Lead Position Research Articles

Anesthetic management of a patient with situs inversus totalis undergoing coronary artery bypass grafting surgery: a case report

BackgroundAnesthetic management of coronary artery bypass grafting surgery (CABG) in a dextrocardia patient with situs inversus totalis is rarely encountered and seldom reported in the literature.Case presentationA 76-year-old Japanese female patient had been diagnosed with situs inversus totalis and coronary artery disease of 3 vessels, and she subsequently underwent elective CABG. A preoperative examination showed almost normal results. ECG showed right deviation with the normal lead position. In the operating room, ECG leads were applied in reverse. Pulmonary artery catheterization was performed via the left internal jugular vein. A transesophageal echocardiography (TEE) probe was introduced without difficulty. A different angle was needed to acquire the desired views because of her atypical anatomy.ConclusionCareful perioperative evaluation, intraoperative management, and inspection of multiplane angle and probe adjustments in TEE are needed for anatomically abnormal patients.

Localization of right ventricular non-apical lead position: comparison of three-dimensional echocardiography, computed tomography, and fluoroscopic imaging.

ObjectiveRight ventricular (RV) septal pacing is considered a better pacing procedure compared with traditional apical pacing. This study aimed to investigate agreement among computed tomography (CT), three-dimensional echocardiography (3D-echo), and fluoroscopy for evaluating the tip of the RV pacing lead in the non-apical position in patients with permanent pacemaker implantation.MethodsFifty-four patients were prospectively enrolled. Data on patients’ characteristics and imaging findings were analyzed. The agreement rate in distinguishing the RV septal lead position among the three imaging modalities was determined.ResultsThirty-three (61%) patients were men and the median age was 76 years. Overall, the agreement rate among the three imaging modalities was 87% (47/54; Kappa ratio: 0.734). The agreement of 3D-echo compared with thoracic CT (Kappa ratio: 0.893) was better than that for thoracic CT and fluoroscopy (Kappa ratio: 0.658). Agreement between fluoroscopy and 3D-echo was lowest (Kappa ratio: 0.632).ConclusionsAgreement in evaluating the position of the septal lead between thoracic CT and 3D-echo is better than that between other imaging modalities. Our findings indicate that 3D-echo imaging might be the best imaging tool for defining the tip of the RV non-apical lead position and be useful for guiding positioning of the RV lead.

The Accuracy of Direct Targeting Using Fusion of MR and CT Imaging for Deep Brain Stimulation of the Subthalamic Nucleus in Patients with Parkinson's Disease.

In 33 consecutive patients with Parkinson's disease (PD) undergoing awake deep brain stimulation (DBS) without microelectrode recording (MER), we assessed and validated the precision and accuracy of direct targeting of the subthalamic nucleus (STN) using preoperative magnetic resonance imaging (MRI) and stereotactic computed tomography (CT) image fusion combined with immediate postoperative stereotactic CT and postoperative MRI, and we report on the side effects and clinical results up to 6 months' follow-up. Preoperative nonstereotactic MRI and stereotactic CT images were merged and used for planning the trajectory and final lead position. Immediate postoperative stereotactic CT and postoperative nonstereotactic MRI provided the validation of the final electrode position. Changes in the Unified Parkinson's Disease Rating Scale III (UPDRS III) scores and the levodopa equivalent daily doses (LEDD) and appearance of adverse side effects were assessed. The mean Euclidian distance (ED) error between the planned position and the final position of the lead in the left STN was 1.69 ± 0.82 mm and that in the right STN was 2.12 ± 1.00. The individual differences between planned and final position in each of the three coordinates were less than 2 mm. The UPDRS III scores improved by 75% and LEDD decreased by 45%. Few patients experienced complications, such as postoperative infection (n = 1), or unwanted side effects, such as emotional instability (n = 1). Our results confirm that direct targeting of an STN on stereotactic CT merged with MRI could be a valid method for placement the DBS electrode. The magnitude of our targeting error is comparable with the reported errors when using MER and other direct targeting approaches.

