Vascular function in continuous-flow left ventricular assist device recipients: effect of a single pulsatility treatment session.

Vascular function is further attenuated in patients with chronic heart failure implanted with a continuous-flow left ventricular assist device (LVAD), likely due to decreased arterial pulsatility, and this may contribute to LVAD-associated cardiovascular complications. However, the impact of increasing pulsatility on vascular function in this population is unknown. Therefore, 15 LVAD recipients and 15 well-matched controls underwent a 45-min, unilateral, arm pulsatility treatment, evoked by intermittent cuff inflation/deflation (2-s duty cycle), distal to the elbow. Vascular function was assessed by percent brachial artery flow-mediated dilation (%FMD) and reactive hyperemia (RH) (Doppler ultrasound). Pretreatment, %FMD (LVAD: 4.0 ± 1.7; controls: 4.2 ± 1.4%) and RH (LVAD: 340 ± 101; controls: 308 ± 94 mL) were not different between LVAD recipients and controls; however, %FMD/shear rate was attenuated (LVAD: 0.10 ± 0.04; controls: 0.17 ± 0.06%/s-1, P < 0.05). The LVAD recipients exhibited a significantly attenuated pulsatility index (PI) compared with controls prior to treatment (LVAD: 2 ± 2; controls: 15 ± 7 AU, P < 0.05); however, during the treatment, PI was no longer different (LVAD: 37 ± 38; controls: 36 ± 14 AU). Although time to peak dilation and RH were not altered by the pulsatility treatment, %FMD (LVAD: 7.0 ± 1.8; controls: 7.4 ± 2.6%) and %FMD/shear rate (LVAD: 0.19 ± 0.07; controls: 0.33 ± 0.15%/s-1) increased significantly in both groups, with, importantly, %FMD/shear rate in the LVAD recipients being restored to that of the controls pretreatment. This study documents that a localized pulsatility treatment in LVAD recipients and controls can recover local vascular function, an important precursor to the development of approaches to increase systemic pulsatility and reduce systemic vascular complications in LVAD recipients.

A Novel Technique for the Management of Massive Hemoptysis: The Customized Endobronchial Silicone Blocker.

OBJECTIVE: Massive hemoptysis (MH) has a high mortality rate. Therapeutic options include bronchoscopy for endobronchial lesions, bronchial artery embolization (BAE), and emergency surgery. Scant options exist for patients who are not candidates for these modalities. Culprit bronchial segment occlusion is an option to prevent "spillover flooding → hypoxia." Applying this concept, we describe a case series of MH control using a novel bronchoscopically inserted customized endobronchial silicone blocker (CESB). We analyzed the safety and efficacy of CESBs in a select subset of patients with MH. METHODS: Inclusion criteria were patients with MH who were unstable for surgery/BAE, failed BAE, or relatively contraindicated/refused BAE. CESBs were manufactured on-site by modifying silicone stents, inserted using rigid bronchoscopy and reinforced with glue. The CESB was removed after 6 weeks when possible. A successful outcome was defined as immediate bleeding control with no recurrence after removal. RESULTS: Over 4.5 years, 13 episodes of MH in 12 patients meeting the criteria specified earlier were treated with CESBs. Seven of 12 patients had tuberculosis, 4 active and 3 inactive. One patient had mucormycosis, 1 post-lobectomy, 1 endobronchial renal cell carcinoma, 1 fibrosing mediastinitis, and 1 patient had metastatic laryngeal Ca. Eight of 12 patients were taken for primary-CESB placement. Four of 12 patients were sent for BAE, which was unsuccessful, and rescue-CESB was done for definitive management. The success rate, as defined earlier, was 92.3%, with no deaths from MH. CONCLUSIONS: Innovative bronchoscopically inserted CESBs are an effective strategy in MH when patients are unstable or fail conventional management.

Three-Dimensional Imaging Improves Accuracy in Clip Sizing During Thoracoscopic Left Atrial Appendage Exclusion.

The AtriClip is an epicardially applied occlusion device for the left atrial appendage. Accurate sizing and placement of the device is essential to its success. We describe the use of 3-dimensional computed tomography imaging to aid in accurate sizing of the AtriClip device during thoracoscopic surgical ablation. This technique reduces the risk of improper sizing of the device and thus mitigates the risk of malpositioning and potential damage or compression to surrounding structures such as the circumflex coronary artery.

