Cannulation-related adverse events of peripheral veno-arterial extracorporeal membrane oxygenation support in heart transplantation: Axillary versus femoral artery cannulation.

BACKGROUND: In heart transplantation (HT), peripheral veno-arterial extracorporeal membranous oxygenation (VA-ECMO) is utilized preoperatively as a direct bridge to HT or postoperatively for primary graft dysfunction (PGD). Little is known about wound complications of an arterial VA-ECMO cannulation site which can be fatal. METHODS: From 2009 to 2021, outcomes of 80 HT recipients who were supported with peripheral VA-ECMO either preoperatively or postoperatively were compared based on the site of arterial cannulation: axillary (AX: N = 49) versus femoral artery (FA: N = 31). RESULTS: Patients in the AX group were older (AX: 59 years vs. 52 years, p = .006), and less likely to have extracorporeal cardiopulmonary resuscitation (0% vs. 12.9%, p = .040). Survival to discharge (AX, 81.6% vs. FA. 90.3%, p = .460), incidence of stroke (10.2% vs. 6.5%, p = .863), VA-ECMO cannulation-related bleeding (6.1% vs. 12.9%, p = .522), and arm or limb ischemia (0% vs. 3.2%, p = .816) were comparable. ECMO cannulation-related wound complications were lower in the AX group (AX, 4.1% vs. FA, 45.2%, p < .001) including the wound infections (2.0% vs. 32.3%, p < .001). In FA group, all organisms were gram-negative species. In univariate logistic regression analysis, AX cannulation was associated with less ECMO cannulation-related wound complications (Odds ratio, .23, p < .001). There was no difference between cutdown and percutaneous FA insertion regarding cannulation-related complications. CONCLUSIONS: Given the lower rate of wound complications and comparable hospital outcomes with femoral cannulation, axillary VA-ECMO may be an excellent option in HT candidates or recipients when possible.

A Craniomaxillofacial Surgical Assistance Workstation for Enhanced Single-Stage Reconstruction Using Patient-Specific Implants.

BACKGROUND: Craniomaxillofacial reconstruction with patient-specific, customized craniofacial implants (CCIs) is ideal for skeletal defects involving areas of aesthetic concern-the non-weight-bearing facial skeleton, temporal skull, and/or frontal-forehead region. Results to date are superior to a variety of "off-the-shelf" materials, but require a protocol computed tomography scan and preexisting defect for computer-assisted design/computer-assisted manufacturing of the CCI. The authors developed a craniomaxillofacial surgical assistance workstation to address these challenges and intraoperatively guide CCI modification for an unknown defect size/shape. METHODS: First, the surgeon designed an oversized CCI based on his/her surgical plan. Intraoperatively, the surgeon resected the bone and digitized the resection using a navigation pointer. Next, a projector displayed the limits of the craniofacial bone defect onto the prefabricated, oversized CCI for the size modification process; the surgeon followed the projected trace to modify the implant. A cadaveric study compared the standard technique (n = 1) to the experimental technique (n = 5) using surgical time and implant fit. RESULTS: The technology reduced the time and effort needed to resize the oversized CCI by an order of magnitude as compared with the standard manual resizing process. Implant fit was consistently better for the computer-assisted case compared with the control by at least 30%, requiring only 5.17 minutes in the computer-assisted cases compared with 35 minutes for the control. CONCLUSION: This approach demonstrated improvement in surgical time and accuracy of CCI-based craniomaxillofacial reconstruction compared with previously reported methods. The craniomaxillofacial surgical assistance workstation will provide craniofacial surgeons a computer-assisted technology for effective and efficient single-stage reconstruction when exact craniofacial bone defect sizes are unknown.

The Effect of Celecoxib on the Progression of Calcific Aortic Valve Disease-Protective or Pathogenic?

