of Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Innovative Cardiovascular Engineering and Technology Laboratory (ICETLAB), Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Charles McDonald
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital. Chermside, QLD, Australia
| | - Jo P Pauls
- Innovative Cardiovascular Engineering and Technology Laboratory (ICETLAB), Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Engineering and Built Environment, Griffith University, Southport, QLD, Australia
| | - Zhiyong Li
- School of Mechanical, Medical and Process Engineering, Faculty of Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia
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11
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Ferrante MS, Pisano C, Van Rothem J, Ruvolo G, Abouliatim I. Cerebrovascular events after cardiovascular surgery: diagnosis, management and prevention strategies. KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2023; 20:118-122. [PMID: 37564967 PMCID: PMC10410632 DOI: 10.5114/kitp.2023.130020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/06/2023] [Indexed: 08/12/2023]
Abstract
Introduction Cerebrovascular events after cardiac surgery are among the most serious complications, related to a greater risk of patient mortality. This problem can occur following the formation of gas emboli during open heart surgery. Aim To address all the mechanisms that can lead to embolic events after cardiovascular surgery, how to manage them and how to possibly prevent them. Material and methods A search of the PubMed database was conducted. We reviewed the clinical literature and examined all aspects to identify the root causes that can lead to the formation of emboli. Results Among the studies reviewed, it was found that the main causes include manipulation of the aorta, inadequate deaeration after cardiac surgery, and blood-component contact of extracorporeal circulation. It has been reported that gas emboli can lead to deleterious damage such as damage to the cerebral vascular endothelium, disruption of the blood-brain barrier, complement activation, leukocyte aggregation, increased platelet adhesion, and fibrin deposition in the microvascular system. Conclusions Stroke after cardiovascular surgery is one of the most important complications, with a great impact on operative mortality and patient survival. Efforts have been made over time to understand all the pathophysiological mechanisms related to this complication, with the aim of reducing its incidence. One of the goals should be to improve both the surgical technique and the perfusion modality and minimize the formation of air bubbles or to facilitate their elimination during the cardiopulmonary bypass procedure.
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Affiliation(s)
| | - Calogera Pisano
- Cardiac Surgery Division, Tor Vergata University Hospital, Rome, Italy
| | | | - Giovanni Ruvolo
- Cardiac Surgery Division, Tor Vergata University Hospital, Rome, Italy
| | - Issam Abouliatim
- Cardiovascular and Thoracic Surgery Department, Clinique Pasteur, Toulouse, France
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12
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Ishida M, Takahashi S, Okamura H. Comparison of bubble removal performances of five membrane oxygenators with and without a pre-filter. Perfusion 2023; 38:530-538. [PMID: 35105222 DOI: 10.1177/02676591211064960] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
When employing minimal invasive extracorporeal circulation (MiECC), the removal of bubbles in the circuit is important to prevent air embolism. We investigated the bubble removal performance of the FHP oxygenator with a pre-filter and compared it with that of four oxygenators, including the Fusion oxygenator, Quadrox oxygenator, Inspire oxygenator, and FX oxygenator. A closed test circuit filled with an aqueous glycerin solution was used. Air injection (10 mL) was performed prior to the oxygenator, and the number and volume of the bubbles were measured at the inlet and outlet of each oxygenator. At the inlet of the five oxygenators, there were no significant differences in the total number of bubbles detected. At the outlet, bubbles were classified into two groups according to the bubble size: ≥100 μm and <100 μm. Tests were performed at pump flow rates of 4 and 5 L/min. For bubbles ≥100 μm, which are considered clinically detrimental, the FHP was the lowest number and volume of bubbles at both pump flow rates compared to the other oxygenators. Regarding the bubbles <100 μm, the number of bubbles was higher in the FHP than those in others; however, the volume of bubbles was significantly lower at 4 L/min and tended to be lower at 5 L/min. The use of the FHP with the pre-filter removed more bubbles ≥100 μm in the circuit than that by the other oxygenators.
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Affiliation(s)
- Mitsuru Ishida
- Department of Medical Engineering, RinggoldID:%2083943Nerima Hikarigaoka Hospital, Nerima-ku, Japan
| | - Sho Takahashi
- Department of Medical Engineering, RinggoldID:%2083943Nerima Hikarigaoka Hospital, Nerima-ku, Japan
| | - Homare Okamura
- Department of Cardiovascular Surgery, RinggoldID:%2083943Nerima Hikarigaoka Hospital, Nerima-ku, Japan
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13
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Hague JP, Keelan J, Beishon L, Swienton D, Robinson TG, Chung EML. Three-dimensional simulations of embolic stroke and an equation for sizing emboli from imaging. Sci Rep 2023; 13:3021. [PMID: 36810427 PMCID: PMC9944911 DOI: 10.1038/s41598-023-29974-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 02/14/2023] [Indexed: 02/23/2023] Open
Abstract
Stroke simulations are needed to run in-silico trials, develop hypotheses for clinical studies and to interpret ultrasound monitoring and radiological imaging. We describe proof-of-concept three-dimensional stroke simulations, carrying out in silico trials to relate lesion volume to embolus diameter and calculate probabilistic lesion overlap maps, building on our previous Monte Carlo method. Simulated emboli were released into an in silico vasculature to simulate 1000 s of strokes. Infarct volume distributions and probabilistic lesion overlap maps were determined. Computer-generated lesions were assessed by clinicians and compared with radiological images. The key result of this study is development of a three-dimensional simulation for embolic stroke and its application to an in silico clinical trial. Probabilistic lesion overlap maps showed that the lesions from small emboli are homogeneously distributed throughout the cerebral vasculature. Mid-sized emboli were preferentially found in posterior cerebral artery (PCA) and posterior region of the middle cerebral artery (MCA) territories. For large emboli, MCA, PCA and anterior cerebral artery (ACA) lesions were comparable to clinical observations, with MCA, PCA then ACA territories identified as the most to least probable regions for lesions to occur. A power law relationship between lesion volume and embolus diameter was found. In conclusion, this article showed proof-of-concept for large in silico trials of embolic stroke including 3D information, identifying that embolus diameter could be determined from infarct volume and that embolus size is critically important to the resting place of emboli. We anticipate this work will form the basis of clinical applications including intraoperative monitoring, determining stroke origins, and in silico trials for complex situations such as multiple embolisation.
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Affiliation(s)
- James P. Hague
- grid.10837.3d0000 0000 9606 9301School of Physical Sciences, The Open University, Walton Hall, Milton Keynes, MK7 6AA UK
| | - Jonathan Keelan
- grid.10837.3d0000 0000 9606 9301School of Physical Sciences, The Open University, Walton Hall, Milton Keynes, MK7 6AA UK
| | - Lucy Beishon
- grid.9918.90000 0004 1936 8411Department of Cardiovascular Sciences, University of Leicester, Leicester, LE1 7RH UK
| | - David Swienton
- grid.269014.80000 0001 0435 9078Department of Radiology, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW UK
| | - Thompson G. Robinson
- grid.511501.1NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Leicester, LE3 9QP UK
| | - Emma M. L. Chung
- grid.9918.90000 0004 1936 8411Department of Cardiovascular Sciences, University of Leicester, Leicester, LE1 7RH UK ,grid.269014.80000 0001 0435 9078Department of Medical Physics, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW UK ,grid.13097.3c0000 0001 2322 6764School of Life Course and Population Sciences, King’s College London, Guy’s Campus, London, SE1 1UL UK
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14
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Vandenberghe S, Singjeli G, Demertzis S. Patient tilt improves efficacy of CO 2 field-flooding in minimally invasive cardiac surgery. J Cardiothorac Surg 2022; 17:164. [PMID: 35733212 PMCID: PMC9219288 DOI: 10.1186/s13019-022-01916-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 06/12/2022] [Indexed: 11/18/2022] Open
Abstract
Objective Space limitations during minimally invasive cardiac surgery impede consistent use of CO2 field-flooding. We compared different gas delivery methods, flow rates and the effect of patient inclination. Methods A gastight model of MICS surgery with internal organs and right thoracotomy wound was created from a mannequin and equipped with a CO2 concentration sensor in the left ventricle. Maximum achievable CO2 concentration was compared for gas delivery via three commercial CO2 diffusors (CarbonMini, Temed, Andocor) and also via a trocar with side port. Gas flow rates of 1, 3, 5 and 8 L per minute were tested. The model was placed either in supine position or with 20° oblique tilt. A simplified transparent model was also created and placed in an optical test bench to evaluate the gas cloud motions via real-time visualization. Results The trocar consistently achieved higher CO2 concentrations inside the left ventricle. At 1 l/min, approximately 2.5 min were needed to fill the supine model to its maximum CO2 concentration, which was limited to a range of 48–82% in the left ventricle. At higher flow rates, filling time and concentration were significantly improved. In a tilted model, all devices and all flow rates generated on average 99% CO2 in the ventricle. Imaging revealed constant gas exchange via the main incision, with CO2 outflow via bottom and air inflow via the top of the incision. Conclusions CO2 field flooding in minimally invasive cardiac surgery is highly effective if the patient is tilted. Else a flow rate of 5 l/min is recommended to achieve the same protection. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-022-01916-5.
