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Scagliola R, Caponi D, Scaglione M. Atrial septal pouches and ridges: Morphological features and potential implications in clinical practice. Trends Cardiovasc Med 2023:S1050-1738(23)00115-9. [PMID: 38158028 DOI: 10.1016/j.tcm.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/22/2023] [Accepted: 12/23/2023] [Indexed: 01/03/2024]
Abstract
Incomplete or irregular fusion of the interatrial septum may result in several anatomic variants, including atrial septal pouches and ridges, whose knowledge and recognition are still poorly widespread in clinical practice. An educational review focused on the definition, clinical significance and diagnostic work-up of these anatomic findings was performed using PubMed, MEDLINE, Embase and Cochrane Central databases up to June 2023. Atrial septal pouches and ridges have been associated with an increased difficulty of catheter-based interventions requiring a transseptal approach, due to procedural challenges for transseptal puncture and the restricted motion of guidewires and catheters through the transseptal access. Additionally, left atrial septal pouch may serve as a thrombogenic nidus and a source of systemic embolism, mostly in the presence of factors leading to higher left atrial pressure and/or atrial blood stasis, which increase the risk of thrombus formation and embolic events, rather than for the only presence of left atrial septal pouch itself. Further investigations are needed in order to better elucidate the implications of such anatomic findings in daily clinical practice, and to provide the most appropriate decision-making strategies.
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Affiliation(s)
- Riccardo Scagliola
- Division of Cardiology, Cardinal G. Massaia Hospital, C.so Dante Alighieri n. 202 - 14100, Asti, Italy.
| | - Domenico Caponi
- Division of Cardiology, Cardinal G. Massaia Hospital, C.so Dante Alighieri n. 202 - 14100, Asti, Italy
| | - Marco Scaglione
- Division of Cardiology, Cardinal G. Massaia Hospital, C.so Dante Alighieri n. 202 - 14100, Asti, Italy
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Hertel JN, Jerltorp K, Hansen MEH, Isaksen JL, Sattler SM, Linz B, Chaldoupi SM, Jespersen T, Saljic A, Gang U, Manninger M, Linz D. 3D-electroanatomical mapping of the left atrium and catheter-based pulmonary vein isolation in pigs: A practical guide. Front Cardiovasc Med 2023; 10:1139364. [PMID: 36970354 PMCID: PMC10033609 DOI: 10.3389/fcvm.2023.1139364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 02/14/2023] [Indexed: 03/29/2023] Open
Abstract
Aim To propose a standardized workflow for 3D-electroanatomical mapping guided pulmonary vein isolation in pigs. Materials and methods Danish female landrace pigs were anaesthetized. Ultrasound-guided puncture of both femoral veins was performed and arterial access for blood pressure measurement established. Fluoroscopy- and intracardiac ultrasound-guided passage of the patent foramen ovale or transseptal puncture was performed. Then, 3D-electroanatomical mapping of the left atrium was conducted using a high-density mapping catheter. After mapping all pulmonary veins, an irrigated radiofrequency ablation catheter was used to perform ostial ablation to achieve electrical pulmonary vein isolation. Entrance- and exit-block were confirmed and re-assessed after a 20-min waiting period. Lastly, animals were sacrificed to perform left atrial anatomical gross examination. Results We present data from 11 consecutive pigs undergoing pulmonary vein isolation. Passage of the fossa ovalis or transseptal puncture was uneventful and successful in all animals. Within the inferior pulmonary trunk 2-4 individual veins as well as 1-2 additional left and right pulmonary veins could be cannulated. Electrical isolation by point-by-point ablation of all targeted veins was successful. However, pitfalls including phrenic nerve capture during ablation, ventricular arrhythmias during antral isolation close to the mitral valve annulus and difficulties in accessing right pulmonary veins were encountered. Conclusion Fluoroscopy- and intracardiac ultrasound-guided transseptal puncture, high-density electroanatomical mapping of all pulmonary veins and complete electrical pulmonary vein isolation can be achieved reproducibly and safely in pigs when using current technologies and a step-by-step approach.