Calcific aortic valve disease (CAVD) is a debilitating condition for which there are limited therapeutic options aside from valve replacement. As such, it is crucial to explore alternative management strategies for CAVD. Non-steroidal anti-inflammatory drugs (NSAIDs), particularly celecoxib, have been the subject of debate in the literature regarding their potential impact on CAVD. We conducted an in-depth analysis of five studies exploring the effect of celecoxib on CAVD and found discrepancies in both methods and results. Our findings suggest that celecoxib may impact the development of this disease via multiple mechanisms, each of which may have different effects on its pathogenesis. We also discovered limited clinical research examining the connection between celecoxib use and CAVD in medical patients. As such, further studies are needed to clarify the role of celecoxib and other NSAIDs in CAVD progression in order to inform future treatment options and clarify their impact on the disease.

Ex Vivo Heart Perfusion for Cardiac Transplantation Allowing for Prolonged Perfusion Time and Extension of Distance Traveled for Procurement of Donor Hearts: An Initial Experience in the United States.

Scarcity of donor hearts continues to be a challenge for heart transplantation (HT). The recently Food and Drug Administration-approved Organ Care System (OCS; Heart, TransMedics) for ex vivo organ perfusion enables extension of ex situ intervals and thus may expand the donor pool. Because postapproval real-world outcomes of OCS in HT are lacking, we report our initial experience. Methods: We retrospectively reviewed consecutive patients who received HT at our institution in the post-Food and Drug Administration approval period from May 1 to October 15, 2022. Patients were divided into 2 groups: OCS versus conventional technique. Baseline characteristics and outcomes were compared. Results: A total of 21 patients received HT during this period, 8 using OCS and 13 conventional techniques. All hearts were from donation after brain death donors. The indication for OCS was an expected ischemic time of >4 h. Baseline characteristics in the 2 groups were comparable. The mean distance traveled for heart recovery was significantly higher in the OCS group (OCS, 845 ± 337, versus conventional, 186 ± 188 mi; P < 0.001), as was the mean total preservation time (6.5 ± 0.7 versus 2.5 ± 0.7 h; P < 0.001). The mean OCS time was 5.1 ± 0.7 h. In-hospital survival in the OCS group was 100% compared with 92.3% in the conventional group (P = 0.32). Primary graft dysfunction was similar in both groups (OCS 12.5% versus conventional 15.4%; P = 0.85). No patient in the OCS group required venoarterial extracorporeal membrane oxygenation support after transplant compared with 1 in the conventional group (0% versus 7.7%; P = 0.32). The mean intensive care unit length of stay after transplant was comparable. Conclusions: OCS allowed utilization of donors from extended distances that otherwise would not be considered because ischemic time would be prohibitive by conventional technique.

Complications associated with revision of Sprint Fidelis leads: report from the Canadian Heart Rhythm Society Device Advisory Committee.

BACKGROUND: It has been observed that replacement of an implantable cardioverter-defibrillator generator in response to a device advisory may be associated with a substantial rate of complications, including death. The risk of lead revision in response to a lead advisory has not been determined previously. METHODS AND RESULTS: Twenty-five implantable cardioverter-defibrillator implantation and follow-up centers from the Canadian Heart Rhythm Society Device Advisory Committee were surveyed to assess complication rates as a result of lead revisions due to the Sprint Fidelis advisory issued in October 2007. As of June 1, 2009, there had been 310 lead failures found in 6237 Sprint Fidelis leads in Canada (4.97%) over a follow-up of 40 months. There were 469 leads to be revised, 66% for confirmed fracture. Of the patients who underwent revision, 95% had a new lead inserted, whereas 4% had a pace/sense lead added. The lead was removed in 248 cases (53%), by simple traction in 61% and by laser lead extraction in 33%. Complications were encountered in 14.5% of the lead revisions; 7.25% of these were major, whereas 7.25% were minor. There were 2 deaths (0.43%). The overall risk of complications (19.8%) was greater in those who underwent lead removal at the time of revision than in those whose leads were abandoned (8.6%; P=0.0008). CONCLUSIONS: The overall rate of major complications that arose from lead revision due to the Sprint Fidelis advisory was significant. This must be taken into account when lead revision is planned in those patients who have not yet demonstrated an abnormality in lead performance.

