Optimal Perfusion Research Articles

Variations in Autoregulation-Based Optimal Cerebral Perfusion Pressure Determination Using Two Integrated Neuromonitoring Platforms in a Trauma Patient.

Neuromonitoring devices are often used in traumatic brain injury.The objective of this report is to raise awareness concerning variations in optimal cerebral perfusion pressure (CPPopt) determination using exploratory information provided by two neuromonitoring monitors that are part of research programs (Moberg CNS Monitor and RAUMED NeuroSmart LogO). We connected both monitors simultaneously to a parenchymal intracranial pressure catheter and recorded the pressure reactivity index (PRx) and the derived CPPopt estimates for a patient with a severe traumatic brain injury. These estimates were available at the bedside and were updated at each minute. Using the Bland and Altman method, we found a mean variation of - 3.8 (95% confidence internal from - 8.5 to 0.9) mm Hg between the CPPopt estimates provided by the two monitors (limits of agreement from - 26.6 to 19.1mm Hg). The PRx and CPPopt trends provided by the two monitors were similar over time, but CPPopt trends differed when PRx values were around zero. Also, almost half of the CPPopt estimates differed by more than 10mm Hg. These wide variations recorded in the same patient are worrisome and reiterate the importance of understanding and standardizing the methodology and algorithms behind commercial neuromonitoring devices prior to incorporating them in clinical use.

Effect of resuscitative endovascular balloon occlusion of the aorta in nontraumatic out-of-hospital cardiac arrest: a multinational, multicenter, randomized, controlled trial

BackgroundOut-of-hospital cardiac arrest (OHCA) is a significant public health issue worldwide and is associated with low survival rates and poor neurological outcomes. The generation of optimal coronary perfusion pressure (CPP) via high-quality chest compressions is a key factor in enhancing survival rates. However, it is often challenging to provide adequate CPP in real-world cardiopulmonary resuscitation (CPR) scenarios. Based on animal studies and human trials on improving CPP in patients with nontraumatic OHCA, resuscitative endovascular balloon occlusion of the aorta (REBOA) is a promising technique in these cases. This study aims to investigate the benefits of REBOA adjunct to CPR compared with conventional CPR for the clinical management of nontraumatic OHCA.MethodsThis is a parallel-group, randomized, controlled, multinational trial that will be conducted at two urban academic tertiary hospitals in Korea and Taiwan. Patients aged 20–80 years presenting with witnessed OHCA will be enrolled in this study. Eligible participants must fulfill the inclusion criteria, and written informed consent should be collected from their legal representatives. Patients will be randomly assigned to the intervention (REBOA-CPR) or control (conventional CPR) group. The intervention group will receive REBOA and standard advanced cardiovascular life support (ACLS). Meanwhile, the control group will receive ACLS based on the 2020 American Heart Association guidelines. The primary outcome is the return of spontaneous circulation (ROSC). The secondary outcomes include sustained ROSC, survival to admission, survival to discharge, neurological outcome, and hemodynamic changes.DiscussionOur upcoming trial can provide essential evidence regarding the efficacy of REBOA, a mechanical method for enhancing CPP, in OHCA resuscitation. Our study aims to determine whether REBOA can improve treatment strategies for patients with nontraumatic OHCA based on clinical outcomes, thereby potentially providing valuable insights and guiding further advancements in this critical public health area.Trial registrationClinicalTrials.gov NCT06031623. Registered on September 9, 2023

Obstetric echodynamics: Approaching a new field of multidisciplinary action

Maternal cardiovascular adaptation during pregnancy is essential for fetal development. Structural and functional changes, including increased blood volume, heart rate, and myocardial hypertrophy, are crucial for optimal tissue perfusion. Recent evidence supports viewing maternal and fetal cardiovascular systems as a unified functional unit, emphasizing the significance of hemodynamic evaluation in pregnancy. Some obstetrical syndromes result from maladaptive maternal cardiovascular responses. Non-invasive hemodynamic tests, like transthoracic echocardiography, aid in distinguishing phenotypes, guiding tailored management strategies for hypertensive disorders. Establishing obstetric hemodynamics as a multidisciplinary field, termed “Obstetric Echodynamics,” promises improved clinical care through standardized practices, interdisciplinary cooperation, and enhanced education.

