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Schaefer TC, Greive S, Bierwisch C, Mohseni-Mofidi S, Heiland S, Kramer M, Möhlenbruch MA, Bendszus M, Vollherbst DF. Iatrogenic air embolism: influence of air bubble size on cerebral infarctions in an experimental in vivo and numerical simulation model. J Neurointerv Surg 2023:jnis-2023-020739. [PMID: 37673679 DOI: 10.1136/jnis-2023-020739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/10/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Cerebral infarctions resulting from iatrogenic air embolism (AE), mainly caused by small air bubbles, are a well-known and often overlooked event in endovascular interventions. Despite their significance, the underlying pathophysiology remains largely unclear. METHODS In 24 rats, AEs were induced using a microcatheter, positioned in the carotid artery via femoral access. Rats were divided into two study groups, based on the size of the bubbles (85 and 120 µm) and two sub-groups, differing in air volume (0.39 and 0.64 µl). Ultra-high-field magnetic resonance imaging (MRI) was performed 1.5 hours after intervention. MRI findings including the number, single volume and total volume of the infarctions were assessed. A software-based numerical simulation was performed to qualitatively assess the microvascular pathomechanisms. RESULTS In the study groups 22 of 24 rats (92%) revealed cerebral infarctions. The number of infarctions per rat was higher for the smaller bubbles, for the lower (medians: 5 vs 3; p=0.049) and higher air volume sub-groups (medians: 6 vs 4; p=0.012). Correspondingly, total infarction volume was higher for the smaller bubbles (1.67 vs 0.5 mm³; p=0.042). Simulations confirmed the results of the experiments and suggested that fusion of microbubbles to larger bubbles is the underlying pathomechanism of vascular occlusions. CONCLUSION In iatrogenic AE, the size of the bubbles can have a major impact on the number and total volume of cerebral infarctions. These findings can help to better understand the pathophysiology of this frequent, often underestimated adverse event in endovascular interventions.
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Affiliation(s)
- Tabea C Schaefer
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Veterinary Clinical Sciences, Small Animal Clinic, Justus-Liebig-University Giessen, Giessen, Germany
| | - Svenja Greive
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Sabine Heiland
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Kramer
- Department of Veterinary Clinical Sciences, Small Animal Clinic, Justus-Liebig-University Giessen, Giessen, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
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Moy-Trigilio KE, Keene BW, Barker P, Adin D. Myocardial Enhancement Following Agitated Saline Contrast Study in a Boxer Dog. CASE (PHILADELPHIA, PA.) 2023; 7:292-294. [PMID: 37546359 PMCID: PMC10403648 DOI: 10.1016/j.case.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
•Myocardial enhancement after agitated saline contrast study in a dog is described. •Suspect air microemboli can inadvertently be introduced into coronary vasculature. •Air microemboli are a theoretic risk of saline contrast echocardiography.
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Affiliation(s)
- Karen E. Moy-Trigilio
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida
| | - Bruce W. Keene
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Piers Barker
- Duke Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, North Carolina
| | - Darcy Adin
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida
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Verma A, Asivatham SJ, Deneke T, Castellvi Q, Neal RE. Primer on Pulsed Electrical Field Ablation: Understanding the Benefits and Limitations. Circ Arrhythm Electrophysiol 2021; 14:e010086. [PMID: 34538095 DOI: 10.1161/circep.121.010086] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Pulsed electrical field (PEF) energy is a promising technique for catheter ablation of cardiac arrhythmias. In this article, the key aspects that need to be considered for safe and effective PEF delivery are reviewed, and their impact on clinical feasibility is discussed. The most important benefit of PEF appears to be the ability to kill cells through mechanisms that do not alter stromal proteins, sparing sensitive structures to improve safety, without sacrificing cardiomyocyte ablation efficacy. Many parameters affect PEF treatment outcomes, including pulse intensity, waveform shape, and number of pulses, as well as electrode configuration and geometry. These physical and electrical characteristics must be titrated carefully to balance target tissue effects with collateral implications (muscle contraction, temperature rise, risk of electrical arcing events). It is important to note that any combination of parameters affecting PEF needs to be tested for clinical efficacy and safety. Applying PEF clinically requires knowledge of the fundamentals of this technology to exploit its opportunities and generate viable, durable health improvements for patients.
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Affiliation(s)
- Atul Verma
- Division of Cardiology, Southlake Regional Health Center, University of Toronto, Newmarket, Canada (A.V.)
| | - Samuel J Asivatham
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (S.J.A.)
| | - Thomas Deneke
- Division of Cardiology, Rhon-Klinikum Campus Bad Neustadt, Bad Neustadt, Germany (T.D.)