[Monocentric experience of left atrial appendage occlusion among patients with advanced chronic kidney disease and non-valvular atrial fibrillation].

Atrial fibrillation is the most common cardiac disorder among chronic nephropathic patients. Possible therapeutic approaches include the use of anticoagulants, which are able to reduce the risk of thromboembolism but lead to an increasing bleeding risk, especially in this cohort of patients. Also, novel oral anticoagulant agents (NAO), due to their mainly renal clearance, are a relative contraindication in advanced renal disease. As an alternative to the oral anticoagulant therapy, left atrial appendage occlusion seems a promising opportunity in high risk, difficult to manage patients. Since there is limited evidence of LAAO in advanced chronic renal disease or dialysis patients, we report here a monocenter experience on 12 patients (6 of which in regular dialytic treatment) with a median clinical follow-up of fourteen months (3-22 months).

What Does the Future Hold?: Ideal Device, Newer Devices, and More.

Please verify if "pigtail guided" should be "pigtail catheter-guided": Recent design changes for left atrial appendage (LAA) closure devices have led to significant improvement by facilitating the procedural workflow (no need for pigtail guided LAA intubation), moving the workspace from distal LAA to the landing zone (closed distal end design), and improving device stability (different anchor design). The availability of different device types (plug vs disc-lobe design) offers an option to tailor a device type to a patient's anatomy; thereby, sealing results have improved substantially. The issue of device-related thrombus has not been resolved and deserves future research, with the goal of eliminating postprocedural antithrombotic medication without increasing risk for stroke.

Anatomic Considerations for Epicardial and Endocardial Left Atrial Appendage Closure.

Left atrial appendage closure is an increasingly used means of achieving thromboprophylaxis in atrial fibrillation, particularly in patients with contraindications to anticoagulation. Left atrial appendage anatomy is highly variable, and preprocedural imaging is critical to choosing the correct device and approach for left atrial appendage closure. This article reviews the common endocardial and epicardial closure systems, including anatomic considerations, advantages and disadvantages, as well as complications to be avoided.

Epicardial versus Endocardial Closure: Is One Better than the Other?

Left atrial appendage occlusion is an evolving technology with demonstrable benefits of stroke prophylaxis in patients with atrial fibrillation unsuitable for anticoagulation. This has resulted in the development of a plethora of transcatheter devices to achieve epicardial exclusion and endocardial occlusion. In this review, the authors summarize the differences in technique, target patient population, outcomes, and complication profiles of endocardial and epicardial techniques.

Effectiveness of the combat application tourniquet for arterial occlusion in young children.

BACKGROUND: Tourniquet use for extremity hemorrhage has become a mainstay in adult trauma care in last 15 years. The efforts of the Stop the Bleed campaign have increased the distribution and use of tourniquets in civilian settings in response to mass shootings and as part of disaster preparedness. Little research or published experience exists regarding the use of tourniquets in the pediatric population. This study sought to determine the minimum patient age on which the combat application tourniquet (CAT) is able to control extremity hemorrhage. METHODS: A convenience sample of pediatric patients, ages 1 year to 8 years, scheduled for elective orthopedic surgery at an academic hospital, were eligible for enrollment. Subject age, weight, height, blood pressure, and arm and leg circumferences were obtained. Once under general anesthesia, the pulse of an upper and a lower limb were obtained by Doppler, a CAT was then placed at the most proximal practical location of the limb until the corresponding pulse was either no longer obtainable by Doppler or until the tourniquet was as tight as its design allows. The tourniquet was removed after 30 seconds of arterial occlusion. RESULTS: Thirteen children, ages 2 years to 7 years were enrolled. Weights ranged from 12.8 kg to 23.9 kg, with a mean of 16.7 kg. Leg circumferences were 24.5 cm to 34.5 cm, with a mean of 27.9 cm and arm circumferences were 13 cm to 24 cm, with a mean of 16.3 cm. Subject heights were 87 cm to 122 cm, with a mean of 103.4 cm. Twenty-four total extremities were tested, 11 arms and 13 legs. Arterial occlusion was obtained on 100% of limbs tested (95% confidence interval, 85.8-100%). CONCLUSION: This study is similar to previous adult tourniquet efficacy studies in design, size and outcomes. It is the first to show successful arterial occlusion on preschool-aged children with a commercial tourniquet in a controlled setting. The results suggest that the CAT can be used in school-aged children with severe extremity hemorrhage with a high likelihood of success. LEVEL OF EVIDENCE: Therapeutic, level II.

