Balloon Tip Research Articles

Carotid artery stenting with flow inversion cerebral protection and MicroNet-covered stent.

The study aims to evaluate the association of proximal flow-inversion cerebral protection and MicroNet-covered CGuard stents in reducing early and late embolic events in carotid artery stenting procedures. From 2018 to 2023, we performed 204 procedures in 180 patients with flow inversion cerebral protection and CGuard stents at the Vascular Surgery Unit of Sant'Eugenio Hospital in Rome. Cerebral protection was achieved with a Flow-Gate2 catheter connected to a peripheral vein. The tip balloon is inflated in the CCA to obtain an effective endoclamping, the pressure difference between the carotid bifurcation and the venous compartment ensures a constant back flow with wash-out in the venous compartment. Inclusion criteria were: life expectancy of >12 months, target lesions indicating treatment according to ESVS Guidelines, increased surgical risk due to comorbidities or anatomic issues. ECD follow-up was performed immediately postoperatively, at 30 days, 6 and 12 months, and subsequently annually. The treatment protocol was successfully implemented in 99% of cases. No major strokes occurred, while one minor stroke (0.5%) occurred within 8 hours of the procedure, regressing in the following months. One perioperative death (0.5%) due to cerebral hemorrhage occurred three hours after the procedure. All patients remained asymptomatic, with no short or medium-term neurological score deterioration. One hemodynamically significant restenosis (0.5%) was detected at the 6-month follow-up. All patients completed the 6 months follow-up, though 6 (3%) were lost at the 12-month appointment. Our prospective monocentric study has demonstrated the effectiveness and safety of the FlowGate2 flow inversion cerebral protection system in association with MicroNet covered CGuard stent.

491 Clinical and Radiographic Features of Mesenteric Ischemia after Intra-Aortic Balloon Pump Placement

OBJECTIVES/GOALS: Intra-aortic balloon pumps are commonly used as circulatory support in patients with critically reduced cardiac function. The goal of this study is to estimate the incidence of mesenteric ischemia as an understudied vascular complication and to describe the clinical and radiographic characteristics of patients experiencing this complication. METHODS/STUDY POPULATION: We will be conducting a retrospective analysis of the electronic medical records of all patients who underwent intra-aortic balloon pump (IABP) placement between October 2020 and April 2023 at our academic medical center to identify the incidence of mesenteric ischemia. We will describe the clinical course of these patients and characterize them based on demographic features and risk factors for vascular complications including medical comorbidities. Finally, we will assess available chest x-ray and thoracoabdominal CT imaging for adequacy of balloon tip positioning, concordance between balloon size and aortic dimensions, and compromise of any visceral arteries in patients who experienced mesenteric ischemia vs. those who did not. RESULTS/ANTICIPATED RESULTS: We anticipate approximately 150 patients to have recieved IABPs over this period with at least 4 known cases of mesenteric ischemia. We will describe the clinical presentation of these cases and their often fatal outcomes. We expect several known risk factors will be present in these patients, including history of peripheral vascular disease, diabetes, or smoking history. On chest x-ray, we predict balloon tip positioning to be suboptimal (defined as >5cm below the aortic arch) in many patients, both those with mesenteric ischemia and those without, but a greater discordance on CT imaging between balloon size and aortic dimensions with greater evidence of visceral compromise in patients with mesenteric ischemia compared to those without. DISCUSSION/SIGNIFICANCE: Mesenteric ischemia is a serious and poorly studied complication of intra-aortic balloon pumps. Understanding the hospital course, clinical characteristics, and radiographic features present in these patients may guide clinicians in the early recognition and management of this potentially fatal complication.

Balloon dacryoplasty: A boon for dacryologists in managing persistent congenital nasolacrimal duct obstructions.

