Mobile Application for Communication Increases the Efficiency of Organ Procurement and Transplantation.

BACKGROUND: Donor organ recovery is a complex process involving organ procurement organizations and multiple surgical teams from various transplant centers. Nearly 30% of discarded organs are wasted due to reasons related to improper coordination and communication. PROBLEM STATEMENT: Lack of real-time communication results in many hours of preventable delay between procurement and transplant teams resulting in the high volume of organ waste, clinical frustration, and critical delays. METHODS: A Plan-Do-Study-Act performance improvement methodology was utilized to design and implement a dedicated mobile communication application (app). Critical time points in the organ offer, procurement, and transplant processes were analyzed from the Report of Organ Offers, and relation coordination metrics were measured. PROCESSES ADDRESSED: Members of procurement and transplant teams in Iowa were interviewed and a dedicated smartphone application was implemented to replace phone calls, e-mails, faxes, and text messages during upcoming kidney offers from July 31, 2017 to July 31, 2018. OUTCOMES: Teams reported a substantial increase in clinical productivity and case progress awareness, including a noteworthy reduction in phone calls. The relational coordination data indicated substantially higher relationship and communication quality with the app. The Report of Organ Offer data revealed a 35% increase in organs transplanted and a 50% reduction in time from initial organ offer to transplant with the use of the mobile application. IMPLICATIONS FOR PRACTICE: The use of a dedicated communication application reduces clinical frustration and delays during the coordination of organ offer, procurement, and transplant. Technologies that improve communication have the potential to improve organ utilization.

Removal of Impacted Supernumerary Teeth Using a Dynamic Surgical Navigation System: A Case Report.

Removal of impacted supernumerary teeth can present a unique set of challenges to the dentoalveolar surgeon. Complications associated with these challenges have been well documented in the literature. The use of dynamically guided surgical navigation technology for the removal of impacted supernumerary teeth has the potential to mitigate these challenges and improve clinical outcomes. Although not a currently Food and Drug Administration-approved indication, the use of dynamic surgical navigation systems for the removal of impacted supernumerary teeth will be elucidated in this case report.

Implant Placement Is More Accurate Using Dynamic Navigation.

PURPOSE: The purpose of this prospective study was to measure and compare the accuracy and precision of dynamic navigation with freehand (FH) implant fixture placement. The authors hypothesized that the evaluated dynamic navigation system would have high accuracy and precision and would be superior to FH methods. MATERIALS AND METHODS: The authors designed and implemented a prospective cohort study and enrolled patients who had implants placed from December 2014 through December 2016. The predictor variable was implant placement technique comparing fully guided (FG) and partially guided (PG) dynamic navigation with FH placement. The outcome variables were accuracy measured as deviation from the virtual plan, and precision was represented as the standard deviation of the measurements. Analysis of variance (ANOVA) was used to compare measurements. Virtual implant placement was compared with post-implant placement using mesh analysis. Deviations from the virtual plan were recorded for each implant for each surgeon. FH implant placement was evaluated by comparing a virtual plan with postoperative scans for patients who did not have the navigation system used for their implant placement. One-way ANOVA was performed to determine within-group and between-groups differences to determine whether there were meaningful differences among surgeons and methods (FG, PG, and FH) of placement. RESULTS: Prospective data from 478 patients involving 714 implants were evaluated. There were no demographic differences among surgeons. The sample size differed by the number of implants placed by each surgeon. Within each method group, the only difference among surgeons was angular deviation. All surgeons' data were combined. For FG navigation, the mean angular deviation was 2.97 ± 2.09°, the mean global platform position deviation was 1.16 ± 0.59 mm, and the mean global apical position deviation was 1.29 ± 0.65 mm. For PG navigation, the mean angular deviation was 3.43 ± 2.33°, the mean global platform position deviation was 1.31 ± 0.68 mm, and the mean global apical position deviation was 1.52 ± 0.78 mm. For FH placement, the mean angular deviation was 6.50 ± 4.21°, the mean global platform position deviation was 1.78 ± 0.77 mm, and the mean global apical position deviation was 2.27 ± 1.02 mm. Differences in measurements comparing FG and PG navigation with FH indicated significantly less deviation from the virtual plan (P < .05) using navigation. CONCLUSIONS: Accuracy and precision for implant placement were achieved using dynamic navigation. The use of this type of method results in smaller deviations from the planned placement compared with FH approaches.