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Affiliation(s)
- Stijn Vandenberghe
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Via Giuseppe Buffi 13, 6900, Lugano, Switzerland. .,Department of Cardiac Surgery, Istituto Cardiocentro Ticino, EOC, Lugano, Switzerland.
| | - Geni Singjeli
- Department of Cardiac Surgery, Istituto Cardiocentro Ticino, EOC, Lugano, Switzerland
| | - Stefanos Demertzis
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Via Giuseppe Buffi 13, 6900, Lugano, Switzerland.,Department of Cardiac Surgery, Istituto Cardiocentro Ticino, EOC, Lugano, Switzerland
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15
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Segal R, Mezzavia PM, Krieser RB, Sampurno S, Taylor M, Ramsay R, Kluger M, Lee K, Loh FL, Tatoulis J, O'Keefe M, Chen Y, Sindoni T, Ng I. Warm humidified CO2 insufflation improves pericardial integrity for cardiac surgery: a randomized control study. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:369-375. [PMID: 35343658 DOI: 10.23736/s0021-9509.22.12004-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Flooding the surgical field with dry cold CO<inf>2</inf> during open-chamber cardiac surgery has been used to mitigate air entrainment into the systemic circulation. However, exposing epithelial surfaces to cold, dry gas causes tissue desiccation. This randomized controlled study was designed to investigate whether the use of humidified warm CO<inf>2</inf> insufflation into the cardiac cavity could reduce pericardial tissue damage and the incidence of micro-emboli when compared to dry cold CO<inf>2</inf> insufflation. METHODS Forty adult patients requiring elective open-chamber cardiac surgery were randomized to have either dry cold CO<inf>2</inf> insufflation via a standard catheter or humidified warm CO<inf>2</inf> insufflation via the HumiGard device (Fisher & Paykel Healthcare, Panmure, Auckland, New Zealand). The primary endpoint was biopsied pericardial tissue damage, assessed using electron microscopy. We assessed the percentage of microvilli and mesothelial damage, using a damage severity score (DSS) system. We compared the proportion of patients who had less damage, defined as DSS<2. Secondary endpoints included the severity of micro-emboli, by visual assessment of bubble load on transesophageal echocardiogram; lowest near infrared spectroscopy; total de-airing time; highest cardio-pulmonary bypass sweep speed; hospital length of stay and complications. RESULTS A higher proportion of patients in the humidified warm CO<inf>2</inf> group displayed conserved microvilli (47% vs. 11%, P=0.03) and preserved mesothelium (42% vs. 5%, P=0.02) compared to the control group. There were no differences in the secondary outcomes. CONCLUSIONS Humidified warm CO<inf>2</inf> insufflation significantly reduced pericardial epithelial damage when compared to dry cold CO<inf>2</inf> insufflation in open-chamber cardiac surgery. Further studies are warranted to investigate its potential clinical benefits.
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Affiliation(s)
- Reny Segal
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Paul M Mezzavia
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
| | - Roni B Krieser
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
| | | | | | - Robert Ramsay
- University of Melbourne, Melbourne, Australia
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Michael Kluger
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
| | - Keat Lee
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Francis L Loh
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
| | - James Tatoulis
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Michael O'Keefe
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Yinwei Chen
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
| | - Teresa Sindoni
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
| | - Irene Ng
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia -
- University of Melbourne, Melbourne, Australia
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16
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Ho R, McDonald C, Pauls JP, Li Z. Effect of aortic cannulation depth on air emboli transport during cardiopulmonary bypass: A computational study. Perfusion 2022:2676591221092942. [DOI: 10.1177/02676591221092942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Varying the insertion depth of the aortic cannula during cardiopulmonary bypass (CPB) has been investigated as a strategy to mitigate cerebral emboli, yet its effectiveness associated with CPB flow is not fully understood. We compared different arterial cannula insertion depths and pump flow influencing air microemboli entering the aortic arch branch arteries (AABA). Methods A computational approach used a patient-specific aorta model to evaluate four cannula locations at (1) proximal arch, (2) mid arch, (3) distal arch, and (4) descending aorta. We injected 0.1 mm microemboli (N=720) at 2 and 5 L/min and assessed the embolic load and the particle averaged transit times ( entering the AABA. Results Location 4 had the lowest embolic load (2 L/min: N= 63) and (5 L/min: N= 54) compared to locations 1 to 3 in the range of (N= 118 to 116 at 2 L/min:) and (N= 92 to 146 at 5 L/min). There was no significant difference between 2 L/min and 5 L/min (p = 0.31), despite 5 L/min attaining a lower mean (±standard deviation) than 2 L/min (38.0±23.4 vs 44.5±21.1), respectively. Progressing from location 1 to 4, increased 3.11s -7.40 s at 2 L/min and 1.81s -4.18s at 5 L/min. Conclusion It was demonstrated that the elongated cannula insertion length resulted in lower embolic loads, particularly at a higher flow rate. The numerical results suggest that CPB management could combine active flow variation with improving cannula performance and provide a foundation for a future experimental and clinical investigation to reduce surgical cerebral air microemboli.
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Affiliation(s)
- Raymond Ho
- School of Mechanical, Medical and Process Engineering, Faculty of Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Innovative Cardiovascular Engineering and Technology Laboratory (ICETLAB), Critical Care Research Group, The Prince Charles Hospital, Brisbane, Qld, Australia
| | - Charles McDonald
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, Qld, Australia
| | - Jo P Pauls
- Innovative Cardiovascular Engineering and Technology Laboratory (ICETLAB), Critical Care Research Group, The Prince Charles Hospital, Brisbane, Qld, Australia
- School of Engineering and Built Environment, Griffith University, Southport, QLD, Australia
| | - Zhiyong Li
- School of Mechanical, Medical and Process Engineering, Faculty of Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia
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17
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Jabur GNS, Merry AF, McGeorge A, Cavadino A, Donnelly J, Mitchell SJ. A prospective observational study on the effect of emboli exposure on cerebral autoregulation in cardiac surgery requiring cardiopulmonary bypass. Perfusion 2022:2676591221094696. [DOI: 10.1177/02676591221094696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Cerebrovascular autoregulation impairment has been associated with stroke risk in cardiac surgery. We hypothesized that greater arterial emboli exposure in open-chamber surgery might promote dysautoreguation. Methods: Forty patients underwent closed or open-chamber surgery. Transcranial Doppler detected emboli and measured bilateral middle cerebral artery flow velocities. Cerebral autoregulation was assessed by averaging the mean velocity index (“Mx,” a continuous moving correlation between cerebral blood flow velocity and mean arterial pressure) over 30 min before and after aortic cross-clamp removal. Results: Median (interquartile range) emboli counts were 775 (415, 1211) and 2664 (793, 3734) in the closed-chamber and open-chamber groups. Most appeared after the removal of the aortic cross-clamp (open-chamber 1631 (606, 2296)), (closed-chamber 229 (142, 384)), with emphasis on the right hemisphere (open-chamber: 826 (371, 1622)), (closed-chamber 181 (66, 276)). Linear mixed model analyses of mean velocity index change showed no significant overall effect of group (0.08, 95% CI: −0.04, 0.21; p = 0.19) or side (0.01, 95% CI: −0.03, 0.05; p = 0.74). There was an interaction between group and side ( p = 0.001), manifesting as a greater increase in mean velocity index in the right hemisphere in the open than the closed group (mean difference: 0.15, 95% CI: 0.02, 0.27; p = 0.03). Conclusions: Overall, change in mean velocity index before and after cross-clamp removal did not differ between groups. However, most emboli entered the right cerebral hemisphere where this change was significantly greater in the open-chamber group, suggesting a possible association between embolic exposure and dysautoregulation.