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Affiliation(s)
- Julie Norup Hertel
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kezia Jerltorp
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Malthe Emil Høtbjerg Hansen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonas L. Isaksen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Stefan Michael Sattler
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark
| | - Benedikt Linz
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Emergency Department, Frederiksberg and Bispebjerg Hospital, Copenhagen, Denmark
| | - Sevasti-Maria Chaldoupi
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, Netherlands
| | - Thomas Jespersen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Arnela Saljic
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- West German Heart and Vascular Center, Institute of Pharmacology, University Duisburg-Essen, Essen, Germany
| | - Uffe Gang
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark
| | - Martin Manninger
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, Netherlands
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Dominik Linz
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, Netherlands
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark
- Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
- *Correspondence: Dominik Linz,
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Ruemmler R, Stein J, Duenges B, Renz M, Hartmann EK. Standardized post-resuscitation damage assessment of two mechanical chest compression devices: a prospective randomized large animal trial. Scand J Trauma Resusc Emerg Med 2021; 29:79. [PMID: 34090500 PMCID: PMC8179713 DOI: 10.1186/s13049-021-00892-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 05/18/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Mechanical chest compression devices are accepted alternatives for cardiopulmonary resuscitation (CPR) under specific circumstances. Current devices lack prospective and comparative data on their specific cardiovascular effects and potential for severe thoracic injuries. OBJECTIVES To compare CPR effectiveness and thoracic injuries of two mechanical chest compression devices in pigs. STUDY DESIGN Prospective randomised trial. ANIMALS Eighteen male German landrace pigs. METHODS Ventricular fibrillation was induced in anaesthetised and instrumented pigs and the animals were randomised into two intervention groups. Mechanical CPR was initiated by means of LUCAS™ 2 (mCCD1) or Corpuls™ cpr (mCCD2) device. Advanced life support was applied for a maximum of 10 cycles and animals achieving ROSC were monitored for 8 h. Ventilation/perfusion measurements were performed and blood gas analyses were taken. Thoracic injuries were assessed via a standardised damage score. RESULTS Five animals of the mCCD1 group and one animal of the mCCD2 group achieved ROSC (p = 0.048). Only the mCCD1 animals survived until the end of the monitoring period (p < 0.01). MCCD1 animals showed less pulmonary shunt (p = 0.025) and higher normal V/Q (p = 0.017) during CPR. MCCD2 animals showed significantly more severe thoracic injuries (p = 0.046). CONCLUSION The LUCAS 2 device shows superior resuscitation outcomes and less thoracic injuries compared to Corpuls cpr when used for experimental CPR in juvenile pigs. Researchers should be aware that different mCCDs for experimental studies may significantly influence the respective outcome of resuscitation studies and affect comparability of different trials. Controlled human and animal CPR studies and a standardised post-resuscitation injury evaluation could help to confirm potential hazards. TRIAL REGISTRATION Trial approval number: G16-1-042-E4.
