Use Of Protection Devices Research Articles

From sawdust to safety: Examining knowledge and practices of respiratory protective measures among sawmill workers in South-Eastern Nigeria

The availability of timber products and the increase in demand for construction and export have made it a thriving business in Nigeria. . Chronic respiratory symptoms are common among sawmill workers because of their exposure to occupational-related sawdust hazards. This study aimed to assess the knowledge, self-reported respiratory symptoms, and protective measure in place by the sawmill workers. This was a cross-sectional study and it was carried out at Timber market, Nkwo-Nnewi, Anambra state, Nigeria with a sample size of 157. Structured interviewer-administered questionnaire was used for data collection. Data were analyzed with the statistical package for social sciences. The result of the study showed that nearly all the respondents were male (97.5%) and the majority were between 30-49 years of age. 45.9% of the respondents had worked at the sawmill for 10 years and above. The majority of the respondents were aware that the sawmill dust can affect their respiratory health 119(75.8%).Some of the respiratory problem reported include: Cough 97(61.8%), Cold 81(51.6%), Chest tightness 18(11.5%), Wheeze 17(10.5%), Shortness of breath 12(7.6%). The study indicated that majority of the respondents do not make use of personal protective device 100(63.7%) whilst only 57(36.3%) make use of personal protective equipment. Some of the common reasons cited for not using PPE were that it was not comfortable 44(43%) and that the PPE was not available 34(34%). A great percentage of the sawmill workers had poor knowledge of respiratory protective measures (37.0%). The sawmill workers had a high prevalence of respiratory symptoms probably because poor safety practices were evident. It is therefore essential to improve the level of knowledge among sawmill workers about occupational hazards and safety practices in order to mitigate its negative consequences. These can be achieved via periodic health awareness campaigns, and health policies by the government with the aim to enforce the sawmill workers to observe proper protective measures while working.

Site Variability in Cerebral Embolic Protection for Transcatheter Aortic Valve Implantation and Association With Outcomes

BackgroundThe effectiveness of CEPD in mitigating post-TAVI stroke remains uncertain, and therefore CEPD may be utilized differently across US hospitals. This study aims to characterize the hospital-level pattern of cerebral embolic protection device (CEPD) use during transcatheter aortic valve implantation (TAVI) in the United States and its association with outcomes. MethodsPatients treated with nontransapical TAVI in the 2019 Nationwide Readmissions Database were included. Hospitals were categorized as CEPD non-users and CEPD users. The following outcomes were compared: the composite of in-hospital stroke or transient ischemic attack (TIA), in-hospital ischemic stroke, death, and cost of hospitalization. Logistic regression models were used for risk adjustment of clinical outcomes. ResultsOf 41,822 TAVI encounters, CEPD was used in 10.6% (n = 4422). Out of 392 hospitals, 65.8% were CEPD non-user hospitals and 34.2% were CEPD users. No difference was observed between CEPD non-users and CEPD users in the risk of in-hospital stroke or TIA (adjusted odds ratio (OR) = 0.99 [0.86-1.15]), ischemic stroke (adjusted OR = 1.00 [0.85-1.18]), or in-hospital death (adjusted OR = 0.86 [0.71-1.03]). The cost of hospitalization was lower in CEPD non-users. ConclusionsTwo-thirds of hospitals in the US do not use CEPD for TAVI, and no significant difference was observed in neurologic outcomes among patients treated at CEPD non-user and CEPD user hospitals.

Bioaerosol-induced in vitro activation of toll-like receptors and inflammatory biomarker expression in waste workers