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Affiliation(s)
- Ghazwan NS Jabur
- Department of Clinical Perfusion, Auckland City Hospital, New Zealand
- Department of Anaesthesiology, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Alan F Merry
- Department of Anaesthesiology, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
- Department of Anaesthesia, Auckland City Hospital, New Zealand
| | - Alastair McGeorge
- Cardiovascular Intensive Care Unit, Auckland City Hospital, New Zealand
| | - Alana Cavadino
- Epidemiology & Biostatistics, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Joseph Donnelly
- Department of Anaesthesiology, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Simon J Mitchell
- Department of Anaesthesiology, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
- Department of Anaesthesia, Auckland City Hospital, New Zealand
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18
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C Schaefer T, Greive S, Heiland S, Kramer M, Bendszus M, Vollherbst DF. Investigation of Experimental Endovascular Air Embolisms Using a New Model for the Generation and Detection of Highly Calibrated Micro Air Bubbles. J Endovasc Ther 2022; 30:461-470. [PMID: 35255747 DOI: 10.1177/15266028221082010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Air embolism (AE), especially when affecting the brain, is an underrated and potentially life-threatening complication in various endovascular interventions. This study aims to investigate experimental AEs using a new model to generate micro air bubbles (MAB), to assess the impact of a catheter on these MAB, and to demonstrate the applicability of this model in vivo. MATERIALS AND METHODS Micro air bubbles were created using a system based on microfluidic channels. The MAB were detected and analyzed automatically. Micro air bubbles, with a target size of 85 µm, were generated and injected through a microcatheter. The MAB diameters proximal and distal to the catheter were assessed and compared. In a subsequent in vivo application, 2000 MAB were injected into the aorta (at the aortic valve) and into the common carotid artery (CCA) of a rat, respectively, using a microcatheter, resembling AE occurring during cardiovascular interventions. RESULTS Micro air bubbles with a highly calibrated size could be successfully generated (median: 85.5 µm, SD 1.9 µm). After passage of the microcatheter, the MAB were similar in diameter (median: 86.6 µm) but at a lower number (60.1% of the injected MAB) and a substantially higher scattering of diameters (SD 29.6 µm). In vivo injection of MAB into the aorta resulted in cerebral microinfarctions in both hemispheres, whereas injection into the CCA caused exclusively ipsilateral microinfarctions. CONCLUSION Using this new AE model, MAB can be generated precisely and reproducibly, resulting in cerebral microinfarctions. This model is feasible for further studies on the pathophysiology and prevention of AE in cardiovascular procedures.
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Affiliation(s)
- Tabea C Schaefer
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany.,Clinic for Small Animals, Justus Liebig University Gießen, Gießen, Germany
| | - Svenja Greive
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sabine Heiland
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Kramer
- Clinic for Small Animals, Justus Liebig University Gießen, Gießen, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
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19
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Puthettu M, Vandenberghe S, Bagnato P, Gallo M, Demertzis S. Gaseous Microemboli in the Cardiopulmonary Bypass Circuit: Presentation of a Systematic Data Collection Protocol Applied at Istituto Cardiocentro Ticino. Cureus 2022; 14:e22310. [PMID: 35350483 PMCID: PMC8933722 DOI: 10.7759/cureus.22310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 11/05/2022] Open
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20
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Nakahara M, Uozumi Y, Enami H, Arai A, Kanda T, Nakai H, Kohmura E, Sasayama T. Symptomatic Intracranial Artery Stenosis Due to an Unknown Embolus Following Cardiac Surgery: A Case Report. NMC Case Rep J 2022; 8:513-518. [PMID: 35079511 PMCID: PMC8769471 DOI: 10.2176/nmccrj.cr.2020-0404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/24/2021] [Indexed: 11/26/2022] Open
Abstract
Intracranial artery occlusion due to a foreign body is a complication associated with cardiac surgery that is treated by various techniques. However, little is known about appropriate strategies for symptomatic intracranial artery stenosis due to an unknown embolic source. We reported a case of middle cerebral artery (MCA) stenosis after mitral valve repair (MVR) for infective endocarditis (IE). An 80-year-old man presented with right hemiplegia. MR angiography findings were normal, and diffusion-weighted imaging revealed subtle ischemic change in the left MCA territory. The patient was diagnosed with cardioembolic stroke owing to IE and performed MVR. Four days later, he suddenly presented with consciousness disorder and left hemiplegia. Computed tomography (CT) confirmed a very low-density area within the right MCA. MR angiography revealed right MCA stenosis, which corresponded to the low-density area on CT images. Diffusion-weighted imaging revealed new ischemic change in the right MCA territory. Angiography confirmed an irregular stenosis at the right M2 with antegrade blood flow, and the hemiplegia resolved during angiography. Conservative therapy was performed; however, the resting 123 I-IMP-single photon emission CT revealed moderate perfusion defect in the right MCA territory, and transient left hemiplegia appeared every few days. Therefore, 19 days after the initial transient ischemic attack, the patient was performed superficial temporal artery–MCA anastomosis, and the patient responded with a good clinical course without recurrence of the ischemic symptoms. This strategy may be a safe and effective treatment for symptomatic intracranial artery stenosis due to an unknown embolic source.
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Affiliation(s)
- Masahiro Nakahara
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yoichi Uozumi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Haruka Enami
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Atsushi Arai
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Tomonori Kanda
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Hidekazu Nakai
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Eiji Kohmura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Takashi Sasayama
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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21
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Verma A, Asivatham SJ, Deneke T, Castellvi Q, Neal RE. Primer on Pulsed Electrical Field Ablation: Understanding the Benefits and Limitations. Circ Arrhythm Electrophysiol 2021; 14:e010086. [PMID: 34538095 DOI: 10.1161/circep.121.010086] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Pulsed electrical field (PEF) energy is a promising technique for catheter ablation of cardiac arrhythmias. In this article, the key aspects that need to be considered for safe and effective PEF delivery are reviewed, and their impact on clinical feasibility is discussed. The most important benefit of PEF appears to be the ability to kill cells through mechanisms that do not alter stromal proteins, sparing sensitive structures to improve safety, without sacrificing cardiomyocyte ablation efficacy. Many parameters affect PEF treatment outcomes, including pulse intensity, waveform shape, and number of pulses, as well as electrode configuration and geometry. These physical and electrical characteristics must be titrated carefully to balance target tissue effects with collateral implications (muscle contraction, temperature rise, risk of electrical arcing events). It is important to note that any combination of parameters affecting PEF needs to be tested for clinical efficacy and safety. Applying PEF clinically requires knowledge of the fundamentals of this technology to exploit its opportunities and generate viable, durable health improvements for patients.