Promoting self-efficacy in minimally invasive surgery training.

Many surgeons continue to actively pursue surgical approaches that are less invasive for their patients. This pursuit requires the surgeon to adapt to new instruments, techniques, technologies, knowledge bases, visual perspectives, and motor skills, among other changes. The premise of this paper is that surgeons adopting minimally invasive approaches are particularly obligated to maintain an accurate perception of their own competencies and learning needs in these areas (ie, self-efficacy). The psychological literature on the topic of self-efficacy is vast and provides valuable information that can help assure that an individual develops and maintains accurate self-efficacy beliefs. The current paper briefly summarizes the practical implications of psychological research on self-efficacy for minimally invasive surgery training. Specific approaches to training and the provision of feedback are described in relation to potential types of discrepancies that may exist between perceived and actual efficacy.

Relation of recurrence of atrial fibrillation after non-ST-elevation acute myocardial infarction to left atrial abnormality.

Atrial fibrillation (AF) is common during the course of acute myocardial infarction and is associated with left atrial (LA) dilatation. However, the role of LA depolarization abnormality on the electrocardiogram (ECG) in the setting of LA dilatation was not studied in this context. Patients admitted with non-ST-segment elevation myocardial infarction (NSTEMI) who developed new-onset AF (International Classification of Diseases, Ninth Revision code 427.31) were prospectively identified. Baseline ECGs and echocardiograms before the admission event were reviewed. Follow-up was directed toward pertinent cardiovascular events, atrial tachyarrhythmias, and death as end points. Of 101 patients with NSTEMI who had new-onset AF, 88 had current echocardiograms and 69 had LA dilatation (78%). Total follow-up was 24 months (mean 21.4). Prolonged P-wave duration (> or =110 ms) and decreased left ventricular fractional shortening were most significant in those with LA dilatation and were independently associated with AF. In those with LA dilatation, the prevalence of such abnormal atrial depolarization on ECGs was 56%. AF (43% vs 15%; p = 0.03) and heart failure (63% vs 35%; p = 0.03) occurred more often in this subset, but there was no difference in mortality. However, the overall prevalence of late cardiovascular complications in this subset was higher (71% vs 45%; p = 0.02) compared with that of immediate complications (20% vs 26%; p = 0.60). In conclusion, there is higher recurrence of AF in patients with NSTEMI who have a combination of electrocardiographic and echocardiographic LA abnormalities compared with those without.

Full disclosure: Unraveling the mystery of a wide complex tachycardia.

Wide complex tachycardia is not uncommon in patients with underlying structural heart disease and reduced ejection fraction. It is important to make the correct diagnosis as it carries prognostic and clinical implications. We present a case of a challenging wide complex rhythm detected on remote telemetry monitoring. This case outlines the differential diagnosis of a wide complex tachycardia and the clues to making a diagnosis of artifact. It highlights the importance of correct diagnosis as an incorrect diagnosis may lead to inappropriate treatments and unnecessary investigations.

Embedded clutter reduction and face detection algorithms for a visual prosthesis.

Retinal prosthetic devices can significantly and positively impact the ability of visually challenged individuals to live a more independent life. We describe a visual processing system which leverages image analysis techniques to produce visual patterns and allows the user to more effectively perceive their environment. These patterns are used to stimulate a retinal prosthesis to allow self guidance and a higher degree of autonomy for the affected individual. Specifically, we describe an image processing pipeline that allows for object and face localization in cluttered environments as well as various contrast enhancement strategies in the "implanted image." Finally, we describe a real-time implementation and deployment of this system on the Argus II platform. We believe that these advances can significantly improve the effectiveness of the next generation of retinal prostheses.