Cerebrovascular reactivity (PRx) and optimal cerebral perfusion pressure in elderly with traumatic brain injury

PurposeCerebral perfusion pressure (CPP) guidance by cerebral pressure autoregulation (CPA) status according to PRx (correlation mean arterial blood pressure (MAP) and intracranial pressure (ICP)) and optimal CPP (CPPopt = CPP with lowest PRx) is promising but little is known regarding this approach in elderly. The aim was to analyze PRx and CPPopt in elderly TBI patients.MethodsA total of 129 old (≥ 65 years) and 342 young (16–64 years) patients were studied using monitoring data for MAP and ICP. CPP, PRx, CPPopt, and ΔCPPopt (difference between actual CPP and CPPopt) were calculated. Logistic regression analyses with PRx and ΔCPPopt as explanatory variables for outcome. The combined effects of PRx/CPP and PRx/ΔCPPopt on outcome were visualized as heatmaps.ResultsThe elderly had higher PRx (worse CPA), higher CPPopt, and different temporal patterns. High PRx influenced outcome negatively in the elderly but less so than in younger patients. CPP close to CPPopt correlated to favorable outcome in younger, in contrast to elderly patients. Heatmap interaction analysis of PRx/ΔCPPopt in the elderly showed that the region for favorable outcome was centered around PRx 0 and ranging between both functioning and impaired CPA (PRx range − 0.5–0.5), and the center of ΔCPPopt was − 10 (range − 20–0), while in younger the center of PRx was around − 0.5 and ΔCPPopt closer to zero.ConclusionsThe elderly exhibit higher PRx and CPPopt. High PRx influences outcome negatively in the elderly but less than in younger patients. The elderly do not show better outcome when CPP is close to CPPopt in contrast to younger patients.

Abstract TP132: Optimal CT Perfusion Post-Processing Method in Posterior Circulation Stroke

Objective: CT-perfusion (CTP) has revolutionised stroke care by improving diagnostic accuracy and expanding eligibility to acute therapies. Software packages utilise various mathematical techniques to transform raw perfusion data into measures of infarct core and ischaemic penumbra. These techniques have been derived from studies of anterior-circulation stroke and not yet validated in posterior circulation stroke (PCS). We examined the optimal CTP thresholds for acute PCS. Methods: Data were analysed from 331-patients diagnosed with a PCS enrolled in the International-stroke-perfusion-registry (INSPIRE). Twenty-seven-patients with baseline multimodal-CT with occlusion of a large posterior-circulation (PC) artery and follow up diffusion-weighted-MRI at 24-48 hours were included. CTP parametric maps were generated using five different post-processing methods. Receiver-operating-curve analysis was used to determine the optimal perfusion parameter and thresholds. Results: Partial deconvolution was the optimal post-processing method for characterisation of ischaemic penumbra and infarct core. Mean transit time (MTT) at a threshold of >165% and >195% most accurately defined ischaemic core (AUC=0.73) and penumbra (AUC=0.78) respectively. Post-processing technique influenced accuracy of core (AUC range=0.54-0.73) and penumbra (AUC range=0.72-0.79) estimates. MTT was consistently the most accurate parameter at distinguishing core and penumbra across all post-processing methods. Conclusion: CTP has significant diagnostic utility in PCS. Accuracy of CTP varies considerably by post-processing method. The underlying post-processing technique employed by individual software packages should be considered when interpreting the accuracy of ischemic core and penumbra estimates.

