Inadequate Blood Flow Research Articles

Use of indocyanine green fluorescence imaging to determine the area of ileum with poor blood flow during robot-assisted laparoscopic radical cystectomy with complete intracorporeal urinary diversion

Introduction: The utility of Firefly mode, a technology using near-infrared imaging, used with the intravenous injection of indocyanine green, and which is available as an optional feature for the Da Vinci surgical platform has recently been explored. We herein describe a case in which we detected the ileum with inadequate blood flow using Firefly mode during the processing of the robot-assisted radical cystectomy with intracorporeal urinary diversion. Presentation of the case: A 75-year-old woman diagnosed as having invasive bladder cancer underwent robot-assisted laparoscopic radical cystectomy with complete intracorporeal urinary diversion using a Da Vinci Xi surgical system. We used Firefly mode after injection of indocyanine green during the processing of the intracorporeal digestive restoration, which resulted in providing intraoperative visual assessment of blood flow to the ileum, allowing us to detect intestine with inadequate blood flow which was not so obvious under the normal visible light mode. We resected the ileum with poor blood flow and reanastomosed the residual small bowel. The patient was released from the hospital only with minor complications. Conclusion: Firefly mode, used with indocyanine green has a potential to be a useful tool that may facilitate robotic surgery including robot-assisted radical cystectomy with intracorporeal urinary diversion. Level of evidence: 5 (case report)

Abstract 14860: Echocardiographic Assessment of Shunt Fraction in Complex Cyanotic Heart Diseases Palliated With Aortopulmonary Shunts

Introduction: Neonates with complex heart defects with inadequate pulmonary blood flow require aortopulmonary shunts (APS) either as surgical-placed modified Blalock-Taussig shunt or a catheter-based stent implantation into a patent ductus arteriosus. An ideal APS provides equal pulmonary blood flow (Qp) as the systemic blood flow (Qs), which is considered balanced circulation. Pulmonary over-circulation leads to complications from inadequate systemic circulation, such as organ dysfunction, shock, and death. Accurately determining Qp:Qs ratio in these patients relies on catheterization, which is invasive and may falsely lower the Qp due to anesthetic effects. To our knowledge, there has not been any studies on echocardiographic comparisons of balanced versus overcirculated APS. We aim to evaluate echocardiographic Doppler assessment of velocity-time integral (VTI) at the aortic arch isthmus distal to APS origin as a measure of shunt fraction in APS patients. We defined shunt fraction ratio (SFR) as retrograde to prograde flow by VTI. Methods: This is a retrospective pilot study of neonates with APS. We selected two cohorts of patients with appropriately balanced circulation (n=12) and those with excessive Qp (n=5) resulting in end-organ damage. We analyzed serial echocardiograms, with repeated measurements for inter-observer agreement. Results: Mean SFR is lower in balanced cohort compared to the overcirculated cohort (0.45 ± 0.07 vs. 0.55 ± 0.09, p=0.02). For both groups, SFR was positively associated with oxygen saturation (r= 0.57, p=0.01), as well as markers of ventricular volume load, such as the highest brain naturetic peptide during hospitalization (Pearson’s correlation r=0.83, p= 0.04) and as outpatient (r= 0.72, p =0.02). Inter-observer agreement was 0.74, suggesting that this is a reproducible technique. Conclusions: SFR by VTI is a simple echocardiographic technique to estimate the volume of APS flow and appears to have important implications for clinical outcomes. Prompt characterization of pulmonary overcirculation without invasive assessment could improve clinical management. Further prospective studies are needed to validate these findings.

Abstract 240: Comparison of Hemodynamics Generated by Synchronized and Interposed Compressions During Treatment of Pseudo Electro-mechanical Dissociation

Introduction: Pseudo electro-mechanical dissociation (P-EMD) is a cardiac arrest variant characterized by a life-threatening reduction in cardiac output in the presence of organized electrical activity. Synchronization of chest compressions to the R-wave in the ECG may be preferable to the delivery of standard CPR. However, in the bradycardic P-EMD state, synchronization may result in inadequate blood flow due to the low compression/heart rate. This pilot study examined the hemodynamic effect of interposing additional chest compressions between synchronized chest compressions during bradycardic P-EMD to increase the compression rate. Methods: P-EMD was induced via hypoxia in three female swine (~30 kg) and treated with synchronized compressions until the onset of asystole (HR<12 BPM). Interposed compressions were added when the heart rate fell below 60 BPM. A chest compression was classified as synchronized or interposed depending on the presence or absence of a co-incident R-wave. Hemodynamic parameters were integrated or averaged over each compression interval. Results: Synchronized compressions tended to produce larger aortic pressures, larger carotid blood flows, and lower right atrial pressures than interposed compressions. Data from one experiment are shown in Figure 1. The relative hemodynamic benefit of a synchronized chest compression appears to depend on the effectiveness of the underlying heart contraction. The interposed chest compressions generated forward carotid blood flow and increased the compression rate during bradycardia. Discussion: During bradycardic P-EMD, synchronized compressions may generate better hemodynamics than interposed compressions, and the combination of synchronized and interposed compressions may result in more blood flow than the delivery of synchronized compressions alone. Figure 1. Comparison of hemodynamics generated by synchronized compressions (blue) and interposed compressions (red).

