Transesophageal echocardiography (TEE)-guided transvenous pacing (TVP) in emergency department

BACKGROUND

Placement of a temporary pacemaker is a vital skill in the emergency setting in patients that present with life-threatening bradycardia. Transvenous pacing is the definitive method of stabilizing the arrhythmia compared to transcutaneous pacing, as it provides more comfort and better control of heart rate, until the insertion of a permanent pacemaker.

CASE REPORT

In this case report, we describe the steps using TEE to guide the insertion of transvenous pacer at the emergency department. Traditionally, the process of floating a transvenous pacer wire is performed "blindly" using landmarks and a monitoring ECG finding for capture, or under transthoracic echocardiography (TTE) ultrasound guidance. The blind procedure is associated with higher rate of failure and complications. While guidance using TTE is associated with higher success rates and fewer complications, inadequate imaging of the right side of the heart may limit the utility of this imaging modality. The use of transesophageal echocardiography (TEE) by emergency medicine and critical care physicians has gained traction in recent years due to its clear images and lack of interference with procedures being performed on the chest. In this article, we describe a protocol using TEE to guide the insertion of transvenous pacer through a case illustration.

Introduction of a Geminin mScarlet Reporter into H2B-mTurq2 hiPSCs for Live-cell Imaging of Proliferation and Cell Cycling

We previously generated a doxycycline-inducible H2B-mTurq2 reporter in hiPSCs to track cells and study cell division and apoptosis. To improve visualization of cycling cells, we introduced a ubiquitously transcribed mScarletI-Geminin (GMMN) (1-110) into the previously untargeted second AAVS1 allele. Fusion to the N-terminal part of GMNN provided tightly controlled mScarletI expression during the cell cycle. mScarletI fluorescence increased gradually from the S-phase through the M-phase of the cell cycle and was lost at the metaphase-anaphase transition. The resulting hiPSC reporter line generated, which we named ProLiving, is a valuable tool to study cell division and cell cycle characteristics in living hiPSC-derived cells.

Generation of LUMCi041-A-2: Equipping a PAX3 reporter iPSC line with doxycycline inducible H2B-mTurquoise2 for live cell imaging

An induced pluripotent stem cell (iPSC) line, in which a H2B-fluorescent protein fusion is temporally expressed, is a valuable tool to track cells and study cell divisions and apoptosis. To this end we introduced a 3rd generation "all-in-one" doxycycline-inducible H2B-mTurquoise2 vector into the AAVS1 locus of PAX3-Venus iPSCs via CRISPR/Cas9. H2B-mTurquoise2 expression is absent but readily induced by doxycycline allowing quantification of cell divisions and imaging of living cells. Besides being a universal reporter in iPSC-based differentiation and toxicity assays, the generated pluripotent and genomically normal LUMCi041-A-2 line is particularly suited to study PAX3-positive stages of development.

Resuscitative transesophageal echocardiography in the diagnosis of post-CABG loculated pericardial clot causing cardiac tamponade

Background

Pericardial effusion is a known complication of post-open cardiac surgery which can progress to life-threatening cardiac tamponade. Classical signs of tamponade such as hypotension and pulsus paradoxus are often absent. Diagnosing acute cardiac tamponade with transthoracic echocardiography (TTE) can be challenging in post-cardiac surgical patients due to distorted anatomy and limited scanning windows by the presence of surgical dressings or scar. Additionally, this patient population is more likely to have a loculated pericardial effusion, or an effusion that is isoechoic in appearance secondary to clotted blood. These findings can be challenging to visualize with traditional TTE. Missed diagnosis of cardiac tamponade due to loculated pericardial clot can result in delayed diagnosis and clinical management.

Case presentation

We report a case series that illustrates the diagnostic challenge and value of resuscitative transesophageal echocardiography (TEE) in the emergency department (ED) for the diagnosis of cardiac tamponade due to posterior loculated pericardial clot in post-surgical coronary artery bypass graft (CABG) patients.

Conclusions

Cardiac tamponade due to loculated posterior pericardial clot post-CABG requires prompt diagnosis and appropriate management to avoid the potential for hemodynamic instability. Transesophageal echocardiography allows a rapid diagnosis, early appropriate referral and an opportunity to institute appropriate therapeutic measures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-021-00225-7.

