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Kristiansen S, Jarmund AH, Hilmo J, Mollnes TE, Leth-Olsen M, Nyrnes SA, Nilsen BA, Grønli RH, Faldaas BO, Storm B, Espenes A, Nielsen EW. Femoral Nailing in a Porcine Model Causes Bone Marrow Emboli in the Lungs and Systemic Emboli in the Heart and Brain. JB JS Open Access 2024; 9:e23.00128. [PMID: 38419616 PMCID: PMC10898662 DOI: 10.2106/jbjs.oa.23.00128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
Background Shaft fractures of the femur are commonly treated with intramedullary nailing, which can release bone marrow emboli into the bloodstream. Emboli can travel to the lungs, impairing gas exchange and causing inflammation. Occasionally, emboli traverse from the pulmonary to the systemic circulation, hindering perfusion and resulting in injuries such as heart and brain infarctions, known as fat embolism syndrome. We studied the extent of systemic bone marrow embolization in a pig model. Methods Twelve anesthetized pigs underwent bilateral intramedullary nailing of the femur, while 3 animals served as sham controls. Monitoring included transesophageal echocardiography (TEE), pulse oximetry, electrocardiography, arterial blood pressure measurement, and blood gas and troponin-I analysis. After surgery, animals were monitored for 240 minutes before euthanasia. Post mortem, the heart, lungs, and brain were biopsied. Results Bone marrow emboli were found in the heart and lungs of all 12 of the pigs that underwent intramedullary nailing and in the brains of 11 of them. No emboli were found in the sham group. The pigs subjected to intramedullary nailing exhibited significant hypoxia (PaO2/FiO2 ratio, 410 mm Hg [95% confidence interval (CI), 310 to 510) compared with the sham group (594 mm Hg [95% CI, 528 to 660]). The nailing group exhibited ST-segment alterations consistent with myocardial ischemia and a significant increase in the troponin-I level compared with the sham group (1,580 ng/L [95% CI, 0 to 3,456] versus 241 ng/L [95% CI, 0 to 625] at the 240-minute time point; p = 0.005). TEE detected emboli in the right ventricular outflow tract, but not systemically, in the nailing group. Conclusions Bilateral intramedullary nailing caused bone marrow emboli in the lungs and systemic emboli in the heart and brain in this pig model. The observed clinical manifestations were consistent with coronary and pulmonary emboli. TEE detected pulmonary but not systemic embolization. Clinical Relevance Femoral intramedullary nailing in humans is likely to result in embolization as described in our pig model. Focused monitoring is necessary for detection of fat embolism syndrome. Absence of visual emboli in the left ventricle on TEE does not exclude the occurrence of systemic bone marrow emboli.
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Affiliation(s)
- Steinar Kristiansen
- Department of Surgery, Nordland Hospital, Bodø, Norway
- Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Anders Hagen Jarmund
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jonas Hilmo
- Department of Surgery, Nordland Hospital, Bodø, Norway
- Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Tom Eirik Mollnes
- Research Laboratory, Nordland Hospital, Bodø, Norway
- Department of Immunology, Oslo University Hospital, University of Oslo, Norway
| | - Martin Leth-Olsen
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Children's Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Siri Ann Nyrnes
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Children's Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Bent Aksel Nilsen
- Department of Surgery, Nordland Hospital, Bodø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | | | - Bjørn Ove Faldaas
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | - Benjamin Storm
- Department of Surgery, Nordland Hospital, Bodø, Norway
- Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | - Arild Espenes
- Department of Basic Sciences and Aquatic Medicine, Norwegian School of Veterinary Science, Oslo, Norway
| | - Erik Waage Nielsen
- Department of Surgery, Nordland Hospital, Bodø, Norway
- Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
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Kim G, Ji Y, Jeong HG, Lee T, Lee K, Yoon H. Case report: Imaging features of aorta-right atrial tunnel in a dog using two-dimensional echocardiography and computed tomography. Front Vet Sci 2023; 10:1160390. [PMID: 37465274 PMCID: PMC10352079 DOI: 10.3389/fvets.2023.1160390] [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: 02/07/2023] [Accepted: 06/19/2023] [Indexed: 07/20/2023] Open
Abstract
A 7-year-old castrated male Pomeranian dog weighing 5 kg presented with a right-sided continuous murmur without any clinical signs. Thoracic radiographs indicated cardiomegaly and right atrial (RA) bulging. Echocardiography revealed a tunnel originating from the right coronary sinus of Valsalva and terminating in the RA. Contrast echocardiography revealed pulmonary arteriovenous anastomoses. Computed tomography (CT) demonstrated a tortuous shunting vessel that originated from the aorta extending in a ventral direction, ran along the right ventricular wall, and was inserted into the RA. Based on these diagnostic findings, the dog was diagnosed with the aorta-RA tunnel. At the 1-year follow-up visit without treatment, the dog showed no significant change except for mild left ventricular volume overload and mildly decreased contractility. To the best of our knowledge, this is the first case report of an aorta-RA tunnel that has been described in detail using echocardiography and CT in a dog. In conclusion, the aorta-RA tunnel should be included in the clinical differential diagnoses if a right-sided continuous murmur is heard or shunt flow originating from the aortic root is identified.
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Affiliation(s)
- Geunha Kim
- Department of Veterinary Medical Imaging, College of Veterinary Medicine, Jeonbuk National University, Iksan-si, Republic of Korea
| | - Yewon Ji
- Department of Veterinary Medical Imaging, College of Veterinary Medicine, Jeonbuk National University, Iksan-si, Republic of Korea
| | | | - Taekwon Lee
- Animal Medical Center, Jeonju, Republic of Korea
| | - Kichang Lee
- Department of Veterinary Medical Imaging, College of Veterinary Medicine, Jeonbuk National University, Iksan-si, Republic of Korea
| | - Hakyoung Yoon
- Department of Veterinary Medical Imaging, College of Veterinary Medicine, Jeonbuk National University, Iksan-si, Republic of Korea
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González-Ruiz FJ, Lazcano-Díaz EA, Baeza Herrera LA, Villalobos-Pedroza M, Toledo Alemán EL, Zuñiga-Salcedo MG, Cruz-Rodríguez C, López-Polanco A, Torres-Pulido A, Sierra-González de Cossio A, Cota Apodaca LA, Manzur-Sandoval D. Endotheliitis, Shunts, and Ventilation–Perfusion Mismatch in Coronavirus Disease 2019: A Literature Review of Disease Mechanisms. Ann Med Surg (Lond) 2022; 78:103820. [PMID: 35600188 PMCID: PMC9112604 DOI: 10.1016/j.amsu.2022.103820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/14/2022] [Accepted: 05/15/2022] [Indexed: 10/27/2022] Open
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Hou H, Guo C, Que C, Nie L, Zhang Q, Zhao H, Nong L, Ma W, Wang Q, Liang Z, Wang B, Ma J, Wang G. Diffuse large B-cell lymphoma presenting as reversible intrapulmonary arteriovenous shunts with hypoxia, fever and progressive jaundice: a case report and literature review. BMC Pulm Med 2022; 22:89. [PMID: 35292006 PMCID: PMC8922084 DOI: 10.1186/s12890-022-01881-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 03/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background Intrapulmonary arteriovenous shunts is rare seen in a patient without lung involvement. Case presentation This is the first report of reversible intrapulmonary arteriovenous shunts secondary to extrapulmonary lymphoma as one initial symptom. The patient presented as fever of unknown origin and dyspnea, and examinations of infection were negative. Diagnosis of DLBCL was finally confirmed through bone marrow and splenic biopsies. Intrapulmonary arteriovenous shunts were diagnosed through 100% oxygen inhalation test and transthoracic contrast echocardiography (TTCE). After the treatment of lymphoma, his respiratory failure was relieved. We rechecked the 100% oxygen inhalation test and TTCE, which both indicated that his intrapulmonary arteriovenous shunts had resolved. Conclusions We speculated the prominent inflammation from active DLBCL was the most possible mechanism associated with the reversible intrapulmonary shunt in this patient. These findings will assist us to better understand the mechanism of intrapulmonary shunts.