Digital processing of ultrasound images on dilated blood vessels from diabetic patients

Introduction Peripheral arterial disease (PAD) is a fairly common degenerative vascular condition in diabetic patients that leads to inadequate blood flow (BF), this disease is mainly due to atherosclerosis that causes chronic narrowing of arteries, which can precipitate acute thrombotic events. In patients with diabetes, atherosclerosis is the main reason for reducing life expectancy, as long as diabetic nephropathy and retinopathy are the largest contributors to end-stage renal disease and blindness, respectively. Objective This was an assessment of dilatation of the blood vessels on diabetic patients vs. healthy volunteers by using digital processing of imaging’s. Materials and Methods The study subject was ultrasound imaging processing of blood vessels dilation on low extremities of diabetic patients, the results were compared with ultrasound images of healthy subjects. Results The digital images processing suggests that there is a significant difference among images experimental of the diabetic group and healthy volunteers’ images, the control group. Discussion The digital imaging processing performed in the Matlab platform is an adequate procedure for blood vessels dilation analysis of the ultrasound images taken from the lower extremities in diabetic patients.

Application of transcranial Doppler in prognosis assessment of nerve function in patients with acute cerebral infarction after intracranial mechanical thrombectomy

To investigate the application value of transcranial Doppler (TCD) in the prognosis assessment of nerve function in patients with acute cerebral infarction (ACI) after intracranial mechanical thrombectomy. A retrospective analysis was conducted. The clinical data of 43 patients with acute anterior circulation cerebral infarction who received intra-arterial mechanical thrombotomy for recanalization admitted to Taizhou Central Hospital from January 2018 to December 2019 were analyzed. The modified Rankin scale (mRS) score of patients were followed up by telephone at 3 months after surgery to evaluate the prognosis of neurologic outcome. Patients with mRS score 0-2 were enrolled in the good prognosis group, while those with a score of 3-6 were enrolled in the poor prognosis group. The gender, age, past history, underlying diseases, occluded arteries, atherosclerotic stenosis and bridging treatment, time from onset to reperfusion, blood flow dynamics under TCD at 1 day after thrombectomy, and National Institutes of Health stroke scale (NIHSS) scores before and 1, 7, and 14 days after thrombectomy were compared between the two groups. Multivariate Logistic regression analysis was used to screen the prognostic factors of nerve function at 3 months after mechanical thrombectomy in patients with ACI. The receiver operating characteristic (ROC) curve was drawn to evaluate the prognostic value for neurological function assessed by TCD. Forty-three patients were enrolled in the final analysis, with 23 patients in the good prognosis group and 20 in the poor prognosis group. The recanalization was successfully achieved in both groups without complications. However, the hemodynamics of intracranial arteries evaluated by TCD 1 day after operation in both groups still showed partial or complete occlusion, and the hemodynamics of patients in the poor prognosis group was worse than that in the good prognosis group (poor blood flow: 40.0% vs. 0%, inadequate blood flow: 30.0% vs. 17.4%, good blood flow: 30.0% vs. 82.6%), and the differences were statistically significant (all P < 0.01). Before thrombotomy, there was no significant difference in NIHSS score between the two groups. After thrombotomy, the NIHSS score of the two groups gradually decreased with the extension of time, but the NIHSS score at 14 days after operation of the poor prognosis group was still significantly higher than that of the good prognosis group (10.55±2.93 vs. 4.65±1.70, P < 0.01). Univariate analysis showed that compared with the good prognosis group, the proportion of patients with diabetes and arteriosclerosis stenosis in the poor prognosis group were significantly increased (30.0% vs. 4.3%, 45.0% vs. 17.4%, both P < 0.05), and the time from onset to reperfusion was prolonged (minutes: 385.9±96.2 vs. 294.5±95.1, P < 0.01). Multivariable Logistic regression analysis showed that the therosclerosis stenosis [odds ratio (OR) = 9.334, 95% confidence interval (95%CI) was 1.092-79.775, P = 0.041] and the reperfusion time (OR = 1.016, 95%CI was 1.006-1.027, P = 0.002) were associated with prognosis of nerve function at 3 months after mechanical thrombectomy in patients with ACI. ROC curve analysis suggested that the evaluation of intracranial hemodynamics by TCD might be able to predict the prognosis of neurological function in patients with ACI after 3 months of intracranial mechanical thrombectomy, the area under ROC curve (AUC) was 0.768 (95%CI was 0.620-0.917), the sensitivity was 65.0%, the specificity was 87.0%, the positive predictive value was 82.6%, and the negative predictive value was 70.0%. The evaluation of intracranial hemodynamics assessed by TCD is helpful in early judging the prognosis of neurological function in patients with ACI after intracranial mechanical thrombectomy.