Pericardial decompression syndrome: A complication of pericardiocentesis

Pericardial Decompression Syndrome (PDS) is an uncommon but life-threatening complication following pericardiocentesis for cardiac tamponade. We report PDS after pericardiocentesis in two patients that presented to the emergency department with cardiac tamponade. In both cases, pericardiocentesis was performed under ultrasound guidance using the left parasternal approach and approximately 1200-1500 mL of pericardial fluid was removed. Immediately after pericardiocentesis, the haemodynamic status of the patients improved. However, 2-3 h post decompression, both patients developed hypotension and pulmonary edema with reduced left ventricular function, suggestive of PDS. PDS is a condition that is described as paradoxical worsening of vital signs after successful decompression of the pericardium in the setting of acute tamponade. Three possible mechanisms explaining PDS are ischaemic, hemodynamic and autonomic processes. If PDS is unrecognized and untreated, it is associated with a high mortality rate secondary to pulmonary edema and cardiogenic shock. If managed urgently, the cardiopulmonary dysfunction in PDS is usually transient and largely reversible with supportive care.

Development and validation of algorithms for heart failure patient care: a Delphi study

INTRODUCTION

Although heart failure (HF) management is available at primary and secondary care facilities in Malaysia, the optimisation of drug therapy is still suboptimal. Although pharmacists can help bridge the gap in optimising HF therapy, pharmacists in Malaysia currently do not manage and titrate HF pharmacotherapy. The aim of this study was to develop treatment algorithms and monitoring protocols for angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers and spironolactone based on extensive literature review for validation and utilization by pharmacists involved in HF management.

METHODS

A Delphi survey involving 32 panellists, from private and government hospitals that provide cardiac services in Malaysia, was conducted to obtain a consensus opinion on the treatment protocols. The panellists completed two rounds of self-administered questionnaires to determine their level of agreement with all the components in the protocols.

RESULTS

Consensus agreement was achieved for most of the sections of the protocols for the four classes of drugs. Panellists' opinions were taken into consideration when amending the components of the protocols that did not achieve consensus opinion. Full consensus agreement was achieved with the second survey conducted, enabling the finalisation of the drug titration protocols.

CONCLUSION

The resulting validated HF titration protocols can be used as a guide for pharmacists when recommending the initiation and titration of HF drug therapy in daily clinical practice. Recommendations should be made in collaboration with the patient's treating physician, with concomitant monitoring of patient's response to the drugs.

3D niche microarrays for systems-level analyses of cell fate

The behaviour of mammalian cells in a tissue is governed by the three-dimensional (3D) microenvironment and involves a dynamic interplay between biochemical and mechanical signals provided by the extracellular matrix (ECM), cell-cell interactions and soluble factors. The complexity of the microenvironment and the context-dependent cell responses that arise from these interactions have posed a major challenge to understanding the underlying regulatory mechanisms. Here we develop an experimental paradigm to dissect the role of various interacting factors by simultaneously synthesizing more than 1,000 unique microenvironments with robotic nanolitre liquid-dispensing technology and by probing their effects on cell fate. Using this novel 3D microarray platform, we assess the combined effects of matrix elasticity, proteolytic degradability and three distinct classes of signalling proteins on mouse embryonic stem cells, unveiling a comprehensive map of interactions involved in regulating self-renewal. This approach is broadly applicable to gain a systems-level understanding of multifactorial 3D cell-matrix interactions.

Elucidating the role of matrix stiffness in 3D cell migration and remodeling

Reductionist in vitro model systems which mimic specific extracellular matrix functions in a highly controlled manner, termed artificial extracellular matrices (aECM), have increasingly been used to elucidate the role of cell-ECM interactions in regulating cell fate. To better understand the interplay of biophysical and biochemical effectors in controlling three-dimensional cell migration, a poly(ethylene glycol)-based aECM platform was used in this study to explore the influence of matrix cross-linking density, represented here by stiffness, on cell migration in vitro and in vivo. In vitro, the migration behavior of single preosteoblastic cells within hydrogels of varying stiffness and susceptibilities to degradation by matrix metalloproteases was assessed by time-lapse microscopy. Migration behavior was seen to be strongly dependent on matrix stiffness, with two regimes identified: a nonproteolytic migration mode dominating at relatively low matrix stiffness and proteolytic migration at higher stiffness. Subsequent in vivo experiments revealed a similar stiffness dependence of matrix remodeling, albeit less sensitive to the matrix metalloprotease sensitivity. Therefore, our aECM model system is well suited to unveil the role of biophysical and biochemical determinants of physiologically relevant cell migration phenomena.

Large-displacement 3D structural analysis of an aortic valve model with nonlinear material properties

Grafts used in aortic valve-sparing procedures should ideally not only reproduce the geometry of the natural aortic root but also its material properties. Indeed, a number of studies using the finite element method have shown the importance of the natural sinus shape of the root in the functioning of the normal aortic valve, and the relative increase in stresses due to the replacement of the valve by a stiffer synthetic graft. Because of the wide range in experimentally measured values of aortic wall and leaflet material properties, studies by different research groups have incorporated very different material properties in their models. The aim of the present study was to investigate the influence of material properties on aortic wall displacements, and to determine which material properties would most closely match reported experimental data. Two geometrically accurate 3D models corresponding to the closed and open valve configurations were created in Pro/Engineer CAD software. Loads corresponding to systolic and diastolic pressures were specified and large-displacement structural analyses were carried out using the ANSYS package. Results have indicated that the closest match to experiments using isotropic material properties occurred for a Young's modulus of about 2000 KPa. Nonlinear models based on experimental stress-strain curves have shown similar displacements, but altered strain distribution patterns and significantly lower stresses. These results suggest that an accurate comparison of potential new graft models would have to be made with natural aortic valve models incorporating nonlinear material behavior.