To study the outcomes of balloon dacryoplasty (BD) or (BDCP) in children with persistent congenital nasolacrimal duct obstruction (pCNLDO) by using new and reused balloon catheters. Our retrospective analysis focused on managing pCNLDO by using the BD or BDCP technique. The study included children aged >1 year to <12 years who underwent single or multiple probings before. Our specific lacrimal workup included a detailed history and examination, as published earlier. We used conventional, straight, 2 mm × 13 mm/3 mm × 15 mm lacrimal balloons (FCI, Ophthacath). We have described a technique to use the same catheter for three BD procedures (1 new + 2 reuse). The outcomes were categorized as complete success, partial success, and failure. The minimum follow-up of each child was 6 months. We analyzed 64 children (89 eyes) with a mean age of 58 months (15-132 months). All children (100%) had epiphora with discharge and positive FDDT. All children underwent BD under general anesthesia - new balloons in 59 eyes and reused balloons in 30 eyes. The balloons were plasma sterilized akin to vitrectomy cutters and tubings of phaco machines. We noted three leaks from reused balloons (2 from the balloon tip and 1 from the plastic hub). At a mean follow-up of 14.5 months, complete success was noted in 77 eyes (86.5%) (52 new and 25 reuse), while 8 eyes had partial success (8.9%) (4 new and 4 reuse). Failure of BD was noted in four eyes (4.5%) (3 new and 1 reuse). None had significant complications with new or reused balloons. BD or BDCP is a quick, safe, easy, and effective procedure that resolves pCNLDO symptoms satisfactorily. Carefully reusing a conventional balloon catheter is possible with comparable efficacy and no additional complications in pCNLDO.

Transcriptional profiles of pulmonary artery endothelial cells in pulmonary hypertension

Pulmonary arterial hypertension (PAH) is characterized by endothelial cell (EC) dysfunction. There are no data from living patients to inform whether differential gene expression of pulmonary artery ECs (PAECs) can discern disease subtypes, progression and pathogenesis. We aimed to further validate our previously described method to propagate ECs from right heart catheter (RHC) balloon tips and to perform additional PAEC phenotyping. We performed bulk RNA sequencing of PAECs from RHC balloons. Using unsupervised dimensionality reduction and clustering we compared transcriptional signatures from PAH to controls and other forms of pulmonary hypertension. Select PAEC samples underwent single cell and population growth characterization and anoikis quantification. Fifty-four specimens were analyzed from 49 subjects. The transcriptome appeared stable over limited passages. Six genes involved in sex steroid signaling, metabolism, and oncogenesis were significantly upregulated in PAH subjects as compared to controls. Genes regulating BMP and Wnt signaling, oxidative stress and cellular metabolism were differentially expressed in PAH subjects. Changes in gene expression tracked with clinical events in PAH subjects with serial samples over time. Functional assays demonstrated enhanced replication competency and anoikis resistance. Our findings recapitulate fundamental biological processes of PAH and provide new evidence of a cancer-like phenotype in ECs from the central vasculature of PAH patients. This “cell biopsy” method may provide insight into patient and lung EC heterogeneity to advance precision medicine approaches in PAH.

Abstract 16801: Effect of Cyclosporine A on Infarct Size in Rat Hearts Donated After Circulatory Death

Introduction: Ischemia-reperfusion injury (IRI) is inherent in heart donation after circulatory death (DCD), hence only hearts with &lt;30 minutes of ischemia are used for transplantation. Mitochondrial permeability-transition pore (MPTP) opening has been implicated in IRI. Cyclosporine A (CyA) is known to inhibit MPTP opening. No data on infarct size reduction with CyA exists in a DCD heart. Hypothesis: CyA given during reperfusion will reduce infarct size in DCD hearts. Methods: Male Sprague-Dawley rats were assigned to either DCD + CyA, DCD + vehicle, or control-beating heart donors (CBD) (n=10 per group). Rats were anesthetized with pentobarbital, intubated and ventilated. Vecuronium and heparin were given for muscle paralysis and anticoagulation respectively. For DCD group, ventilation was terminated (start of anoxia/ischemia time), and hearts procured after 5, 10, 15, 20, 25 minutes. CBD hearts were procured without ischemia. Hearts were then perfused on a Langendorff setup for 90 minutes. Vehicle and CyA groups received DMSO and CyA (2μM) in KH buffer, respectively, for first 15 minutes followed by 75 minutes of KH buffer. Developed pressure (DP) was measured via a balloon tip catheter placed in the left ventricle. Infarct size was measured using triphenyltetrazolium chloride staining. CBD hearts perfused with KH buffer only served as controls. Results: Percent infarct size following 5, 10, 15, 20, and 25 minutes of ischemia was 17.7 ± 4, 19.3 ± 6, 25 ± 4, 27.3 ± 3, and 25.4 ± 11 respectively. CyA given to 25 minutes ischemia group reduced infarct size to 14.7%, corresponding to 6 minutes of ischemia. At 60 minutes CyA treated hearts had higher DP (mmHg) compared to vehicle group (34 ± 13 vs. 51 ± 17, p=0.017 ). Conclusions: CyA given during reperfusion to DCD hearts significantly reduced infarct size and preserved function. CyA use may allow for longer ischemia times during DCD heart procurement.