Right ventricular apical and septal pacing: long term impacts on ventricular function

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): The costs of the study were afforded by the researchers. Background In patients requiring permanent pacemaker, in order to protect left and right ventricular functions the optimal pacing site has yet to be determined. Conflicting results exist about septal and apical pacing sites. Aim Our purpose was to evaluate the long term effects of right ventricular apical and septal pacing on left and right ventricular functions. Methods We scanned 378 patients from 2007 to 2012 who received a permanent pacemaker for the treatment of symptomatic bradyarrythmia. As exclusion criteria we identified the patients who did not have an echocardiography before the procedure, those who had co-morbidities which cause reduction in ventricular functions, ejection fraction <%45, patients who died and those who rejected our invitation. 54 women and 66 men were eligible for our study. To determine the patients’ New York Heart Association Class (NYHA) we questioned and did the physical examination. Lead position confirmed by fluoroscopy in two planes, and electrocardiograms were obtained. Finally, we compared the pre-procedural echocardiographic data with our up-to-date findings. Results In sixteen patients the lead placement was inferoseptal and in one hundred and four patients apical site. Median follow up was 9 years. The mean ejection fraction before the implantation was 58,86 ± 4,08 in the apical, and 56,37 ± 8,8 in the septal group (p < 0,05). The long term follow up showed that these values have been reduced, 56,66 ± 8,38 for the apical group and 51,33 ± 13,94 for the septal group, respectively (p < 0,05). Placing the right ventricular lead in both septal and apical site resulted in reduced tricuspid annular plane systolic excursion (from mean 2,25 to 2,18, (p < 0,05)), and in increased systolic pulmonary artery pressure (from 35,46 ± 9,93 to 39,84 ± 11,21 (p < 0,05)). There were no differences regarding the mitral and tricuspid insufficiencies, and diastolic functions before the implantation and long term follow up. These findings were independent of neither the etiology of implanting the pacemaker nor the underlying diseases. Conclusion These two selective ventricular pacing sites caused a reduction in both left and right ventricular functions. Despite the ejection fraction declines, most of these patients have a good quality of life, without symptoms and signs of heart failure. But certainly, there is emerging need for more randomized trials in order to describe the optimal RV pacing site. The main purpose must be preserving better ventricular functions in patients requiring permanent ventricular pacing.

Price variation and transmission in beans consuming market of Southwest, Nigeria

Nigeria's bean market is still characterized by inefficient and weak integration due to inadequate price information and market infrastructure. Therefore, the study investigates the price variation and transmission of beans markets in Nigeria's Southwest region. The study employed an average monthly price of white and brown beans in rural and urban markets spanning March 2014 to July 2019. Coefficient of variation (CV), Augmented Dickey-Fuller (ADF), Johansen co-integration test and Granger-Causality tests were the analytical tools used for the analysis. The results of CV indicated a spike variation of beans prices over the periods. Urban brown beans experienced the lowest variability of 1.56% in 2015, while rural brown beans experienced the highest variability of 30.03% in 2014. The co-integration test established a long-run dynamic between bean products of different varieties in the same market. However, it failed in the same products in different markets using a bivariate co-integration test. The multivariate co-integration test’s results affirmed that bean markets are strongly linked together in the long-run. The results of Granger-causality showed uni-directional and bi-directional causalities in the beans markets. Rural white beans assumed the lead position and formed the major price transmission in the beans’ markets in the area. Therefore, for more efficiency in the beans’ rural and urban markets, the government should design appropriate market strategies such as accessible market information and infrastructures.

Opportunities for robotic-assisted surgery in treatment of uterine cancer. Current view on the problem

Endometrial cancer holdzone of the lead positions in the pattern of female oncological diseases, affecting annually around 300,000 women worldwide. Compared to other cancers of the female reproductive system, this pathology has been extensively investigated by conducting large-scale randomized controlled trials, which proved safety and efficacy of using laparoscopic surgery for such patients. In the last years, robotic-assisted surgery has been actively developed globally, including gynecological oncology. Minimally invasive technologies can reduce the volume of blood loss, shorten hospital stay, lower rate of postoperative complications and shorten rehabilitation period. It is necessary to conduct randomized prospective studies assessing robotic-assisted surgery for treating endometrial cancer, especially due to concerns about postoperative prognosis in cancer patients. In addition, studies on developing clinical guidelines to select proper surgical intervention, including robotic-assisted access for surgeons-oncologists are required.