A Review of In-Office Dynamic Image Navigation for Extraction of Complex Mandibular Third Molars.

PURPOSE: We performed a retrospective review of in-office removal of complex mandibular third molars with a dynamic image navigation system (DINS). MATERIALS AND METHODS: A retrospective review was conducted of cases completed from 2010 to 2014 by a single oral and maxillofacial surgeon. The average age of the patients was 47 years (range, 27 to 72 years). Extraction complexity was classified with Juodzbalys and Daugela's classification system. The included study cases had complexity scores of 9 or greater. Each patient received custom intraoral splints to secure the tracking array and underwent cone beam computed tomography image acquisition. All surgical procedures were performed with a precalibrated tracking straight handpiece under dynamic navigation. RESULTS: All 25 cases were treated successfully with the use of the DINS. Twelve of these cases were associated with pathologic lesions. Three patients were noted to have inferior alveolar nerve paresthesia. One patient sustained a pathologic fracture at week 2. Postoperative infections were noted in 7 cases, 2 of which had a pre-existing infection. One patient reported temporary limitation of mouth opening. A coronectomy was performed in 1 case. CONCLUSIONS: We present results using a new technology, the DINS, for removal of complex mandibular third molars. Potential advantages are 1) improved visualization and localization of anatomic structures such as the inferior alveolar nerve, lingual cortical plate, and adjacent roots; 2) improved control during osteotomy; 3) decreased surgical access requirements and reduction in overall bone removal; 4) ability to perform complex procedures successfully in an in-office setting; 5) decreased surgical time resulting from improved visualization; and 6) potential use as a teaching tool. Possible limitations of the use of an in-office DINS include increased cost, increased time attributed to presurgical planning, initial learning curve, and optical array interference by the surgeon or assistants during surgery.

Implant Placement Accuracy Using Dynamic Navigation.

PURPOSE: The aim of this prospective study was to determine platform and angle accuracy for dental implants using dynamic navigation, a form of computer-assisted surgery. Three hypotheses were considered: (1) the overall accuracy for implant placement relative to the virtual plan is similar to that of static tooth-borne computerized tomography (CT)-generated guides; (2) the dynamic system is more accurate than freehand methods; and (3) there is a learning curve associated with this method. MATERIALS AND METHODS: This study involved three surgeons placing implants in the mandible and maxilla of patients using a dynamic navigation system (X-Guide, X-Nav Technologies). Virtual implants were placed into planned sites using the navigation system computer. Post-implant placement cone beam CT scans were taken on all patients. For each patient, this scan was mesh overlayed with the virtual plan and used to determine platform and angular deviations to the virtual plan. The primary outcome variables were platform and angular deviations, comparing the actual placement to the virtual plan. Secondary analyses included determination of accuracy related to case experience and freehand placement of implants. Comparisons to published accuracy studies were made for implant placement using static guides. RESULTS: Accuracy deviations from the virtual plan were similar to those reported for static tooth-based guides using literature references as the comparison. The accuracy of dynamic navigation was superior compared to freehand implant placement. The three surgeons had similar accuracies after their learning curve was achieved. Proficiency based on case series was achieved by the 20th surgical procedure. CONCLUSION: Dynamic navigation can achieve accuracy of implant placement similar to static guides and is an improvement over freehand implant placement. In addition, there was a learning curve to achieve proficiency.

The Case for a Conservative Approach to Blood Transfusion Management in Cardiac Surgery.

Limiting blood transfusion in cardiac operations is a well-meaning goal of perioperative care. Potential benefits include decreasing morbidity and limiting procedural costs. It is difficult to identify transfusion as the cause of adverse outcomes. The need for transfusion may identify a sicker patient population at greater risk for a worse outcome that may or may not be related to the transfusion. We reviewed the indications for and adverse effects of blood transfusion in patients undergoing cardiac procedures to provide a balanced approach to management of blood resources in this population. We reviewed current literature, including systematic reviews and practice guidelines, to synthesize a practice management plan in patients having cardiac operations. Several prospective randomized studies and large population cohort studies compared a postoperative restrictive transfusion policy to a more liberal policy and found very little difference in outcomes but decreased costs with a restrictive policy. Evidence-based practice guidelines and implementation standards provide robust intervention plans that can limit harmful effects of transfusion and provide safe and effective procedure outcomes. A restrictive transfusion policy seems to be safe and effective but does not necessarily provide better outcome in most patient cohorts. The implications of these findings suggest that many discretionary transfusions could be avoided. A subset of high-risk patients could undoubtedly benefit from a more liberal transfusion policy, but the definition of high risk is ill defined.