Electron Transport Chain Inhibition to Decrease Injury in Transplanted Donation After Circulatory Death Rat Hearts.

Donation after circulatory death (DCD) donor hearts sustain ischemic damage and are not routinely used for heart transplantation. DCD heart injury, particularly reperfusion injury, is primarily mediated by releasing reactive oxygen species from the damaged mitochondria (complex I of the electron transport chain). Amobarbital (AMO) is a transient inhibitor of complex I and is known to reduce releasing reactive oxygen species generation. We studied the beneficial effects of AMO in transplanted DCD hearts. Sprague-Dawley rats were assigned to 4 groups-DCD or DCD + AMO donors and control beating-heart donors (CBD) or CBD + AMO donors (n = 6-8 each). Anesthetized rats were connected to a ventilator. The right carotid artery was cannulated, heparin and vecuronium were administered. The DCD process started by disconnecting the ventilator. DCD hearts were procured after 25 minutes of in-vivo ischemia, whereas CBD hearts were procured without ischemia. At procurement, all donor hearts received 10 mL of University of Wisconsin cardioplegia solution. The CBD + AMO and DCD + AMO groups received AMO (2 mM) dissolved in cardioplegia. Heterotopic heart transplantation was performed by anastomosing the donor aorta and pulmonary artery to the recipient's abdominal aorta and inferior vena cava. After 14 days, transplanted heart function was measured with a balloon tip catheter placed in the left ventricle. Compared with CBD hearts, DCD hearts had significantly lower developed pressure. AMO treatment significantly improved cardiac function in DCD hearts. Treatment of DCD hearts at the time of reperfusion with AMO resulted in an improvement of transplanted heart function that was comparable with the CBD hearts.

Abstract 12689: Electron Transport Chain Inhibition to Decrease Reperfusion Injury in Transplanted Donation After Circulatory Death Rat Hearts

Introduction: Intrinsic to the donation after circulatory death (DCD) donation is ischemia and reperfusion injury, primarily mediated through release of reactive oxygen species (ROS) from the damaged mitochondria. Amobarbital (AMO) is a transient, reversible inhibitor of complex I known to decrease ROS generation. We studied whether AMO treatment during reperfusion can improve function in transplanted DCD hearts. Methods: Sprague Dawley rats, were assigned to four heart donor groups- DCD or DCD+AMO and control beating-heart donor (CBD) or CBD+AMO (n=6-8 each). Donor rats were anesthetized using ketamine/xylazine, intubated and connected to a ventilator. The carotid access was used to deliver heparin (1000 U/kg) and vecuronium bromide (4 mg/kg) to paralyze diaphragmatic muscles. The DCD process was initiated by disconnecting the ventilator. Donor hearts were procured following 25 minutes of in-vivo ischemia in the DCD groups, while CBD hearts were procured without terminating the ventilation. At procurement, after clamping the aortic arch, all donor hearts received 10 ml of University of Wisconsin cardioplegia solution delivered through the carotid cannula. The CBD+AMO and DCD+AMO groups received AMO (2 mM), dissolved in the cardioplegia. Heterotopic heart transplantation was performed in recipient rat’s abdomen. After 14 days the transplanted heart function was measured with a balloon tip catheter. Results: Compared to CBD hearts, DCD hearts had significantly lower developed pressure, the rate pressure product (developed pressure times heart rate), and negative dP/dt indicating decreased contractile and impaired diastolic function (Figure). AMO treatment of the DCD hearts resulted in significantly improved cardiac function compared to the untreated DCD hearts. Conclusions: A single treatment with AMO during the heart procurement improves the transplanted DCD heart function which was comparable to the control CBD hearts.

Hirschsprung Disease.

Hirschsprung Disease.