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Affiliation(s)
- Atul Verma
- Division of Cardiology, Southlake Regional Health Center, University of Toronto, Newmarket, Canada (A.V.)
| | - Samuel J Asivatham
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (S.J.A.)
| | - Thomas Deneke
- Division of Cardiology, Rhon-Klinikum Campus Bad Neustadt, Bad Neustadt, Germany (T.D.)
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22
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Groen MHA, van Es R, van Klarenbosch BR, Stehouwer M, Loh P, Doevendans PA, Wittkampf FH, Neven K. In vivo analysis of the origin and characteristics of gaseous microemboli during catheter-mediated irreversible electroporation. Europace 2021; 23:139-146. [PMID: 33111141 PMCID: PMC7842095 DOI: 10.1093/europace/euaa243] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 07/27/2020] [Indexed: 01/21/2023] Open
Abstract
Aims Irreversible electroporation (IRE) ablation is a non-thermal ablation method based on the application of direct current between a multi-electrode catheter and skin electrode. The delivery of current through blood leads to electrolysis. Some studies suggest that gaseous (micro)emboli might be associated with myocardial damage and/or (a)symptomatic cerebral ischaemic events. The aim of this study was to compare the amount of gas generated during IRE ablation and during radiofrequency (RF) ablation. Methods and results In six 60–75 kg pigs, an extracorporeal femoral shunt was outfitted with a bubble-counter to detect the size and total volume of gas bubbles. Anodal and cathodal 200 J IRE applications were delivered in the left atrium (LA) using a 14-electrode circular catheter. The 30 and 60 s 40 W RF point-by-point ablations were performed. Using transoesophageal echocardiography (TOE), gas formation was visualized. Average gas volumes were 0.6 ± 0.6 and 56.9 ± 19.1 μL (P < 0.01) for each anodal and cathodal IRE application, respectively. Also, qualitative TOE imaging showed significantly less LA bubble contrast with anodal than with cathodal applications. Radiofrequency ablations produced 1.7 ± 2.9 and 6.7 ± 7.4 μL of gas, for 30 and 60 s ablation time, respectively. Conclusion Anodal IRE applications result in significantly less gas formation than both cathodal IRE applications and RF applications. This finding is supported by TOE observations.
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Affiliation(s)
- Marijn H A Groen
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - René van Es
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Bas R van Klarenbosch
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marco Stehouwer
- Department of Extracorporeal Circulation, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Peter Loh
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands
| | - Fred H Wittkampf
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Kars Neven
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany.,Faculty of Health, Witten/Herdecke University, Witten, Germany
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23
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Tsaousi G, Tramontana A, Yamani F, Bilotta F. Cerebral Perfusion and Brain Oxygen Saturation Monitoring with: Jugular Venous Oxygen Saturation, Cerebral Oximetry, and Transcranial Doppler Ultrasonography. Anesthesiol Clin 2021; 39:507-523. [PMID: 34392882 DOI: 10.1016/j.anclin.2021.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Accumulating evidence indicates that cerebral desaturation in the perioperative period occurs more frequently than recognized. Combining monitoring modalities that reflect different aspects of cerebral perfusion status, such as near-infrared spectroscopy, jugular bulb saturation, and transcranial Doppler ultrasonography, may provide an extended window for prevention, early detection, and prompt intervention in ongoing hypoxic/ischemic neuronal injury and, thereby, improve neurologic outcome. Such an approach would minimize the impact of limitations of each monitoring modality, while individual components complement each other, enhancing the accuracy of acquired information. Current literature has failed to demonstrate any clear-cut clinical benefit of these modalities on outcome prognosis.
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Affiliation(s)
- Georgia Tsaousi
- Department of Anesthesiology and ICU, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece
| | - Alessio Tramontana
- Department of Anesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I, "Sapienza" University of Rome, viale del Policlinico 151, 00185 Rome, Italy
| | - Farouk Yamani
- Department of Anesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I, "Sapienza" University of Rome, viale del Policlinico 151, 00185 Rome, Italy
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I, "Sapienza" University of Rome, viale del Policlinico 151, 00185 Rome, Italy.
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24
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Puthettu M, Vandenberghe S, Demertzis S. Effect of cannulation site on emboli travel during cardiac surgery. J Cardiothorac Surg 2021; 16:181. [PMID: 34162399 PMCID: PMC8220729 DOI: 10.1186/s13019-021-01564-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 06/06/2021] [Indexed: 11/10/2022] Open
Abstract
Background During cardiac surgery, micro-air emboli regularly enter the blood stream and can cause cognitive impairment or stroke. It is not clearly understood whether the most threatening air emboli are generated by the heart-lung machine (HLM) or by the blood-air contact when opening the heart. We performed an in vitro study to assess, for the two sources, air emboli distribution in the arterial tree, especially in the brain region, during cardiac surgery with different cannulation sites. Methods A model of the arterial tree was 3D printed and included in a hydraulic circuit, divided such that flow going to the brain was separated from the rest of the circuit. Air micro-emboli were injected either in the HLM (“ECC Bubbles”) or in the mock left ventricle (“Heart Bubbles”) to simulate the two sources. Emboli distribution was measured with an ultrasonic bubble counter. Five repetitions were performed for each combination of injection site and cannulation site, where air bubble counts and volumes were recorded. Air bubbles were separated in three categories based on size. Results For both injection sites, it was possible to identify statistically significant differences between cannulation sites. For ECC Bubbles, axillary cannulation led to a higher amount of air bubbles in the brain with medium-sized bubbles. For Heart Bubbles, aortic cannulation showed a significantly bigger embolic load in the brain with large bubbles. Conclusions These preliminary in vitro findings showed that air embolic load in the brain may be dependent on the cannulation site, which deserves further in vivo exploration.
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Affiliation(s)
- Mira Puthettu
- Foundation for Cardiovascular Research and Education (FCRE), Cardiovascular Engineering, Istituto Cardiocentro Ticino, Via ai Söi 24, 6807, Torricella-Taverne, Switzerland.
| | - Stijn Vandenberghe
- Department of Cardiac Surgery, Istituto Cardiocentro Ticino, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Stefanos Demertzis
- Department of Cardiac Surgery, Istituto Cardiocentro Ticino, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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25
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Pandey P, Setya D, Sinha VK, Devra AK, Bhatt AP, Pande A, Kumar P, Singh MK, Ranjan S. Outcome of desensitization in human leukocyte antigen and ABO incompatible living donor kidney transplantation: Single center experience of first 200 incompatible transplants. J Clin Apher 2020; 36:299-312. [PMID: 33316838 DOI: 10.1002/jca.21860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/20/2020] [Accepted: 11/12/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS Although desensitization is well established, concerns about graft outcome, patient survival and rejection still exist. The present study aims at comparing outcomes of renal transplant recipients across simultaneous ABO and human leukocyte antigen (HLA) incompatibility barriers to those with ABO or HLA incompatibility alone. MATERIALS AND METHODS This was a retrospective study conducted from October 2015 to December 2018. All patients with a clinical diagnosis of chronic kidney disease, who were prospective HLA incompatible (HLAi) and/or ABO incompatible (ABOi) renal transplant recipients were included. A total of 400 cases including 36 ABOi transplants, 154 HLAi transplants, 10 simultaneously ABO and HLA incompatible transplants, and 200 ABO (ABOc) and HLA (HLAc) compatible kidney transplants from living donors were included. RESULTS There were significantly more number of blood transfusions, previous transplants and pregnancies in HLAi transplant recipients relative to the ABOi or the control group. Mean number of therapeutic plasma exchange procedures per patient and mean plasma volume processed per procedure were slightly higher in the ABOi + HLAi category. The incidence of graft dysfunction due to suspected antibody-mediated rejection during first year was highest in the ABOi + HLAi group, followed by ABOc + HLAi and ABOi + HLAc, lowest in the ABOc + HLAc category. Mean time to first episode of graft dysfunction was significantly shorter with incompatible transplants. There were no kidney transplant recipient deaths in the study. CONCLUSION Patient outcome and graft outcomes observed with incompatible transplants were not worse than those observed with compatible transplants.