PurposeOccupational exposure to bioaerosols during waste handling remains a health concern for exposed workers. However, exposure-related health effects and underlying immunological mechanisms are still poorly described.MethodsThe present study assessed the inflammatory potential of work-air samples (n = 56) in vitro and investigated biomarker expression in exposed workers (n = 69) compared to unexposed controls (n = 25). These quantitative results were compared to self-reported health conditions.ResultsPersonal air samples provoked an activation of TLR2 and TLR4 HEK reporter cells in one-third of all samples, indicating that the work environment contained ligands capable of inducing an immune response in vitro. Monocyte levels, as well as plasma biomarker levels, such as IL-1Ra, IL-18 and TNFα were significantly higher in exposed workers, compared to the control group when confounding factors such as BMI, sex, age and smoking habits were accounted for. Furthermore, a significant exposure-related increase in midweek IL-8 levels was measured among exposed workers. Tendencies of increased prevalence of health effects of the respiratory tract were identified in exposed workers.ConclusionInhalable dust provoked TLR activation in vitro, indicating that an exposure-related immune response may be expected in susceptible workers. However, despite significant differences in inflammatory plasma biomarker levels between exposed and unexposed workers, prevalence of self-reported health effects did not differ between the groups. This may be due to the healthy worker effect, or other factors such as adequate use of personal protective respiratory devices or adaptation to the work environment with reduced activation of the immune system.

Cornea opacity, uveitis with iris atrophy and lens damage following cosmetic high-intensity ultrasound of the eyelid: a case report

BackgroundHigh-intensity focused ultrasound (HIFU) is a cosmetic procedure that aims to tone the skin through thermal collagen coagulation. The energy is delivered in the deep layers of the skin, and because of these characteristics, the risks of severe damage to adjacent tissue and the ocular surface may be underestimated. Previous reports have demonstrated superficial corneal opacities, cataracts, increased intraocular pressure, or ocular refractive changes in different patients following HIFU. In this case, we report deep stromal opacities associated with anterior uveitis, iris atrophy and lens opacity formation following a single HIFU superior eyelid application.Case presentationA 47-year-old female presented to the ophthalmic emergency department complaining of pain, hyperemia and photophobia in the right eye following a HIFU application to the superior right eyelid. A slit lamp examination showed three temporal-inferior corneal infiltrates with edema and severe anterior uveitis. The patient was treated with topical corticosteroids, and six months later, there was residual corneal opacity, iris atrophy and peripherical cataract formation. No surgical procedure was needed, and the final vision was Snellen 20/20 (1.0).ConclusionThe risk of severe impairment to the ocular surface and ocular tissues may be underestimated. Cosmetic surgeons and ophthalmologists must be aware of the complications, and the long-term follow-up of these changes needs further investigation and discussion. Safety protocols of the HIFU intensity threshold for thermal lesions in the eye and the use of protective eye devices should be better evaluated.

P115 "WHEN THE GOING GETS TOUGH, THE TOUGH GET GOING": LARGE THROMBOSIS ASPIRATION DURING PERCUTANEOUS APPENDAGE OCCLUSION

Abstract Background An 83–year–old woman with permanent atrial fibrillation was referred for percutaneous left atrial appendage closure (LAAC) following a spontaneous intracranial hemorrhage caused by pituitary macroadenomas that the patient refused to excise. Pre–procedural EET revealed no formed thrombus. Intravenous unfractionated heparin (UFH) was administered. After multiple attempts, the device (Amplatzer Amulet) was correctly positioned but before final release, a large thrombus was noted within the left atrium, attached to delivery system. A further 4000 IU of UFH and 300 mg of salicylic acid were administrated, and a subsequent 300 s activated clotting time was recorded. Under continuous negative pressure in the delivery sheath via a 50 mL Luer–Lock syringe, suction of the thrombus was performed. Similarly, the device was released and the delivery system withdrawn into the delivery sheath and removed. Final EET revealed no residual thrombus within the left atrium with adequate device compression and no peri–device leaks. No further aspiration through the sheath was possible, indicating successful thrombus retrieval into the delivery sheath. Discussion Device–related thrombus (DRT) is a possible and terrible complication of percutaneous LAAC due to patient–specific (hypercoagulability disorders, renal insufficiency, nonparoxysmal AF) and/or procedural factors (LAAO depth of implantation >10 mm from the pulmonary vein limbus, pericardial effusion). For this patient, potential causes could be both the long intervention time required for correct positioning of the device and non–optimal pre interventional medical therapy and procedural options included either recapturing the device into the delivery sheath and abandoning the procedure or surgical thrombectomy. Both options would increase the risk of clot dislodgement and embolization. An off–label device deployment under continuous negative pressure was performed reducing embolic risk by minimizing both mechanical forces on the thrombus as well as procedural time. Conclusion Therefore, shorter procedural times and optimized preoperative medical therapy could reduce DRT risk. The evidence for the use of cerebral protection devices in the setting of LAAO insertion is limited to a small single case series. Randomized multicentric studies are necessary to approve routine use of these devices when the patient is deemed to be at high risk of thromboembolism based on clinical or intraprocedural factors.