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Affiliation(s)
- Huan Hou
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Cuiyan Guo
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Chengli Que
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Ligong Nie
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Qi Zhang
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Hong Zhao
- Department of Infectious Diseases, Center for Liver Disease, Peking University First Hospital, Beijing, China
| | - Lin Nong
- Department of Pathology, Peking University First Hospital, Beijing, China
| | - Wei Ma
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Qian Wang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Zeyin Liang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Bingjie Wang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Jing Ma
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China.
| | - Guangfa Wang
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
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Kristiansen S, Storm B, Dahle D, Domaas Josefsen T, Dybwik K, Nilsen BA, Waage-Nielsen E. Intraosseous fluid resuscitation causes systemic fat emboli in a porcine hemorrhagic shock model. Scand J Trauma Resusc Emerg Med 2021; 29:172. [PMID: 34930433 PMCID: PMC8686379 DOI: 10.1186/s13049-021-00986-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Intraosseous cannulation can be life-saving when intravenous access cannot be readily achieved. However, it has been shown that the procedure may cause fat emboli to the lungs and brain. Fat embolization may cause serious respiratory failure and fat embolism syndrome. We investigated whether intraosseous fluid resuscitation in pigs in hemorrhagic shock caused pulmonary or systemic embolization to the heart, brain, or kidneys and if this was enhanced by open chest conditions. METHODS We induced hemorrhagic shock in anesthetized pigs followed by fluid-resuscitation through bilaterally placed tibial (hind leg) intraosseous cannulas. The fluid-resuscitation was limited to intraosseous or i.v. fluid therapy, and did not involve cardiopulmonary resuscitation or other interventions. A subgroup underwent median sternotomy with pericardiectomy and pleurotomy before hemorrhagic shock was induced. We used invasive hemodynamic and respiratory monitoring including Swan Ganz pulmonary artery catheter and transesophageal echocardiography and obtained biopsies from the lungs, heart, brain, and left kidney postmortem. RESULTS All pigs exposed to intraosseous infusion had pulmonary fat emboli in postmortem biopsies. Additionally, seven of twenty-one pigs had coronary fat emboli. None of the pigs with open chest had fat emboli in postmortem lung, heart, or kidney biopsies. During intraosseous fluid-resuscitation, three pigs developed significant ST-elevations on ECG; all of these animals had coronary fat emboli on postmortem biopsies. CONCLUSIONS Systemic fat embolism occurred in the form of coronary fat emboli in a third of the animals who underwent intraosseous fluid resuscitation. Open chest conditions did not increase the incidence of systemic fat embolization.
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Affiliation(s)
- Steinar Kristiansen
- Surgery and Intensive Care Unit, University Hospital of Northern Norway, Tromsø, Norway.
- Department of Surgery, Nordland Hospital Trust, Bodø, Norway.
- Department of Clinical Medicine, Faculty of Health Sciences, Arctic University of Norway, Tromsø, Norway.
| | - Benjamin Storm
- Department of Surgery, Nordland Hospital Trust, Bodø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, Arctic University of Norway, Tromsø, Norway
- Research Laboratory, Nordland Hospital Trust, Bodø, Norway
| | - Dalia Dahle
- Faculty of Biosciences and Aquaculture, Nord University, Bodø, Norway
| | | | - Knut Dybwik
- Department of Surgery, Nordland Hospital Trust, Bodø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | | | - Erik Waage-Nielsen
- Department of Surgery, Nordland Hospital Trust, Bodø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, Arctic University of Norway, Tromsø, Norway
- Research Laboratory, Nordland Hospital Trust, Bodø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
- Department of Immunology, Oslo University Hospital, University of Oslo, Oslo, Norway
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Galambos C, Bush D, Abman SH. Intrapulmonary bronchopulmonary anastomoses in COVID-19 respiratory failure. Eur Respir J 2021; 58:13993003.04397-2020. [PMID: 33863743 PMCID: PMC8051184 DOI: 10.1183/13993003.04397-2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 04/05/2021] [Indexed: 11/22/2022]
Abstract
The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to a devastating and worldwide pandemic disease known as coronavirus disease 2019 (COVID-19). COVID-19 causes acute hypoxic respiratory failure (COVID-ARF), a major cause of mortality and morbidity, with an incompletely understood pathophysiological mechanism. Gattinoniet al. [1] noted that COVID-19 patients with acute hypoxic respiratory failure have lung disease that is often characterised by a remarkable dissociation between relatively well-preserved lung mechanics, including lung compliance, and severe hypoxaemia. These findings are consistent with the concept that profound hypoxaemia occurring in ventilated patients with highly compliant lungs could be due to the loss of regulation of lung perfusion and impaired hypoxic pulmonary vasoconstriction. Early autopsy studies suggest that the lung circulation is a major target of coronavirus infection, which leads to striking pulmonary vascular disease due to variable degrees of thrombosis, apoptosis, oedema, inflammation and angiogenesis [2–4]. These changes contribute to dysregulation of the pulmonary vasculature, which induces perfusion abnormalities and contributes to the physiological phenotypes reported in COVID-19 pneumonia. Further, computed tomography suggests a unique “tree in bud” appearance of small pulmonary arteries [3] and transcranial agitated saline microbubble doppler studies of COVID-19 patients with hypoxaemia have demonstrated intrapulmonary shunting of these bubbles, and that the presence and degree of transpulmonary bubble transit correlates with the degree of hypoxaemia [5]. Despite these studies, histopathological correlates of severe hypoxaemia and shunt in the setting of relatively normal lung compliance in COVID-19 patients are largely lacking. Open intrapulmonary bronchopulmonary anastomoses (IBA) were identified in COVID-19 patients who died of respiratory failure. IBA may be the microanatomical basis of intrapulmonary right to left shunt leading to severe hypoxaemia in COVID-19.https://bit.ly/3e2GajO
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Affiliation(s)
- Csaba Galambos
- Pediatric Heart Lung Center, Aurora, CO, USA .,Children's Hospital Colorado, Aurora, CO, USA.,University of Colorado Anschutz School of Medicine, Aurora, CO, USA
| | - Douglas Bush
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven H Abman
- Pediatric Heart Lung Center, Aurora, CO, USA.,Children's Hospital Colorado, Aurora, CO, USA.,University of Colorado Anschutz School of Medicine, Aurora, CO, USA
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Clark AR, Burrowes KS, Tawhai MH. Integrative Computational Models of Lung Structure-Function Interactions. Compr Physiol 2021; 11:1501-1530. [PMID: 33577123 DOI: 10.1002/cphy.c200011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Anatomically based integrative models of the lung and their interaction with other key components of the respiratory system provide unique capabilities for investigating both normal and abnormal lung function. There is substantial regional variability in both structure and function within the normal lung, yet it remains capable of relatively efficient gas exchange by providing close matching of air delivery (ventilation) and blood delivery (perfusion) to regions of gas exchange tissue from the scale of the whole organ to the smallest continuous gas exchange units. This is despite remarkably different mechanisms of air and blood delivery, different fluid properties, and unique scale-dependent anatomical structures through which the blood and air are transported. This inherent heterogeneity can be exacerbated in the presence of disease or when the body is under stress. Current computational power and data availability allow for the construction of sophisticated data-driven integrative models that can mimic respiratory system structure, function, and response to intervention. Computational models do not have the same technical and ethical issues that can limit experimental studies and biomedical imaging, and if they are solidly grounded in physiology and physics they facilitate investigation of the underlying interaction between mechanisms that determine respiratory function and dysfunction, and to estimate otherwise difficult-to-access measures. © 2021 American Physiological Society. Compr Physiol 11:1501-1530, 2021.