Efecto hipotensor agudo del ejercicio de oclusión vascular sobre adultos mayores / Acute hypotensor effect of the vascular occlusion exercise on elderly adults

Objetivo: El objetivo de este estudio fue evaluar la respuesta cardíaca aguda después de realizar una sesión de ejercicio con oclusión vascular en adultos mayores (AM). Sujetos y método: 22 participantes voluntarios, fueron sometidos al protocolo experimental de ejercicio dinámico de prensión manual con un 30% de presión de oclusión (PO), después de registrar los valores basales y en reposo de presión arterial sistólica (PAS), presión arterial diastólica (PAD) y frecuencia cardíaca (FC). Evaluadas en condiciones basales y entre los 5 y 30 minutos post-oclusión. Resultados: Al finalizar el protocolo se observó una reducción significativa en la PAS y FC a los 15', 20' y 25' (p<0,05) y para la PAD a los 10' y 20' (p<0,05). Conclusión: El efecto agudo del ejercicio con oclusión vascular genera una reducción significativa de PAS, PAD y FC hasta 25 minutos post-oclusión, en los AM analizados

The objective of this study was to evaluate the acute cardiac response after performing an exercise session with vascular occlusion in elderly adults (EA). Twenty-two volunteer participants underwent the experimental protocol of dynamic manual grip exercise with 30% occlusion pressure (OP), after recording the baseline values and resting systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR). All measures were taken in basal conditions and between 5 and 30 minutes' post-occlusion. At the end of the protocol, there was a significant reduction in SBP and HR at 15 ', 20' and 25 '(p <0.05) and for DBP at 10' and 20 '(p <0.05).). The acute effect of exercise with vascular occlusion generates a significant reduction of SBP, Basal Diastolic Pressure (BDP) and HR up to 25 minutes' post-occlusion, in the EA analyzed

The Effect of Remote Ischaemic Preconditioning on Arterial Stiffness in Patients Undergoing Vascular Surgery: A Randomised Clinical Trial.

OBJECTIVES: The main aim of this study was to evaluate the effect of remote ischaemic preconditioning (RIPC) on arterial stiffness in patients undergoing vascular surgery. METHODS: This was a randomised, sham controlled, double blind, single centre study. Patients undergoing open abdominal aortic aneurysm repair, surgical lower limb revascularisation surgery or carotid endarterectomy were recruited. A RIPC or a sham procedure was performed, using a blood pressure cuff, along with preparation for anaesthesia. The RIPC protocol consisting of four cycles of 5 min of ischaemia, followed by 5 min of reperfusion was applied. Arterial stiffness and haemodynamic parameters were measured pre-operatively and 20-28 h after surgery. Two primary outcomes were selected: augmentation index and pulse wave velocity. RESULTS: Ninety-eight patients were randomised. After dropouts 44 and 46 patients were included in the RIPC and sham groups, respectively. Both groups were comparable. There were no statistically significant differences in augmentation index (p = .8), augmentation index corrected for heart rate of 75 beats per minute (p = .8), pulse wave velocity (p = .7), large artery elasticity indices (p = .8), small artery elasticity indices (p = .6), or mean arterial pressure (p = .7) changes between the RIPC and sham groups. There occurred statistically significant (p ≤ .01) improvement in augmentation index (-5.8% vs. -5.5%), augmentation index corrected for a heart rate of 75 beats per minute (-2.5% vs. -2%), small artery elasticity indices (0.7 mL/mmHg × 100 vs. 0.9 mL/mmHg × 100), and mean arterial pressure post-operatively in both the RIPC and the sham groups (change median values in RIPC and sham groups, respectively). CONCLUSIONS: RIPC had no significant effect on arterial stiffness, but there was significant improvement in arterial stiffness after surgery in both groups. Arterial stiffness and haemodynamics may be influenced by surgery or anaesthesia or oxidative stress or all factors combined. Further studies are needed to clarify these findings. CLINICALTRIALS.GOV: NCT02689414.

Experience of left atrial appendage occlusion with the WATCHMAN device in Chinese patients.