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Affiliation(s)
- Robert Ruemmler
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - Jakob Stein
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Bastian Duenges
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Miriam Renz
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Erik Kristoffer Hartmann
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
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Ruemmler R, Ziebart A, Kuropka F, Duenges B, Kamuf J, Garcia-Bardon A, Hartmann EK. Bi-Level ventilation decreases pulmonary shunt and modulates neuroinflammation in a cardiopulmonary resuscitation model. PeerJ 2020; 8:e9072. [PMID: 32377456 PMCID: PMC7195831 DOI: 10.7717/peerj.9072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/06/2020] [Indexed: 11/23/2022] Open
Abstract
Background Optimal ventilation strategies during cardiopulmonary resuscitation are still heavily debated and poorly understood. So far, no convincing evidence could be presented in favour of outcome relevance and necessity of specific ventilation patterns. In recent years, alternative models to the guideline-based intermittent positive pressure ventilation (IPPV) have been proposed. In this randomized controlled trial, we evaluated a bi-level ventilation approach in a porcine model to assess possible physiological advantages for the pulmonary system as well as resulting changes in neuroinflammation compared to standard measures. Methods Sixteen male German landrace pigs were anesthetized and instrumented with arterial and venous catheters. Ventricular fibrillation was induced and the animals were left untreated and without ventilation for 4 minutes. After randomization, the animals were assigned to either the guideline-based group (IPPV, tidal volume 8–10 ml/kg, respiratory rate 10/min, FiO21.0) or the bi-level group (inspiratory pressure levels 15–17 cmH2O/5cmH2O, respiratory rate 10/min, FiO21.0). Mechanical chest compressions and interventional ventilation were initiated and after 5 minutes, blood samples, including ventilation/perfusion measurements via multiple inert gas elimination technique, were taken. After 8 minutes, advanced life support including adrenaline administration and defibrillations were started for up to 4 cycles. Animals achieving ROSC were monitored for 6 hours and lungs and brain tissue were harvested for further analyses. Results Five of the IPPV and four of the bi-level animals achieved ROSC. While there were no significant differences in gas exchange or hemodynamic values, bi-level treated animals showed less pulmonary shunt directly after ROSC and a tendency to lower inspiratory pressures during CPR. Additionally, cytokine expression of tumour necrosis factor alpha was significantly reduced in hippocampal tissue compared to IPPV animals. Conclusion Bi-level ventilation with a constant positive end expiratory pressure and pressure-controlled ventilation is not inferior in terms of oxygenation and decarboxylation when compared to guideline-based IPPV ventilation. Additionally, bi-level ventilation showed signs for a potentially ameliorated neurological outcome as well as less pulmonary shunt following experimental resuscitation. Given the restrictions of the animal model, these advantages should be further examined.
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Affiliation(s)
- Robert Ruemmler
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Alexander Ziebart
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Frances Kuropka
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Bastian Duenges
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Jens Kamuf
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Andreas Garcia-Bardon
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Erik K Hartmann
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg University, Mainz, Germany
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Hołda MK, Pietsch-Fulbiszewska A, Trybus M, Koziej M. Morphological variations of the interatrial septum in ovine heart. PLoS One 2018; 13:e0209604. [PMID: 30566482 PMCID: PMC6300291 DOI: 10.1371/journal.pone.0209604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 12/07/2018] [Indexed: 11/18/2022] Open
Abstract
Smooth septum interatrial septum, patent foramen ovale (PFO) channel and atrial septal pouches (SPs) are commonly described variants in humans. Recent discoveries on the clinical significance of left-sided SP may encourage the creation of new strategies and devices for the management of SPs. However, these strategies may first be tested in the ovine model before implementation in humans. Unfortunately, little is known about the presence of SPs in ovine. In this study a total of 60 ovine (Ovis aries) hearts were examined. The interatrial septum morphology was assessed and the PFO channel and SPs were measured. The most commonly occurring variant were PFO channels (25.0%) with channel lengths of 5.4±2.3 mm. Smooth septums were observed in 18.3% of hearts. In the remaining cases, septums had a left septal ridge (15.0%), left SP (11.7%), left septal bridge (10.0%), right SP (10.0%), or had both a right SP and left septal ridge (10.0%). No double SPs were observed. The mean right SP depth was 3.4 ± 1.2 mm, and its mean ostium width and height were 7.9±1.8 mm and 2.8±1.0, respectively. For the left SP, the mean depth was 6.0±1.7mm, the ostium width was 7.9±2.4mm, and the ostium height was 4.1±1.6mm (range: 2.3-6.4mm). In conclusion the interatrial septum of ovine hearts exhibit morphologies that are more similar to humans than they are to swine, which should be taken into account during experimental studies. The presence of a left SP in sheep hearts make ovine models a promising alternative to the human heart for developing left-sided SP management devices and techniques.
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Affiliation(s)
- Mateusz K. Hołda
- HEART—Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
- * E-mail:
| | | | - Marek Trybus
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz Koziej
- HEART—Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
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