Cardioprotective effects of memantine in myocardial ischemia: Ex vivo and in vivo studies

Myocardial infarction (MI) refers to the loss of cardiomyocytes due to inadequate coronary blood flow and subsequently a reduced oxygen supply. Activation of N-methyl-D-aspartate (NMDA) receptors has been linked to myocardial infarction. The aim of the present study was to determine the cardioprotective effects of memantine, in myocardial infarction both in ex vivo and in vivo models. Effects of memantine on the electrocardiogram (ECG) pattern, cardiodynamic parameters, infarct size and lipid peroxidation were evaluated in the isolated perfused rat heart. Moreover, in in vivo studies in rats, the protective effects of memantine on isoproterenol-induced myocardial infarction model (administration of 100 mg/kg isoproterenol subcutaneously for 2 consecutive days) was evaluated by measuring ECG pattern, mean arterial pressure, malondialdehyde (MDA) levels, myeloperoxidase (MPO) activity, cardiac tumor necrosis factor-alpha (TNF-α) level and cardiac remodeling. The results from the ex vivo isolated perfused heart showed that memantine treatment increased heart rate, left ventricular systolic pressure and left ventricular maximal rate of pressure increase, and decreased cardiac arrhythmia, MDA level and infarct size in comparison to ischemia/reperfusion (IR) group. The isoproterenol-induced MI (Iso) as used in the in vivo model demonstrated that MDA levels and MPO activity were decreased in memantine groups. Memantine treatment reduced the expression of cardiac TNF-α in comparison to Iso group. Cardiac fibrosis and hypertrophy were lower in memantine groups. In conclusion, memantine exerts cardioprotective effects in models of myocardial infarction, which may be attributed to reduction of pro-inflammatory and oxidative stress factors and subsequently a decrease in cardiac remodeling.

PRESSÃO ARTICULAR NA OSTEOARTROSE FEMOROTIBIAL DE CÃES (CANIS LUPUS FAMILIARIS) – UMA REVISÃO SISTEMÁTICA

Os principais sinais clínicos da osteoartrose incluem a claudicação e a diminuição da amplitude de movimento articular. A diminuição do espaço articular é uma característica importante e comum em osteoartrose femorotibial, podendo induzir ao aumento da pressão intra-articular dentro do espaço fascial ou osseofascial e desencadear a Síndrome Compartimental Articular, quer pela diminuição do tamanho do espaço intra-articular ou pelo acúmulo de líquido sanguinolento, seroma ou linfa. Essa síndrome pode resultar na inadequada perfusão sanguínea e causar isquemia local, e consequentemente, maior dano articular. Visto que a aferição da pressão intra-articular não é uma prática comum na Medicina Veterinária, o presente estudo teve como objetivo realizar uma revisão da literatura sobre a pressão intra-articular da articulação femorotibial de cães acometidos por osteoartrose.

P1335AA NOVEL NON-INVASIVE DOPPLER ULTRASOUND GUIDED MANAGEMENT TECHNIQUE OF ACCESSORY CEPHALIC VEIN AS A CAUSE OF MATURATION FAILURE IN RADIOCEPHALIC DIALYSIS ACCESS