経肛門イレウス管を介したコーラ溶解療法で治療した糞便性イレウスの1例(A case of obstructive colitis treated with Cola dissolution therapy administered via a transanal ileus tube)

要旨症例は78歳の男性。腹痛と嘔吐を主訴に前医受診し大腸イレウスを指摘され，当科へ紹介となった。CTでは完全内臓逆位を認め，横行結腸に高吸収を呈する糞便（約75×45×55mm）が貯留し, 口側結腸に拡張を認め, 脾湾曲付近の横行結腸に糞石が嵌頓しており糞便性イレウスと診断した。緊急下部消化管内視鏡検査では閉塞性大腸炎を疑う所見を認め，嵌頓は解除できたが，糞石は除去できず経肛門イレウス管の留置を行った。血圧低下・血清乳酸値上昇があり敗血症性ショックであった。ショックから離脱した後，経肛門イレウス管を使用しコーラ溶解療法を実施したところ速やかに糞石が排泄された。コーラ溶解療法により治療した糞便性イレウスの1例を経験したので報告する。

The advantages and disadvantages of the novel fourth-generation cryoballoon as compared to the second-generation cryoballoon in the current short freeze strategy

The novel fourth-generation cryoballoon (4th-CB) is characterized by a shorter-tip that potentially facilitates better time-to-isolation(TTI) monitoring. We sought to clarify the advantages and disadvantages of the 4th-CB compared to the second-generation cryoballoon (2nd-CB) inpulmonary vein isolation (PVI). Forty-one and 49 consecutive atrial fibrillation patients underwent 2nd-CB and 4th-CB PVIs using 28-mm balloons and short freeze strategies.When effective freezing was not obtained, the CB was switched to the other CB. The rate of successful PVIs was significantly higher for 2nd-CBs than 4th-CBs (162/162[100%] vs. 178/193[92.2%] PVs, p < 0.0001). Thedifference was significant for lower PVs, especially right inferior PVs (RIPVs)(p = 0.005). In a total of 15 PVs in 11 patients, 4th-CBs were switched to 2nd-CBs, and 14/15(93.3%) PVs were successfully isolated. The balloon temperature tended to reach -55℃ more frequently with 2nd-CBs than 4th-CBs duringRIPV ablations (15/41[36.6%] vs. 12/49[24.5%], p = 0.21). The TTI monitoring capability was significantly higher with 4th-CBs than 2nd-CBs(131/188[69.7%] vs. 83/160[51.9%] PVs, p = 0.0007). The difference was significant for right superior and left inferior PVs, but not for left superior PVs.Even if PVs requiring crossover were excluded, the total freeze duration (715±152 vs. 755±215 seconds, p = 0.31) tended to be shorter for 2nd-CBs than 4th-CBs. The incidence of phrenic nerve injury was similar for 2nd-CB and 4th-CB ablation (0/41 vs. 2/49, p = 0.12) CONCLUSIONS: The 4th-CB's shorter balloon tip enabled a significantly higher capability of TTI monitoring; however, it resulted in significantly lower rates of successful PVIs than the 2nd-CB, especially for the RIPVs.

MRI for Guided Right and Left Heart Cardiac Catheterization: A Prospective Study in Congenital Heart Disease.

BackgroundImprovements in outcomes for patients with congenital heart disease (CHD) have increased the need for diagnostic and interventional procedures. Cumulative radiation risk is a growing concern. MRI‐guided interventions are a promising ionizing radiation‐free, alternative approach.PurposeTo assess the feasibility of MRI‐guided catheterization in young patients with CHD using advanced visualization passive tracking techniques.Study TypeProspective.PopulationA total of 30 patients with CHD referred for MRI‐guided catheterization and pulmonary vascular resistance analysis (median age/weight: 4 years / 15 kg).Field Strength/Sequence1.5T; partially saturated (pSAT) real‐time single‐shot balanced steady‐state free‐precession (bSSFP) sequence.AssessmentImages were visualized by a single viewer on the scanner console (interactive mode) or using a commercially available advanced visualization platform (iSuite, Philips). Image quality for anatomy and catheter visualization was evaluated by three cardiologists with >5 years' experience in MRI‐catheterization using a 1–5 scale (1, poor, 5, excellent). Catheter balloon signal‐to‐noise ratio (SNR), blood and myocardium SNR, catheter balloon/blood contrast‐to‐noise ratio (CNR), balloon/myocardium CNR, and blood/myocardium CNR were measured. Procedure findings, feasibility, and adverse events were recorded. A fraction of time in which the catheter was visible was compared between iSuite and the interactive mode.Statistical Tests T‐test for numerical variables. Wilcoxon signed rank test for categorical variables.ResultsNine patients had right heart catheterization, 11 had both left and right heart catheterization, and 10 had single ventricle circulation. Nine patients underwent solely MRI‐guided catheterization. The mean score for anatomical visualization and contrast between balloon tip and soft tissue was 3.9 ± 0.9 and 4.5 ± 0.7, respectively. iSuite provided a significant improvement in the time during which the balloon was visible in relation to interactive imaging mode (66 ± 17% vs. 46 ± 14%, P < 0.05).Data ConclusionMRI‐guided catheterizations were carried out safely and is feasible in children and adults with CHD. The pSAT sequence offered robust and simultaneous high contrast visualization of the catheter and cardiac anatomy.Level of Evidence2Technical Efficacy Stage1