Directional Leads for Deep Brain Stimulation: Technical Notes and Experiences

Objective: Deep brain stimulation (DBS) is an approved treatment for movement disorders. Despite high precision in electrode placement, side effects do occur by current spread to adjacent fibers or nuclei. Directional leads (D-leads) are designed to adapt the volume of stimulation relative to the position within the target by horizontal and vertical current steering directions. The feasibility of implanting these new leads, possible difficulties, and complications were the focus of this study. Material and Methods: This analysis is based on 31 patients who underwent a DBS procedure with D-leads and an implantable pulse generator (IPG) capable of multiple independent current control and 31 patients who received non-D-leads with a similar IPG. While trajectory planning and most steps of the surgical procedure were identical to conventional DBS lead implantation, differences in indication, electrode handling, lead control, and complications were documented and analyzed in comparison to a control group with ring electrodes. Results: During a consecutive series of 51 patients implanted with a DBS system, 31 patients (60.1%) were selected for implantation of D-leads and received 59 D-leads, 28 bilateral, and 3 unilateral implantations. The control group consisted of a consecutive series of a comparable time period, with 31 patients who received conventional ring electrodes. Indication of D-lead implantation was based on the anatomic conditions of the trajectory and target regions and the results of intraoperative test stimulations. In 1 patient, primary D-lead implantation on both sides was performed without any microelectrode implantation to minimize risk for hemorrhage. In the absence of an externally visible marker, the control of implant depth and of the orientation of the D-lead needs to be controlled by X-ray resulting in a longer fluoroscopy time and, therefore, higher X-ray dose compared to conventional lead implantations (415.53 vs. 328.96 Gy cm²; p = 0.09). Mean procedure duration for complete system implantation did not differ between either type of leads (ring electrodes vs. D-leads, 08:55 vs. 09:02 h:min). Surgical complications were unrelated to the type of electrode: surgical revision was necessary and successfully performed in 1 subcutaneous hematoma and 1 unilateral electrode dislocation. A rather rare complication, symptomatic idiopathic delayed-onset edema, was observed in 4 patients with D-leads. They recovered completely within 1–3 weeks, spontaneously or after short-term cortisone medication. In the control group, in a series of 31 patients (20 implanted with Medtronic 3389 lead and 11 with Boston Scientific Vercise lead), not a single problem of this kind was encountered at any time. Conclusion: Precise positioning of D-leads is more challenging than that of conventional DBS leads. By adding an external lead marker, control of optimal lead position and orientation is enhanced. In case of supposed increased risk for hemorrhage because of vessels crossing all possible trajectories in the pre-surgical navigated simulation program, primary D-lead implantation instead of the sharper microelectrodes may be a feasible alternative and it may offer more options than ring electrodes especially in these cases. Prospective studies comparing ring-mode stimulation to directional stimulation to examine the differences of the clinical effects have been started.

Fusing of Preoperative Magnetic Resonance and Intraoperative O-arm Images in Deep Brain Stimulation Enhance Intuitive Surgical Planning and Increase Accuracy of Lead Placement

Intraoperative fluoroscopy and microelectrode recording (MER) are useful techniques for guiding lead placement in deep brain stimulation (DBS). Recent advances in magnetic resonance imaging (MRI) have enabled information on the location of the basal ganglia, as the target of DBS, to be obtained preoperatively. However, intraoperative images with few artifacts are required to enable accurate fusion of preoperative imaging data with intraoperative lead position data. With our method, we first fuse preoperative MRI and pre-frame fixed computed tomography (CT) images, then fuse the CT images exactly after mounting the frame, using this fusion image as a platform image. Compared with before and after frame fixation, the pre-frame fixed CT has less artifacts, facilitating the identification of soft tissues such as the ventricles and cortical surface on pre-frame fixed CT images. By fusing the structural information for these soft tissues between pre-frame fixed CT and MR images, this fusion process can provide improved accuracy that is intuitively understood by the surgeon. Using platform images, surgical planning and intraoperative lead positioning can then be evaluated on the same coordinate axis. Positional data on the lead acquired as three-dimensional (3D) data are then added to the platform image. The proposed surgical steps permit the acquisition of accurate lead position data.

In silico analysis of SARS-CoV-2 papain-like protease potential inhibitors.