Abstract Background and Aims: Background Arterio-venous fistulae (AVF) are the primary access in considerable number of patients on hemodialysis or approaching hemodialysis. A distally created AVF are preferred over proximal approach, as recommended by the guidelines. Non maturation of AVF fistulae remains a major caveat as compared to arteriovenous grafts. A consensus definition of non-maturation is not well defined; however characteristics of non-maturation include inadequate blood flow. Female gender and forearm location have been identified by previous analysis as predisposing factors for non-maturation. Patients with radiocepalic arterio-venous fistula experience the highest rate of non-maturation rates. One important cause of failed AVF maturation is the presence of collateral or veins or tributaries; this may or may not be associated with stenosis. These tributaries may reduce blood in the primary outflow vein, consequently, leading to delayed maturation of the AVF. Options to overcome this problem include coiling or embolization of the collaterals with variable success rate. Aim To examine the efficacy of a novel non-invasive technique to manage maturation failure in radio- cephalic arteriovenous fistulae, through ultrasound guided compression obliteration of the collaterals (accessory cephalic) as identified cause of maturation failure to augment flow in the primary cephalic vein. Method The application of this maneuver to patients according to selected criteria was approved by the institutional Ethical Review Board. Patients’ selection Non maturation was defined by the Rule of Sixes criteria by endorsed by as follows Flow in the fistula should be greater than 600 mL/min, 6 mm caliber, not more than 6 mm depth, discernible margins and ready for use within six weeks Assessing non-maturation in absence of stenosis Ultrasound and Doppler evaluation of main cephalic and accessory cephalic veins to confirm insufficient flow volume at main cephalic vein used in radio-cephalic AVF due to distributed flow to one or more accessory cephalic veins missed by vascular surgeons during surgical radiocephalic AVF creation. To be eligible for this technique, a downstream stenosis should be ruled out by ultrasound, as in such case angioplasty will offer the ideal treatment. 13 patients with failing to mature AVF were consented to this technique. The consent stated that the techniques is totally non-invasive and that, in case of failure of the technique, an endovascular management by coiling for example or a vascular surgical opinion will be sought without delay. Technique summary: using high frequency probe linear ultrasound to perform long term compression for at least 20 minutes in short axis view over the accessory cephalic vein to obtain complete thrombosis and then examine the main cephalic vein to measure post procedure improving flow volume rate Results Patients’ characteristics 13 patients underwent the procedure. Baseline characteristics are shown below: The technique was successful in 9 (5 males and 4 females) out of 13 patients Not referred to interventional radiologist or vascular surgeons Baseline patient’s characteristics Age(years)Means63±9 SexMale5Female8 Conclusion The novel technique as described may provide a safe non-invasive solution to patient with failing to mature radiocephalic arteriovenous fistula and may be referred for a trial of noninvasive ultrasound guided accessory cephalic vein compression obliteration to avoid invasive interventional radiology techniques or surgical repair. A surgical option remains the ultimate solution in case of failure of this ultrasound guided maneuver.

P1324TARGETING ZERO INFECTIONS IN HEMODIALYSIS PATIENTS. AN EXPERIENCE OF ONLY TWO CATHETER-RELATED BLOODSTREAM INFECTION (CR-BSI) OVER A PERIOD OF 1430 DAYS

Abstract Background and Aims Patients undergoing hemodialysis (HD) through a tunneled central venous catheter are exposed to several risks. Catheter-related bloodstream infection (CR-BSI) is the second major cause of death in this population. To reduce the incidence of CR-BSI we conducted a non-randomized pre-post intervention study aimed to eliminate all preventable CR-BSI. Method A quasi-experimental study was conducted in an intra-hospital hemodialysis unit with 15 HD machines and attending 70 patients until March 2019, and 24 machines and 90 patients from that date until today. The CDC, CR-BSI criteria for dialysis event surveillance protocol, defined as the presence of a positive blood culture with the suspect source report as the vascular access or uncertain was used to define CR-BSI. A sequential implementation of evidence-based interventions, associated in literature with the reduction of CR-BSI rate, were developed between January 2011 and January 2020. The intervention package included: 1. Alcohol based gel delivery system fixed in every HD machine to enhance hand hygiene adherence 2. A new strict aseptic protocol for connecting/disconnecting HD lines that included: 2.1 Wrapping catheter rubs for 1-2 minutes with alcoholic chlorhexidine-saturated gauze before removal catheters caps 2.2 Nurses and patients wear masks during catheter manipulation 2.3 Apply a sterile fenestrate drape with sterile gloves before removing the caps 2.4 The scrub-the-hub aseptic technic after removing the caps with alcoholic chlorhexidine-saturated gauze 2.5 Precocious use of Tissue Plasminogen Activator (rTPA) to correct inadequate blood flow, avoiding excess of catheter manipulation 3. Use of chlorhexidine-impregnated dressing changed once a week 4. Training all nurse staff admitted, catheter care skill evaluation semiannually, re-training when necessary and monthly infection rate feedback 5. Use of citrate 30% as lock solution. Results During the follow-up period (January 2011 to January 2020) a mean of 45 patients (range 30-55) used tunneled catheter as vascular access each year. The mean age was 69±15 years (range 11-96 years), with 60% of patients been diabetic. After implementation the of the new strategies we observed a continuous reduction in the CR-BSI rate: 2010 the year before strategies implementation CR-BSI rate was 1.1/1000 catheter-days; 2011 CR-BSI rate 0.6/1000 catheter-days; 2012 CR-BSI rate 0.6/1000 catheter-days; 2013 CR-BSI rate 0.1/1000 catheter-days; 2014 CR-BSI rate 0.1/1000 catheter-days; 2015 CR-BSI rate 0.2/1000 catheter-days; 2016 CR-BSI rate 0.2/1000 catheter-days; 2017 CR-BSI rate 0.0/1000 catheter-days, 2018 CR-BSI rate 0.08/1000 catheter-days, and 2019 CR-BSI rate 0.06/1000 catheter-days. Between April 10th of 2016 and January 10th of 2020, a 1430 days period, we observed only 2 CR-BSI. Between April 10th of 2016 and January 3rd of 2018 there was a period of 633 days with no CR-BSI. Conclusion Implementation of several evidence-based practices and continuous education can reduce CR-BSI in HD patients to a very low level. Targeting zero infection proposing to eliminate all preventable infection should be the routine practice of all dialysis units.