Accuracy of Dynamic Navigation for Dental Implant Placement-Model-Based Evaluation.

The purpose of this model-based study was to determine the accuracy of placing dental implants using a new dynamic navigation system. This investigation focuses on measurements of overall accuracy for implant placement relative to the virtual plan in both dentate and edentulous models, and provides a comparison with a meta-analysis of values reported in the literature for comparable static guidance, dynamic guidance, and freehand placement studies. This study involves 1 surgeon experienced with dynamic navigation placing implants in models under clinical simulation using a dynamic navigation system (X-Guide, X-Nav Technologies, LLC, Lansdale, Pa) based on optical triangulation tracking. Virtual implants were placed into planned sites using the navigation system computer. Post-implant placement cone-beam scans were taken. These scans were mesh overlaid with the virtual plan and used to determine deviations from the virtual plan. The primary outcome variables were platform and angular deviations comparing the actual placement to the virtual plan. The angular accuracy of implants delivered using the tested device was 0.89° ± 0.35° for dentate case types and 1.26° ± 0.66° for edentulous case types, measured relative to the preoperative implant plan. Three-dimensional positional accuracy was 0.38 ± 0.21 mm for dentate and 0.56 ± 0.17 mm for edentulous, measured from the implant apex.

Validation of an External Support for Coronary Artery Saphenous Vein Grafts without Fibrin Sealant.

BACKGROUND: The aim of the study is to report on a new technique for applying the eSVS Mesh (Kips Bay Medical, Minneapolis, Minnesota, United States), an external saphenous vein support system, without the use of fibrin sealant. METHODS: The mesh covers the entire body of the graft with the exception of both anastomoses. Fibrin sealant was not used to fix the mesh. Two patients underwent surgery using this preparation. EVALUATION: At 4 weeks, computed tomographic angiography revealed no signs of mesh compression at either anastomotic area. The proximal anastomosis inflow diameter was greater than the diameter of the mesh-supported body of the graft. CONCLUSION: This technique successfully eliminates the need for the use of sealant and supports favorable anastomotic geometry.

Static or Dynamic Navigation for Implant Placement-Choosing the Method of Guidance.

The purpose of the present report is to contrast and compare 2 methods of dental implant placement. One method uses computed tomography data for computer-aided design and computer-aided manufacturing to generate static guides for implant placement. The second method is a dynamic navigation system that uses a stereo vision computer triangulation setup to guide implant placement. A review of the published data was performed to provide evidence-based material to compare each method. Finally, the indications for each type of method are discussed.

Implantation of the eSVS Mesh: modification of recommended technique.

The eSVS Mesh is a knitted wire lattice manufactured in cylindrical sheaths of various diameters, designed to be placed around the outer surface of a saphenous vein graft before use in coronary surgery. The goal is to improve long-term vein graft patency by preventing expansive endothelial injury obviating neointimal hyperplasia and subsequent graft atherosclerosis. Since the First-In-Man feasibility trial of the eSVS Mesh, postmarket studies in Europe and a feasibility trial in the United States are ongoing. Consensus from the principal investigators indicated the trials had confounding variables that may impact results other than evaluation of the eSVS Mesh alone. With input from these investigators, the recommended operative technique has been modified for future trials by removing the mesh from proximal and distal anastomoses and eliminating the use of fibrin sealant. These changes allow for use of an implant technique closer to standard vein bypass grafting and a more focused evaluation of the eSVS Mesh.

Clinical evaluation of the eSVS Mesh: First-in-Man trial outcomes.