The emergent outbreak caused by severe acute respiratory syndrome coronavirus 2 continues spreading and causing huge social and economic disruption. Papain-like protease (PLpro) has a crucial role in the cleavage of viral polyproteins, and disruption of host responses. PLpro is considered an important goal for the development of SARS-CoV-2 inhibitors. ZINC101291108 (lead 1) and ZINC16449029 (lead 2) were identified as potent SARS-CoV-2 PLpro inhibitors with IC50 values of 0.085 μM and 0.063 μM, respectively. Molecular dynamics simulations (MD) were carried out for lead 1, 2 and several reported SARS-CoV-2 inhibitors. Analysis results of the simulations confirmed the stability of both compounds and showed that they adopted two confirmations along the simulation period. The per-residue decomposition results revealed that the key residues involved in inhibitor binding were E167, P247, P248, Y264, Y268 and Q269. H-bond analyses showed H-bonds with G266 and N267 and salt bridges with G209 and Y273, which are essential for strengthening the substrate-binding pocket. Both inhibitors showed hydrophobic interactions with the S4 site and BL2 loop residues. The RMSD of the BL2 loop with the two inhibitors was investigated, and the results showed that the Y268 and Q269 BL2 loop residues moved outward to accommodate the large size of lead 2. The van der Waals interaction was the main energy contribution that stabilized lead 2, while van der Waals and electrostatic interactions were the main energy contributions stabilizing lead 1. Rational design strategies were suggested to replace the 2-(2-hydroxybenzylidene) hydrazine moiety with naphthalene or nitrobenzene at the P4 position of lead 2 and introduce polar substituents as aniline and benzoate groups at position P1 to enhance hydrophobic interactions and H-bonds, respectively.

Low-Dose High-Pitch Cardiac CT to Evaluate Abnormal Pacemaker Lead Position

Displacement of a cardiac pacemaker lead or myocardial perforation by a lead is an infrequent complication of pacemaker implantation. While standard cardiac CT is useful for diagnosing such complications when routine examinations can not, the potential risks associated with exposure to the high doses of radiation used in CT are of concern. Here, we report three cases in which pacemaker lead displacement or myocardial perforation was definitively diagnosed by low-dose cardiac CT used in the high-pitch spiral mode, when other more routine examinations failed to suggest their occurrence. The mean dose of radiation used for definitively diagnosing the three patients was relatively low (2.19 mSv).

Electrical characteristics of pacing different portions of the His bundle in bradycardia patients.

His-bundle pacing (HBP) can be achieved in either atrial-side HBP (aHBP) or ventricular-side HBP (vHBP). The study compared the pacing parameters and electrophysiological characteristics between aHBP and vHBP in bradycardia patients. Fifty patients undergoing HBP implantation assisted by visualization of the tricuspid valvular annulus (TVA) were enrolled. The HBP lead position was identified by TVA angiography. Twenty-five patients were assigned to undergo aHBP and compared with 25 patients who underwent vHBP primarily in a prospective and randomized fashion. Pacing parameters and echocardiography were routinely assessed at implant and 3-month follow-up. His-bundle pacing was successfully performed in 45 patients (90% success rate with 44.4% aHBP and 55.6% vHBP). The capture threshold was lower in vHBP than aHBP at implant (vHBP: 1.1 ± 0.5 vs. aHBP: 1.4 ± 0.4 V/1.0 ms, P = 0.014) and 3-month follow-up (vHBP: 0.8 ± 0.4 vs. aHBP: 1.7 ± 0.8 V/0.4 ms, P < 0.001). The R-wave amplitude was higher in vHBP than in aHBP at implant (vHBP: 4.5 ± 1.4 vs. aHBP: 2.0 ± 0.8 mV, P < 0.001) and at 3-month follow-up (vHBP: 4.4 ± 1.5 vs. aHBP: 1.8 ± 0.7 mV, P < 0.001). No procedure-related complications and aggravation of tricuspid valve regurgitation were observed in most patients and echocardiographic assessment of cardiac function remained in the normal range in all patients during the follow-up. This study demonstrates that vHBP features a low and stable pacing capture threshold and high R-wave amplitude, suggesting better pacing mode management and battery longevity can be achieved by HBP in the ventricular side.