Vascular and Blood Flow Responses to Acute Upper Limb Exercise: Impact of Sex and Menstrual Cycle Phase

PurposeThis study sought to determine whether fluctuations in estrogen levels throughout the menstrual cycle (early (EF) vs late follicular (EF) phase) altered the vascular and blood flow responses to acute upper limb exercise and if these responses were different when compared to males.MethodsTen young females (YF: 21±3 yrs) were recruited and completed two identical visits (EF and LF) consisting of an acute upper limb exercise bout (progressive, rhythmic handgrip). Peripheral (brachial artery (BA) diameter, shear rate, and blood flow) and central (mean arterial pressure, heart rate) hemodynamic measurements were obtained during the last minute of each 3‐minute handgrip workload (3kg, 6kg, and 9kg) via Doppler ultrasonography and finger plethysmography, respectively. Male controls (YM: n = 21; 21±3 yrs) matched for age completed one visit to provide a biological sex comparison. Data is presented as mean ± standard deviation.ResultsIn young females, brachial artery flow mediated dilation (controlled for shear rate) [EF (3kg: 0.006±0.01; 6kg: 0.015±0.01; 9kg: 0.022±0.01); LF (3kg: 0.008±0.01; 6kg: 0.017±0.01; 9kg: 0.024±0.01)], blood flow [EF (3kg: 162±61; 6kg: 236±74; 9kg: 332±104 ml.min−1); LF (3kg: 151±23; 6kg: 237±47; 9kg: 330±104 ml.min−1)], and vascular conductance [EF (3kg: 1.8±0.7; 6kg: 2.5±0.7; 9kg: 3.1±0.7 ml.min−1.mmHg−1); LF (3kg: 1.8±0.4; 6kg: 2.6±0.6; 9kg: 3.3±1.1 ml.min−1.mmHg−1)] were significantly increased with each progressive handgrip workload but were unaltered when comparing the EF and LF conditions. When compared to young males (YM), young females reported no differences in BA FMD [YF vs YM (3kg: 0.006±0.01 vs 0.007±0.01; 6kg: 0.015±0.01 vs 0.013±0.01; 9kg: 0.022±0.01 vs 0.018±0.01)], but did report significantly lower blood flow [YF vs YM (3kg: 162±61 vs 228±64; 6kg: 236±74 vs 347±94; 9kg: 332±104 vs 474±119 ml.min−1)] and vascular conductance [YF vs YM (3kg: 1.8±0.7 vs 2.5±0.7; 6kg: 2.5±0.7 vs 3.8±0.9; 9kg: 4.9±1.1 vs ml.min−1.mmHg−1)].ConclusionThe findings of this study revealed that fluctuations in estrogen throughout the menstrual cycle do not alter vascular and blood flow regulation during exercise, but, when compared to young males, young female’s exhibited lower blood flow/vascular conductance. Additional research is necessary to determine if these sex differences in blood flow/conductance represent adequate or inadequate blood flow regulation during exercise.

A Hypothetical Vascular Stent with Locally Enlarged Segment and the Hemodynamic Evaluation.