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Affiliation(s)
- Prashant Pandey
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Divya Setya
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Vijay Kumar Sinha
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Amit K Devra
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Anil Prasad Bhatt
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Amit Pande
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Praveen Kumar
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Mukesh Kumar Singh
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Shweta Ranjan
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
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26
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Patel N, Banahan C, Janus J, Horsfield MA, Cox A, Marshall D, Colman J, Morlese J, Evans DH, Hannon C, Egan V, Garrard P, Hague JP, Chung EML. Neurological impact of emboli during adult cardiac surgery. J Neurol Sci 2020; 416:117006. [PMID: 32623144 PMCID: PMC7718579 DOI: 10.1016/j.jns.2020.117006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/05/2020] [Accepted: 06/19/2020] [Indexed: 11/29/2022]
Abstract
Objectives This study draws on advances in Doppler ultrasound bubble sizing to investigate whether high volumes of macro-bubbles entering the brain during cardiac surgery increase the risk of new cerebral microbleeds (CMBs), ischemic MR lesions, or post-operative cognitive decline (POCD). Methods Transcranial Doppler (TCD) ultrasound recordings were analysed to estimate numbers of emboli and macrobubbles (>100 μm) entering the brain during cardiac surgery. Logistic regression was used to explore the hypothesis that emboli characteristics affect the incidence of new brain injuries identified through pre- and post-operative MRI and neuropsychological testing. Results TCD, MRI, and neuropsychological test data were compared between 28 valve and 18 CABG patients. Although valve patients received over twice as many emboli per procedure [median: 1995 vs. 859, p = .004], and seven times as many macro-bubbles [median: 218 vs. 28, p = .001], high volumes of macrobubbles were not found to be significantly associated with new CMBs, new ischaemic lesions, or POCD. The odds of acquiring new CMBs increased by approximately 5% [95% CI: 1 to 10%] for every embolus detected in the first minute after the release of the aortic cross-clamp (AxC). Logistic regression models also confirmed previous findings that cardiopulmonary bypass time and valve surgery were significant predictors for new CMBs (both p = .03). Logistic regression analysis estimated an increase in the odds of acquiring new CMBs of 6% [95% CI: 1 to 12%] for every minute of bypass time over 91 mins. Conclusions This small study provides new information about the properties and numbers of bubbles entering the brain during surgery, but found no evidence to substantiate a direct link between large numbers of macrobubbles and adverse cognitive or MR outcome. Clinical Trial Registration URL - http://www.isrctn.com. Unique identifier: 66022965. Higher numbers of macrobubbles enter the brain during valve surgery compared to bypass graft surgery. Macrobubbles did not appear to be linked to new cerebral microbleeds, ischemic lesions, or cognitive decline. Emboli received following release of the aortic cross-clamp predicted new cerebral microbleeds. Other factors predicting new microbleeds included cardiopulmonary bypass duration and surgery type.
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Affiliation(s)
- Nikil Patel
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK; Leicester Biomedical Research Centre, Glenfield Hospital, Leicester LE3 9QP, UK; Department of Clinical Neurosciences, St George's, University of London, London SW17 ORE, UK
| | - Caroline Banahan
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK
| | - Justyna Janus
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK
| | - Mark A Horsfield
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK
| | - Anthony Cox
- Department of Clinical Neurosciences, St George's, University of London, London SW17 ORE, UK
| | - David Marshall
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK
| | - Jordan Colman
- Department of Clinical Neurosciences, St George's, University of London, London SW17 ORE, UK
| | - John Morlese
- University Hospitals of Leicester NHS Trust, Leicester LE1 5WW, UK
| | - David H Evans
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK
| | - Claire Hannon
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK
| | - Vincent Egan
- Department of Psychiatry and Applied Psychology, University of Nottingham, Nottingham NG8 1BB, UK
| | - Peter Garrard
- Department of Clinical Neurosciences, St George's, University of London, London SW17 ORE, UK
| | - James P Hague
- School of Physical Sciences, The Open University, Walton Hall, Milton Keyns, MK7 6AA, UK
| | - Emma M L Chung
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK; Leicester Biomedical Research Centre, Glenfield Hospital, Leicester LE3 9QP, UK; University Hospitals of Leicester NHS Trust, Leicester LE1 5WW, UK.
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27
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Zhang H, Yang A, Xu M, Liu S. A Modiied 3-Way Tap to Enhance the Stability and Uniformity of Sclerosant Foam. Ann Vasc Surg 2020; 70:501-505. [PMID: 32889163 DOI: 10.1016/j.avsg.2020.08.116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/03/2020] [Accepted: 08/23/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND The Tessari method, mixing air with the sclerosant through a 3-way tap and 2 syringes, is the most widely used method to prepare foam in foam sclerotherapy. Uniform foam with smaller bubbles has great clinical significance for venous insufficiency. We aim to modify the traditional 3-way tap to produce more uniform and stable foam with smaller bubbles. METHODS The traditional 3-way tap was modified by inserting a porous film within its channel. EXPERIMENT DESIGN the foam was prepared with 2 mL polidocanol plus 8 mL air plus 0.05 mL hyaluronic acid; group 1, foam prepared with 20 quick passes through a traditional 3-way tap; and groups 2-7, foam prepared using the modified 3-way tap, with 10, 12, 14, 16, 18, and 20 quick passes, respectively. The uniformity of the foam was observed under optical microscopy, and the size of bubbles quantified using the Nano measurement software. The stability of the foam was evaluated using the foam half-life time. RESULTS The foam half-life times of groups 1-7 were 306.4, 257.4, 285.6, 304.4, 318.6, 330.2, 331.3 sec, respectively. The modified tap also produced a more uniform distribution of smaller bubbles (group 7) compared with traditional tap (group 1). CONCLUSIONS Modified 3-way tap enhanced the stability of the sclerosant foam, with a more uniform distribution of smaller bubbles.
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Affiliation(s)
- Hao Zhang
- Department of Oral and Maxillofacial Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China; Institute of Stomatology, Shandong University, Jinan, Shandong, China; Department of Oral and Maxillofacial Surgery, School of Stomatology, Shandong University, Jinan, Shandong, China
| | - AiJun Yang
- Library of Shandong University, Jinan, Shandong, China
| | - MingPei Xu
- Institute of Stomatology, Shandong University, Jinan, Shandong, China; Department of Plastic Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - ShaoHua Liu
- Department of Oral and Maxillofacial Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China; Institute of Stomatology, Shandong University, Jinan, Shandong, China.
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Izzat MB. Effective handling of substantial arterial air embolization during extracorporeal perfusion. Clin Case Rep 2019; 7:2568-2570. [PMID: 31893101 PMCID: PMC6935650 DOI: 10.1002/ccr3.2510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/17/2019] [Accepted: 09/26/2019] [Indexed: 11/05/2022] Open
Abstract
This report highlights the need for a coordinated approach to substantial arterial air embolization, considering the high risk of neurologic injury. Appropriate management may involve systemic hypothermia, hyperoxia, and retrograde cerebral perfusion.