Fixation beats: A novel marker for reaching the left bundle branch area during deep septal lead implantation

One of the challenges of left bundle branch (LBB) pacing is placing the pacing lead deep enough in the septum to reach the LBB area, yet not too deep to avoid perforation. The purpose of this study was to investigate whether the occurrence of the ectopic beats with qR/rsR' morphology in lead V1 (fixation beats) during lead fixation would predict whether the desired intraseptal lead depth had been reached, whereas the lack of fixation beats would indicate a too-shallow position and the need for more lead rotations. Consecutive patients during LBB pacing device implantation were analyzed retrospectively and then prospectively with respect to the occurrence of fixation beats during each episode of lead rotation. We compared the presence of fixation beats during the lead rotation event directly before the LBB area depth was reached vs during the events before intermediate/unsuccessful positions. A total of 339 patients and 1278 lead rotation events were analyzed. In the retrospective phase, fixation beats were observed in 327 of 339 final lead positions and in 9 of 939 intermediate lead positions (P <.001). Sensitivity, specificity, and positive and negative predictive values of the fixation beats as a marker for reaching the LBB area were 96.4%, 97.3%, 97.3%, and 96.5%, respectively. In the prospective, fixation beats-guided implantation phase, fixation beats were observed in all patients and only at the LBB capture depth. Monitoring fixation beats during deep septal lead deployment can facilitate the procedure and possibly increase the safety of lead implantation.

Interprofessional Collaboration to Address Elder Abuse, Neglect, and Exploitation With Adult Protective Services

Adult Protective Services (APS) is responsible for investigating reports of abuse, exploitation, and neglect among vulnerable adults. Additionally, APS also refers or provides needed services to victims. Though APS also takes the lead position in investigation and service planning, determining harm and designing person-centered remedies often require other professionals to be prepared to address these elder justice issues with APS. Afterall, adult safeguarding is everybody’s business. This symposium includes four presentations on researchers’ findings working with APS and other professionals. Dr. Burnes will compare outcomes on usual APS care (APS only) versus enhanced APS care (APS plus advocate who are case managers). Dr. Pi-Ju (Marian) Liu will examine nurses’ role in working in and with APS, focusing on how their job responsibilities are different from other nurses and APS social workers. Dr. Jason Burnett will present an innovative referral portal linking banks and other financial firms directly to APS. Lastly, Dr. Zachary Gassoumis will appraise the multidisciplinary teams across the country, including professionals involved, and provide input on what makes a team work well together. Following the four presentations, Dr. Bridget Penhale will open up the discussion regarding protective agencies’ operations and collaboration with other agencies, focusing on the comparison between protective agencies in the United States and European countries. Abuse, Neglect and Exploitation of Elderly People Interest Group Sponsored Symposium.

Postoperative Lead Movement after Deep Brain Stimulation Surgery and the Change of Stimulation Volume

Introduction: Lead movement after deep brain stimulation may occur and influence the affected volume of stimulation. The aim of the study was to investigate differences in lead position between the day after surgery and approximately 1 month postoperatively and also simulate the electric field (EF) around the active contacts in order to investigate the impact of displacement on affected volume. Methods: Twenty-three patients with movement disorders underwent deep brain stimulation surgery (37 leads). Computed tomography at the 2 time points were co-fused respectively with the stereotactic images in Surgiplan. The coordinates (x, y, and z) of the lead tips were compared between the 2 dates. Eleven of these patients were selected for the EF simulation in Comsol Multiphysics. Postoperative changes of EF spread in the tissue due to conductivity changes in perielectrode space and due to displacement were evaluated by calculating the coverage coefficient and the Sørensen-Dice coefficient. Results: There was a significant displacement (mean ± SD) on the left lead: x (0.44 ± 0.72, p < 0.01), y (0.64 ± 0.54, p < 0.001), and z (0.62 ± 0.71, p < 0.001). On the right lead, corresponding values were: x (−0.11 ± 0.61, ns), y (0.71 ± 0.54, p < 0.001), and z (0.49 ± 0.81, p < 0.05). The anchoring technique was a statistically significant variable associated with displacement. No correlation was found between bilateral (n = 14) versus unilateral deep brain stimulation, gender (n = 17 male), age <60 years (n = 8), and calculated air volume. The simulated stimulation volume was reduced after 1 month because of the perielectrode space. When considering perielectrode space and displacement, the volumes calculated the day after surgery and approximately 1 month later were partly overlapped. Conclusion: The left lead tip displayed a tendency to move lateral, anterior, and inferior and the right a tendency to move anterior and inferior. The anchoring technique was associated to displacement. New brain territory was affected due to the displacement despite considering the reduced stimulated volume after 1 month. Postoperative changes in perielectrode space and small lead movements are reasons for delaying programming to 4 weeks following surgery.