Among the interventional stenting methods for treating coronary bifurcation lesions, the conventional treatments still have disadvantages, which include increased intervention difficulties or inadequate supply of blood flow to side branches and may alter the physiological function of downstream organs. Thus, the optimized design of stent geometry needs to be improved based on the specific shape of branches to minimize the complications of inadequate blood flow to the downstream organs and tissues. Our research used 3D modeling and fluid dynamics simulation to design and evaluate a new stent with locally enlarged segment by altering the proportion and length of enlarged surface area based on Bernoulli's equation. The aim is to increase the pressure and blood flow supply at side branches. According to series of blood flow simulations, the stent with 10% enlargement of surface area and length of 3 folders of stent diameter was assigned as the optimized design. The results revealed that by using this design, according to the simulation results, the average pressure on side branches increased at the rate of 43.6%, which would contribute to the adequate blood supply to the downstream organs. Besides, the average wall shear stress (WSS) at sidewalls increased at 9.2% while the average WSS on the host artery wall decreased at 14.1%. There is in the absent of noticeable rise in the total area of low WSS that blows the threshold of 0.5 Pa. Therefore, the present study provides a new method to optimize the hemodynamics features of stent for bifurcation arteries.

Role of intraoperative flowmetric assessment of coronary artery bypass grafts established on-pump

This study was undertaken to evaluate the efficacy of three-stage measurement of the transit-time flow through coronary bypass grafts with the help of flowmetry for early verification of technical errors during on-pump coronary artery bypass graft surgery. We performed an intraoperative analysis of 214 bypass grafts with the help of three-stage flowmetry. The first stage of measuring was performed on-pump with and without the proximal loop test, the second stage of measurement was performed after weaning the patient off the heart-lung machine, and the third stage of measurement was carried out after heparin inactivation prior to chest wound closure. Amongst the 214 transplants regarded as functioning, intraoperative flowmetry revealed insufficient blood flow in 9 (4.2%) cases. Technical surgical errors were confirmed in these shunts during revision thereof. In 6 (2.8%) of the 9 such grafts we detected non-optimal parameters of flowmetry during the first measurement (while the heart was stopped); of these, in 5 (2.3%) cases non-optimal blood flow was verified with the use of the proximal loop test on the target coronary artery and in 1 (0.47%) case without it. In another one (0.47%) of the nine such transplants, inadequate blood flow was revealed during the second measurement, which confirmed technical errors in proximal anastomoses. In a further 2 (0.93%) of the 9 such transplants we observed low parameters of blood flow during the third measurement, which was related to kinking of the shunts due to their excessive length. All surgical errors were corrected immediately at the stage of verification thereof. The strategy of three-stage assessment of flowmetry makes it possible to ensure and confirm adequate functionality of coronary artery bypass grafts at all stages of the operation, thus allowing timely verification and immediate correction of any technical problems with coronary artery bypass grafts.

Sustained Total All-Region (STAR) Perfusion for Norwood Reconstruction

The acute phase of recovery following the Norwood procedure can be complicated by considerable instability due in part to bleeding, acute kidney injury, systemic inflammatory response, and low cardiac function. The traditional conduct of cardiopulmonary bypass with cooling, re-warming, myocardial ischemia, and upper or lower body ischemia likely exacerbates these problems. Total body perfusion during Norwood reconstruction, without significant cooling or ischemic time to any organs, may improve postoperative recovery by reducing coagulopathy and end-organ injury. Here, we introduce a novel technique for sustained total all-region perfusion of the heart, upper body, and lower body throughout the Norwood operation.

Antithrombotic Management of Ischemic Stroke.

Ischemic stroke describes a condition in which inadequate blood flow leads to lack of oxygenation to the brain tissue and ensuing neuronal death. There are multiple causes of ischemic stroke, each of which may indicate different antithrombotic management strategies. The goal of this review is to provide information about antithrombotic therapies for secondary stroke prevention based on etiology of stroke. New studies of existing antiplatelet and antithrombotic therapies have demonstrated varied efficacies of treatments based on the underlying risk factor of ischemic stroke. Understanding the optimal therapies for secondary stroke prevention can enhance care of stroke patients and lower the incidence of recurrent cerebrovascular ischemia.