65Zn incorporation in the male reproductive organs following gossypol treatment

Male hamsters and rats were administered gossypol 10 mg/kg/day for 45 and 56 days respectively. Twenty four hours before the last dose, animals were administered 65Zn (specific activity 0.258 uci/mg) subcutaneously. A marked decrease in 65Zn incorporation was observed in testis, epididymis, seminal vesicles and prostate following drug administration. A significant increase in 65Zn uptake was however observed in vas deferens in both rat and hamster following drug administration. Our results suggest that whatever the mechanism of gossypol action on testis-epididymis complex may be, the marked decrease in 65Zn uptake by testis--epididymis complex following gossypol treatment may be related to the antispermatogenic effect of gossypol.

Effect of gossypol on rats maintained on protein deficient and low potassium diets

Sexually mature male albino rats were divided into four groups of 5 animals each. Animals of group I served as control, whereas animals of group II received gossypol (20 mg/kg body weight/day) for 45 days. Animals of groups III and IV were maintained on protein deficient diet. Animals of group IV received 20 mg/kg gossypol in addition to the protein deficient diet. Animals of group III and IV received protein deficient diet for 45 days before initiating gossypol treatment. The total period of maintaining the animals on protein deficient diet was 90 days. In another experiment, the same experimental protocol was followed except that the animals were maintained on low potassium diet instead of protein deficient diet. A significant decrease in body weight of animals was observed following protein deficient and gossypol (group IV) treatment. Testis weight decreased significantly in the animals of group III (protein deficient) and group IV (protein deficient + gossypol). Similar observations were made in the animals maintained on low potassium diet. In both the experiments, sperm motility was reduced significantly. Histologically, in the testis of animals of group IV (protein deficient + gossypol) almost all the tubules were disorganised and vacuolated and total arrest of spermatogenesis could be observed in majority of the tubules.

Early events in rat testis after gossypol administration

Eighty male rats were grouped into 8 groups of 10 animals each. Animals in groups I-IV were given gossypol (40 mg/kg/day) for 7, 14, 21 and 28 days respectively. Animals of groups V-VIII served as respective controls for groups I-IV. Marked changes in the activities of ATPase and SDH were observed following drug treatment. Decrease in the activity of testis LDH was evident even after 7 days of drug treatment. Activities of B-galactosidase, Glucose-6-phosphatase and Fructose-1-6-diphosphatase were not affected by gossypol treatment. Glycogen contents in testis were not different from those of the controls. A significant decrease in the tubular diameter and germinal height of the seminiferous tubules was observed after 21 days of drug treatment. Quantitative analysis of spermatogenic elements revealed marked decrease in the ratios of resting spermatocyte. A type spermatogonia, pachytene spermatocyte/resting spermatocyte, and stage 19 spermatids/stage 7 spermatids after 7 days of drug treatment. A progressive decrease in the ratios of these cell types was observed as the duration of the drug treatment was extended. Liver enzymes (except SDH and LDH after 28 days of drug treatment) were not affected by gossypol treatment. Our data strongly suggest that degenerative changes in the testis start after one week of drug administration. The histological changes visible at light microscopy level start appearing after 14 days of drug treatment.

Effect of gossypol on the fertility of male rats

Thirty male rats were grouped into 5 groups of 6 animals each. Animals in groups II-V were given gossypol at a dose of 5 mg/kg, 10 mg/kg, 20 mg/kg and 40 mg/kg body weight per day for 45 days respectively. Animals of group I served as control. A significant decrease in body weight after administration of 40 mg/kg body weight of gossypol was observed; low doses of gossypol, however did not affect the body weight. Testis, epididymis, prostate and seminal vesicles weights decreased gradually with the increasing doses of gossypol. With the increasing doses of gossypol, a marked decrease in the vas deferens sperm motility was observed. At 40 mg/kg dose there was a total inhibition of sperm motility. Histological studies after 5 mg/kg revealed no apparent sign of degeneration, while after 10 mg/kg dose the changes in the individual cell types were accompanied by overall disorganisation of the germinal epithelium involving displacement of the spermatocytes. The rats treated with 20-40 mg/kg gossypol showed a pronounced deleterious effect on the histological structure of the testis. The drug effect was dose dependent developing sequentially; from the uppermost layer of elongated spermatids affecting round spermatids and finally spermatocytes. Quantitatively the ratios of pachytene spermatocytes: resting spermatocytes, stage 7 spermatids: pachytene spermatocytes, and stage 19 spermatids: stage 7 spermatids and tubular diameter and germinal height decreased significantly. The activities of glucose-6-phosphatase, fructose 1, 6-diphosphatase, glucose-6-phosphate isomerase in testis decreased significantly at high dose (40 mg/kg), while the activity of amylase and glycogen content increased significantly with the increasing doses of gossypol.(ABSTRACT TRUNCATED AT 250 WORDS)