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Affiliation(s)
- Alys R Clark
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Kelly S Burrowes
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Merryn H Tawhai
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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The Value of Contrast-Enhanced Transesophageal Echocardiography in the Detection of Cardiac Right-to-Left Shunt Related with Cryptogenic Stroke and Migraine. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8845652. [PMID: 33415164 PMCID: PMC7752281 DOI: 10.1155/2020/8845652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/26/2020] [Accepted: 11/28/2020] [Indexed: 12/17/2022]
Abstract
Purpose To analyze the characteristics of right-to-left shunt (RLS) in patients with cryptogenic stroke and migraine by contrast-enhanced transesophageal echocardiography (c-TEE). Methods The study population consisted of 330 patients with cryptogenic stroke and 330 patients with migraine who suspected PFO. All of them received c-TEE examination successfully. In terms of c-TEE analyses, RLS could be diagnosed when microbubbles were visualized in the transition from the right atrium to the left atrium. For semiquantitative analysis, a small amount of RLS was grade 1, indicating 1-10 microvesicles per frame could be seen in the left atrium, a moderate amount of RLS was grade 2, indicating 11-30 microvesicles per frame could be seen in the left atrium, and a large amount of RLS was grade 3, indicating more than 30 microvesicles per frame, or the left atrium is filled with microvesicles. Results A total of 660 patients were analyzed in the study. PFO-RLS was detected in 348 (348/660, 52.7%) cases by TEE, while in 392 (392/660, 59.3%) cases by c-TEE. Simultaneously, P-RLS was detected in 239 (239/660, 36.2%) cases by c-TEE. Among 330 patients with cryptogenic stroke, PFO-RLS was detected in 198 cases; according to the c-TTE method (198/330, 60.0%), concurrently, 83 participants suffered from PFO-RLS and P-RSL (83/330, 25.1%), including 1 case with PFO and pulmonary arteriovenous fistula. Among 330 patients with migraine, PFO-RLS was detected in 194 cases; according to the c-TTE method (194/330, 58.7%), specifically, 90 participants suffered from PFO-RLS and P-RSL (90/330, 27.2%). There was no statistical significance between the two groups. P-RLS singly was detected in 28 cases with cryptogenic stroke, while in 38 cases with migraine, excluding from pulmonary arteriovenous fistula by CTA examination. In addition, semiquantitative results on c-TTE grading of RLS were compared between the two groups: grade 1 RLS in the migraine group (144/322) was significantly higher than that in the cryptogenic stroke group (71/309) (P < 0.05). Grade 3 RLS in the cryptogenic stroke group (113/309) was significantly higher than that in the migraine group (67/322) (P < 0.05). For grade 2 RLS, there was no statistical difference between the two groups (P = 0.12). Conclusions c-TEE can increase the positive rate of PFO diagnosis compared with TEE color Doppler. There is no significant difference in the incidence of PFO-PLS and P-RLS between the cryptogenic stroke group and the migraine group. The grades 2-3 RLS are mainly detected in the cryptogenic stroke group, while grades 1-2 RLS are mostly detected in the migraine group.
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Abstract
The pulmonary circulation carries deoxygenated blood from the systemic veins through the pulmonary arteries to be oxygenated in the capillaries that line the walls of the pulmonary alveoli. The pulmonary circulation carries the cardiac output with a relatively low driving pressure, and so differs considerably in structure and function from the systemic circulation to maintain a low-resistance vascular system. The pulmonary circulation is often considered to be a quasi-static system in both experimental and computational studies of pulmonary perfusion and its matching to ventilation (air flow) for exchange. However, the system is highly dynamic, with cardiac output and regional perfusion changing with posture, exercise, and over time. Here we review this dynamic system, with a focus on understanding the physiology of pulmonary vascular dynamics across spatial and temporal scales, and the changes to these dynamics that are reflective of disease. © 2019 American Physiological Society. Compr Physiol 9:1081-1100, 2019.
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Affiliation(s)
- Alys Clark
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Merryn Tawhai
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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Matsuda K, Fissell R, Ash S, Stegmayr B. Long-Term Survival for Hemodialysis Patients Differ in Japan Versus Europe and the USA. What Might the Reasons Be? Artif Organs 2018; 42:1112-1118. [PMID: 30417399 DOI: 10.1111/aor.13363] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 09/25/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Kenichi Matsuda
- Department of Emergency and Critical Care Medicine, University of Yamanashi School of Medicine, Yamanashi, Japan
| | - Rachel Fissell
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephen Ash
- HemoCleanse Technologies, LLC and Ash Access Technology, Inc, Lafayette, IN, USA
| | - Bernd Stegmayr
- Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden
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Feng C, Luo T, Luo Y, Zhao N, Huang K, Xiao C. Contrast-enhanced transthoracic echocardiography applied in evaluation of pulmonary right-to-left shunt: A preliminary study. Comput Med Imaging Graph 2018; 68:55-60. [PMID: 30056290 DOI: 10.1016/j.compmedimag.2018.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/13/2018] [Accepted: 04/23/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To investigate the detection rate of patent foramen ovale-right to left shunt (PFO-RLS) and/or pulmonary-right to left shunt (P-RLS) via contrast-enhanced transthoracic echocardiography (c-TTE) in healthy participants, patients suffering from cryptogenic stroke and migraine with aura. METHODS Initially, 20 healthy volunteers, 21 cases with cryptogenic stroke, and 18 cases with migraine aura were randomly selected, and all of them received c-TTE and transesophageal echocardiography (TEE) examinations. First of all, 0.9% sodium chloride solution was rapidly injected into upper extremiry vein, when these volunteers and patients were at rest or following a Valsalva maneuver with 40 mm Hg pressure exerted against a manometer. Secondly, c-TTE detection was carried out in order to distinguish PFO-RLS and P-RLS and make semi-quantitative classification of RLS from many different sources, according to the occurrence and duration time of microvesicles in left atrial after the developing of left atrium. In terms of c-TTE analyses, RLS could be diagnosed when micro bubbles were visualized in transition from the right atrium to the left atrium. Particularly, a small amounts of RLS was 1 level, indicating 1-10 microvesicles per frame could be seen in left atrium, moderate amounts of RLS was 2 level, indicating 11-30 microvesicles per frame could be seen in left atrium, and a large amounts of RLS was 3 level, indicating more than 30 microvesicles per frame, or the left atrium is filled with micro vesicles. RESULTS A total of 20 healthy adult volunteers were identified into this research. RLS was detected in 7 cases, according to c-TTE method (7/20, 35%). In detail, 3 participants suffered from PFO-RLS and P-RSL (3/20, 15%) simultaneously, 5 cases suffered from PFO-RLS (5/20, 25%), and 5 cases suffered from P-RLS (5/20, 25%). Among 21 patients with cryptogenic stroke, RLS was detected in 14 cases, according to cTTE method (14/20, 67%), and then compared with healthy participants group, the difference between them was significant (χ2 = 4.11, P = 0.04). Specifically, 2 participants suffered from PFO-RLS and P-RSL (2/21, 9.5%), 11 cases suffered from PFO-RLS (11/21, 52.4%), and 5 cases suffered from P-RLS (5/21, 23.8%). Among 21 patients suffering from migraine with aura, RLS was detected in 13 cases, according to c-TTE method (13/18, 72%), and then compared with healthy participants group, the difference of detection rate between them was significant (χ2 = 5.2, P = 0.02). In detail, 3 participants suffered from PFO-RLS and P-RSL (3/18, 16.7%), 8 cases suffered from PFO-RLS (8/18, 44.4%), and 8 cases suffered from P-RLS (8/18, 44.4%). In addition, the grading of PFO-RLS in patients suffering from cryptogenic stroke and migraine with aura was mostly grade 2-grade 3. On the contrary, the grading of PFO-RLS in healthy adult volunteers was mostly grade 1-2. Besides, the semi-quantitative grading of P-RLS in each group was mostly grade 1 to grade 2, and difference between healthy volunteer group and cryptogenic stroke group was significant (Z = -2.77, P = 0.006). CONCLUSION P-RLS with lower semiquantitative grade is common in healthy individuals, patients with cryptogenic stroke and migraine aura. And P-RLS can be considered as a significant influencing factor in the pathogenesis of migraine with aura.