Safety and efficacy of advanced atrial pacing therapies for atrial tachyarrhythmias in patients with a new implantable dual chamber cardioverter-defibrillator.

OBJECTIVES: This study evaluated the safety and efficacy of atrial pacing therapies for the treatment and prevention of atrial tachycardia (AT) or atrial fibrillation (AF) in a new dual chamber implantable cardioverter defibrillator (ICD). BACKGROUND: Patients with an ICD may also experience AT or AF that is amenable to pace termination. METHODS: The efficacy of atrial antitachycardia pacing (ATP) therapies for atrial tachycardia or atrial fibrillation (AT/AF) was determined in 151 patients after implantation of a GEM III AT ICD (Medtronic Inc., Minneapolis, Minnesota). The percentage of episodes successfully terminated was adjusted for multiple episodes per patient. RESULTS: A total of 717 of 728 (96%) episodes classified as AT or AF were judged to be appropriate detections. By device classification, atrial ATP terminated 187 of 383 (40% adjusted) episodes classified as AT compared with 65 of 240 episodes classified as AF (26% adjusted, p = 0.013). Atrial Ramp or Burst+ ATP terminated 184 of 378 episodes of AT (39% adjusted), whereas 50-Hz Burst pacing therapy terminated only 12 of 109 episodes of AT (12% adjusted) and 65 of 240 episodes of AF (26% adjusted). If efficacy was defined as termination of AT/AF within 20 s of delivery of the pacing therapy, ATP therapies terminated 139 of 383 (32% adjusted) episodes of AT compared with 34 of 240 episodes of AF (15% adjusted, p = 0.003). Efficacy was dependent on AT cycle length. Frequent transitions between AT and AF predicted inefficacy of atrial ATP (p < 0.001). Ventricular proarrhythmia secondary to atrial ATP was not observed. CONCLUSIONS: Atrial ATP therapies terminate many episodes of AT without ventricular proarrhythmia. The addition of 50-Hz Burst pacing has minimal efficacy for AT/AF.

Gender differences in genetic damage induced by the tobacco-specific nitrosamine NNK and the influence of the Thr241Met polymorphism in the XRCC3 gene.

The rapid increase in adenocarcinoma of the lung and mortality amongst women strongly suggests that gender differences exist in sensitivity to certain tobacco carcinogens. In the current study, we performed the mutagen-sensitivity assay, with the tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), to test the hypothesis that women are more sensitive to the genotoxic effects of NNK than men. Chromosome aberration (CA) frequencies in peripheral blood lymphocytes (PBLs) from 99 patients were evaluated before and after in vitro exposure to NNK. Because the Thr241Met polymorphism in the DNA-repair gene XRCC3 is associated with increased risk of tobacco-related cancers, especially among women, we also tested the hypothesis that individuals who inherit the homozygous variant 241Met allele are more sensitive to the genotoxic effects of NNK. CA frequency was significantly higher 1 hr after NNK treatment in women, compared with men (P = 0.02). When smoking and gender were considered together, a significant interaction was observed. PBLs from female smokers had significantly higher frequencies of NNK-induced CA, compared with female nonsmokers 1 hr after treatment (P = 0.02). We observed no overall effect of the Thr241Met polymorphism on NNK-induced CA in men, women, smokers, or nonsmokers. Overall, our data indicate that women are more sensitive to the genotoxic effects of NNK than men. Because in past years smoking among women has increased, and in view of the close correlation between NNK exposure and adenocarcinoma of the lung, our data provide a plausible explanation for the recent increase in the incidence of this cancer among women.

Computer-assisted single-stage cranioplasty.