Atlas-independent, N-of-1 tissue activation modeling to map optimal regions of subthalamic deep brain stimulation for Parkinson disease

BackgroundMotor outcomes after subthalamic deep brain stimulation (STN DBS) for Parkinson disease (PD) vary considerably among patients and strongly depend on stimulation location. The objective of this retrospective study was to map the regions of optimal STN DBS for PD using an atlas-independent, fully individualized (N-of-1) tissue activation modeling approach and to assess the relationship between patient-level therapeutic volumes of tissue activation (VTAs) and motor improvement. MethodsThe stimulation-induced electric field for 40 PD patients treated with bilateral STN DBS was modeled using finite element analysis. Neurostimulation models were generated for each patient, incorporating their individual STN anatomy, DBS lead position and orientation, anisotropic tissue conductivity, and clinical stimulation settings. A voxel-based analysis of the VTAs was then used to map the optimal location of stimulation. The amount of stimulation in specific regions relative to the STN was measured and compared between STNs with more and less optimal stimulation, as determined by their motor improvement scores and VTA. The relationship between VTA location and motor outcome was then assessed using correlation analysis. Patient variability in terms of STN anatomy, active contact position, and VTA location were also evaluated. Results from the N-of-1 model were compared to those from a simplified VTA model. ResultsTissue activation modeling mapped the optimal location of stimulation to regions medial, posterior, and dorsal to the STN centroid. These regions extended beyond the STN boundary towards the caudal zona incerta (cZI). The location of the VTA and active contact position differed significantly between STNs with more and less optimal stimulation in the dorsal-ventral and anterior-posterior directions. Therapeutic stimulation spread noticeably more in the dorsal and posterior directions, providing additional evidence for cZI as an important DBS target. There were significant linear relationships between the amount of dorsal and posterior stimulation, as measured by the VTA, and motor improvement. These relationships were more robust than those between active contact position and motor improvement. There was high variability in STN anatomy, active contact position, and VTA location among patients. Spherical VTA modeling was unable to reproduce these results and tended to overestimate the size of the VTA. ConclusionAccurate characterization of the spread of stimulation is needed to optimize STN DBS for PD. High variability in neuroanatomy, stimulation location, and motor improvement among patients highlights the need for individualized modeling techniques. The atlas-independent, N-of-1 tissue activation modeling approach presented in this study can be used to develop and evaluate stimulation strategies to improve clinical outcomes on an individual basis.

Single full-FOV reconstruction Fourier ptychographic microscopy.

Fourier ptychographic microscopy (FPM) is a recently developed computational imaging technique that has high-resolution and wide field-of-view (FOV). FPM bypasses the NA limit of the system by stitching a number of variable-illuminated measured images in Fourier space. On the basis of the wide FOV of the low NA objective, the high-resolution image with a wide FOV can be reconstructed through the phase recovery algorithm. However, the high-resolution reconstruction images are affected by the LED array point light source. The results are: (1) the intensities collected by the sample are severely declined when edge LEDs illuminate the sample; (2) the multiple reconstructions are caused by wavevectors inconsistency for the full FOV images. Here, we propose a new lighting scheme termed full FOV Fourier ptychographic microscopy (F3PM). By combining the LED array and telecentric lens, the method can provide plane waves with different angles while maintaining uniform intensity. Benefiting from the telecentric performance and f‒θ property of the telecentric lens, the system stability is improved and the relationship between the position of LED and its illumination angle is simplified. The excellent plane wave provided by the telecentric lens guarantees the same wavevector in the full FOV, and we use this wavevector to reconstruct the full FOV during one time. The area and diameter of the single reconstruction FOV reached 14.6mm 2 and 5.4 mm, respectively, and the diameter is very close to the field number (5.5 mm) of the 4× objective. Compared with the traditional FPM, we have increased the diameter of FOV in a single reconstruction by ∼ 10 times, eliminating the complicated steps of computational redundancy and image stitching.

Pneumocephalus in subthalamic deep brain stimulation for Parkinson's disease: a comparison of two different surgical techniques considering factors conditioning brain shift and target precision.