S2057 Novel Gabriel Feeding Tube Produces Duodenal Ulcer

INTRODUCTION: Early enteral feeding is an essential part of the care of the critically ill patient. Post pyloric feeding in these patients may lower the risk of aspiration pneumonia. Traditional feeding tubes often do not reach the proximal duodenum or do not remain in place if placed correctly. Endoscopic placement is an option but it is invasive, costly, and may ultimately be ineffective due to tube migration back to the stomach. A novel device, the Gabriel Feeding Tube with Balloon, has been designed to address these issues. This device utilizes peristalsis to move its balloon tip to the small intestine. While effective, we are reporting a case of duodenal bulb ulceration as a complication of the Gabriel Feeding Tube balloon. CASE DESCRIPTION/METHODS: A 63 year old female with a history of GERD and Hepatitis C cirrhosis presented for elective lumbar fusion surgery. Her postoperative course was complicated by a dural tear leading to admission to the intensive care unit. In the ICU, she developed pneumonia with altered mental status. Enteral feeding was initiated after placement of a Gabriel feeding tube with balloon. Seven days post placement of the Gabriel Feeding tube, the patient developed maroon-colored stool suggestive of an upper gastrointestinal bleed. An esophagogastroduodenoscopy revealed a large, 11 mm semi-circumferential white based ulcer in the duodenal bulb extending into the postbulbar duodenum. The Gabriel Feeding tube was removed and the patient was treated with a proton pump inhibitor. The patient was negative for H. pylori. No further bleeding occurred. DISCUSSION: Post-pyloric nasogastric tubes have been shown to have lower risk of pneumonia without increase in complications nor decline in nutritional support. The balloon in the Gabriel Feeding Tube ensures proper placement of the tube and assists in movement via peristalsis. However, the balloon may result in unexpected ulceration due to pressure on the intestinal wall as was discovered in this patient. Complications of the Gabriel Feeding Tube have not been reported in the literature. To our knowledge, this is the first reported case of duodenal ulceration as a complication of the Gabriel Feeding Tube with Balloon. More widespread use of this device may result in reporting of this or other complications. Knowledge of potential complications will enhance assessment of risks and benefits and ultimately improve medical decision making in the critically ill patient.Figure 1.: Clean Based Ulcer in the Postbulbar Duodenums.

Evaluation of a Nasoenteral Feeding Tube With Balloon to Facilitate Placement.

Enteral feeding is essential for critically ill, head trauma, and burn patients who are unable to swallow. To evaluate a new nasoenteral feeding tube with distal tip balloon designed to facilitate post-pyloric migration and avoid misplacement in the trachea. A case series was conducted in 50 critically ill patients aged 19 to 89 years receiving mechanical ventilation and requiring enteral nutrition in a teaching hospital. Patients received a soft, flexible, kink-resistant nasoenteral feeding tube with a balloon near the distal tip to enhance postpyloric migration by peristalsis. The feeding tube was inserted with a novel thread technique to reduce posterior nasopharyngeal trauma and tube misplacement. Pulse oximetry provided early detection of misplacement into the trachea. Placement was verified by abdominal radiography performed shortly after the procedure and repeated within 24 hours if needed. Postpyloric placement was achieved at 30 minutes in 24% of patients and by the following morning in 70% of patients. Tracheal intubation occurred in 1 patient but was recognized and corrected without injury. No tube occlusion from kinking occurred. Early gastric or postpyloric feeding can be provided with this novel feeding tube. Its use facilitates quick bedside recognition of accidental misplacement in the trachea, reducing the chance of pneumothorax. The tip balloon reduces deeper placement into a lung and promotes distal migration into the small intestine. The design prevents occlusion from kinking, which is common with conventional feeding tubes. Nurses easily adopted the tube and insertion technique.