Cerebral autoregulation in traumatic brain injury: ultra-low-frequency pressure reactivity index and intracranial pressure across age groups

BackgroundThe ultra-low-frequency pressure reactivity index (UL-PRx) has been established as a surrogate method for bedside estimation of cerebral autoregulation (CA). Although this index has been shown to be a predictor of outcome in adult and pediatric patients with traumatic brain injury (TBI), a comprehensive evaluation of low sampling rate data collection (0.0033 Hz averaged over 5 min) on cerebrovascular reactivity has never been performed.ObjectiveTo evaluate the performance and predictive power of the UL-PRx for 12-month outcome measures, alongside all International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) models and in different age groups. To investigate the potential for optimal cerebral perfusion pressure (CPPopt).MethodsDemographic data, IMPACT variables, in-hospital mortality, and Glasgow Outcome Scale Extended (GOSE) at 12 months were extracted. Filtering and processing of the time series and creation of the indices (cerebral intracranial pressure (ICP), cerebral perfusion pressure (CPP), UL-PRx, and deltaCPPopt (ΔCPPopt and CPPopt-CPP)) were performed using an in-house algorithm. Physiological parameters were assessed as follows: mean index value, % time above threshold, and mean hourly dose above threshold.ResultsA total of 263 TBI patients were included: pediatric (17.5% aged ≤ 16 y) and adult (60.5% aged > 16 and < 70 y and 22.0% ≥ 70 y, respectively) patients. In-hospital and 12-month mortality were 25.9% and 32.7%, respectively, and 60.0% of patients had an unfavorable outcome at 12 months (GOSE). On univariate analysis, ICP, CPP, UL-PRx, and ΔCPPopt were associated with 12-month outcomes. The cutoff of ~ 20–22 for mean ICP and of ~ 0.30 for mean UL-PRx were confirmed in all age groups, except in patients older than 70 years. Mean UL-PRx remained significantly associated with 12-month outcomes even after adjustment for IMPACT models. This association was confirmed in all age groups. UL-PRx resulted associate with CPPopt.ConclusionsThe study highlights UL-PRx as a tool for assessing CA and valuable outcome predictor for TBI patients. The results emphasize the potential clinical utility of the UL-PRx and its adaptability across different age groups, even after adjustment for IMPACT models. Furthermore, the correlation between UL-PRx and CPPopt suggests the potential for more targeted treatment strategies.Trial registration: ClinicalTrials.gov identifier: NCT05043545, principal investigator Paolo Gritti, date of registration 2021.08.21.

European Society of Pediatric Radiology survey of perioperative imaging in pediatric liver transplantation: (2) intraoperative imaging

BackgroundLiver transplantation is the state-of-the-art curative treatment for end-stage liver disease. Imaging is a key element in the detection of intraoperative and postoperative complications. So far, only limited data regarding the best radiological approach to monitor children during liver transplantation is available.ObjectiveTo harmonize the imaging of pediatric liver transplantation, the European Society of Pediatric Radiology Abdominal Taskforce initiated a survey addressing the current status of imaging including the pre-, intra- and postoperative phase. This paper reports the responses related to intraoperative imaging.Materials and methodsAn online survey, initiated in 2021, asked European centers performing pediatric liver transplantation 48 questions about their imaging approach. In total, 26 centers were contacted, and 22 institutions from 11 countries returned the survey.ResultsIntraoperative ultrasound (US) is used by all sites to assess the quality of the vascular anastomosis in order to ensure optimal perfusion of the liver transplant. Vessel depiction is commonly achieved using color Doppler (95.3%). Additional US-based techniques are employed by fewer centers (power angio mode, 28.6%; B-flow, 19%; contrast-enhanced US, 14.3%). Most centers prefer a collaborative approach, with surgeons responsible for probe handling, while radiologists operate the US machine (47.6%). Less commonly, the intraoperative US is performed by the surgeon alone (28.6%) or by the radiologist alone (23.8%). Timing of US, imaging frequency, and documentation practices vary among centers.ConclusionIntraoperative US is consistently utilized across all sites during pediatric liver transplantation. However, considerable variations were observed in terms of the US setup, technique preferences, timing of controls, and documentation practices. These differences provide valuable insights for future optimization and harmonization studies.