In coronary artery bypass graft surgery, saphenous vein graft (SVG) patency is much lower than that of the internal mammary artery (IMA). To address this problem, an external support device, the eSVS Mesh was developed. A prospective randomized First-in-Man feasibility trial was conducted in 90 patients after institutional ethics committee approval at seven international centers. The left IMA was used to bypass the anterior descending artery. A mesh-supported (treated) saphenous vein was randomized to either the right or the circumflex coronary system, and an unsupported (control) vein was grafted to the opposing territory. Device diameters available for use were 3.0, 3.5, 4.0, and 4.5 mm. Primary end-points were 30 day adverse cardiac and cerebral events and angiographic patency at 9-12 months. Eighty-five of 90 patients returned for 30 day clinical follow-up (94%). Five patients refused to return, but by telephone contacts were asymptomatic. There was one late noncardiac death and 73 patients returned for angiography (82%), thus 12 additional patients were lost to follow-up at 1 year. Overall patency rate was 49% for the treated versus 81% for controls (p < 0.001). Subset analysis revealed significantly lower patency at one center and with use of the 3.0 mm device (p < 0.05). Removing these data, patency was 72% vs. 81% (p = NS). Sternal wound infection was higher than expected at 5.0%, but this was center specific. The eSVS Mesh is safe, but at up to 1 year, patency is equivalent to untreated vein grafts after removal of outlying data. This study provides insight into operative events and parameters that may optimize outcomes and point to potential improvements in the external SVG support device. Furthermore, longer term studies are pending.

Computerized tomographic angiography in patients having eSVS Mesh(R) supported coronary saphenous vein grafts: intermediate term results.

BACKGROUND: The Saphenous Vein (SVG) is used in over 80% of coronary artery bypass procedures (CABG) and SVG patency is the Achilles heel of CABG. To address this issue, the eSVS Mesh(R), an external Nitinol knitted mesh, fitted like a sleeve over the vein graft preventing over expansion in the high pressure arterial system, has been introduced to improve disease management. Patency data is limited. The objective of this retrospective study is to report patency rates (>3 months) in patients having external mesh support as part of CABG. METHODS: From October 25, 2010 through February 13, 2012, 21 patients had external mesh support of SVG grafts in addition to internal thoracic artery grafting to the Anterior Descending artery. Patients were invited to return for patency evaluation using Computerized Tomographic angiography (CTA) an average of 7.2 months post-operative (R = 3-14 months). RESULTS: 21 male patients (age 57+/- 9 years) underwent on-pump surgery. The eSVS Mesh was successfully placed on all SVGs. All grafts were determined patent intra-operative by transit time Doppler measurement and there were no operative revisions. There was no operative mortality. 12 of the 21 contacted patients returned for CTA, 8 non-returning patients contacted were alive and asymptomatic but refused to return due to travel restrictions or cost. One patient was lost to follow up. 11 returning patients underwent CTA. One patient was excluded (asymptomatic) due to elevated creatinine. Of the 23 anastomoses in 11 patients(Average: 2.09 grafts/patient) using SVG available for examination, 21 were patent (92%). CONCLUSIONS: In this retrospective non-randomized experience, the external mesh supported grafts displayed excellent intermediate patency.

Intraoperative transit-time flow measurement is not altered in venous bypass grafts covered by the eSVS mesh.

OBJECTIVE: The aim of this study was to determine whether the eSVS Mesh interferes with transit-time flow measurement (TTFM) assessing intraoperative coronary vein graft patency. METHODS: In four swine undergoing off-pump bypass grafting to the anterior descending coronary artery, five TTFMs were sequentially obtained on meshed and bare grafts at baseline and under Dobutamine stress at five separate locations on the graft in each animal. The Medistim VeriQ was used for TTFM. The grafts were examined for patency after the swine were killed. RESULTS: There was no difference in hemodynamics or TTFM either at baseline or under Dobutamine stress between the eSVS Mesh covered and uncovered grafts. Dobutamine, however, significantly increased hemodynamics and graft flow parameters measured from baseline. CONCLUSIONS: The eSVS Mesh does not interfere with Doppler flow measurement in covered coronary vein grafts.

Over the next hill.

In the tradition of Dr Arom, who had many interests in his clinical and research career, I will touch on three things that will impact the practice of clinical cardiac surgery over the next several years: use of bilateral internal mammary arteries, use of external mesh support to improve saphenous vein graft patency, and anticoagulation of mechanical heart valves. The remainder of the presentation goes into depth on the development of a bloodless heart surgery program, which is contemporary and timely as it encompasses some thoughts of this society.