Transradial left ventricular endomyocardial biopsy: assessment of safety and efficacy.

BACKGROUND: We aimed at assessing the safety and efficacy of a systematic transradial approach for left ventricular endomyocardial biopsy using a new hydrophilic sheathless guiding catheter. METHODS AND RESULTS: Forty-two consecutive patients were included. The transradial success rate was 98% (41 of 42). In one case, cross over to femoral access due to irreversible spasm of the right radial artery was necessary. No radial spasm was observed in the other 41 patients. Depending on the indication, several other procedures, such as coronary angiography or ventricular angiography, were additionally performed through the same transradial access site. Median fluoroscopy time was 7.9 min. The mean dose area product was 1867 cGy × cm(2). All biopsy samples were graded as good or excellent quality. No patient had any complications. Immediate post-procedural ambulation could be achieved in all patients. Radial artery patency was confirmed by duplex sonography 24 h after removal of the guide. CONCLUSION: The present study demonstrates safety and efficacy of a systematic transradial access for left ventricular EMB using a highly hydrophilic sheathless guiding catheter. This is of clinical importance since this new technique may overcome critical limitations of the common approach.

Auditory evoked potentials compared with bispectral index for monitoring of midazolam and propofol sedation during colonoscopy.

OBJECTIVES: The purpose of this study was to evaluate and compare Bispectral index (BIS) and A-line auditory evoked potential index (AAI) for monitoring depth of low-dose midazolam and propofol sedation during colonoscopy. METHODS: A total of 115 consecutive patients (ASA I-IV), receiving low-dose midazolam and propofol sedation for colonoscopy, were evaluated. BIS and AAI levels, Observer's Assessment of Alertness/Sedation (OAA/S) scores, blood pressure, heart rate, oxygen saturation, as well as the presence or absence of eyelash reflex, patient reaction to an external noxious stimulus and to procedure-related pain were recorded every 1-3 min by a single trained observer. RESULTS: There was a positive correlation between BIS and OAA/S scores (correlation coefficient=0.77) and to a lesser extent AAI and OAA/S scores (correlation coefficient=0.47). BIS and AAI showed significant differences between subsequent levels of sedation (P<0.001). The clustered receiver operating characteristic curve estimate of BIS for the detection of deep sedation was significantly better than that of AAI (P<0.001). Regarding the presence or absence of eyelash reflex and patient reaction to an external noxious stimulus and to procedure-related pain, significant different levels were found for BIS as well as AAI, respectively. Only small changes were observed in hemodynamic variables and oxygen saturation. Overall, our data suggest target BIS levels of slightly above 73 for moderate sedation (defined as OAA/S scores 2 and 3). CONCLUSIONS: BIS and AAI correlated with the level of sedation. Hemodynamic variables were poor indicators of the hypnotic-anesthetic status of the patient. BIS discriminated best between moderate and deep sedation and could complement clinical observation for guidance of moderate sedation.

Percutaneously assisted endoscopic surgery using a new PEG-minitrocar for advanced endoscopic submucosal dissection (with videos).

BACKGROUND: For endoscopic submucosal dissection (ESD), adequate exposure and visualization of the submucosa for controlled dissection is of eminent importance. OBJECTIVE: To determine the feasibility and safety of percutaneously assisted endoscopic surgery (PA-ES) with a new prototype PEG-minitrocar (PMT) for advanced ESD in a porcine model. INTERVENTIONS: Placement of the PMT was done in all pigs by the use of a modified pull-through technique. After endoscopic incision of the mucosa, traction was provided for ESD by grasping the incisional margins of the mucosa with a rigid forceps introduced through the PMT, enabling stepwise dissection of the exposed submucosa under direct vision. MAIN OUTCOME MEASUREMENTS: Feasibility and safety of the new PMT for PA-ES and en bloc resection of prespecified mucosal areas. RESULTS: The study started with acute experiments in 8 animals, followed by a 10-day survival study in another 8 pigs. A total of 20 mucosal pieces were resected. The sizes of the resected pieces varied up to 7.5 x 4.0 cm ex vivo. All but one could be resected en bloc. Percutaneous assistance resulted in an excellent exposure of the submucosal space and enabled stepwise dissection of the submucosal connective tissue. Neither the PMT nor advanced ESD led to relevant complications. CONCLUSIONS: We demonstrated the feasibility and safety of a new PMT for advanced ESD. With the use of PA-ES, mucosal pieces of various sizes can be resected en bloc in gastric locations that are difficult to access by flexible endoscopy alone.

Intravenous application of fluorescein for confocal laser scanning microscopy: evaluation of contrast dynamics and image quality with increasing injection-to-imaging time.

BACKGROUND: Confocal laser scanning microscopy (CLSM) is reported to be a promising tool for in vivo histopathology during an endoscopy. The most commonly used fluorophore is fluorescein sodium given intravenously. However, so far, there are no objective data on contrast dynamics and image quality over time after injection of the substance. OBJECTIVE: We aimed to investigate the ideal time period for the best CLSM imaging when using fluorescein sodium. DESIGN: The proximal stomachs of 4 anesthetized pigs were examined via standard endoscopes with a portable confocal miniprobe. After injection of 1% fluorescein intravenously (0.1 mL/kg body weight), consecutive sequences were recorded after 1, 2, 3, 5, 8, 20, 30, 40, 50, and 60 minutes. After the procedure, histograms, which represented signal intensity of 20 images (at respective time points), were analyzed from representative regions of interest (ROI). The mean (standard deviation [SD]) pixel value of the pixel values in the ROI were noted. A signal-to-noise ratio (SNR), defined as the ratio between the mean and the SD, was calculated. In addition, 5 images per time period were put into a random order and then blindly evaluated by 2 endoscopists. RESULTS: A total of 560 histograms from selected ROIs were analyzed. The SNR decreased significantly after 8 minutes, with the lowest values being reached after 30 minutes. Subjective evaluation of still images also demonstrated a continuous decrease, with the lowest image quality after 30 minutes. A slight increase of image quality after 40 minutes occurred because of extramucosal leakage of fluorescein, with fluorophore deposits in the crypt orifices. CONCLUSIONS: In the pig model, fluorescein-based CLSM of the GI tract delivered the best contrast and image quality within the first 8 minutes after injection of the fluorophore. These data might facilitate standardization of the procedure for research purposes but may also help when applying this new technology in a daily routine manner.