ОСТРОЕ НАРУШЕНИЕ МОЗГОВОГО КРОВООБРАЩЕНИЯ В ДЕТСКОМ ВОЗРАСТЕ: КЛИНИЧЕСКИЕ ПРОЯВЛЕНИЯ И ИНТЕНСИВНАЯ ТЕРАПИЯ

Acute cerebrovascular accident (CVA) is a severe condition in children and adolescents with a high risk of disability. A literature review was carried outon intensive stroke care in children and adolescents using databases such as PubMed, Science Direct, and eLibrary. The search utilized keywords suchas "acute cerebrovascular accident", "stroke", "children", "clinical manifestations", and "intensive care". The review includes sources for the last 10years (2014-2024). The inclusion criteria consisted of descriptions of clinical manifestations and intensive care management for stroke in childhood and adolescence. The exclusion criteria referred to articles on the clinical presentation and treatment of stroke in adult patients. The main factors for stroke in childhood include sickle cell anemia, cardiovascular diseases, cancer pathology, and genetic disorders. The manifestations of stroke in children and adolescents have nonspecific clinical features. There are currently no approved protocols for the treatment of stroke in children, and there are insufficient clinical studies for this condition. Therefore, pediatric practice often extrapolates aspects of intensive care for stroke from the adult population. The type of stroke, such as arterial ischemic stroke (AIS) or hemorrhagic stroke (HS), cerebral venous sinus thrombosis, or stroke due to sickle cell anemia, determines the emergency care required for children. Intensive therapy should be carried out in a pediatric intensive care unit (PICU), focusing on stabilizing vital functions and maintaining optimal cerebral perfusion pressure. Developing specific protocols for intensive stroke treatment in children and adolescents is necessary to improve the quality of emergency care for this patient population

The heart, a secondary organ in the control of blood circulation.

Circulation of the blood is a fundamental physiological function traditionally ascribed to the pressure-generating function of the heart. However, over the past century the 'cardiocentric' view has been challenged by August Krogh, Ernst Starling, Arthur Guyton and others, based on haemodynamic data obtained from isolated heart preparations and organ perfusion. Their research brought forth experimental evidence and phenomenological observations supporting the concept that cardiac output occurs primarily in response to the metabolic demands of the tissues. The basic tenets of Guyton's venous return model are presented and juxtaposed with their critiques. Developmental biology of the cardiovascular system shows that the blood circulates before the heart has achieved functional integrity and that its movement is intricately connected with the metabolic demands of the tissues. Long discovered, but as yet overlooked, negative interstitial pressure may play a role in assisting the flow returning to the heart. Based on these phenomena, an alternative circulation model has been proposed in which the heart functions like a hydraulic ram and maintains a dynamic equilibrium between the arterial (centrifugal) and venous (centripetal) forces which define the blood's circular movement. In this focused review we introduce some of the salient arguments in support of the proposed circulation model. Finally, we present evidence that exercising muscle blood flow is subject to local metabolic control which upholds optimal perfusion in the face of a substantive rise in muscle vascular conductance, thus lending further support to the permissive role of the heart in the overall control of blood circulation.

Comparison of outcomes of coronary artery stenting in acute myocardial infarction due to massive coronary thrombosis

Introduction. Therapy of patients with acute ST-elevation myocardial infarction and massive coronary thrombosis (TTG 3) is a far from solved problem of modern medicine, since often in such patients immediate stent implantation is associated with the development of myocardial hypoperfusion, reducing the long-term prognosis of life.Aim. To evaluate short-term and long-term efficacy and safety of delayed and immediate coronary artery stenting techniques in patients with acute ST-elevation myocardial infarction and massive coronary thrombosis.Material and methods. Comparative study in parallel groups, a total of 153 patients with ST-elevation myocardial infarction and massive coronary thrombosis (TTG 3), 75 patients in the delayed coronary artery stenting group, 78 patients in the immediate coronary artery stenting group. In the immediate coronary artery stenting group, percutaneous coronary intervention was performed in one stage with stent implantation, in the delayed coronary artery stenting group; percutaneous coronary intervention was performed in two stages: the first was achieving TIMI-3 blood flow using a minimally invasive mechanical strategy, the second was control coronary angiography 5-6 days and the decision on the implantation of the stent. The primary endpoint is: the rate of achieving optimal myocardial perfusion according to angiography, the secondary combined endpoint is the rate of major adverse cardiovascular events.Results. In the hospital period, optimal reperfusion (TIMI-3 and MBG 2-3) after the primary procedure was achieved in 88% in the delayed coronary artery stenting group and 69.2% of immediate coronary artery stenting with an advantage in the delayed coronary artery stenting group (p=0.005). Of the 75 patients in the delayed coronary artery stenting group, 38 patients (51%) did not receive a stent in the delayed period due to the insignificance of stenosis on the control coronary angiography. There was no significant difference in the incidence of major adverse cardiovascular events between the groups. In the long-term period, the median follow-up period was 47 months. The frequency of major adverse cardiovascular events was 13.3% in the delayed coronary artery stenting group and 23.1% in the immediate coronary artery stenting group, with a trend towards the advantage in the delayed coronary artery stenting group (p=0.1). Overall mortality (9.3% vs. 11.7%), recurrent myocardial infarction (2.6% vs. 5.1%), target vessel revascularization rate (1.3% vs. 6.4%) were without significant benefit. between subgroups.Conclusion. In patients with ST-elevation myocardial infarction and massive coronary thrombosis, the use of delayed coronary artery stenting gives an advantage in achieving myocardial perfusion after the procedure, and demonstrates a tendency to reduce adverse cardiovascular events in the long-term period.