Cranioplasty treats and repairs cranial defects with a custom craniofacial implant (CCI). Typically, surgeons know the defect size prior to surgery. Recent efforts consider single-stage cranioplasty-performing the bony resection and fixating the CCI in a single operation. This paper develops a computer-assisted technique to perform single-stage cranioplasty. Intraoperatively, the surgeon traces the bony resection. The outline of the bony cuts is projected on a preoperatively-designed CCI to guide the surgeon during the resizing. A cadaveric case study showed good fit with minimal gaps between the implant and remaining skull. Moreover, the procedure reduced the time to resize the implant by an order of magnitude compared to manual resizing without the use of the computer-assisted technique. This approach represents the next step in quickly, effectively, and robustly performing single-stage CCI to treat craniofacial defects.

Effect of XPD/ERCC2 polymorphisms on chromosome aberration frequencies in smokers and on sensitivity to the mutagenic tobacco-specific nitrosamine NNK.

Polymorphisms in DNA-repair genes could contribute to the interindividual differences in cancer susceptibility in smokers. By reducing DNA-repair capacity, these polymorphisms may influence the net level of smoking-induced genetic damage significantly, a critical step in the cascade of events leading to cancer. In this biomonitoring study, we examined the relationship between polymorphisms in the DNA-repair gene XPD/ERCC2 and genetic damage. We tested the hypothesis that coding polymorphisms in XPD/ERCC2 limit DNA-repair efficiency in humans leading to increased frequencies of chromosome aberration (CA) in their lymphocytes. We also used the mutagen-sensitivity assay, with the tobacco-specific nitrosamine NNK as a model mutagen, to determine whether lymphocytes from individuals with the variant XPD alleles are more sensitive to this tobacco-specific carcinogen. We calculated odds ratios (ORs) as estimates of relative risk of increased frequencies of CA associated with two XPD polymorphisms (Asp312Asn in exon 10 and Lys751Gln in exon 23). We observed a 2.57-fold (95% confidence limit [CL] = 0.88-7.50; P = 0.10) increase in risk of elevated in vivo frequencies of CA associated with the variant 312Asn allele in the total population. The relative risk was more pronounced in smokers (OR = 4.67; 95% CL = 1.04-20.90; P = 0.04) and in all subjects >48 years old (OR = 7.33; 95% CL = 1.53-35.10; P = 0.01). Similarly, elevations in NNK-induced aberrations were significantly associated with the 312Asn allele (OR = 3.69; 95% CL = 1.29-10.56; P = 0.02). The risk was higher in smokers (OR = 4.62; 95% CL = 1.14-18.70; P = 0.04) and in subjects >48 years old (OR = 5.76; 95% CL = 1.30-25.41; P = 0.03). No significant effect was observed with the 715Gln variant allele in relation to either in vivo or NNK-induced CA. These data suggest that the Asp312Asn polymorphism may alter the phenotype of the XPD protein, resulting in reduced DNA-repair capacity.

Effects of tools inserted through snake-like surgical manipulators.

Snake-like manipulators with a large, open lumen can offer improved treatment alternatives for minimally-and less-invasive surgeries. In these procedures, surgeons use the manipulator to introduce and control flexible tools in the surgical environment. This paper describes a predictive algorithm for estimating manipulator configuration given tip position for nonconstant curvature, cable-driven manipulators using energy minimization. During experimental bending of the manipulator with and without a tool inserted in its lumen, images were recorded from an overhead camera in conjunction with actuation cable tension and length. To investigate the accuracy, the estimated manipulator configuration from the model and the ground-truth configuration measured from the image were compared. Additional analysis focused on the response differences for the manipulator with and without a tool inserted through the lumen. Results indicate that the energy minimization model predicts manipulator configuration with an error of 0.24 ± 0.22mm without tools in the lumen and 0.24 ± 0.19mm with tools in the lumen (no significant difference, p = 0.81). Moreover, tools did not introduce noticeable perturbations in the manipulator trajectory; however, there was an increase in requisite force required to reach a configuration. These results support the use of the proposed estimation method for calculating the shape of the manipulator with an tool inserted in its lumen when an accuracy range of at least 1mm is required.