Cerebral Embolic Risk in Coronary and Structural Heart Interventions: Clinical Evidence.

Surgical and endovascular procedures for coronary and structural heart interventions carry a meaningful risk of acute stroke with greatly increased likelihood of disability and long-term neurocognitive sequelae. In the last decade, transcatheter aortic valve replacement procedures have focused our attention on a spectrum of procedure-related neurologic injuries that have led to various efforts to prevent ischemic injury with the use of embolic protection devices. As the number of patients undergoing surgical and transcatheter cardiac procedures in the United States continues to increase, the risk of iatrogenic brain injury is concerning, particularly in patient populations already at increased risk of thromboembolism and cognitive decline. In this study, we reviewed the current estimates of the incidence of iatrogenic cerebral embolization and ischemic infarction after surgical and percutaneous transcatheter interventions for coronary artery disease, stenotic aortic and mitral valves, atrial fibrillation, left atrial appendage and patent foramen ovale closure. Our findings show that every year in the United States, nearly 2 million patients undergo coronary and structural heart interventions, with approximately 8000 at risk of experiencing a symptomatic stroke and 330,225 (95% CI, 249,948-430,377) at the risk of ischemic brain injury after the procedure. Given the increased use of surgical and endovascular cardiac procedures in clinical practice, the risk of iatrogenic cerebral embolism is significant and demands careful consideration through neurologic and cognitive assessments and appropriate risk mitigation.

Profile of Dermatological Disorders among Construction Workers: A Cross-Sectional Study

Background: The construction industry is a growing industry worldwide, including India, employing a large population. Construction workers perform a variety of work including mixing concrete and carrying heavy objects. Occupational contact dermatitis is a significant occupational dermatosis, cement being the most important agent and is an occupational hazard. Objective: The objective of this study was to estimate the prevalence of occupational skin diseases among construction workers. Materials and Methods: This cross-sectional study was conducted in Manipal, Karnataka, among 300 construction workers. A detailed inquiry was made on demographic parameters such as age, sex, nature of work, duration of the job, chemicals exposed to, symptoms, and use of protective devices. They were examined to note the symptoms, clinical pattern, and distribution of lesions. Results: The majority of the workers belonged to the age group between 20 and 29 years. The common skin disorders noticed were callosities (17.33%), traumatic injuries (10%), dermatophyte infections (8.33%), and dermatitis (5.7%) along with few other dermatoses encountered due to increased exposure to heat and due to increased wet work in workers who did not wear protective devices. Conclusions: There is a lack of preemployment and periodic medical examinations for construction workers. Common dermatoses seen among the construction workers were mainly due to the lack of preventive measures. Hence, it is important to raise health awareness to recognize early signs and symptoms of various dermatoses and educate regarding the use of personal protective equipment.

Prevalence of hearing protection use and subjective auditory symptoms among Spanish classical orchestral musicians

IntroductionSensorineural hearing loss caused by exposure to noise is one of the most frequent causes of deafness. Professional musicians have significant occupational exposure to high levels of noise. Use of hearing protection among musicians could substantially prevent hearing damage, though the rate of use is quite low. Methods and materialA questionnaire on the use of protective hearing devices, hearing care, and subjective judgments of hearing difficulties was completed by a group of classical musicians from Spain. We analysed the frequency of device use by instrument based on contingency tables analysed by χ2 tests. ResultsOne hundred and ninety-four Spanish classical orchestral musicians voluntarily completed the questionnaire. The percentage of musicians who reported using hearing protection in our survey was very low and varied with the type of instrument played. However, we found a high prevalence of subjective auditory disorders within this group. ConclusionFew Spanish musicians use hearing protection. Training on hearing-loss prevention in this field and better protective devices could increase device use and improve the auditory health of this group.