Time spent above optimal cerebral perfusion pressure is not associated with failure to improve in outcome in traumatic brain injury

BackgroundOptimal cerebral perfusion pressure (CPPopt) has emerged as a promising personalized medicine approach to the management of moderate-to-severe traumatic brain injury (TBI). Though literature demonstrating its association with poor outcomes exists, there is yet to be work done on its association with outcome transition due to a lack of serial outcome data analysis. In this study we investigate the association between various metrics of CPPopt and failure to improve in outcome over time.MethodsCPPopt was derived using three different cerebrovascular reactivity indices; the pressure reactivity index (PRx), the pulse amplitude index (PAx), and the RAC index. For each index, % times spent with cerebral perfusion pressure (CPP) above and below its CPPopt and upper and lower limits of reactivity were calculated. Patients were dichotomized based on improvement in Glasgow Outcome Scale-Extended (GOSE) scores into Improved vs. Not Improved between 1 and 3 months, 3 and 6 months, and 1- and 6-month post-TBI. Logistic regression analyses were then conducted, adjusting for the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) variables.ResultsThis study included a total of 103 patients from the Winnipeg Acute TBI Database. Through Mann–Whitney U testing and logistic regression analysis, it was found that % time spent with CPP below CPPopt was associated with failure to improve in outcome, while % time spent with CPP above CPPopt was generally associated with improvement in outcome.ConclusionsOur study supports the existing narrative that time spent with CPP below CPPopt results in poorer outcomes. However, it also suggests that time spent above CPPopt may not be associated with worse outcomes and is possibly even associated with improvement in outcome.

Optimal antegrade cerebral perfusion flow in patients undergoing surgery for acute type A aortic dissection: A retrospective single-center analysis.

Systemic hypothermia with bilateral antegrade selective cerebral perfusion (ASCP) is the preferred cerebral protective strategy for type A aortic dissection surgery. The optimal ASCP flow rate remains uncertain and the target flow cannot always be reached due to pressure limitations. The aim of this study was to assess the correlation between ASCP flow and regional cerebral oxygen saturation (rSO2). A retrospective analysis was performed on 140 patients with acute type A aortic dissection who underwent surgery with moderate hypothermic circulatory arrest and bilateral ASCP between 2015 and 2021. Pearson correlation analysis was performed between ASCP flow and rSO2. The median circulatory arrest duration was 46.5 (IQR:37.0-61.0) minutes. There was no significant correlation between ASCP flow and rSO2 for both the right (r = -.02, p = .851), and the left hemisphere (r = - .04, p = .618). The rSO2 values for ten patients who received > 10mL/kg/min flow did not differ significantly from 130 patients who received 10mL/kg/min or less for both the left hemisphere (p = .135), and the right hemisphere (p = .318). The ASCP flow was 5.1 (IQR:5.0- 6.5) mL/kg/min in five patients with, and 7.2 (IQR:5.8-8.3) mL/kg/min in 135 patients without a watershed infarction (p = .098). There was no correlation between ASCP flow rate and rSO2 in patients with acute type A aortic dissection. Furthermore, ASCP flow below 10mL/kg/min was not associated with a reduction in rSO2. Definitive associations between ASCP flow and neurological outcome after type A aortic dissection surgery need further investigation.