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Critello CD, Pullano SA, Matula TJ, De Franciscis S, Serra R, Fiorillo AS. Recent developments on foaming mechanical and electronic techniques for the management of varicose veins. Expert Rev Med Devices 2019; 16:931-940. [PMID: 31622557 DOI: 10.1080/17434440.2019.1682549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Introduction: Varicose veins are a common disease, causing significant impairment of quality of life to afflicted individuals. Conventional surgery has represented the traditional treatment for years, with significant post-operative complications. By the end of the 20th century, novel approaches had been developed to induce biochemical sclerosis into the treated vein in order to exclude it from blood circulation.Areas covered: Foaming techniques for treatment of varicose veins, both clinically-approved methods and those under experimental studies. A brief description of cavitation, which is the basis of microbubbles formation, and an overview of foam properties have been also provided, including a discussion on clinical efficacy and safety profile.Expert commentary: Foam sclerotherapy has rapidly gained popularity since it represents the most minimally invasive and cost-effective procedure in the short term. Several different methods of foam preparation have been described in literature. In general, the foam generation method may affect characteristics such as stability and bubble size distribution, which in turn affect the therapeutic action of foam itself. Therefore, the selection of a suitable foaming technique is of importance for treatment success. Future developments on foaming techniques are expected to make sclerotherapy, already an effective treatment, even safer and more versatile therapeutic procedure.
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Affiliation(s)
- C Davide Critello
- Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Salvatore A Pullano
- Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Thomas J Matula
- Applied Physics Laboratory, University of Washington, Seattle, WA, USA
| | - Stefano De Franciscis
- Department of Surgical and Medical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- Department of Surgical and Medical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Antonino S Fiorillo
- Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
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Patel N, Banahan C, Janus J, Horsfield MA, Cox A, Li X, Cappellugola L, Colman J, Egan V, Garrard P, Chung EM. Perioperative Cerebral Microbleeds After Adult Cardiac Surgery. Stroke 2019; 50:336-343. [PMID: 30572811 PMCID: PMC6354910 DOI: 10.1161/strokeaha.118.023355] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background and Purpose- Cerebral microbleeds (CMBs) have been observed using magnetic resonance imaging in patients with cardiovascular risk factors, cognitive deterioration, small vessel disease, and dementia. They are a well-known consequence of cerebral amyloid angiopathy, chronic hypertension, and diffuse axonal injury, among other causes. However, the frequency and location of new CMBs postadult cardiac surgery, in association with cognition and perioperative risk factors, have yet to be studied. Methods- Pre- and postsurgery magnetic resonance susceptibility-weighted images and neuropsychological tests were analyzed from a total of 75 patients undergoing cardiac surgery (70 men; mean age, 63±10 years). CMBs were identified by a neuroradiologist blinded to clinical details who independently assessed the presence and location of CMBs using standardized criteria. Results- New CMBs were identified in 76% of patients after cardiac surgery. The majority of new CMBs were located in the frontal lobe (46%) followed by the parietal lobe (15%), cerebellum (13%), occipital lobe (12%), and temporal lobe (8%). Patients with new CMBs typically began with a higher prevalence of preexisting CMBs ( P=0.02). New CMBs were associated with longer cardiopulmonary bypass times ( P=0.003), and there was a borderline association with lower percentage hematocrit ( P=0.04). Logistic regression analysis suggested a ≈2% increase in the odds of acquiring new CMBs during cardiac surgery for every minute of bypass time (odds ratio, 1.02; 95% CI, 1.00-1.05; P=0.04). Postoperative neuropsychological decline was observed in 44% of patients and seemed to be unrelated to new CMBs. Conclusions- New CMBs identified using susceptibility-weighted images were found in 76% of patients who underwent cardiac surgery. CMBs were globally distributed with the highest numbers in the frontal and parietal lobes. Our regression analysis indicated that length of cardiopulmonary bypass time and lowered hematocrit may be significant predictors for new CMBs after cardiac surgery. Clinical Trial Registration- URL: http://www.isrctn.com . Unique identifier: 66022965.
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Affiliation(s)
- Nikil Patel
- From the Department of Cardiovascular Sciences, University of Leicester, United Kingdom (N.P., J.J., M.A.H., L.C., E.M.L.C.)
- NIHR Leicester Biomedical Research Centre–Cardiovascular Theme, Glenfield Hospital, United Kingdom (N.P., E.M.L.C.)
- Department of Clinical Neurosciences, St George’s, University of London, United Kingdom (N.P., X.L., J.C., P.G.)
| | - Caroline Banahan
- Department of Medical Physics, University Hospitals of Leicester NHS Trust, United Kingdom (C.B., E.M.L.C.)
| | - Justyna Janus
- From the Department of Cardiovascular Sciences, University of Leicester, United Kingdom (N.P., J.J., M.A.H., L.C., E.M.L.C.)
| | - Mark A. Horsfield
- From the Department of Cardiovascular Sciences, University of Leicester, United Kingdom (N.P., J.J., M.A.H., L.C., E.M.L.C.)
| | - Anthony Cox
- Neuroradiology Department, St George’s Hospital, London, United Kingdom (A.C.)
| | - Xingfeng Li
- Department of Clinical Neurosciences, St George’s, University of London, United Kingdom (N.P., X.L., J.C., P.G.)
| | - Laurie Cappellugola
- From the Department of Cardiovascular Sciences, University of Leicester, United Kingdom (N.P., J.J., M.A.H., L.C., E.M.L.C.)
| | - Jordan Colman
- Department of Clinical Neurosciences, St George’s, University of London, United Kingdom (N.P., X.L., J.C., P.G.)
| | - Vincent Egan
- Department of Psychiatry and Applied Psychology, University of Nottingham, United Kingdom (V.E.)
| | - Peter Garrard
- Department of Clinical Neurosciences, St George’s, University of London, United Kingdom (N.P., X.L., J.C., P.G.)
| | - Emma M.L. Chung
- From the Department of Cardiovascular Sciences, University of Leicester, United Kingdom (N.P., J.J., M.A.H., L.C., E.M.L.C.)
- NIHR Leicester Biomedical Research Centre–Cardiovascular Theme, Glenfield Hospital, United Kingdom (N.P., E.M.L.C.)
- Department of Medical Physics, University Hospitals of Leicester NHS Trust, United Kingdom (C.B., E.M.L.C.)
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Born F, König F, Chen J, Günther S, Hagl C, Thierfelder N. Generation of microbubbles in extracorporeal life support and assessment of new elimination strategies. Artif Organs 2019; 44:268-277. [DOI: 10.1111/aor.13557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/08/2019] [Accepted: 08/09/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Frank Born
- Department of Cardiac Surgery, Grosshadern Medical Center Ludwig Maximilian University of Munich Munich Germany
| | - Fabian König
- Department of Cardiac Surgery, Grosshadern Medical Center Ludwig Maximilian University of Munich Munich Germany
- Institute of Medical and Polymer Engineering Technical University of Munich Garching Germany
| | - Jinchi Chen
- Institute of Medical and Polymer Engineering Technical University of Munich Garching Germany
| | - Sabina Günther
- Department of Cardiac Surgery, Grosshadern Medical Center Ludwig Maximilian University of Munich Munich Germany
| | - Christian Hagl
- Department of Cardiac Surgery, Grosshadern Medical Center Ludwig Maximilian University of Munich Munich Germany
| | - Nikolaus Thierfelder
- Department of Cardiac Surgery, Grosshadern Medical Center Ludwig Maximilian University of Munich Munich Germany
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Es R, Groen MHA, Stehouwer M, Doevendans PA, Wittkampf FHM, Neven K. In vitro analysis of the origin and characteristics of gaseous microemboli during catheter electroporation ablation. J Cardiovasc Electrophysiol 2019; 30:2071-2079. [DOI: 10.1111/jce.14091] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/04/2019] [Accepted: 07/21/2019] [Indexed: 12/15/2022]
Affiliation(s)
- René Es
- Department of CardiologyUniversity Medical Center UtrechtUtrecht The Netherlands
| | - Marijn H. A. Groen
- Department of CardiologyUniversity Medical Center UtrechtUtrecht The Netherlands
| | - Marco Stehouwer
- Department of Extracorporeal CirculationSt Antonius HospitalNieuwegein The Netherlands
| | - Pieter A. Doevendans
- Department of CardiologyUniversity Medical Center UtrechtUtrecht The Netherlands
- Netherlands Heart InstituteUtrecht The Netherlands
| | - Fred H. M. Wittkampf
- Department of CardiologyUniversity Medical Center UtrechtUtrecht The Netherlands
| | - Kars Neven
- Department of CardiologyUniversity Medical Center UtrechtUtrecht The Netherlands
- Department of ElectrophysiologyAlfried Krupp KrankenhausEssen Germany
- Faculty of HealthWitten/Herdecke UniversityWitten Germany
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Graf A, Steffen C, Frick S. Spontaneous intracardiac microcavitations in a patient with a colonic carcinoma. BMJ Case Rep 2019; 12:12/9/e229932. [PMID: 31492727 PMCID: PMC6731782 DOI: 10.1136/bcr-2019-229932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Intracardiac microcavitations consist of airy microbubbles. They are typically found in patients with an intravascular line or device, mechanical heart valves or in decompression sickness. We report a case of a patient in mid-70s who was admitted due to weakness in both legs, left-thoracic pain and fever. Despite the lack of any of the risk factors mentioned above, spontaneous microcavitations were detected in the right sided cardiac cavities. After the detection of liver lesions suspicious for a metastatic disease, a colonoscopy was performed. An ulcerated colonic carcinoma at the ileocoecal valve was diagnosed and highly suspicious for being the entry port of the microcavitations. This unusual presentation of microcavitations together with a colonic neoplasia leads to hypotheses about the journey of the microbubbles from the ascending colon into the right heart. Gastrointestinal tumours are described as being the causes of microbubbles. Translocation of microbubbles through hepatopulmonary shunting are described in the context of locally applied particles of similar size during radioembolisation. A thorough aetiological workup is of importance since the underlying cause is potentially dangerous due to its own nature of disease and due the complications of the microcavitations such as paradoxical emboli or pulmonary sequelae.