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Affiliation(s)
- Cheng Feng
- Department of Ultrasound, The Third People's Hospital of Shenzhen, Shenzhen, 518116, Guangdong, China.
| | - Tingting Luo
- Department of Ultrasound, The Third People's Hospital of Shenzhen, Shenzhen, 518116, Guangdong, China.
| | - Yongfang Luo
- Department of Ultrasound, The Third People's Hospital of Shenzhen, Shenzhen, 518116, Guangdong, China.
| | - Ningbo Zhao
- Department of Ultrasound, The Third People's Hospital of Shenzhen, Shenzhen, 518116, Guangdong, China.
| | - Kun Huang
- Department of Ultrasound, The Third People's Hospital of Shenzhen, Shenzhen, 518116, Guangdong, China.
| | - Chang Xiao
- Department of Ultrasound, The Third People's Hospital of Shenzhen, Shenzhen, 518116, Guangdong, China.
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Shah AH, Osten M, Benson L, Alnasser S, Bach Y, Vishwanath R, Van De Bruaene A, Shulman H, Navaranjan J, Khan R, Horlick E. Incidence and Outcomes of Positive Bubble Contrast Study Results After Transcatheter Closure of a Patent Foramen Ovale. JACC Cardiovasc Interv 2018; 11:1095-1104. [DOI: 10.1016/j.jcin.2018.03.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 02/05/2018] [Accepted: 03/06/2018] [Indexed: 10/14/2022]
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13
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Abstract
Transcranial Doppler (TCD) is useful in stroke prevention for at least three purposes: diagnosis of intracranial stenosis, detection of right-to-left shunt in patients with suspected paradoxical embolism, and detection of microemboli in patients with carotid stenosis. Other uses may include assessment of cerebral blood flow, which is not discussed in this review. TCD saline studies are more sensitive than transesophageal echocardiography, and more strongly predictive of risk of recurrent events. TCD embolus detection is the best-validated method for identifying among patients with asymptomatic carotid stenosis the few who could benefit from carotid endarterectomy or stenting.
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Affiliation(s)
- J. David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
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14
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Norris HC, Mangum TS, Kern JP, Elliott JE, Beasley KM, Goodman RD, Mladinov S, Barak OF, Bakovic D, Dujic Z, Lovering AT. Intrapulmonary arteriovenous anastomoses in humans with chronic obstructive pulmonary disease: implications for cryptogenic stroke? Exp Physiol 2018; 101:1128-42. [PMID: 27339093 DOI: 10.1113/ep085811] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 06/20/2016] [Indexed: 12/13/2022]
Abstract
What is the central question of this study? Do individuals with chronic obstructive pulmonary disease have blood flow through intrapulmonary arteriovenous anastomoses at rest or during exercise? What is the main finding and its importance? Individuals with chronic obstructive pulmonary disease have a greater prevalence of blood flow through intrapulmonary arteriovenous anastomoses at rest than age-matched control subjects. Given that the intrapulmonary arteriovenous anastomoses are large enough to permit venous emboli to pass into the arterial circulation, patients with chronic obstructive pulmonary disease and an elevated risk of thrombus formation may be at risk of intrapulmonary arteriovenous anastomosis-facilitated embolic injury (e.g. stroke or transient ischaemic attack). The pulmonary capillaries prevent stroke by filtering venous emboli from the circulation. Intrapulmonary arteriovenous anastomoses are large-diameter (≥50 μm) vascular connections in the lung that may compromise the integrity of the pulmonary capillary filter and have recently been linked to cryptogenic stroke and transient ischaemic attack. Prothrombotic populations, such as individuals with chronic obstructive pulmonary disease (COPD), may be at increased risk of stroke and transient ischaemic attack facilitated by intrapulmonary arteriovenous anastomoses, but the prevalence and degree of blood flow through intrapulmonary arteriovenous anastomoses in this population has not been fully examined and compared with age-matched healthy control subjects. We used saline contrast echocardiography to assess blood flow through intrapulmonary arteriovenous anastomoses at rest (n = 29 COPD and 19 control subjects) and during exercise (n = 10 COPD and 10 control subjects) in subjects with COPD and age-matched healthy control subjects. Blood flow through intrapulmonary arteriovenous anastomoses was detected in 23% of subjects with COPD at rest and was significantly higher compared with age-matched healthy control subjects. Blood flow through intrapulmonary arteriovenous anastomoses at rest was reduced or eliminated in subjects with COPD after breathing hyperoxic gas. Sixty per cent of subjects with COPD who did not have blood flow through the intrapulmonary arteriovenous anastomoses at rest had blood flow through them during exercise. The combination of blood flow through intrapulmonary arteriovenous anastomoses and potential for thrombus formation in individuals with COPD may permit venous emboli to pass into the arterial circulation and cause stroke and transient ischaemic attack. Breathing supplemental oxygen may reduce this risk in COPD. The link between blood flow through intrapulmonary arteriovenous anastomoses, stroke and transient ischaemic attack is worthy of future investigation in COPD and other populations.