Could timber winching operations be cleaner? An evaluation of two options in terms of residual stand damage, soil disturbance and operational efficiency

Forests provide multiple services, products and values and finding ways to preserve their multifunctionality is important. However, all of the currently used harvesting systems produce some degree of environmental damage, potentially affecting the provision services on the long term. Skidding operations are common in many regions of the world. Skidding may suppose three operational steps: winching, strip-road skidding and landing operations. By using cables for winching, wounds are commonly inflicted to the residual trees, while the mechanical traction of logs may cause damage to the residual trees and soil. This study was designed to check if the use of pans during winching deployed in thinning operations of coniferous forests may help lowering the environmental impact in terms of damage to residual trees and soil, while accounting for operational efficiency of such operations. Four treatments were considered and framed around the winching direction (uphill, downhill) and the use of protective devices (use, nonuse) and detailed data was collected on the residual stand damage, soil damage and time consumption. The main finding was that uphill winching by the use of a pan performed the best in terms of lowering the environmental damage. It shown the smallest wounds by their average area per tree, the lowest number of wounds per tree, the lowest rate of wounding per hectare, as well as one of the lowest rates of soil damage. By excluding delays, working with a pan did not cause additional time consumption, supporting acceptable rates of operational efficiency. Further experiments would be needed to validate and extend the results of this study, as the forests and their type of management are heterogeneous systems in terms of terrain configuration and slope, soil, species, stand density, removal intensity, operational timing and operational conditions.

Iatrogenic Strokes and Covert Brain Infarcts After Percutaneous Cardiac Procedures: An Update.

Millions of cardiac procedures are performed worldwide each year, making the potential complication of periprocedural iatrogenic stroke an important concern. These strokes can occur intraoperatively or within 30 days of a procedure and can be categorised as either overt or covert, occurring without obvious acute neurologic symptoms. Understanding the prevalence, risk factors, and strategies for preventing overt and covert strokes associated with cardiac procedures is imperative for reducing periprocedural morbidity and mortality. In this narrative review, we focus on the impacts of perioperative ischemic strokes for several of the most common interventional cardiac procedures, their relevance from a neurologic standpoint, and future directions for the care and research on perioperative strokes. Depending on the percutaneous procedure, the rates of periprocedural overt strokes can range from as little as 0.01% to as high as 2.9%. Meanwhile, covert brain infarctions (CBIs) occur much more frequently, with rates for different procedures ranging from 10%-84%. Risk factors include previous stroke, atherosclerotic disease, carotid stenosis, female sex, and African race, as well as other patient- and procedure-level factors. While the impact of covert brain infarctions is still a developing field, overt strokes for cardiac procedures lead to longer stays in hospital and increased costs. Potential preventative measures include screening and vascular risk factor control, premedicating, and procedural considerations such as the use of cerebral embolic protection devices. In addition, emerging treatments from the neurologic field, including neuroprotective drugs and remote ischemic conditioning, present promising avenues for preventing these strokes and merit investigation in cardiac procedures.

Safety and efficacy of cerebral embolic protection devices in transcatheter aortic valve implantation: a meta-analysis

Abstract Funding Acknowledgements Type of funding sources: None. Background Stroke during Transcatheter Aortic Valve implantation (TAVI) is not an uncommon complication with potential devastating consequences. With the extension of TAVI to the low-risk patient, stroke prevention takes on increasing importance. The use of cerebral embolic protection device (EPD) reveals conflicting data. This meta-analysis aims to evaluate the clinical efficacy and safety of EPDs. Methods A comprehensive literature search for all studies till May 2022 reporting clinical safety and efficacy outcomes of the only EPD approved for use by the Food and Drug Administration (FDA) was performed. Study outcomes were divided based on time period - overall (up to 30 days and in-hospital) and short (≤7 days). Primary outcome was stroke - major and minor. Secondary outcomes included transient ischaemic attack (TIA), mortality, acute kidney injury (AKI), major vascular and bleeding complications. Results A total of 12 studies involving 288531 patients were analysed, which included 3 randomised controlled trials (RCTs), 7 propensity-matched and 2 cohort studies. Regarding overall outcomes, significant differences were noted for mortality (OR 0.59 [0.42-0.84], p=0.0036) and major stroke (OR 0.40 [0.18-0.91], p=0.028) (Fig 1). No significant differences were noted for all stroke (p=0.058), minor stroke (p=0.32), TIA (p=0.49), AKI (p=0.17), major vascular complications (p=0.40) and major bleeding complications (p=0.11). There was significant heterogeneity across the studies for mortality (p=0.032) and all stroke (p=0.009). In the subgroup analysis of studies reporting ≤7 days outcomes (n=5), EPDs showed significantly lower rates of all stroke (0.33 [95% CI 0.19-0.56], p=<0.0001), major stroke (0.19 [0.08-0.48], p=0.0004) and major bleeding complications (OR 0.29 [0.10-0.79], p=0.016), but no significant differences for mortality (p=0.67) and minor stroke (p=0.070). There was no significant heterogeneity across the studies (all p>0.05) Conclusions In this meta-analysis including non-randomised studies, the use of EPDs was associated with lower mortality and major stroke rates, although significant heterogeneity was noted for the studies reporting mortality. Further ongoing larger scale RCTs will further clarify these results.