Challenges With the Implementation of Machine Perfusion in Clinical Liver Transplantation.

Dynamic organ preservation is a relatively old technique which has regained significant interest in the last decade. Machine perfusion (MP) techniques are applied in various fields of solid organ transplantation today. The first clinical series of ex situ MP in liver transplantation was presented in 2010. Since then, the number of research and clinical applications has substantially increased. Despite the notable beneficial effect on organ quality and recipient outcome, MP is still not routinely used in liver transplantation. Based on the enormous need to better preserve organs and the subsequent demand to continuously innovate and develop perfusion equipment further, this technology is also beneficial to test and deliver future therapeutic strategies to livers before implantation. This article summarizes the various challenges observed during the current shift from static to dynamic liver preservation in the clinical setting. The different organ perfusion strategies are discussed first, together with ongoing clinical trials and future study design. The current status of research and the impact of costs and regulations is highlighted next. Factors contributing to costs and other required resources for a worldwide successful implementation and reimbursement are presented third. The impact of research on cost-utility and effectivity to guide the tailored decision-making regarding the optimal perfusion strategy is discussed next. Finally, this article provides potential solutions to the challenging field of innovation in healthcare considering the various social and economic factors and the role of clinical, regulatory, and financial stakeholders worldwide.

Modeling of bioprocess pre-stages for optimization of perfusion profiles and increased process understanding.

Improving bioprocess efficiency is important to reduce the current costs of biologics on the market, bring them faster to the market, and to improve the environmental footprint. The process intensification efforts were historically focused on the main stage, while intensification of pre-stages has started to gain attention only in the past decade. Performing bioprocess pre-stages in the perfusion mode is one of the most efficient options to achieve higher viable cell densities over traditional batch methods. While the perfusion-mode operation allows to reach higher viable cell densities, it also consumes large amount of medium, making it cost-intensive. The change of perfusion rate during a process (perfusion profile) determines how much medium is consumed, thereby running a process in optimal conditions is key to reduce medium consumption. However, the selection of the perfusion profile is often made empirically, without full understanding of bioprocess dynamics. This fact is hindering potential process improvements and means for cost reduction. In this study, we propose a process modeling approach to identify the optimal perfusion profile during bioprocess pre-stages. The developed process model was used internally during process development. We could reduce perfused medium volume by 25%-45% (project-dependent), while keeping the difference in the final cell within 5%-10% compared to the original settings. Additionally, the model helps to reduce the experimental workload by 30%-70% and to predict an optimal perfusion profile when process conditions need to be changed (e.g., higher seeding density, change of operating mode from batch to perfusion, etc.). This study demonstrates the potential of process modeling as a powerful tool for optimizing bioprocess pre-stages and thereby guiding process development, improving overall bioprocess efficiency, and reducing operational costs, while strongly reducing the need for wet-lab experiments.

Pro: Individualized Optimal Perfusion Pressure-Maximizing Patient Care During Cardiopulmonary Bypass

Cardiopulmonary bypass (CPB) has revolutionized cardiac surgery but poses challenges such as hemodynamic instability and adverse clinical outcomes. Achieving optimal perfusion during CPB ensures adequate oxygen delivery to vital organs. Although mean arterial pressure is a key determinant of perfusion pressure, clear guidelines for optimal perfusion have yet to be established. Autoregulation, the organ's ability to maintain consistent blood flow, plays a vital role in perfusion. Individual variability in autoregulation responses and intraoperative factors necessitate an individualized approach to determining the autoregulation range. Continuous assessment of autoregulation during surgery allows for personalized perfusion targets, optimizing organ perfusion. Exploring techniques like multimodal intravenous anesthesia guided by electroencephalogram can enhance perfusion maintenance within the auto-regulatory range. By adopting an individualized approach to perfusion targets on CPB, we can improve outcomes and enhance patient care.