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Affiliation(s)
- H Cameron Norris
- Department of Human Physiology, University of Oregon, Eugene, OR, UK
| | - Tyler S Mangum
- Department of Human Physiology, University of Oregon, Eugene, OR, UK
| | - Julia P Kern
- Department of Human Physiology, University of Oregon, Eugene, OR, UK
| | | | - Kara M Beasley
- Department of Human Physiology, University of Oregon, Eugene, OR, UK
| | | | - Suzana Mladinov
- Clinical Department for Pulmonary Diseases, University Hospital Center Split, Split, Croatia
| | - Otto F Barak
- Department of Physiology, University of Novi Sad, Novi Sad, Serbia
| | - Darija Bakovic
- Division of Cardiology, Department of Internal Medicine, University Hospital Center Split, Split, Croatia.,Department of Integrative Physiology, University of Split School of Medicine, Split, Croatia
| | - Zeljko Dujic
- Department of Integrative Physiology, University of Split School of Medicine, Split, Croatia
| | - Andrew T Lovering
- Department of Human Physiology, University of Oregon, Eugene, OR, UK
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15
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Bates ML, Jacobson JE, Eldridge MW. Beta Adrenergic Regulation of Intrapulmonary Arteriovenous Anastomoses in Intact Rat and Isolated Rat Lungs. Front Physiol 2017; 8:218. [PMID: 28469578 PMCID: PMC5396286 DOI: 10.3389/fphys.2017.00218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/27/2017] [Indexed: 11/18/2022] Open
Abstract
Intrapulmonary arteriovenous anastomoses (IPAVA) allow large diameter particles of venous origin to bypass the pulmonary capillary bed and embolize the systemic arterial circulation. IPAVA have been routinely observed in healthy humans with exercise, hypoxia, and catecholamine infusion, but the mechanism by which they are recruited is not well-defined. We hypothesized that beta-adrenergic receptor stimulation recruits IPAVA and that receptor blockade would limit hypoxia-induced IPAVA recruitment. To test our hypothesis, we evaluated the transpulmonary passage of microspheres in intact rats and isolated rats lung infused with the beta-adrenergic receptor agonist isoproterenol. We also evaluated IPAVA recruitment in intact rats with hypoxia and the beta-adrenergic receptor blocker propranolol. We found that IPAVA are recruited in the intact rat by isoproterenol and their recruitment by hypoxia can be minimized by propranolol, suggesting a role for the adrenergic system in the recruitment of IPAVA by hypoxia. IPAVA recruitment is completely abolished by ventilation with 100% oxygen. Isoproterenol also recruits IPAVA in isolated rat lungs. The fact that isoproterenol can recruit IPAVA in isolated lungs, without increased pulmonary flow, suggests that elevated cardiac output is not required for IPAVA recruitment.
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Affiliation(s)
- Melissa L Bates
- Critical Care Division and the John Rankin Laboratory of Pulmonary Medicine, Department of Pediatrics, University of IowaIowa City, IA, USA.,Department of Health and Human Physiology, University of IowaIowa City, IA, USA
| | - Joseph E Jacobson
- Critical Care Division and the John Rankin Laboratory of Pulmonary Medicine, Department of Pediatrics, University of IowaIowa City, IA, USA.,Michigan State University College of Human MedicineEast Lansing, MI, USA
| | - Marlowe W Eldridge
- Critical Care Division and the John Rankin Laboratory of Pulmonary Medicine, Department of Pediatrics, University of IowaIowa City, IA, USA.,Departments of Biomedical Engineering and Kinesiology, University of WisconsinMadison, WI, USA
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16
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Affiliation(s)
- Bernd Stegmayr
- Department of Public Health and Clinical Medicine; Umeå University; Umea Sweden
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17
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Fatal Cerebral Air Embolism: A Case Series and Literature Review. Case Rep Crit Care 2016; 2016:3425321. [PMID: 27635266 PMCID: PMC5011199 DOI: 10.1155/2016/3425321] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 08/02/2016] [Indexed: 11/29/2022] Open
Abstract
Cerebral air embolism (CAE) is an infrequently reported complication of routine medical procedures. We present two cases of CAE. The first patient was a 55-year-old male presenting with vomiting and loss of consciousness one day after his hemodialysis session. Physical exam was significant for hypotension and hypoxia with no focal neurologic deficits. Computed tomography (CT) scan of head showed gas in cerebral venous circulation. The patient did not undergo any procedures prior to presentation, and his last hemodialysis session was uneventful. Retrograde rise of venous air to the cerebral circulation was the likely mechanism for venous CAE. The second patient was a 46-year-old female presenting with fever, shortness of breath, and hematemesis. She was febrile, tachypneic, and tachycardic and required intubation and mechanical ventilation. An orogastric tube inserted drained 2500 mL of bright red blood. Flexible laryngoscopy and esophagogastroduodenoscopy were performed. She also underwent central venous catheter placement. CT scan of head performed the next day due to absent brain stem reflexes revealed intravascular air within cerebral arteries. A transthoracic echocardiogram with bubble study ruled out patent foramen ovale. The patient had a paradoxical CAE in the absence of a patent foramen ovale.
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18
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Sharkey J, Scarfe L, Santeramo I, Garcia-Finana M, Park BK, Poptani H, Wilm B, Taylor A, Murray P. Imaging technologies for monitoring the safety, efficacy and mechanisms of action of cell-based regenerative medicine therapies in models of kidney disease. Eur J Pharmacol 2016; 790:74-82. [PMID: 27375077 PMCID: PMC5063540 DOI: 10.1016/j.ejphar.2016.06.056] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 06/30/2016] [Indexed: 12/16/2022]
Abstract
The incidence of end stage kidney disease is rising annually and it is now a global public health problem. Current treatment options are dialysis or renal transplantation, which apart from their significant drawbacks in terms of increased morbidity and mortality, are placing an increasing economic burden on society. Cell-based Regenerative Medicine Therapies (RMTs) have shown great promise in rodent models of kidney disease, but clinical translation is hampered due to the lack of adequate safety and efficacy data. Furthermore, the mechanisms whereby the cell-based RMTs ameliorate injury are ill-defined. For instance, it is not always clear if the cells directly replace damaged renal tissue, or whether paracrine effects are more important. Knowledge of the mechanisms responsible for the beneficial effects of cell therapies is crucial because it could lead to the development of safer and more effective RMTs in the future. To address these questions, novel in vivo imaging strategies are needed to monitor the biodistribution of cell-based RMTs and evaluate their beneficial effects on host tissues and organs, as well as any potential adverse effects. In this review we will discuss how state-of-the-art imaging modalities, including bioluminescence, magnetic resonance, nuclear imaging, ultrasound and an emerging imaging technology called multispectral optoacoustic tomography, can be used in combination with various imaging probes to track the fate and biodistribution of cell-based RMTs in rodent models of kidney disease, and evaluate their effect on renal function.
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Affiliation(s)
- Jack Sharkey
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GE, UK; Centre for Preclinical Imaging, University of Liverpool, Liverpool L69 3GE, UK
| | - Lauren Scarfe
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GE, UK; Centre for Preclinical Imaging, University of Liverpool, Liverpool L69 3GE, UK
| | - Ilaria Santeramo
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GE, UK
| | - Marta Garcia-Finana
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GE, UK
| | - Brian K Park
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GE, UK
| | - Harish Poptani
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GE, UK; Centre for Preclinical Imaging, University of Liverpool, Liverpool L69 3GE, UK
| | - Bettina Wilm
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GE, UK; Centre for Preclinical Imaging, University of Liverpool, Liverpool L69 3GE, UK
| | - Arthur Taylor
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GE, UK; Centre for Preclinical Imaging, University of Liverpool, Liverpool L69 3GE, UK
| | - Patricia Murray
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GE, UK; Centre for Preclinical Imaging, University of Liverpool, Liverpool L69 3GE, UK.