AIUM Official Statement: Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers and Equipment Between Patients as Well as Safe Handling and Use of Ultrasound Coupling Gel.

AIUM Official Statement: Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers and Equipment Between Patients as Well as Safe Handling and Use of Ultrasound Coupling Gel.

Trial for scheme design of machine considering inherently safe design measure

It is shown that only inherently safe design measure, which is defined in ISO 12100 as protective measure which either eliminates hazards or reduces the risks associated with hazards by changing the design or operating characteristics of the machine without the use of guards or protective devices, can eliminate hazards or reduce the severity of risks. However, mechanical designers actually apt to use safe guards and other measures because they do not have concrete design methods to apply them. In the consequence the machine does not have adequate inherently safe design measures. This paper proposes the process of scheme design for newly designed machinery to adhere adequate inherently safe design measures and other safe measures. Scheme design process consists of four stages, required specification definition, function definition, component and mechanism choice and structure design. These four stages are in order of consideration. The 14 items of inherently safe design measures those are classified according to their contents are shown in ISO12100. And each of them is suitably assigned to each stage of design process according to its content. Each stage study is narrowed down and clarified by this assignment. This process is proceeded in the matrix table to get adequate and less omission design by comparing and evaluating various ideas that can be thought of. By this proposal, front loading design process is implemented and the machinery design will obtain adequate inherently safe design measures and other safety methods.

Real world single center experience with saphenous vein grafts interventions: should filters be filtered out?

Percutaneous coronary intervention (PCI) of saphenous vein grafts (SVG) can be challenging due to no reflow phenomenon from distal embolization of debris and microvascular vasoconstriction, resulting in myocardial injury post-procedure. Guidelines promote the use of distal embolic protection devices (EPD) to protect the distal arterial bed during SVG PCI. However, this approach has shown less-than-optimal results in many studies. We report our data using the Borgess protocol [prophylactic intracoronary (IC) nicardipine injection and direct stenting], as an alternative to EPDs in a large series of SVG interventions. This is a retrospective, cohort study of our single center experience with SVG interventions between 2017 and 2021. The primary outcome of the study was major adverse cardiovascular events (MACE) [a composite of death, emergent coronary artery bypass graft surgery (CABG), myocardial infarction (MI), and target vessel revascularization (TVR)] at 30 days post-procedure. There were 424 consecutive SVG interventions performed during the study period, and 76% of cases presented with acute coronary syndrome. Full adherence to the Borgess protocol was observed in 36% of cases; IC nicardipine was utilized in 72% of cases. MACE rate was 3.5% at 30 days driven primarily by MI (2.6%). The Borgess protocol approach to vein graft interventions proved good outcomes when compared to SVG PCI in randomized trials utilizing EPDs. Our study is limited by the retrospective nature and single center experience.

From surgical clamping to endovascular flow arrest/reversal: the concept behind the system.