Precise placement of electrodes in deep brain stimulation (DBS) may be influenced by brain shift caused by cerebrospinal fluid leaking or air inflow. We compared accuracy and treatment outcomes between a standard technique and one aiming at reducing brain shift. We retrospectively reviewed 46 patients (92 targets) treated with bilateral subthalamic-DBS for Parkinson's disease. The patients were divided into two groups: group A surgery was performed in supine position with standard burr hole, dural opening, fibrin glue and gelfoam plugging. Group B patients were operated in a semi-sitting position with direct dural puncture to reduce CSF loss. We analysed target deviation on head CT performed immediately after surgery and at 1 month merged with preoperative MRI planning. We recorded pneumocephalus volume, brain atrophy and target correction by intraoperative neurophysiology (ION). In group A, the mean pneumocephalus volume was 10.55 cm3, mean brain volume 1116 cm3, mean target deviation 1.09 mm and ION corrected 70% of targets. In group B, mean pneumocephalus was 7.60 cm3 (p = 0.3048), mean brain volume 1132 cm3 (p = 0.6526), mean target deviation 0.64 mm (p = 0.0074) and ION corrected 50% of targets (p = 0.4886). Most leads' deviations realigned to the planned target after pneumocephalus reabsorbtion suggesting a deviation caused by displacement of anatomical structures due to brain shift. Definitive lead position was always decided with ION. The modified DBS technique significantly reduced errors of electrode placement, though such difference was clinically irrelevant. ION corrected a high amount of trajectories in both groups (70% vs 50%). The choice of either strategy is acceptable.

Acute response to cardiac re-synchronization therapy: ventricular properties adaptation?

Abstract Background Cardiac re-synchronization therapy (CRT) reduces mortality and hospitalization in patients with heart failure, reduced left ventricular ejection fraction (LVEF) and left bundle branch block (LBBB). However, there is no conclusive evidence on baseline parameters able to discriminate responder vs non-responder patients. Purpose In this study, we tested whether echocardiographic parameters describing LV dyssynchrony and efficiency may predict an acute LV recovery after CRT and whether lead position can modify such relationship. Methods We enrolled 65 consecutive patients (75% males, aged 71.2±10.5 years) referred for CRT according to current guidelines; 45% had an underlying ischaemic cardiopathy and 1/3 of them presented diabetes mellitus. We performed a CRT-off and CRT–on 2D and 3D echocardiography during devices optimization (time between programming change 10/12 min). We evaluated ventricular dyssynchrony by speckle-tracking analysis based on temporary uniformity of strain (TUS) 3D longitudinal and circumferential. We also derived non-invasive myocardial efficiency (Effic) by interaction between pressure work index (PWI), representing an estimation of myocardial oxygen consumption, and mechanical external work. We indicated as concordant those patients presenting a LV lead position (defined from a chest X-ray using 2 orthogonal views) in the same segment as the latest systolic 3D circumferential strain curves. Results In the CRT-on phase, a non-statistically significant raise in LVEF was observed [from 0.37 (0.28–0.46) to 0.41 (0.34–0.47), p=0.27]. No improvement in both longitudinal and circumferential 3D TUS was demonstrated during CRT-on (p=0.44 and 0.47, respectively). Conversely, the gain in Effic from CRT-off to CRT-on phase was overall significant (from 0.43±0.14 to 0.50±0.16; p&amp;lt;0.001). After switching to CRT-on, the increase in longitudinal 3D TUS was higher in concordant compared to discordant patients (from 0.83±0.08 to 0.87±0.07 vs 0.88±0.11 to 0.87±0.12, respectively), but without significant interaction (interaction p 0.24). No interaction was also found between variations of PWI after switching to CRT-on and LV lead position (concordant: from 12.99±4.18 to 12.84±2.99 ml/min/100g; discordant: from 13.58±3.89 to 13.95±3.97 ml/min/100g; interaction p 0.75). Conclusions Effic was overall acutely augmented during CRT-on phase in patients with LV dysfunction undergoing cardiac re-synchronization. In the acute phase, no significant relationship between LV changes in speckle-tracking analyses after CRT and LV lead position was found. 2-way ANOVA for myocardial efficiency Funding Acknowledgement Type of funding source: None

Lateral left ventricular lead position is superior to posterior position in long-term outcome of patients underwent cardiac resynchronization therapy