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Es R, Groen MHA, Stehouwer M, Doevendans PA, Wittkampf FHM, Neven K. In vitro analysis of the origin and characteristics of gaseous microemboli during catheter electroporation ablation. J Cardiovasc Electrophysiol 2019; 30:2071-2079. [DOI: 10.1111/jce.14091] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/04/2019] [Accepted: 07/21/2019] [Indexed: 12/15/2022]
Affiliation(s)
- René Es
- Department of CardiologyUniversity Medical Center UtrechtUtrecht The Netherlands
| | - Marijn H. A. Groen
- Department of CardiologyUniversity Medical Center UtrechtUtrecht The Netherlands
| | - Marco Stehouwer
- Department of Extracorporeal CirculationSt Antonius HospitalNieuwegein The Netherlands
| | - Pieter A. Doevendans
- Department of CardiologyUniversity Medical Center UtrechtUtrecht The Netherlands
- Netherlands Heart InstituteUtrecht The Netherlands
| | - Fred H. M. Wittkampf
- Department of CardiologyUniversity Medical Center UtrechtUtrecht The Netherlands
| | - Kars Neven
- Department of CardiologyUniversity Medical Center UtrechtUtrecht The Netherlands
- Department of ElectrophysiologyAlfried Krupp KrankenhausEssen Germany
- Faculty of HealthWitten/Herdecke UniversityWitten Germany
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Heterogeneity of hypoxia in solid tumours and mechanochemical reactions with oxygen nanobubbles. Med Hypotheses 2017; 102:82-86. [DOI: 10.1016/j.mehy.2017.03.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 03/05/2017] [Indexed: 01/20/2023]
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Basciani R, Kröninger F, Gygax E, Jenni H, Reineke D, Stucki M, Hagenbuch N, Carrel T, Eberle B, Erdoes G. Cerebral Microembolization During Aortic Valve Replacement Using Minimally Invasive or Conventional Extracorporeal Circulation: A Randomized Trial. Artif Organs 2016; 40:E280-E291. [DOI: 10.1111/aor.12744] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Reto Basciani
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| | - Felix Kröninger
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| | - Erich Gygax
- Department of Cardiovascular Surgery; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern; Bern
| | - Hansjörg Jenni
- Department of Cardiovascular Surgery; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern; Bern
| | - David Reineke
- Department of Cardiovascular Surgery; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern; Bern
| | - Monika Stucki
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| | | | - Thierry Carrel
- Department of Cardiovascular Surgery; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern; Bern
| | - Balthasar Eberle
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
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Mitchell SJ, Merry AF. Perspective on Cerebral Microemboli in Cardiac Surgery: Significant Problem or Much Ado About Nothing? THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2015; 47:10-15. [PMID: 26390674 PMCID: PMC4566815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 01/31/2015] [Indexed: 06/05/2023]
Abstract
From the time an association was perceived between cardiac surgery and post-operative cognitive dysfunction (POCD), there has been interest in arterial microemboli as one explanation. A succession of studies in the mid-1990s reported a correlation between microemboli exposure and POCD and there followed a focus on microemboli reduction (along with other strategies) in pursuit of peri-operative neuroprotection. There is some evidence that the initiatives developed during this period were successful in reducing neurologic morbidity in cardiac surgery. More recently, however, there is increasing awareness of similar rates of POCD following on and off pump cardiac operations, and following many other types of surgery in elderly patients. This has led some to suggest that cardiopulmonary bypass (CPB) and microemboli exposure by implication are non-contributory. Although the risk factors for POCD may be more patient-centered and multifactorial than previously appreciated, it would be unwise to assume that CPB and exposure to microemboli are unimportant. Improvements in CPB safety (including emboli reduction) achieved over the last 20 years may be partly responsible for difficulty demonstrating higher rates of POCD after cardiac surgery involving CPB in contemporary comparisons with other operations. Moreover, microemboli (including bubbles) have been proven harmful in experimental and clinical situations uncontaminated by other confounding factors. It remains important to continue to minimize patient exposure to microemboli as far as is practicable.
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Affiliation(s)
- Simon J. Mitchell
- Department of Anaesthesiology, School of Medicine, University of Auckland, Auckland, New Zealand
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - Alan F. Merry
- Department of Anaesthesiology, School of Medicine, University of Auckland, Auckland, New Zealand
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
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Bassett GC, Lin JW, Tran MM, Sistino JJ. Evaluating the potential risks of bubble studies during echocardiography. Perfusion 2014; 30:219-23. [DOI: 10.1177/0267659114539182] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Cardiac shunts are often identified using bubble studies in echocardiography, with agitated saline. Previous studies have recommended various safe amounts of agitated saline. This poses a potential risk for air microembolism. The purpose of this study was to quantify the bubbles created by various quantities of agitated saline. Methods: A closed circuit was constructed with a HeartMate pneumatic ventricular assist pump and a cardiotomy reservoir to remove air during recirculation. One empty 10 mL syringe and one 10 mL syringe containing 1 mL of air and 9 mL of saline were attached to a three-way stopcock. The air/saline bolus was then agitated between the two syringes five times to create bubbles and injected into the tubing proximal to the HeartMate. An EDAC bubble detector sensor was attached prior to the saline injection site and distal to the HeartMate I to measure the size and volume of the bubbles. This technique was repeated using 0.5 mL of air and 9.5 mL of saline bolus and 2 mL of air and 8 mL of saline bolus. Each bolus was tested 20 times. Results: This study identifies the potential risks of air administration and proposes a safer air volume to agitate for the administration of a bubble study. Conclusions: Further studies should be conducted to create either a guideline or a standard for agitated saline administration by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL) in order to minimize the risk of air microembolism
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Affiliation(s)
- GC Bassett
- Medical University of South Carolina, Charleston, USA
| | - JW Lin
- Medical University of South Carolina, Charleston, USA
| | - MM Tran
- Medical University of South Carolina, Charleston, USA
| | - JJ Sistino
- Medical University of South Carolina, Charleston, USA
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