OBJECTIVE: Little is known about left atrial appendage occlusion (LAAO) with WATCHMAN device in patients with atrial fibrillation (AF) in China. The aim of the present study was to evaluate the acute procedural performance and complication rate of LAAO procedures and patient selection in China. METHODS: A total of 658 consecutive Chinese patients who were referred to receive LAAO procedures with the WATCHMAN device between 2014 and 2017 were retrospectively included in the study. Patients were divided into four groups according to the year of procedures: Group 2014, Group 2015, Group 2016, and Group 2017. The procedural success, complication rates, and characteristics of Chinese patients, as well as the trends of patients' selection and management, were analyzed. RESULTS: The average age of the patients was 67.7+-9.2 years, the CHA2DS2-VASc score was 3.7+-1.6, and the HAS-BLED score was 2.5+-1.1. Both scores of patients in different years show obvious increasing trends (r=0.126, p=0.001 and r=0.145, p<0.001, respectively). Indications for LAAO included increased bleeding risk (45.6%), recent bleeding under oral anticoagulation (OAC) (9.0%), and non-compliance with OAC (51.4%). The implantation was successful in 643 (97.7%) patients, with a procedural complication rate of 0.6%. Approximately 80.1% of the patients received OAC after LAAO. CONCLUSION: In China, LAAO with WATCHMAN devices in patients with AF can be performed successfully with a low complication rate. Most of the target population had increased bleeding risk or non-compliance for OAC as indications and received OAC for antithrombotic therapy after the procedure.

3D printing and biocompatibility study of a new biodegradable occluder for cardiac defect.

OBJECTIVE: To fabricate a biodegradable occluder for heart defect using the three-dimensional (3D) printing technique and evaluate its biosafety in an animal model. METHODS: Occluder samples were made by 3D printing technique using the self-developed lactide-sanya methyl carbonate-glycolide (PLLA-TMC-GA) co-polymer or PLTG as the bio-material. The biocompatibility (cytological and hematological) of the materials was evaluated by cytotoxicity experiments, hemolysis test, dynamic blood clotting test, and platelet adhesion test. Finally, the histocompatibility of the occluder was evaluated by implantation in a rabbit model. RESULTS: Occluder samples were printed satisfactorily. Cytotoxicity assay showed no significant toxicity of PLTG in the cells. Hemolysis test showed less than 5% hemolysis rate of PLTG indicating only a mild effect on the red blood cells. The dynamic coagulation test showed poor activation of endogenous clotting factors. PLTG resulted in lower platelet activation compared to PLLA, as indicated by the platelet adhesion test. Finally, no obvious tissue damage or necrosis was seen in the in vivo implantation experiment. CONCLUSION: A new PLTG-based biodegradable occluder for heart defects with good biocompatibility can be manufactured by the 3D printing technique.

Punctal and canalicular plugs: Indications, efficacy and safety.

Lacrimal occlusion with punctal or canalicular plugs have been used to treat dry eye disease for more than 40 years. Indeed, punctal plugs constitute a safe and effective tool to retain the natural tear film and prolong the effect of tear substitutes. A wide variety of plugs is available, differing in their design, location (punctal versus canalicular) and their resorbability. There indications have increasingly broadened, and they are now one of the treatment options for numerous ocular surface diseases. Current research focuses on using punctal plugs for extended delivery of drugs to the ocular surface. This review addresses physiology of lacrimal drainage, available models of punctal plugs, their indications, practical details of prescribing and placing punctal and canalicular plugs, and possible complications.

Perceptual and arterial occlusion responses to very low load blood flow restricted exercise performed to volitional failure.

PURPOSE: Studies examining perceptual and arterial occlusion responses between blood flow restricted exercise and high load exercise often prescribe an arbitrary number of repetitions, making it difficult for direct comparisons. Therefore, the purpose of this study was to compare these protocols when performed to volitional failure. METHODS: Individuals completed four exercise conditions varying in load and pressure: (i) 15% 1RM; no restrictive pressure, (ii) 15% 1RM; 40% arterial occlusion pressure, (iii) 15% 1RM; 80% arterial occlusion pressure, and (iv) 70% 1RM; no pressure. Four sets of knee extension exercises were performed until volitional failure (or until 90 repetitions per set) was completed. RESULTS: A total of 23 individuals completed the study. While all conditions increased arterial occlusion pressure, the greatest increases (~30%) were observed in the blood flow restriction conditions. All lower load conditions resulted in greater RPE and discomfort than that of the high load condition, but only discomfort was increased further when adding blood flow restriction. CONCLUSION: High load exercise will likely be perceived more favourably than lower load exercise to volitional failure; however, those who are incapable or unwilling to lift heavier loads may use blood flow restriction to help reduce the volume needed to reach volitional failure, although this will likely increase discomfort.