Strategy of delayed intervention without stent implantation in myocardial infarction with ST segment elevation caused by massive thrombosis of the infarct-related artery

Aim. TIntroduction. To evaluate in-hospital angiographic and five-year posthospital clinical outcomes of percutaneous intervention strategy without stent implantation with immediate coronary artery stenting technique in STEMI patients with massive coronary thrombosis.Material and methods. The study enrolled 116 patients with primary STEMI myocardial infarction with the signs of massive thrombosis in the lumen of the main epicardial coronary artery with TIMI thrombus grade greater than 3 after antegrade blood flow restoration. In the 1st group of delayed intervention at the primary stage the blood flow was restored by small diameter balloon inflation and/ or manual vacuum thrombus aspiration until stable TIMI grade 3 blood flow was achieved, at control CAG on day 5-6 in 36 people the stent was not implanted due to insignificance of infarct-related coronary artery stenosis (stenosis less than 50% according to QCA). Immediate stent implantation was performed in 78 patients (group 2). The primary endpoint was the incidence of adverse cardiovascular events, including total mortality, recurrent myocardial infarction, repeated revascularization of the infarct-responsive artery. Secondary endpoint: frequency of achieving optimal myocardial perfusion as measured by angiography – TIMI blood flow and Myocardial Blush Grade.Results. The median follow-up period was 47 months. The incidence of the primary end point (MACE) was 15,8% in group 1 and 23,1% in group 2, with no statistically significant difference (p=0,408). Overall mortality (10,5% and 11,7%), the rate of repeat myocardial infarction (2,6% and 5,1%), and the rate of repeat target vessel revascularization (2,6% and 6,4%) were without significant advantage between subgroups. Optimal reperfusion (TIMI-3 and Myocardial Blush Grade 2-3 after primary procedure was achieved in significantly (p=0,02) more patients in group 1 (89%) than in group 2 (69,2%) ST segment resolution ≥70% after intervention was achieved in 87% of cases in group 1 and in 64,1% of cases in group 2 (p=0,011).Conclusion. In STEMI patients with massive coronary thrombosis, the method of delayed percutaneous intervention increases the rate of achieving optimal blood flow and allows avoiding stent implantation in the infarct-related artery in 50% of cases as compared to the method of immediate stenting. Both methods have comparable hospital and five-year clinical risks.

Composition of ex vivo perfusion solutions and kinetics define differential cytokine/chemokine secretion in a porcine cardiac arrest model of lung preservation.

Ex vivo lung perfusion (EVLP) uses continuous normothermic perfusion to reduce ischemic damage and to improve post-transplant outcomes, specifically for marginal donor lungs after the donation after circulatory death. Despite major efforts, the optimal perfusion protocol and the composition of the perfusate in clinical lung transplantation have not been identified. Our study aims to compare the concentration levels of cytokine/chemokine in different perfusion solutions during EVLP, after 1 and 9 h of cold static preservation (CSP) in a porcine cardiac arrest model, and to correlate inflammatory parameters to oxygenation capacities. Following cardiac arrest, the lungs were harvested and were categorized into two groups: immediate (I-EVLP) and delayed EVLP (D-EVLP), after 1 and 9 h of CSP, respectively. The D-EVLP lungs were perfused with either Steen or modified Custodiol-N solution containing only dextran (CD) or dextran and albumin (CDA). The cytokine/chemokine levels were analyzed at baseline (0 h) and after 1 and 4 h of EVLP using Luminex-based multiplex assays. Within 4 h of EVLP, the concentration levels of TNF-α, IL-6, CXCL8, IFN-γ, IL-1α, and IL-1β increased significantly (P < 0.05) in all experimental groups. The CD solution contained lower concentration levels of TNF-α, IL-6, CXCL8, IFN-γ, IL-2, IL-12, IL-10, IL-4, IL-1RA, and IL-18 (P < 0.05) compared with those of the Steen solution. The concentration levels of all experimental groups have correlated negatively with the oxygenation capacity values (P < 0.05). Protein concentration levels did not reach statistical significance for I-EVLP vs. D-EVLP and CD vs. CDA solutions. In a porcine cardiac arrest model, a longer period of CSP prior to EVLP did not result in an enhanced protein secretion into perfusates. The CD solution reduced the cytokine/chemokine secretion most probably by iron chelators and/or by the protecting effects of dextran. Supplementing with albumin did not further reduce the cytokine/chemokine secretion into perfusates. These findings may help in optimizing the preservation procedure of the lungs, thereby increasing the donor pool of organs.