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Affiliation(s)
| | | | - Sonia Frick
- Internal Medicine, Spital Lachen, Lachen, Switzerland
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34
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Stehouwer MC, de Vroege R, Bruggemans EF, Hofman FN, Molenaar MA, van Oeveren W, de Mol BA, Bruins P. The influence of gaseous microemboli on various biomarkers after minimized cardiopulmonary bypass. Perfusion 2019; 35:202-208. [DOI: 10.1177/0267659119867572] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Gaseous microemboli that originate from the cardiopulmonary bypass circuit may contribute to adverse outcome after cardiac surgery. We prospectively evaluated the influence of gaseous microemboli on the release of various biomarkers after use of a minimally invasive extracorporeal technology system. Methods: In 70 patients undergoing coronary artery bypass grafting with minimized cardiopulmonary bypass, gaseous microemboli were measured intraoperatively with a bubble counter. Intra- and postoperative biomarker levels for inflammatory response (interleukin-6, C5b-9), endothelial damage (von Willebrand factor, soluble vascular cell adhesion molecule-1), oxidative stress (malondialdehyde, 8-isoprostane, neuroketal), and neurological injury (neuron-specific enolase, brain-type fatty acid-binding protein) were analyzed using immune assay techniques. The relationship between gaseous microemboli number or volume and the incremental area under the curve (iAUC24h) or peak change for the biomarkers was calculated. Results: All biomarkers except for malondialdehyde increased at least temporarily after coronary artery bypass grafting with a minimally invasive extracorporeal technology system. The median total gaseous microemboli number was 6,174 (interquartile range: 3,507-10,531) and the median total gaseous microemboli volume was 4.31 µL (interquartile range: 2.71-8.50). There were no significant correlations between total gaseous microemboli number or volume and iAUC24h or peak change for any of the biomarkers. After controlling for the variance of possible other predictor variables, multiple linear regression analysis showed no association between gaseous microemboli parameters and release of biomarkers. Conclusion: This study showed no evidence that gaseous microemboli contribute to increased biomarker levels after coronary artery bypass grafting with cardiopulmonary bypass. A reason for the absence of damage by gaseous microemboli may be the relative and considerably small amount of gaseous microemboli entering the patients in this study.
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Affiliation(s)
- Marco C Stehouwer
- Department of Extracorporeal Circulation, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Roel de Vroege
- Department of Extracorporeal Circulation, HAGA Hospital, The Hague, The Netherlands
| | | | - Frederik N Hofman
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Meyke A Molenaar
- Department of Anaesthesiology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Wim van Oeveren
- Laboratory for Blood Compatibility and Biomarker Detection, HaemoScan, Groningen, The Netherlands
| | - Bastian A de Mol
- Section Cardiovascular Biomechanics, Faculty of Biomedical Technology, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Peter Bruins
- Department of Anaesthesiology, Intensive Care and Pain Management, St. Antonius Hospital, Nieuwegein, The Netherlands
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35
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Breiding PS, Duerrenmatt JT, Meinel FG, Carrel T, Schönhoff F, Zibold F, Kaesmacher J, Gralla J, Pilgrim T, Jung S, Fischer U, Arnold M, Meinel TR. Prevalence and Evolution of Susceptibility-Weighted Imaging Lesions in Patients With Artificial Heart Valves. J Am Heart Assoc 2019; 8:e012814. [PMID: 31379252 PMCID: PMC6761656 DOI: 10.1161/jaha.119.012814] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background In patients with mechanical heart valves, cerebral susceptibility‐weighted imaging (SWI) lesions on magnetic resonance imaging, postulated to be caused by degenerative metallic abrasion, are frequently referred to as valve abrasion. It remains unclear whether valve implantation not requiring cardiopulmonary bypass or biological heart valves also shows those lesions. Methods and Results Two blinded readers rated SWI lesions and cerebral amyloid angiopathy probability according to established criteria on brain magnetic resonance imaging pre‐ and postinterventionally. We assessed the association between valve type/cardiopulmonary bypass use and SWI lesion count on the first postinterventional scan using multivariable logistic regression. On postinterventional magnetic resonance imaging, 57/58 (98%) patients with mechanical heart valves had at least 1 and 46/58 (79%) 3 or more SWI lesions, while 92/97 (95%) patients with biological heart valves had at least 1 and 72/97 (74%) 3 or more SWI lesions. On multivariate analysis, duration of cardiopulmonary bypass during implantation significantly increased the odds of having SWI lesions on the first postinterventional magnetic resonance imaging (β per 10 minutes 0.498; 95% CI, 0.116–0.880; P=0.011), whereas valve type showed no significant association (P=0.338). Thirty‐seven of 155 (23.9%) patients fulfilled the criteria of possible/probable cerebral amyloid angiopathy. Conclusions SWI lesions in patients with artificial heart valves evolve around the time point of valve implantation and the majority of patients had multiple lesions. The missing association with the valve type weakens the hypothesis of degenerative metallic abrasion and highlights cardiopulmonary bypass as the main risk factor for SWI occurrence. SWI lesions associated with cardiac procedures can mimic cerebral amyloid angiopathy. Further research needs to clarify whether those lesions are associated with intracranial hemorrhage after intravenous thrombolysis or anticoagulation.