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19
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Novo Matos J, Malbon A, Dennler M, Glaus T. Intrapulmonary arteriovenous anastomoses in dogs with severe Angiostrongylus vasorum infection: clinical, radiographic, and echocardiographic evaluation. J Vet Cardiol 2016; 18:110-24. [DOI: 10.1016/j.jvc.2015.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 10/08/2015] [Accepted: 10/14/2015] [Indexed: 11/25/2022]
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20
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Aparci M, Guney Senol M, Yalcin M, Tansel Kendirli M, Isilak Z. Effective Valsalva maneuvering during TCCD and unrevealed etiology of RLS. Acta Neurol Scand 2016; 133:313-4. [PMID: 26935909 DOI: 10.1111/ane.12485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Either transcranial color-coded Doppler (TCCD) or contrast echocardiography (CE) is the bests of clinically applicable and reproducible methods to evaluate the functionality of right-to-left shunts that can be found in different localization on atrial septum. As the anatomical features of right-to-left shunts could vary in many forms, detection of RLS by functional tests may aid the clinician to do risk prediction and management of patients. Sensitivity of TCDD or CE can be increased by performing effective Valsalva maneuvering during the test procedure. Timing of RLS during the cardiac cycles may help interpreting about the etiology of RLS, atrial septum or intrapulmonary shunts. Intrapulmonary shunts have been recently reported to be associated with RLS and frequently overlooked unless the tests prolonged up to 10th cardiac beat. Migraine, cryptogenic strokes, and paradoxic embolism are closely associated with RLS which should be evaluated by the collaboration of cardiologists and neurologists. Success of diagnostic procedure depends on high suspicion of index for RLS and application of contrast-enhanced tests that are effectively performed at each step.
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Affiliation(s)
- M. Aparci
- Department of Cardiology and Aviation Examination Center; Kasimpasa Military Hospital; Istanbul Turkey
| | - M. Guney Senol
- Department of Neurology; Haydarpasa Training Hospital; Istanbul Turkey
| | - M. Yalcin
- Department of Cardiology; Haydarpasa Training Hospital; Istanbul Turkey
| | | | - Z. Isilak
- Department of Cardiology; Haydarpasa Training Hospital; Istanbul Turkey
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21
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Tobe J, Bogiatzi C, Munoz C, Tamayo A, Spence JD. Transcranial Doppler is Complementary to Echocardiography for Detection and Risk Stratification of Patent Foramen Ovale. Can J Cardiol 2015; 32:986.e9-986.e16. [PMID: 26952158 DOI: 10.1016/j.cjca.2015.12.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 12/03/2015] [Accepted: 12/06/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In patients with patent foramen ovale (PFO), strategies are needed to identify patients at higher risk, who might benefit from PFO closure. METHODS We studied the frequency of detection of a right-to-left shunt (RLS) using transesophageal echocardiography (TEE) among patients with cryptogenic stroke and transcranial Doppler (TCD) to detect RLS, and analyzed the prediction of recurrent stroke according to TCD shunt grade, by detection of RLS on TEE, and by atrial septal aneurysm or mobility. RESULTS Among 334 patients with TCD, 69.8% were female, with a mean (SD) age of 53 (14) years, with a median follow-up of 420 days. There were 284 cases with TCD and TEE; 54 (19%) had atrial septal aneurysm or mobility. Echocardiography failed to show a RLS in 43 (15.1%) of the patients who had TCD and TEE, even in some patients with high-grade shunts on TCD: 18 (42%) were grade 3 or higher on TCD. Survival free of stroke or transient ischemic attack was predicted significantly by TCD shunt grade < 2 (P = 0.028), shunt grade < 3 (P = 0.03), and shunt grade < 4 (P < 0.0001); this was attenuated by adjustment for risk factors in Cox regression (P = 0.08). Neither RLS on TEE (P = 0.47), or atrial septal aneurysm or mobility (P = 0.08), predicted events. CONCLUSIONS Our findings suggest that TCD might be more sensitive than TEE for detection of RLS, which misses some cases with substantial RLS, and might be valuable for prediction of recurrent stroke or transient ischemic attack in patients with PFO. TCD complements TEE for management of suspected paradoxical embolism.
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Affiliation(s)
- Joshua Tobe
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Chrysi Bogiatzi
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Claudio Munoz
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Arturo Tamayo
- Brandon Regional Health Centre, Brandon, Manitoba, Canada
| | - J David Spence
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada.
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22
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Aparci M, Isilak Z, Kendirli MT, Yalcin M. Are Right to Left Shunts Underdiagnosed in the Etiology of Migraine Headache? Headache 2015; 55:1268-9. [DOI: 10.1111/head.12692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Mustafa Aparci
- Department of Cardiology and Aviation Examination Center; Kasimpasa Military Hospital; Istanbul Turkey
| | - Zafer Isilak
- Department of Cardiology; Haydarpasa Training Hospital; Istanbul Turkey
| | | | - Murat Yalcin
- Department of Cardiology; Haydarpasa Training Hospital; Istanbul Turkey
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23
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BARAK OTTOF, MADDEN DENNIS, LOVERING ANDREWT, LAMBRECHTS KATE, LJUBKOVIC MARKO, DUJIC ZELJKO. Very Few Exercise-Induced Arterialized Gas Bubbles Reach the Cerebral Vasculature. Med Sci Sports Exerc 2015; 47:1798-805. [DOI: 10.1249/mss.0000000000000625] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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24
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Eum DH, Lee SH, Kim HW, Jung MJ, Lee JG. Cerebral air embolism following the removal of a central venous catheter in the absence of intracardiac right-to-left shunting: a case report. Medicine (Baltimore) 2015; 94:e630. [PMID: 25837752 PMCID: PMC4554025 DOI: 10.1097/md.0000000000000630] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Air embolism following central venous catheter (CVC) removal is a relatively uncommon complication. Despite its rare occurrence, an air embolism can lead to serious outcomes. One of the most fatal complications is cerebral air embolism. We report a case of cerebral air embolism that occurred after the removal of a CVC in a patient with an underlying idiopathic pulmonary fibrosis, subcutaneous emphysema, pneumomediastinum, and a possible intrapulmonary shunt. Although the patient had a brief period of recovery, his condition deteriorated again, and retention of carbon dioxide was sustained due to aggravation of pneumonia. Despite full coverage of antibiotics and maximum care with the ventilator, the patient died about 5 weeks after the removal of the CVC. We suggest that strict compliance to protocols is required even while removing the catheter. Furthermore, additional caution to avoid air embolism is demanded in high-risk patients, such as in this case.