Carotid artery lesions are frequently composed of friable, thrombotic, ulcerated and/or hemorrhagic materials which can embolize during surgical or endovascular interventions. The use of embolic protection devices (EPD) during carotid angioplasty and stenting (CAS) has been proven to be associated with a reduction of the embolic load. Many studies indicate that the clinical results of CAS are comparable with the best surgical series, when EPD are routinely applied. The proximal EPD work by interrupting or reversing the blood flow in the common carotid artery/internal carotid artery (CCA/ICA). Once established the endovascular flow arrest/reversal, these systems have the advantages of promoting a protected crossing of the lesion and blocking both macro-emboli and micro-emboli. Moreover, proximal neuroprotection implies no manipulation of the device in the distal ICA, neither during device deployment nor during device retrieval, and reduces the risk of arterial spasm, dissection, or intimal damage. The choice between transfemoral and transcervical proximal EPD should account for different factors: local availability, operator expertise, and patient characteristics including anatomical features precluding flow arrest/reversal (e.g., incomplete circle of Willis), femoral access (e.g., unfavorable aortic arch anatomy), or transcervical access (e.g., diseased CCA).

Epidemiology and Predictors of Visual Outcome in Patients with Occupational Eye InjuriesA Prospective Observational Study

Introduction: Work Related Eye Injuries (WREI) constitute majority of eye injuries affecting younger age group. Trauma mainly affects people from lower socioeconomic background. People having workplace related eye injuries have an added financial burden. Challenges with respect to workplace related eye injuries include lack of occupational safety and health cover, lack of related information about pattern and exact incidence and management protocols. Aim: To study epidemiological profile, risk factors and predictors of visual outcome in occupational eye injury patients. Materials and Methods: This prospective observational/cohort study was conducted in Department of Ophthalmology, at Rajiv Gandhi Medical college and CSM Hospital, Kalva, Thane between October 2020 to February 2022. Study population included 42 patients having occupational eye injuries. After obtaining written informed consent, detailed history regarding their occupation, mode of injury and awareness and history of use of any Protective Eye Device (PED) at the time of injury was noted. Best Corrected Visual Acuity (BCVA), detailed anterior segment examination and fundus examination was done. Ocular injury was classified as Open Globe Injury (OGI) or Closed Globe Injury (CGI) and ocular trauma scale was calculated. Patients were treated medically or surgically as indicated and followedup next day and subsequently BCVA was noted and progress at each follow-up till six months was recorded. Factors related to good visual outcome (better or equal to 6/24) and bad visual outcome (visual acuity worse than 6/24) were identified. Continuous variables were described as the mean and variation of each observation from the mean value (Standard deviation) represented as mean±SD (analysed using independent t-test). Univariate analysis was done for identifying factors associated with bad visual outcome and p-value of <0.05 was considered significant. Results: Forty-two patients were included in study (40 males and 2 females). There were 21 patients each in OGI and CGI. Most commonly affected were construction workers- 15 (35.72%). A total of 45% workers had access to PED at workplace but none of them used them. Univariate analysis showed open-globe injury, Zone-1 injury, presence of iris prolapse, traumatic cataract, vitreous prolapse/RD were related to bad visual outcome (<6/24). At six months, the median logMAR BCVA improved significantly from logMAR 0.8 to 0.18 (0-1.3) (p=0.0002). Conclusion: Occupational ocular trauma is commonly seen in younger males. Poorer visual outcomes are associated with OGI and Zone-1 injuries, presence of iris prolapse, traumatic cataract, vitreous prolapse/retinal detachment. Lack of use of protective eye gear was universally noted along with its unavailability in many places. Conducting regular educational programs on ocular safety at workplaces, sensitising the workers and their employees regarding the hazards of ocular trauma and strict implementation of mandatory use of eye protective devices is recommended.

Некоторые аспекты проблемы защиты птиц от поражения электрическим током на воздушных линиях электропередачи в Казахстане

Некоторые аспекты проблемы защиты птиц от поражения электрическим током на воздушных линиях электропередачи в Казахстане