Effect of Surgical Adhesive on the Uterus of Rabbits Following Occlusion.

Purpose/Aim of the Study: The present study investigated the effect of surgical adhesives on the uterus of rabbits and the histomorphology alterations following occlusion, to improve the clinical treatment of abnormal fallopian tube with surgical adhesives for in vitro fertilization and embryo transfer (IVF-ET). Materials and Methods: The experimental rabbits received laparotomy and occlusion of the uterus by surgical adhesive adjacent to the two fallopian tubes, while the control rabbits only received laparotomy. The body weight, hysterosalpingography, and histomorphology were measured to evaluate the uterine occlusion at 1 and 6 months after surgery. Results: There was no significant difference in the mortality rate or body weight between the experimental and control groups. In the experimental group, 38 uterine cavities were identified in 19 rabbits, of which 97.37% were occluded, with expanded uterine cavity and tissue oppression at 1 month after surgery. In total, 33 uterine cavities out of the 36 in the control group were occluded, with proliferation of new stratified epithelial cells observed at 6 months after surgery. In the control group, 20 uterine cavities of 10 rabbits were observed to be absent of occlusion at 1 month after surgery, while 18 uterine cavities in the remaining 9 rabbits were also absent of occlusion at 6 months after the surgery. Conclusion: Surgical adhesives are effective in occluding the uterus of rabbits without adverse effects, supporting their potential clinical use to treat the occlusion in abnormal fallopian tubes prior to IVF-ET.

Empyema with Multiple Bronchopleural Fistulae Improved by Bronchial Occlusion Using an Endobronchial Watanabe Spigot with the Push and Slide Method.

The push and slide method is a method of endoscopic bronchial occlusion using an endobronchial Watanabe spigot that facilitates occlusion of the target bronchus rapidly and accurately using a guidewire. We herein report the case of a man who was diagnosed with empyema forming bronchopulmonary fistulae that was successfully treated by endoscopic bronchial occlusion. Because of the multiple fistulae, balloon occlusion was not a favorable therapeutic approach. Instead, the push and slide method was used in order to detect the fistulae. Endoscopic occlusion, particularly that using the push and slide method, may be a valid treatment option for empyema with multiple bronchopulmonary fistulae.

History of Percutaneous Left Atrial Appendage Occlusion with AMPLATZER Devices.

AMPLATZER devices preceded WATCHMAN occluder in 2002 for catheter-based left atrial appendage occlusion. The AMPLATZER technique facilitates simultaneous closure of atrial shunts using two devices through one gear. Randomized WATCHMAN follow-up data showed a mortality benefit over warfarin. AMPLATZER data make this likely valid for the strategy. Particularly young people with atrial fibrillation should be offered left atrial appendage occlusion because the risk is confined to the intervention and early postintervention period. Guidelines should be adapted to make this progress in prevention of stroke and bleeding in patients with atrial fibrillation accessible for all, in the sense of a mechanical vaccination.

Indication, Patient Selection, and Referral Pathways for Left Atrial Appendage Closure.

Left atrial appendage closure (LAAC) has emerged as a viable option for stroke prevention, especially in those intolerant of or not suitable for long-term oral anticoagulation therapy. This article describes the clinical characteristics, indications, and a proposed referral system for potential LAAC patients. Patient selection remains a challenge because of the paradox between the available randomized data on this intervention and the actual patient population who may gain maximum benefit. Further investigations comparing different LAAC devices with each other and with novel oral anticoagulants are needed. Also, the optimal antithrombotic regimen post-procedure has yet to be determined.

The WATCHMAN Left Atrial Appendage Closure Device: Technical Considerations and Procedural Approach.

Randomized clinical trials have demonstrated that left atrial appendage (LAA) closure with the WATCHMAN device provides stroke prevention in nonvalvular atrial fibrillation while significantly reducing morality and major bleeding. Technical and procedural considerations are paramount for the therapeutic success. Maximizing procedural safety is critical. Optimal LAA sealing is required. Improvements in procedural technique and operator training have resulted in a marked reduction in adverse procedural events, which should increase the absolute long-term clinical benefit. This article outlines the key aspects of patient workup and procedural technique for the best possible outcome.