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Affiliation(s)
- Da Hae Eum
- From the Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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25
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Patent Foramen Ovale in Recreational and Professional Divers: An Important and Largely Unrecognized Problem. Can J Cardiol 2015; 31:1061-6. [PMID: 26143138 DOI: 10.1016/j.cjca.2015.03.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 03/10/2015] [Accepted: 03/10/2015] [Indexed: 11/20/2022] Open
Abstract
Patent foramen ovale (PFO) is associated with an increased risk of decompression sickness (DCS) in divers that results from a paradoxical embolization of nitrogen bubbles. The number of scuba divers worldwide is estimated in the millions, and the prevalence of PFO is 25%-30% in adults. It is interesting that despite these numbers, many important issues regarding optimal screening, risk stratification, and management strategy still remain to be resolved. Recently published data suggest the possible effectiveness of both PFO closure and conservative diving measures in preventing arterial gas embolization. This review aims to introduce the basic principles of physiology and the pathophysiology of bubble formation and DCS, summarize the current literature on PFO and diving, and review the possibilities of diagnostic workup and management.
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26
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Lovering AT, Duke JW, Elliott JE. Intrapulmonary arteriovenous anastomoses in humans--response to exercise and the environment. J Physiol 2015; 593:507-20. [PMID: 25565568 DOI: 10.1113/jphysiol.2014.275495] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 12/05/2014] [Indexed: 12/17/2022] Open
Abstract
Intrapulmonary arteriovenous anastomoses (IPAVA) have been known to exist in human lungs for over 60 years. The majority of the work in this area has largely focused on characterizing the conditions in which IPAVA blood flow (Q̇IPAVA ) is either increased, e.g. during exercise, acute normobaric hypoxia, and the intravenous infusion of catecholamines, or absent/decreased, e.g. at rest and in all conditions with alveolar hyperoxia (FIO2 = 1.0). Additionally, Q̇IPAVA is present in utero and shortly after birth, but is reduced in older (>50 years) adults during exercise and with alveolar hypoxia, suggesting potential developmental origins and an effect of age. The physiological and pathophysiological roles of Q̇IPAVA are only beginning to be understood and therefore these data remain controversial. Although evidence is accumulating in support of important roles in both health and disease, including associations with pulmonary arterial pressure, and adverse neurological sequelae, there is much work that remains to be done to fully understand the physiological and pathophysiological roles of IPAVA. The development of novel approaches to studying these pathways that can overcome the limitations of the currently employed techniques will greatly help to better quantify Q̇IPAVA and identify the consequences of Q̇IPAVA on physiological and pathophysiological processes. Nevertheless, based on currently published data, our proposed working model is that Q̇IPAVA occurs due to passive recruitment under conditions of exercise and supine body posture, but can be further modified by active redistribution of pulmonary blood flow under hypoxic and hyperoxic conditions.
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Affiliation(s)
- Andrew T Lovering
- Department of Human Physiology, University of Oregon, Eugene, OR, USA
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27
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Bates ML, Farrell ET, Drezdon A, Jacobson JE, Perlman SB, Eldridge MW. Hypoxia and exercise increase the transpulmonary passage of 99mTc-labeled albumin particles in humans. PLoS One 2014; 9:e101146. [PMID: 25013985 PMCID: PMC4094383 DOI: 10.1371/journal.pone.0101146] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 06/03/2014] [Indexed: 11/19/2022] Open
Abstract
Intrapulmonary arteriovenous anastomoses (IPAVs) are large diameter connections that allow blood to bypass the lung capillaries and may provide a route for right-to-left embolus transmission. These anastomoses are recruited by exercise and catecholamines and hypoxia. Yet, whether IPAVs are recruited via direct, oxygen sensitive regulatory mechanisms or indirect effects secondary to redistribution pulmonary blood flow is unknown. Here, we hypothesized that the addition of exercise to hypoxic gas breathing, which increases cardiac output, would augment IPAVs recruitment in healthy humans. To test this hypothesis, we measured the transpulmonary passage of 99mTc-macroaggregated albumin particles (99mTc-MAA) in seven healthy volunteers, at rest and with exercise at 85% of volitional max, with normoxic (FIO2 = 0.21) and hypoxic (FIO2 = 0.10) gas breathing. We found increased 99mTc-MAA passage in both exercise conditions and resting hypoxia. However, contrary to our hypothesis, we found the greatest 99mTc-MAA passage with resting hypoxia. As an additional, secondary endpoint, we also noted that the transpulmonary passage of 99mTc-MAA was well-correlated with the alveolar-arterial oxygen difference (A-aDO2) during exercise. While increased cardiac output has been proposed as an important modulator of IPAVs recruitment, we provide evidence that the modulation of blood flow through these pathways is more complex and that increasing cardiac output does not necessarily increase IPAVs recruitment. As we discuss, our data suggest that the resistance downstream of IPAVs is an important determinant of their perfusion.
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Affiliation(s)
- Melissa L. Bates
- Department of Pediatrics, Critical Care Division and the John Rankin Laboratory of Pulmonary Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Emily T. Farrell
- Department of Pediatrics, Critical Care Division and the John Rankin Laboratory of Pulmonary Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Alyssa Drezdon
- Department of Pediatrics, Critical Care Division and the John Rankin Laboratory of Pulmonary Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Joseph E. Jacobson
- Department of Pediatrics, Critical Care Division and the John Rankin Laboratory of Pulmonary Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
- Michigan State University College of Human Medicine, East Lansing, Michigan, United States of America
| | - Scott B. Perlman
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Marlowe W. Eldridge
- Department of Pediatrics, Critical Care Division and the John Rankin Laboratory of Pulmonary Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
- Departments of Biomedical Engineering and Kinesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
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28
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Cameron Norris H, Mangum TS, Duke JW, Straley TB, Hawn JA, Goodman RD, Lovering AT. Exercise- and hypoxia-induced blood flow through intrapulmonary arteriovenous anastomoses is reduced in older adults. J Appl Physiol (1985) 2014; 116:1324-33. [DOI: 10.1152/japplphysiol.01125.2013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Mean pulmonary arterial pressure (Ppa) during exercise is significantly higher in individuals aged ≥50 yr compared with their younger counterparts, but the reasons for this are unknown. Blood flow through intrapulmonary arteriovenous anastomoses (IPAVA) can be detected during exercise or while breathing hypoxic gas mixtures using saline contrast echocardiography in almost all healthy young individuals. It has been previously hypothesized that a lower degree of exercise-induced blood flow through IPAVA is associated with high Ppa during exercise. This association may suggest that individuals who are known to have high Ppa during exercise, such as those ≥50 yr of age, may have lower blood flow through IPAVA, but the presence and degree of exercise-induced blood flow through IPAVA has not been specifically studied in older populations. Using transthoracic saline contrast echocardiography, we investigated the potential effects of age on exercise-induced blood flow through IPAVA in a cross-section of subjects aged 19–72 yr. To verify our findings, we assessed the effects of age on hypoxia-induced blood flow through IPAVA. Age groups were ≤41 yr (younger, n = 16) and ≥50 yr (older, n = 14). Qualitatively measured exercise- and hypoxia-induced blood flow through IPAVA was significantly lower in older individuals compared with younger controls. Older individuals also had significantly higher pulmonary arterial systolic pressure and total pulmonary resistance (TPR) during exercise. Low blood flow through IPAVA was independently associated with high TPR. The reasons for the age-related decrease in blood flow through IPAVA are unknown.