Recovery of normal testis function and sperm motility after cessation of gossypol treatment in hamster

The present investigations evaluate the reversibility of the effect of gossypol on the histoarchitecture of the hamster testis and the motility of the vas deferens spermatozoa. Adult male hamsters of proven fertility were treated orally with gossypol (10 mg/kg/day) for 13 weeks (group III). Another group of animals in the Group IV were given gossypol (10 mg/kg/day) for 13 weeks and were sacrificed 13 weeks after termination of the drug treatment. Animals in groups I and II were given vehicle and served as controls for groups III and IV respectively. To all the animals, gossypol or vehicle was administered by oral intubation. A marked reduction in the spermatozoa motility was observed in the animals of group III. In contrast, the motility of the spermatozoa in the animals of group IV (recovery phase) was in the normal range. A large number of seminiferous tubules were affected by gossypol treatment (group III); these tubules showed degeneration of germ cells, vacuolization and loosening of the germinal epithelium. In the quantitative analysis of the spermatogenic events, the ratio of resting spermatocyte/'A' type spermatogonia was not affected but the ratios of pachytene spermatocytes/resting spermatocytes and stage 19 spermatids/stage 7 spermatids decreased by 21%, 47% and 52% respectively. The tubular diameter and germinal height were decreased by 14% and 33% respectively. In group IV, hamsters were allowed to recover from the gossypol treatment. The seminiferous tubules exhibited normal histoarchitecture and the tubular diameter and germinal height recovered markedly. Recovery in different stages of spermatogenic cycle was evidently clear in this group.(ABSTRACT TRUNCATED AT 250 WORDS)

Gossypol inhibition of Ca++ uptake and Ca++-ATPase in human ejaculated spermatozoal plasma membrane vesicles

Gossypol, a plant-derived polyphenolic compound known to exert contraceptive actions in men, inhibits Ca++-transport and Ca++-activated ATPase in isolated plasma membranes of ejaculated human sperm cells. It also inhibits the membrane bound Mg++- and Na+ + K+-dependent ATPases, 5'-nucleotidase and alkaline phosphatase systems. Ca++-ATPase inhibition by gossypol is non-competitive. It abolishes the discontinuity in Arrhenius expression of temperature dependence of Ca++-ATPase and increases the energy of activation. Phosphatidyl choline and Na+-deoxycholate inhibit Ca++-transport activity in the membrane vesicles. The apparent similarity of Ca++-transport inhibition by gossypol and phosphatidyl choline may indicate the possible capability of this compound to induce changes in the lipid microenvironment of the membranes, wherein the integral proteins operate. Inhibitory effect of gossypol on the plasma membrane Ca++-pump suggests that gossypol may affect sperm motility by a mechanism which is related to the structure and functions of the plasma membrane.

Involvement of prostaglandin in the antifertility effects of gossypol

This study was undertaken to determine the effects of gossypol alone and gossypol in combination with prostaglandin and aspirin. Rats were administered gossypol (40 mg/kg/day), gossypol and prostaglandin (PGF2 alpha-2 mg/kg/day), gossypol and aspirin (300 mg/kg) for 4 weeks. A marked effect of the gossypol-prostaglandin combination was observed on sperm motility and spermatogenesis. The effect of the gossypol-aspirin combination was less pronounced. The ratio of body weight to testicular and epididymal weights between the different groups showed no marked difference. No effect of drug treatment on plasma testosterone, LH and FSH was observed. The data presented in this paper suggest that prostaglandin plays an important role in the antifertility effects of gossypol.

Effect of gossypol on immature male rats

In immature male rats the body growth rate, the testis and epididymis weight were not affected by gossypol treatment (4, 8 and 40 mg/kg body weight/24 hrs. for 30 days). There was however a marked reduction in the weight of the prostate after high dose gossypol administration. Furthermore gossypol treatment did not show any effect on the histoarchitecture of the testis nor did the drug treatment have any effect on sperm motility. The plasma levels of testosterone, LH and FSH in gossypol treated animals were no different from those on the controls.