Проблема гибели птиц на ЛЭП и прогресс её решения в бассейне Средней Волги

Проблема гибели птиц на ЛЭП и прогресс её решения в бассейне Средней Волги

76 INSIDE VEIN GRAFT FAILURE: A WORK FOR OCT

Abstract An 84-years-old woman with prior history of triple coronary artery bypass graft and subsequent percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) for right coronary artery (RCA) was admitted for non-ST-elevation myocardial infarction and newly diagnosed atrial fibrillation. Coronary angiography showed chronic occlusion of native vessels and good flow in all grafts, in absence of critical stenoses. However, SVG for RCA presented a small filling defect of non-univocal interpretation (atherothrombosis, thromboembolus, venous valve). Optical coherence tomography (OCT) was performed for better assessment of the lesion, which was found to be a red thrombus, overlying a ruptured thin-cap fibroatheroma. To reduce the risk of distal embolization, a well-known complication of SVG PCI, direct stenting with conservative stent sizing was performed: everolimus-eluting stent diameter (3,5 mm) was chosen according to mean reference lumen diameter, while length (18 mm) was determined to obtain complete plaque coverage. Repeated OCT showed proximal stent malapposition and underexpansion at the mid portion. The stent was post-dilated with 4,0×12 mm non-compliant balloon and final OCT showed correction of both malapposition and underexpansion. The presented case offers an example of the advantages of intravascular imaging in diagnosis and treatment of SVG lesions. Venous grafts have high failure rate: up to 12% of graft are occluded before hospital discharge and up to 60% after 10 years. While in the first year graft occlusion is mainly caused by neointimal hyperplasia, after this period neoatherosclerosis is the leading cause of failure, as exemplified in the case. Intravascular imaging, and particularly OCT, may help to elucidate graft failure mechanism, with important implications for treatment strategy. Moreover, SVG interventions have higher incidence procedural complications, particularly no-reflow and periprocedural myocardial infarction, due to high plaque burden and friable atheromatous material. Proposed strategies to mitigate procedural risk include use of embolic protection devices, direct stenting and use of undersized stents. In this complex setting, intravascular imaging can guide stent sizing and optimization, thus reducing procedural complications and long-term lesion failure.

692 THE USE OF ULTRASOUND ENHANCING AGENTS (UEA) IN THE EVALUATION OF LEFT ATRIAL APPENDAGE (LAA) THROMBUS IN PATIENT CANDIDATE TO PERCUTANEOUS LAA CLOSURE

Abstract Introduction Left atrial appendage closure (LAAC) is an emerging option in patients with atrial fibrillation (AF) and contraindication for oral anticoagulation (OAC) therapy. Patients with left atrial thrombus are usually excluded from this strategy. Therefore, pre-procedural transesophageal echocardiography (TEE) is usually performed for LAA thrombus exclusion. The application of second-generation lipid microspheres ultrasound enhancing agents (UEA) is of growing interest. The following clinical cases reports describe the benefit from UEA implication on subsequent decision-making regarding with LAAC procedure. Case report num.1 an 88-year-old male with history of symptomatic AF and post – traumatic cerebral bleeding was referred to LAAC because of high risk of bleeding in using OAC. Transthoracic echocardiography (TTE) documented a severely dilatated left atrium and preserved left ventricular systolic function. Pre – operative TEE revealed a “chicken wing” shaped LAA with severe spontaneous echo-contrast and sludge effect. Echo-contrast medium “SonoVue” showed an early filling defect with late but complete LAA opacification, excluding thrombus. Of note, ECG-gated cardiac CT (CCT) could not exclude filling defect with certainty. Consecutively, the patient was candidate to LAAC in a short time. Case report num.2 a 75-year-old man with valvular permanent AF and multi-territory ischemic ictus despite being on adequate prophylactic OAC (Warfarin). At TTE a dilated left ventricle with mildly reduced ejection fraction was documented. ECG – gated CCT with delayed phases imaging showed a possible filling defect in LAA, however imaging was suboptimal due to a reverb of voluminous hiatal hernia. TEE revealed a “windstock” shaped LAA with incomplete distal opacification when echo-contrast medium “SonoVue” was used, confirming thrombus. The patient was therefore referred for LAAC procedure with concomitant use of cerebral embolic protection devices (CEPDs). Discussion Transesophageal echocardiography is the test of choice for the exclusion of LAA thrombus. However technical difficulty, spontaneous echo contrast (SEC) and prominent pectinate musculature within the appendage may make the exclusion of LAA thrombus not easy. ECG – gated cardiac CT may be conclusive as well. UEA use is associated with higher diagnostic power for LAA thrombus exclusion and recent study have shown its utility also in terms of LAA sizing. Thus, the most recent guidelines of American Society of Echocardiography mention echo contrast use for the delineation of LAA thrombi and differentiate between them with SEC. Conclusion The use of ultrasound enhancing agents is useful and increases the interpretative confidence in exclusion of LAA thrombus.