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Affiliation(s)
- Philipe S Breiding
- University Institute of Diagnostic and Interventional Neuroradiology University Hospital Bern Inselspital University of Bern Switzerland
| | - Jana T Duerrenmatt
- Department of Neurology University Hospital Bern Inselspital University of Bern Switzerland
| | - Felix G Meinel
- Institute of Diagnostic and Interventional Radiology Rostock University Medical Center Rostock Germany
| | - Thierry Carrel
- Department of Cardiothoracic Surgery University Hospital Bern Inselspital University of Bern Switzerland
| | - Florian Schönhoff
- Department of Cardiothoracic Surgery University Hospital Bern Inselspital University of Bern Switzerland
| | - Felix Zibold
- University Institute of Diagnostic and Interventional Neuroradiology University Hospital Bern Inselspital University of Bern Switzerland
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology University Hospital Bern Inselspital University of Bern Switzerland.,Department of Neurology University Hospital Bern Inselspital University of Bern Switzerland.,Institute of Diagnostic, Interventional and Pediatric Radiology University Hospital Bern Inselspital University of Bern Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology University Hospital Bern Inselspital University of Bern Switzerland
| | - Thomas Pilgrim
- Department of Cardiology University Hospital Bern Inselspital University of Bern Switzerland
| | - Simon Jung
- Department of Neurology University Hospital Bern Inselspital University of Bern Switzerland
| | - Urs Fischer
- Department of Neurology University Hospital Bern Inselspital University of Bern Switzerland
| | - Marcel Arnold
- Department of Neurology University Hospital Bern Inselspital University of Bern Switzerland
| | - Thomas R Meinel
- Department of Neurology University Hospital Bern Inselspital University of Bern Switzerland
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Benstoem C, Bleilevens C, Borchard R, Stoppe C, Goetzenich A, Autschbach R, Breuer T. Retrospective Analysis of Air Handling by Contemporary Oxygenators in the Setting of Cardiac Surgery. Ann Thorac Cardiovasc Surg 2018; 24:230-237. [PMID: 29998925 PMCID: PMC6197996 DOI: 10.5761/atcs.oa.18-00019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Purpose: Cardiac surgery with the use of extracorporeal circulation is associated with a significant risk for gaseous microemboli (GME) despite excellent surgical techniques and highest operative standards. GME are associated with postoperative neurocognitive dysfunction and negative clinical outcome. This study determines whether oxygenator design has influence on perioperative outcome after cardiac surgery. Methods: Three different oxygenator models with integrated arterial filter (HiliteAF 7000, Fusion Affinity, and Synthesis) were retrospectively evaluated in 55 patients undergoing elective cardiac surgery with the use of extracorporeal circulation. The two-channel ultrasound bubble counter BCC200 was used to detect GME in real time. Results: All three oxygenators differ in terms of structural specifications and have different rates of number and volume GME reduction. The Fusion Affinity had the lowest arterial GME volume (1.81 µL ± 0.23 µL), which was statistically significant compared to the Synthesis (3.37 µL ± 0.71 µL, p = 0.014). However, the Synthesis had lower absolute numbers at the venous GME count (31771 µL ± 6579 µL) versus the Fusion Affinity (49304 µL ± 8196 µL). However, with regard to clinical outcome after cardiac surgery (duration of invasive and non-invasive mechanical ventilation, incidence of delirium, stroke, acute renal failure, or new myocardial infarction), we found no differences between groups. Conclusion: Despite significant differences in the design specifications, all oxygenators eliminated relevant GME volumes safely.
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Segers T, Stehouwer MC, de Somer FMJJ, de Mol BA, Versluis M. Optical verification and in-vitro characterization of two commercially available acoustic bubble counters for cardiopulmonary bypass systems. Perfusion 2017; 33:16-24. [PMID: 28766987 PMCID: PMC5734373 DOI: 10.1177/0267659117722595] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Introduction: Gaseous microemboli (GME) introduced during cardiac surgery are considered as a potential source of morbidity, which has driven the development of the first bubble counters. Two new generation bubble counters, introduced in the early 2000s, claim correct sizing and counting of GME. This in-vitro study aims to validate the accuracy of two bubble counters using monodisperse bubbles in a highly controlled setting at low GME concentrations. Methods: Monodisperse GME with a radius of 43 µm were produced in a microfluidic chip. Directly after their formation, they were injected one-by-one into the BCC200 and the EDAC sensors. GME size and count, measured with the bubble counters, were optically verified using high-speed imaging. Results: During best-case scenarios or low GME concentrations of GME with a size of 43 µm in radius in an in-vitro setup, the BCC200 overestimates GME size by a factor of 2 to 3 while the EDAC underestimates the average GME size by at least a factor of two. The BCC200 overestimates the GME concentration by approximately 20% while the EDAC overestimates the concentration by nearly one order of magnitude. Nevertheless, the calculated total GME volume is only over-predicted by a factor 2 since the EDAC underestimates the actual GME size. For the BCC200, the total GME volume was over-predicted by 25 times due to the over-estimation of GME size. Conclusions: The measured errors in the absolute sizing/counting of GME do not imply that all results obtained using the bubble counters are insignificant or invalid. A relative change in bubble size or bubble concentration can accurately be measured. However, care must be taken in the interpretation of the results and their absolute values. Moreover, the devices cannot be used interchangeably when reporting GME activity. Nevertheless, both devices can be used to study the relative air removal characteristics of CPB components or for the quantitative monitoring of GME production during CPB interventions.
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Affiliation(s)
- Tim Segers
- 1 Physics of Fluids Group, MESA+ Institute for Nanotechnology and MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Marco C Stehouwer
- 2 Department of Extracorporeal Circulation, St Antonius Hospital, Utrecht, The Netherlands
| | | | - Bastian A de Mol
- 4 Section of Cardiovascular Biomechanics, Faculty of Biomedical Technology, Technical University Eindhoven, The Netherlands
| | - Michel Versluis
- 1 Physics of Fluids Group, MESA+ Institute for Nanotechnology and MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
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Stehouwer MC, de Vroege R, Hoohenkerk GJF, Hofman FN, Kelder JC, Buchner B, de Mol BA, Bruins P. Carbon Dioxide Flush of an Integrated Minimized Perfusion Circuit Prior to Priming Prevents Spontaneous Air Release Into the Arterial Line During Clinical Use. Artif Organs 2017; 41:997-1003. [DOI: 10.1111/aor.12909] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/12/2016] [Accepted: 11/18/2016] [Indexed: 01/24/2023]
Affiliation(s)
- Marco C. Stehouwer
- Department of Extracorporeal Circulation; St Antonius Hospital; Nieuwegein The Netherlands
| | - Roel de Vroege
- Department of Extracorporeal Circulation; HAGA Hospital; The Hague The Netherlands
| | | | - Frederik N. Hofman
- Department of Cardiothoracic Surgery; St Antonius Hospital; Nieuwegein The Netherlands
| | - Johannes C Kelder
- Department of Cardiology; St Antonius Hospital; Nieuwegein The Netherlands
| | - Bas Buchner
- Department of Extracorporeal Circulation; HAGA Hospital; The Hague The Netherlands
| | - Bastian A. de Mol
- Section Cardiovascular Biomechanics, Faculty of Biomedical Technology; University of Technology; Eindhoven The Netherlands
| | - Peter Bruins
- Department of Anaesthesiology, Intensive Care and Pain Management; St Antonius Hospital; Nieuwegein The Netherlands
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Keelan J, Chung EML, Hague JP. Simulated annealing approach to vascular structure with application to the coronary arteries. ROYAL SOCIETY OPEN SCIENCE 2016; 3:150431. [PMID: 26998317 PMCID: PMC4785968 DOI: 10.1098/rsos.150431] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 01/15/2016] [Indexed: 05/25/2023]
Abstract
Do the complex processes of angiogenesis during organism development ultimately lead to a near optimal coronary vasculature in the organs of adult mammals? We examine this hypothesis using a powerful and universal method, built on physical and physiological principles, for the determination of globally energetically optimal arterial trees. The method is based on simulated annealing, and can be used to examine arteries in hollow organs with arbitrary tissue geometries. We demonstrate that the approach can generate in silico vasculatures which closely match porcine anatomical data for the coronary arteries on all length scales, and that the optimized arterial trees improve systematically as computational time increases. The method presented here is general, and could in principle be used to examine the arteries of other organs. Potential applications include improvement of medical imaging analysis and the design of vascular trees for artificial organs.
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Affiliation(s)
- Jonathan Keelan
- Department of Physical Sciences, The Open University, Milton Keynes MK7 6AA, UK
| | - Emma M. L. Chung
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 5WW, UK
| | - James P. Hague
- Department of Physical Sciences, The Open University, Milton Keynes MK7 6AA, UK
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