Culture of pulmonary artery endothelial cells from pulmonary artery catheter balloon tips: considerations for use in pulmonary vascular disease.

Endothelial dysfunction is a hallmark of pulmonary arterial hypertension (PAH) but there are no established methods to study pulmonary artery endothelial cells (PAECs) from living patients. We sought to culture PAECs from pulmonary artery catheter (PAC) balloons used during right-heart catheterisation (RHC) to characterise successful culture attempts and to describe PAEC behaviour.PAECs were grown in primary culture to confluence and endothelial cell phenotype was confirmed. Standard assays for apoptosis, migration and tube formation were performed between passages three to eight. We collected 49 PAC tips from 45 subjects with successful PAEC culture from 19 balloons (39%).There were no differences in subject demographic details or RHC procedural details in successful versus unsuccessful attempts. However, for subjects who met haemodynamic criteria for PAH, there was a higher but nonsignificant (p=0.10) proportion amongst successful attempts (10 out of 19, 53%) versus unsuccessful attempts (nine out of 30, 30%). A successful culture was more likely in subjects with a lower cardiac index (p=0.03) and higher pulmonary vascular resistance (p=0.04). PAECs from a subject with idiopathic PAH were apoptosis resistant compared to commercial PAECs (p=0.04) and had reduced migration compared to PAECs from a subject with portopulmonary hypertension with high cardiac output (p=0.01). PAECs from a subject with HIV-associated PAH formed fewer (p=0.01) and shorter (p=0.02) vessel networks compared to commercial PAECs.Sustained culture and characterisation of PAECs from RHC balloons is feasible, especially in PAH with high haemodynamic burden. This technique may provide insight into endothelial dysfunction during PAH pathogenesis.

Invasive cardiovascular magnetic resonance (iCMR) for diagnostic right and left heart catheterization using an MR-conditional guidewire and passive visualization in congenital heart disease