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Affiliation(s)
- H. Cameron Norris
- Department of Human Physiology, University of Oregon, Eugene, Oregon; and
| | - Tyler S. Mangum
- Department of Human Physiology, University of Oregon, Eugene, Oregon; and
| | - Joseph W. Duke
- Department of Human Physiology, University of Oregon, Eugene, Oregon; and
| | - Taylor B. Straley
- Department of Human Physiology, University of Oregon, Eugene, Oregon; and
| | - Jerold A. Hawn
- Oregon Heart and Vascular Institute, RiverBend, Springfield, Oregon
| | - Randy D. Goodman
- Oregon Heart and Vascular Institute, RiverBend, Springfield, Oregon
| | - Andrew T. Lovering
- Department of Human Physiology, University of Oregon, Eugene, Oregon; and
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Vaidya VR, DeSimone CV, Asirvatham SJ, Chandra VM, Noheria A, Hodge DO, Slusser JP, Rabinstein AA, Friedman PA. Implanted endocardial lead characteristics and risk of stroke or transient ischemic attack. J Interv Card Electrophysiol 2014; 41:31-8. [PMID: 24771226 DOI: 10.1007/s10840-014-9900-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 03/24/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Patent foramen ovale (PFO) has been recently implicated as a strong predictor of stroke or transient ischemic attack (TIA) in patients with implanted pacemaker or defibrillation leads. Leads in the right heart can form thrombi that embolize to the pulmonary circulation and raise pulmonary pressure. This increases right-to-left shunting through PFO or intrapulmonary shunts and can result in paradoxical embolism. We sought to determine whether certain lead characteristics confer a higher thrombogenic risk resulting in stroke/TIAs in patients either with or without a PFO. METHODS We retrospectively analyzed 5,646 patients (mean age 67.3 ± 16.3 years, 64 % male) who had endocardial device leads implanted in 2000-2010. We performed univariate and multivariate-adjusted proportional hazards models to determine association of lead characteristics with stroke/TIA during follow-up. RESULTS On univariate analysis, passively fixated tined leads were associated with more stroke/TIAs (HR 1.77, 95 % CI 1.27, 2.47; p<0.001), whereas presence of defibrillation coil was associated with fewer stroke/TIAs (HR 0.59, 95 % CI 0.42-0.84; p=0.003). Number of leads per patient, presence of atrial lead, maximum lead size, tip shape, and type of insulating material were not associated with stoke/TIA. On multivariate analyses adjusting for age, sex, diagnosis of PFO, and prior history of stroke/TIA, the presence of tined leads was associated with stroke/TIA (HR 1.41, 95 % CI 1.00-1.97; p=0.049). Defibrillation coils were no longer associated with lower stroke/TIA on multivariate analysis. CONCLUSIONS Most physical characteristics of contemporary leads do not impact rate of stroke/TIA among patients receiving implantable devices. The presence of a PFO is a major risk factor for stroke/TIA in patients with endovascular leads.
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Affiliation(s)
- Vaibhav R Vaidya
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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30
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Nakano S, Sujino Y, Tanno J, Ariyama M, Muramatsu T, Senbonmatsu T, Nishimura S, Tamura Y, Fukuda K. Inducible intrapulmonary arteriovenous shunt in a patient with beriberi heart. Am J Respir Crit Care Med 2013; 187:332-3. [PMID: 23378443 DOI: 10.1164/ajrccm.187.3.332] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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31
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Battle C, Dow A, Timperely J. Fatal Systemic Embolism following Revision of Hip Arthroplasty: A Complication of Pulmonary Arteriovenous Malformation. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A 72-year-old female patient who had a pulmonary arteriovenous malformation (PAVM) suffered systemic emboli causing pulmonary and cerebral infarction following the revision of an infected total hip replacement. Although not ultimately successful in this case, we detail the management of maintaining oxygenation and adequate cardiac output in a critically ill patient with a PAVM. We also discuss techniques that may be employed to minimise the shunt associated with the PAVM, with the aim of reducing the risk of systemic emboli.
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Affiliation(s)
| | - Alasdair Dow
- Consultant Anaesthetist, Royal Devon and Exeter Hospital
| | - John Timperely
- Consultant Orthopaedic Surgeon, Royal Devon and Exeter Hospital
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32
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Tomlinson RE, McKenzie JA, Schmieder AH, Wohl GR, Lanza GM, Silva MJ. Angiogenesis is required for stress fracture healing in rats. Bone 2013; 52:212-9. [PMID: 23044046 PMCID: PMC3513671 DOI: 10.1016/j.bone.2012.09.035] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 09/25/2012] [Accepted: 09/28/2012] [Indexed: 12/12/2022]
Abstract
Although angiogenesis and osteogenesis are critically linked, the importance of angiogenesis for stress fracture healing is unknown. In this study, mechanical loading was used to create a non-displaced stress fracture in the adult rat forelimb. Fumagillin, an anti-angiogenic agent, was used as the water soluble analogue TNP-470 (25mg/kg) as well as incorporated into lipid-encapsulated α(v)β(3) integrin targeted nanoparticles (0.25mg/kg). In the first experiment, TNP-470 was administered daily for 5 days following mechanical loading, and changes in gene expression, vascularity, and woven bone formation were quantified. Although no changes in vascularity were detected 3 days after loading, treatment-related downregulation of angiogenic (Pecam1) and osteogenic (Bsp, Osx) genes was observed at this early time point. On day 7, microCT imaging of loaded limbs revealed diminished woven bone formation in treated limbs compared to vehicle treated limbs. In the second experiment, α(v)β(3) integrin targeted fumagillin nanoparticles were administered as before, albeit with a 100-fold lower dose, and changes in vascularity and woven bone formation were determined. There were no treatment-related changes in vessel count or volume 3 days after loading, although fewer angiogenic (CD105 positive) blood vessels were present in treated limbs compared to vehicle treated limbs. This result manifested on day 7 as a reduction in total vascularity, as measured by histology (vessel count) and microCT (vessel volume). Similar to the first experiment, treated limbs had diminished woven bone formation on day 7 compared to vehicle treated limbs. These results indicate that angiogenesis is required for stress fracture healing, and may have implications for inducing rapid repair of stress fractures.
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Affiliation(s)
- Ryan E. Tomlinson
- Department of Orthopaedic Surgery, Washington University in St. Louis, Saint Louis, MO, USA
- Department of Biomedical Engineering, Washington University in St. Louis, Saint Louis, MO, USA
| | - Jennifer A. McKenzie
- Department of Orthopaedic Surgery, Washington University in St. Louis, Saint Louis, MO, USA
| | - Anne H. Schmieder
- Department of Medicine, Division of Cardiology, Washington University in St. Louis, Saint Louis, MO, USA
| | - Gregory R. Wohl
- Department of Orthopaedic Surgery, Washington University in St. Louis, Saint Louis, MO, USA
| | - Gregory M. Lanza
- Department of Biomedical Engineering, Washington University in St. Louis, Saint Louis, MO, USA
- Department of Medicine, Division of Cardiology, Washington University in St. Louis, Saint Louis, MO, USA
| | - Matthew J. Silva
- Department of Orthopaedic Surgery, Washington University in St. Louis, Saint Louis, MO, USA
- Department of Biomedical Engineering, Washington University in St. Louis, Saint Louis, MO, USA
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Schlundt J, Tzanova I, Werner C. A case of intrapulmonary transmission of air while transitioning a patient from a sitting to a supine position after venous air embolism during a craniotomy. Can J Anaesth 2012; 59:478-82. [DOI: 10.1007/s12630-012-9680-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Accepted: 02/14/2012] [Indexed: 10/28/2022] Open
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