1918 A Case of Recurrent Pneumatosis Intestinalis and Portal Venous Gas

INTRODUCTION: Mesenteric ischemia (MI) is caused by inadequate blood flow through the mesenteric vessels resulting in ischemic bowel. The most serious cases cause gangrenous bowel, leading to pneumatosis intestinalis (PI) and portal venous gas (PVG), often an ominous sign. CASE DESCRIPTION/METHODS: This is a case of a 63-year-old male who presented to the hospital with hematemesis and severe anemia. After massive transfusion, an EGD revealed actively bleeding gastric ulcers, requiring serial EGDs for successful control of bleeding. A CT revealed gastric distention with thickening of the duodenum and bilateral femoral vein opacities, later confirmed as deep vein thromboses. An IVC filter was subsequently placed, as he was not a candidate for anticoagulation. The patient was subsequently discharged on oral pantoprazole. Of note, there was no history of NSAID use or evidence of H. pylori. Repeat EGD 2 months later noted mild gastritis, but no ulcers were seen. A screening colonoscopy at the time noted only diverticulosis. He was continued on pantoprazole. 3 months later he presented to the hospital with acute onset nausea, vomiting, and diarrhea. A CT revealed PI at the gastric fundus, as well as PVG. An infectious work-up was negative, lactate was normal, and his symptoms resolved quickly. A subsequent repeat CT noted resolution of the PVG and reduction in PI. He represented to the hospital 1 month later again with nausea, vomiting, and diarrhea. A CT noted small bowel dilatation with air fluid levels, PI at the esophagus, stomach, and jejunum, and significant PVG. The initial lactate level was mildly elevated and his symptoms resolved quickly after bowel decompression. A subsequent CTA noted a significant reduction in PVG without evidence of vascular occlusion. A follow up EGD showed diffuse subepithelial hemorrhages without any evidence of recurrent ulcers. A subsequent CTE noted a thrombus above the IVC filter and an evolving hepatic infarction. He was asymptomatic at the time, however, he was admitted to the hospital for anticoagulation. He has since remained on warfarin without any recurrence of symptoms, PI, or PVG. A follow-up CTA showed a full resolution of venous thromboses. DISCUSSION: Previous case reports have described the development of PI and PVG secondary to underlying MI. This case highlights an example of MI secondary to an increase in the resistance of mesenteric blood flow due to venous thromboses. When investigating IP and PVG, underlying venous thromboses should always be considered.

Abstract P1112: Gestational Interventions and Fetal Outcomes in a Rat Model of Intrauterine Growth Restriction

Preeclampsia (PE) is a leading cause of maternal and fetal mortality worldwide. Numerous studies indicate blood pressure is increased in individuals exposed to PE during fetal life. Currently, there are no effective therapeutics for PE. Our laboratory utilizes a rat model of PE induced by placental ischemia, the reduced uterine perfusion pressure (RUPP) model that results in intrauterine growth restriction (IUGR) and hypertension in the offspring. IUGR is dictated by inadequate uteroplacental blood flow and insufficient nutrient transport to the fetus. Preclinical use of a soluble guanylate cyclase (sGC) inducer abolishes hypertension in RUPP dams, but its effect on offspring is unknown. The purpose of this study was to test the hypothesis that maternal administration of a sGC inducer improves placental perfusion and nutrient transport, mitigating IUGR. RUPP or sham procedure was performed at day 14 of gestation and dams were administered vehicle or sGC inducer (riociguat, 10mg/kg/day, sc) from days 14 to 20 gestation. At day 20 of gestation uterine artery resistance index (UARI) was increased, indicative of poor perfusion, in vehicle-treated RUPP compared to vehicle-treated Sham (0.64±0.01 vs. 0.57±0.01 mm/s, respectively; p &lt;0.05); UARI was not significantly increased in sGC-treated RUPP (0.59±0.02; p &lt;0.05 mm/s). Fetal pup weight was reduced in vehicle-treated RUPP compared to vehicle-treated Sham (3.74±0.10 vs. 4.19±0.08 g, respectively; p &lt;0.05); yet with treatment, fetal pup weight was not decreased. Heart fatty acid binding protein (hFABP) protein expression is increased in women with PE, a means to maintain normal brain development in IUGR offspring. This increase was observed in vehicle-treated RUPP compared to vehicle-treated Sham (1004±32 vs. 583±65 A.U., respectively, p &lt;0.05). After treatment, placental hFABP protein expression was increased in sGC-treated Sham compared to vehicle-treated Sham (987±95 vs. 583±65 A.U., respectively; p &lt;0.05), but was reduced in sGC-treated RUPP compared to vehicle-treated RUPP (732±54 vs. 1004±32 A.U., respectively; p &lt;0.05). Further studies are warranted to determine the long-term benefit of fetal exposure to a sGC inducer and its effect on blood pressure and long term health in the offspring.

Protocol for a prospective observational diagnostic study: intraoperative simultaneous limb pressure monitoring (INSTANT) study

IntroductionPeripheral vascular disease (PVD) is a condition caused by arterial blockages causing inadequate blood flow, resulting in pain and gangrene of the legs. Endovascular therapy, such as angioplasty, can be...