Interaction of Optimal Cerebral Perfusion Pressure with Early Brain Injury and its Impact on Ischemic Complications and Outcome Following Aneurysmal Subarachnoid Hemorrhage

BackgroundCerebral autoregulation is impaired early on after aneurysmal subarachnoid hemorrhage (aSAH). The study objective was to explore the pressure reactivity index (PRx) and cerebral perfusion pressure (CPP) in the earliest phase after aneurysm rupture and to address the question of whether an optimal CPP (CPPopt)–targeted management is associated with less severe early brain injury (EBI).MethodsPatients with aSAH admitted between 2012 and 2020 were retrospectively included in this observational cohort study. The PRx was calculated as a correlation coefficient between intracranial pressure and mean arterial pressure. By plotting the PRx versus CPP, CPP correlating the lowest PRx value was identified as CPPopt. EBI was assessed by applying the Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) on day 3 after ictus. An SEBES ≥ 3 was considered severe EBI.ResultsIn 90 of 324 consecutive patients with aSAH, intracranial pressure monitoring was performed ≥ 7 days, allowing for PRx calculation and CPPopt determination. Severe EBI was associated with larger mean deviation of CPP from CPPopt 72 h after ictus (r = 0.22, p = 0.03). Progressive edema requiring decompressive hemicraniectomy was associated with larger deviation of CPP from CPPopt on day 2 (r = 0.23, p = 0.02). The higher the difference of CPP from CPPopt on day 3 the higher the mortality rate (r = 0.31, p = 0.04).ConclusionsPatients with CPP near to the calculated CPPopt in the early phase after aSAH experienced less severe EBI, less frequently received decompressive hemicraniectomy, and exhibited a lower mortality rate. A prospective evaluation of CPPopt-guided management starting in the first days after ictus is needed to confirm the clinical validity of this concept.

Quantitative assessment of collateral time on perfusion computed tomography in acute ischemic stroke patients.

Good collateral circulation is recognized to maintain perfusion and contribute to favorable clinical outcomes in acute ischemic stroke. This study aimed to derive and validate an optimal collateral time measurement on perfusion computed tomography imaging for patients with acute ischemic stroke. This study included 106 acute ischemic stroke patients with complete large vessel occlusions. In deriving cohort of 23 patients, the parasagittal region of the ischemic hemisphere was divided into six pial arterial zones according to pial branches of the middle cerebral artery. Within the 85 arterial zones with collateral vessels, the receiver operating characteristic analysis was performed to derive the optimal collateral time threshold for fast collateral flow on perfusion computed tomography. The reference for fast collateral flow was the peak contrast delay on the collateral vessels within each ischemic arterial zone compared to its contralateral normal arterial zone on dynamic computed tomography angiography. The optimal perfusion collateral time threshold was then tested in predicting poor clinical outcomes (modified Rankin score of 5-6) and final infarct volume in the validation cohort of 83 patients. For the derivation cohort of 85 arterial zones, the optimal collateral time threshold for fast collateral flow on perfusion computed tomography was a delay time of 4.04 s [area under the curve = 0.78 (0.67, 0.89), sensitivity = 73%, and specificity = 77%]. Therefore, the delay time of 4 s was used to define the perfusion collateral time. In the validation cohort, the perfusion collateral time showed a slightly higher predicting power than dynamic computed tomography angiography collateral time in poor clinical outcomes (area under the curve = 0.72 vs. 0.67; P < 0.001). Compared to dynamic computed tomography angiography collateral time, the perfusion collateral time also had better performance in predicting final infarct volume (R-squared values = 0.55 vs. 0.23; P < 0.001). Our results indicate that perfusion computed tomography can accurately quantify the collateral time after acute ischemic stroke.

The Enigma of Heart-kidney Transplantation.

The Enigma of Heart-kidney Transplantation.