Abstract Background Preferring side branch of coronary sinus during cardiac resynchronization therapy (CRT) implantation is empirical due to the limited data on the association of left ventricular (LV) lead position and long-term clinical outcome. Purpose We evaluated the long-term all-cause mortality by LV lead non-apical positions and further characterized them by interlead electrical delay (IED). Methods In our retrospective database 2087 patients were registered between 2000 and 2018. Those with non-apical LV lead locations were classified into anterior (n=108), posterior (n=643), and lateral (n=1336) groups. All-cause mortality was assessed by Kaplan-Meier and Cox analyses. Echocardiographic response was measured 6 months after CRT implantation. Results During the median follow-up time of 3.7 years, 1150 (55.1%) patients died, 710 (53.1%) with lateral, 78 (72.2%) with anterior and 362 (56.3%) with posterior positions. Patients with lateral position had significantly better outcome in all-cause mortality compared to others (HR 0.80; 95% CI: 0.71–0.90; p&amp;lt;0.0001), which was also confirmed by multivariate analysis after adjusting for relevant clinical covariates (HR 0.81; 95% CI: 0.72–0.91; p&amp;lt;0.0001). When echocardiographic response was evaluated in the lateral group, patients with an IED longer than 110 ms (ROC AUC 0.63; 95% CI: 0.53–0.73; p=0.012) showed 2.1 times higher odds of improvement in echocardiographic response 6 months after the implantation. Conclusions In this study we proved that after CRT implantation only the lateral LV lead location was associated with long-term mortality benefit. Moreover, patients with this position showed the greatest echocardiographic response over 110 ms IED. Survival of total patient cohort Funding Acknowledgement Type of funding source: None

Comparison of electrical characteristics between atrial and ventricular side His-bundle pacing in bradycardia patients

Abstract Background His-bundle pacing (HBP) is recognized as the most physiological way of pacing but with less study focused on electrical characteristics in different site. Purpose We aimed to evaluate the differences of pacing and echocardiographic parameters between atrial and ventricular side His-bundle pacing. Methods Patients who successfully underwent HBP implantation from September 2018 to August 2019 were retrospectively analyzed. All patients were assigned to atrial-side HBP (aHBP) group or ventricular-side HBP (vHBP) group according to the location of the His-bundle pacing lead, which was confirmed by two methods including postoperative echocardiography and visualization of tricuspid valve annulus (TVA). The pacing and echocardiographic parameters were compared between two groups during the procedure and at 3-month follow-up. Results A total of 71 bradycardia patients who successfully underwent HBP implantation and confirmed lead position were included. Among them, twenty-seven were assigned to aHBP group and the other 44 were assigned to vHBP group with no significant differences in baseline clinical characteristics between two groups. During the procedure, the proportion of selective HBP was significantly higher (77.8% vs. 11.4%; P&amp;lt;0.01) and the intra-procedural HV intervals was significantly longer (50.85±6.53 ms vs. 42.95±6.02 ms, P&amp;lt;0.01) in aHBP group than in vHBP group. The capture threshold in vHBP group was significantly lower than in aHBP group at implantation (0.92±0.22 V/1.0ms vs. 1.05±0.26 V/1.0ms, P=0.03) and remain significantly difference after 3-month follow-up (0.98±0.23 V/1.0ms vs. 1.15±0.44 V/1.0ms, P=0.03). The R-wave amplitude was significantly higher in vHBP group than in aHBP group at implantation (5.82±2.52 mV vs. 3.74±1.81 mV, P&amp;lt;0.01), and these differences still persisted during follow-up (5.88±2.51 mV vs. 3.67±1.61 mV, P&amp;lt;0.01). During 3-month follow-up, an increase in the capture threshold &amp;gt;1 V/1.0ms was seen in 2 cases in aHBP group while all patients remained stable in vHBP group. One patient developed a pocket hematoma in aHBP group compared to none in vHBP group. None of deterioration of tricuspid regurgitation and other procedure-related complications were observed during 3-month follow-up. Conclusions Ventricular side His-bundle pacing can achieve favourable pacing parameters including a lower pacing threshold and a higher R-wave amplitude than atrial side His-bundle pacing, which may be an ideal pacing strategy for patients in need of ventricular pacing. Funding Acknowledgement Type of funding source: None