Linking of different ethnicities, races and religions to lipid profile patterns and hypolipidaemic drug usage patterns in coronary artery disease patients

Background: Coronary artery disease (CAD) is the consequence of atherosclerosis in which inadequate blood flow in the coronary arteries leads to myocardial necrosis. The impact of ethnic on CAD might be underestimated within Indian communities. There have never been any studies done associating them to lipid profile patterns in the Indian setup hence this study is the first of its kind to work towards attending the absence of data in this direction.The study aimed to evaluate the presence of ethnic differences in lipid profile patterns and hypolipidemic drug use in CAD patients.Methods: An 8-week cross-sectional prospective study was conducted in the cardiology OPD of a tertiary care hospital. Adult CAD patients prescribed with at least one hypolipidaemic drug, having their lipid profile values and willing to give informed consent were selected. The prescription pattern was noted, and the lipid profile values of the patients classified as per ATP III guidelines by NCEP. Atherogenic dyslipidaemia was considered when patients had triglyceride levels &gt;150 mg/dl and HDL&lt;40 mg/dl. The collected data was analyzed using SPSS. P value less than 0.05 was considered as statistically significant.Results: A total of 123 patients enrolled. Out of these, 115 were Hindus and among Hindus, most were Brahmins (34). The most prescribed hypolipidaemic drug was Rosuvastatin. Thirty six patients had high triglyceride levels out of which 35 were Hindus. Low HDL (&lt;40 mg/dl) was present in 70 patients out of which 64 were Hindus. Atherogenic dyslipidaemia was seen in 44 patients. Majority of them belonged to the age group of 51-60 years (43.2%) and were Patels. Total cholesterol and LDL were high in 1 and 2 Jains respectively. Lipid values were higher in Tier-3 city patients.Conclusion: Hindu patients in this study showed a poorer lipid profile while among the castes, Jains and Patel’s fared poorly. It was seen that atherogenic dyslipidemia is on a rise in the Indian population.

An overview of herbal alternatives in androgenetic alopecia.

The second most common alopecia-Androgenetic alopecia (AGA)-occurs due to hormonal imbalance. Dihydrotestosterone (DHT) an androgenic hormone is a sex steroid, produced in the gonads. The target sites of DHT are similar to that of testosterone, and it attaches easily remaining bound for 53minutes as compared to 35minutes of testosterone. Excess of DHT causes miniaturization of hair reducing the anagen phase and increasing the telogen phase leading to hair loss. Normally up to ten percent of testosterone in the body irreversibly gets converted into DHT by the action of enzyme 5-alpha-reductase. Inadequate blood flow to the scalp can also be another reason for hair loss encountered due to lower oxygen and nutrients reaching it. AGA affects both sexes; however in males, it leads to major hair loss. Conventional drugs such as minoxidil and finasteride are widely used for the treatment. However, several drawbacks such as allergic contact dermatitis, burning, ejaculation disorder, and decreased libido are reported. Available literature suggests the role of herbal drugs to have the action against 5-alpha-reductase enzyme inhibiting it and reducing the hair loss. This can be further potentiated since they exhibit lesser side effects. Recent advancements observed in the medicinal, cosmetic, and engineering fields can prove to be an asset. This article focuses on herbs which can be used in AGA. A review of Saw palmetto (Serenoa repens), Green tea (Camellia sinensis), Pumpkin seed (Curcurbita pepo), Rosemary (Rosmarinus officinalis), Grape seed (Vitis vinifera), and Licorice (Glycyrrhiza glabra) is attempted.

DNA methylation-reprogrammed oxytocin receptor underlies insensitivity to oxytocin in pre-eclamptic placental vasculature.

Pre‐eclampsia is associated with inadequate placental blood flow and placental ischaemia. Placental vascular tone is essential for maintaining adequate placental blood flow. Oxytocin is increased in placental system at late pregnancy and onset of labour, and presented strongly concentration‐dependent contractions in placental vascular, suggesting that oxytocin could be involved in regulating placental vascular tone and circulation. However, information about the reactivity of oxytocin in pre‐eclamptic placental vasculature is limited. This study used a large number of human placentas to reveal the pathophysiological changes and its underlying mechanisms of oxytocin‐induced vasoconstrictions in placental vessels under pre‐eclamptic condition. Present study found that oxytocin‐induced contractions were significantly decreased in human pre‐eclamptic placental vasculature, associated with a deactivated transcription of oxytocin receptor gene. The deactivated oxytocin receptor gene transcription was ascribed to a relatively higher DNA methylation status of CpG islands in oxytocin receptor gene promoter. This study was first to reveal that a hyper‐methylation of CpG islands in oxytocin receptor gene promoter, leading to a relatively low pattern of oxytocin receptor expression, was responsible for the decreased sensitivity of oxytocin in pre‐eclamptic placental vessels.