BackgroundToday’s standard of care, in the congenital heart disease (CHD) population, involves performing cardiac catheterization under x-ray fluoroscopy and cardiac magnetic resonance (CMR) imaging separately. The unique ability of CMR to provide real-time functional imaging in multiple views without ionizing radiation exposure has the potential to be a powerful tool for diagnostic and interventional procedures. Limiting fluoroscopic radiation exposure remains a challenge for pediatric interventional cardiologists.This pilot study’s objective is to establish feasibility of right (RHC) and left heart catheterization (LHC) during invasive CMR (iCMR) procedures at our institution in the CHD population. Furthermore, we aim to improve simultaneous visualization of the catheter balloon tip, MR-conditional guidewire, and cardiac/vessel anatomy during iCMR procedures.MethodsSubjects with CHD were enrolled in a pilot study for iCMR procedures at 1.5 T with an MR-conditional guidewire. The CMR area is located adjacent to a standard catheterization laboratory. Using the interactive scanning mode for real-time control of the imaging location, a dilute gadolinium-filled balloon-tip catheter was used in combination with an MR-conditional guidewire to obtain cardiac saturations and hemodynamics. A recently developed catheter tracking technique using a real-time single-shot balanced steady-state free precession (bSSFP), flip angle (FA) 35–45°, echo time (TE) 1.3 ms, repetition time (TR) 2.7 ms, 40° partial saturation (pSAT) pre-pulse was used to visualize the gadolinium-filled balloon, MR-conditional guidewire, and cardiac structures simultaneously. MR-conditional guidewire visualization was enabled due to susceptibility artifact created by distal markers. Pre-clinical phantom testing was performed to determine the optimum imaging FA-pSAT combination.ResultsThe iCMR procedure was successfully performed to completion in 31/34 (91%) subjects between August 1st, 2017 to December 13th, 2018. Median age and weight were 7.7 years and 25.2 kg (range: 3 months – 33 years and 8 – 80 kg). Twenty-one subjects had single ventricle (SV) anatomy: one subject was referred for pre-Glenn evaluation, 11 were pre-Fontan evaluations and 9 post-Fontan evaluations for protein losing enteropathy (PLE) and/or cyanosis. Thirteen subjects had bi-ventricular (BiV) anatomy, 4 were referred for coarctation of the aorta (CoA) evaluations, 3 underwent vaso-reactivity testing with inhaled nitric oxide, 3 investigated RV volume dimensions, two underwent branch PA stenosis evaluation, and the remaining subject was status post heart transplant. No catheter related complications were encountered. Average time taken for first pass RHC, LHC/aortic pull back, and to cross the Fontan fenestration was 5.2, 3.0, and 6.5 min, respectively. Total success rate to obtain required data points to complete Fick principle calculations for all patients was 331/337 (98%). Subjects were transferred to the x-ray fluoroscopy lab if further intervention was required including Fontan fenestration device closure, balloon angioplasty of pulmonary arteries/conduits, CoA stenting, and/or coiling of aortopulmonary (AP) collaterals.Starting with subject #10, an MR-conditional guidewire was used in all subsequent subjects (15 SV and 10 BiV) with a success rate of 96% (24/25). Real-time CMR-guided RHC (25/25 subjects, 100%), retrograde and prograde LHC/aortic pull back (24/25 subjects, 96%), CoA crossing (3/4 subjects, 75%) and Fontan fenestration test occlusion (2/3 subjects, 67%) were successfully performed in the majority of subjects when an MR-conditional guidewire was utilized.ConclusionFeasibility for detailed diagnostic RHC, LHC, and Fontan fenestration test occlusion iCMR procedures in SV and BiV pediatric subjects with complex CHD is demonstrated with the aid of an MR-conditional guidewire. A novel real-time pSAT GRE sequence with optimized FA-pSAT angle has facilitated simultaneous visualization of the catheter balloon tip, MR-conditional guidewire, and cardiac/vessel anatomy during iCMR procedures.

2144 Robotic Isthmocele Repair of a Big Cesarean Scar Defect - A Feasible Technique

Video Objective Describe a robotic isthmocele repair of a big cesarean section scar defect. Setting Isthmocele is a reservoir, pouchlike defect, at the site of a previous cesarean section, normally resulted of a cesarean scar defect or dehiscence. Its prevalence may be underestimated. A rare, but important repercussion, is cervical scar pregnancy, one of the rarest forms of ectopic pregnancy, with a high risk of uterine rupture and haemorrhage. Half of the cases occurs to patients who had only one prior caesarea. Isthmocele's treatment must be chosen among different alternatives (hysteroscopic, vaginal, laparotomic, laporoscopic), considering symptoms, plans for future conception, and the size of the defect. Isthmocele resection with myometrium myoplastia must be considered if the residual myometrium thickness is less than 3 mm. Interventions A 38-year old woman, with 1 previous cesarean section and 1 cervical scar ectopic pregnancy treated with methotrexate 8 months ago, preparing to concieve, presented with a large isthmocele. Preoperative MRI exhibited a 26 × 22 mm defect, with a 1 mm remaining myometrium. A robotic approach was used to identify the cervical niche, using a uterine manipulator with its tip balloon placed downwards, right above the internal cervical orifice. After correct identification, the bladder was caudally dissected and the uterine isthmus limits were completed exposed. The isthmocele was resected. All connective tissue was enucleated until vivid myometrium was seem all over its circumference. The defect was closed in two layers with 2.0 vicryl interrupted sutures. Conclusion Robotic isthmocele repair is a feasible technique when correctly chosen. Due to the raising number of cesarean sections, gynecologists will face this problem more frequently and must be aware of its indications as well as different approaches.

Электронное представление «Словаря русского языка XXI века»: возможности развития

The publication of the first volume of “The Dictionary of the Russian Language of the 21st Century” marks a specific stage in the development of traditional lexicography of the modern Russian language. This dictionary represents a model of the lexical system, built on a large volume of words with detailed and comprehensive analysis of semantic structures — the full dictionary will contain more than 200 000 units (compared with over than 12 000 words, idioms and collocations included in the first volume). Systemic links, connecting entries throughout the alphabet (hypero-hyponymic relations, synonyms, antonyms, thematic clusters and so on), are included in semantic explanations whenever possible, although beyond the context of entire the dictionary some definitions illustrating lexical consistency may remain incomplete. These systemic links could be demonstrated in the electronic version of the dictionary by means of balloon tips or hyperlinks, before all the alphabetic parts of the dictionary are ready for print. Each entry field in the dictionary is specifically marked, which provides for the delivery of the results in different searches in the electronic version and, furthermore, presupposes the use of the dictionary as a foundation of the lexicographical system of modern Russian. This lexicographical marking was approbated in a wide range of specific and explanatory dictionaries, which can be used as additional blocks or modules in such a lexicographical system. In addition, this universal marking system can be applied to the majority of other dictionaries and lexicographic materials. Such detailed lexicographical marking can serve as a basis for linking information from different lexicographical resources not only based on vocabulary matches, but also including account collocations, idiomatic meanings and other specific parameters of the dictionary entry. The foundation of a lexicographical system should meet the requirements of scientific validity, contemporaniety, normativity, be explicitly structured and cover a significant amount of data, and the materials of “The Dictionary of the Russian Language of the 21st century” correspond to all these requirements.

Impact on intra-aortic balloon pump placement technique on cardiac surgical patient outcomes

Introduction Although the use of intra-aortic counterpulsation in cardiogenic shock was recently debated¹, it remains widely used device for the treatment of cardiac failure. The aim of our study was to evaluate intra-aortic balloon pump (IABP) placement technique related morbidity in cardiac surgical patient population. Methods Single center retrospective review of 424 cardiac surgical patients treated with intra-aortic counter-pulsation between January 1, 2013 and April 30, 2019 in a tertiary care center. Patient outcomes, procedure related morbidity and IABP insertion technical characteristics were evaluated (elective vs urgent, sheathed vs sheathless, ideal balloon tip position vs malposition). According to tip position patients were divided into three groups: good (at T2-T4 vertebrae), malposition (T5-T6), severe malposition (at T7 or below). Results Median patient age was 67 [Interquartile range (IQR), 59 to 75 years], 307 (72.4%) were male. Median EuroSCORE II was 4.4 [IQR, 2.4 to 10.5], median LVEF was 35 [IQR, 28 to 50]. Indications for IABP treatment were: cardiac failure or angina treatment before surgery in 45 (10.6%) patients, prophylactic use in high risk 178 (42.0%) patients, hemodynamically unstable before CPB in 5 (1.2%), hemodynamically unstable during off-pump CABG in 11 (2.6%), facilitate weaning from CPB in 47 patients (11.1%) low cardiac output following surgery in 137 (32.3%), weaning from ECMO in 1 (0.2%). Three hundred forty nine patients (82.3 %) survived to hospital discharge. In-hospital mortality was 5.1% in elective IABP placement group vs 26.8% in urgent IABP implementation group (p Discussion Elective balloon placement was associated with lower morbidity in cardiac surgical patients. Sheathed insertion showed a tendency of higher rate of vascular complications. Suboptimal IABP tip position was not associated with adverse outcome.

Harvest of Endothelial Cells from the Balloon Tips of Swan-Ganz Catheters after Right Heart Catheterization.

A variety of pathologies lead to pulmonary hypertension (PH), which is defined as a mean pulmonary artery pressure exceeding 25 mmHg at rest. To further diagnose and manage PH, patients undergo repeated right heart catheterizations (RHC) wherein a Swan-Ganz catheter is advanced into a branch of the pulmonary artery and a balloon is inflated to wedge the catheter tip. This article illustrates a protocol whereby pulmonary artery endothelial cells (PAECs) may be harvested from the balloon tips of Swan-Ganz catheters after RHC, and purified with an anti- CD146 affinity column technique to purify putative PAECs. These cells might be used to provide an in situ snapshot of the biological state of the pulmonary vasculature endothelium to complement hemodynamic measurements obtained during RHC. Harvested and purified PAECs may be used for either cell culture or for subsequent analytical assays such as flow cytometery.

Harvest of Endothelial Cells from the Balloon Tips of Swan-Ganz Catheters after Right Heart Catheterization

Harvest of Endothelial Cells from the Balloon Tips of Swan-Ganz Catheters after Right Heart Catheterization