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Kaza AK, Mondal A, Piekarski B, Sachse FB, Hitchcock R. Intraoperative localization of cardiac conduction tissue regions using real-time fibre-optic confocal microscopy: first in human trial. Eur J Cardiothorac Surg 2020; 58:261-268. [PMID: 32083653 DOI: 10.1093/ejcts/ezaa040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/11/2020] [Accepted: 01/17/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the feasibility and safety of fibre-optic confocal microscopy (FCM) using fluorescein sodium dye for the intraoperative location of conduction tissue regions during paediatric heart surgery. METHODS The pilot study included 6 patients undergoing elective surgery for the closure of isolated secundum atrial septal defect aged 30 days to 21 years. FCM imaging was integrated within the normal intraoperative protocol for atrial septal defect repair. Fluorescein sodium dye was applied on the arrested heart. FCM images were acquired at the atrioventricular node region, sinus node region and right ventricle (RV). Total imaging time was limited to 3 min. Any adverse events related to the study were recorded and analysed. Subjects received standard postoperative care. Trained reviewers (n = 9) classified, de-identified and randomized FCM images (n = 60) recorded from the patients as presenting striated, reticulated or indistinguishable microstructures. The reliability of reviewer agreement was assessed using Fleiss' kappa. RESULTS The FCM imaging instruments were integrated effectively into the cardiac surgery operating room. All adverse events found in the study were deemed expected and not related to FCM imaging. Reticulated myocardial microstructures were found during FCM imaging at atrioventricular node and sinus node regions, while striated microstructures were observed in RV. Reliability of agreement of reviewers classifying the FCM images was high (Fleiss' kappa: 0.822). CONCLUSIONS FCM using fluorescein sodium dye was found to be safe for use during paediatric heart surgery. The study demonstrates the potential for FCM to be effective in identifying conduction tissue regions during congenital heart surgery. CLINICAL TRIAL REGISTRATION NUMBER NCT03189134.
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Affiliation(s)
- Aditya K Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Abhijit Mondal
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Breanna Piekarski
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Frank B Sachse
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA.,Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
| | - Robert Hitchcock
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
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Lee CC, Chuang CC, Lai BC, Lu CL, So EC, Lin BS. Dual-wavelength fiber-optic technique to assist needle cricothyroidotomy. Lasers Med Sci 2020; 36:571-582. [PMID: 32700050 PMCID: PMC7952284 DOI: 10.1007/s10103-020-03065-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 06/09/2020] [Indexed: 11/25/2022]
Abstract
The traditional needle cricothyroidotomy procedure is performed blindly without any medical equipment. Complications including posterior tracheal wall perforation, accidental vessel puncture, and missed tracheal puncture are reported. Therefore, we proposed a dual-wavelength fiber-optic technique based on the technique of near-infrared spectroscopy to assist operators performing needle cricothyroidotomy in a swine model. We embedded optical fibers in a 16-gauge intravenous needle catheter. Real-time data were displayed on an oscilloscope, and we used the program to analyze the data immediately. The change of optical density corresponding to 690-nm and 850-nm wavelengths and hemoglobin parameters (HbO2 and Hb concentrations) was analyzed immediately using the program in the laptop. Unique and significant optical differences were presented in this experiment. We could easily identify every different tissue by the change of optical density corresponding to 690-nm and 850-nm wavelengths and hemoglobin parameters (HbO2 and Hb concentrations). Statistical method (Kruskal-Wallis H test) was used to compare differences in tissues at each time-point, respectively. The p values in every tissue in optical density change corresponding to 690 nm and 850 nm were all < 0.001. Furthermore, the p values in every tissue in Hb and HbO2 were also all < 0.001. The results were statistically significant. This is the first and novel study to introduce a dual-wavelength embedded fibers into a standard cricothyroidotomy needle. This proposed system might be helpful to provide us real-time information of the advanced needle tip to decrease possible complications.
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Affiliation(s)
- Chien-Ching Lee
- Institute of Imaging and Biomedical Photonics, National Chiao Tung University, Tainan, 711, Taiwan.,Department of Anesthesia, An Nan Hospital, China Medical University, Tainan, Taiwan.,Department of Medical Sciences Industry, Chang Jung Christian University, Tainan, Taiwan
| | - Chia-Chun Chuang
- Department of Anesthesia, An Nan Hospital, China Medical University, Tainan, Taiwan.,Department of Medical Sciences Industry, Chang Jung Christian University, Tainan, Taiwan
| | - Bo-Cheng Lai
- Institute of Imaging and Biomedical Photonics, National Chiao Tung University, Tainan, 711, Taiwan
| | - Chin-Li Lu
- Graduate Institute of Food Safety, College of Agriculture and Natural Resources, National Chung Hsing University, Taichung, Taiwan
| | - Edmund Cheung So
- Department of Anesthesia, An Nan Hospital, China Medical University, Tainan, Taiwan.,Graduate Institute of Medical Sciences, Chang Jung Christian University, Tainan, Taiwan
| | - Bor-Shyh Lin
- Institute of Imaging and Biomedical Photonics, National Chiao Tung University, Tainan, 711, Taiwan.
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Toward detection of conduction tissue during cardiac surgery: Light at the end of the tunnel? Heart Rhythm 2020; 17:2200-2207. [PMID: 32659372 DOI: 10.1016/j.hrthm.2020.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/02/2020] [Accepted: 07/02/2020] [Indexed: 11/22/2022]
Abstract
Postoperative conduction block requiring lifetime pacemaker placement continues to be a considerable source of morbidity for patients undergoing repair of congenital heart defects. Damage to the cardiac conduction system (CCS) during surgical procedures is thought to be a major cause of conduction block. Intraoperative identification and avoidance of the CCS is thus a key strategy to improve surgical outcomes. A number of approaches have been developed to avoid conduction tissue damage and mitigate morbidity. Here we review the historical and contemporary approaches for identification of conduction tissue during cardiac surgery. The established approach for intraoperative identification is based on anatomic landmarks established in extensive histologic studies of normal and diseased heart. We focus on landmarks to identify the sinus and atrioventricular nodes during cardiac surgery. We also review technologies explored for intraoperative tissue identification, including electrical impedance measurements and electrocardiography. We describe new optical approaches, in particular, and optical spectroscopy and fiberoptic confocal microscopy (FCM) for identification of CCS regions and working myocardium during surgery. As a template for translation of future technology developments, we describe research and regulatory pathways to translate FCM for cardiac surgery. We suggest that along with more robust approaches to surgeon training, including awareness of fundamental anatomic studies, optical approaches such as FCM show promise in aiding surgeons with repairs of heart defects. In particular, for complex defects, these approaches can complement landmark-based identification of conduction tissue and thus help to avoid injury to the CCS due to surgical procedures.
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Mondal A, Lackey J, Saeed M, Wu FY, Johnson JK, Huang C, Sachse FB, Hitchcock R, Kaza AK. An Imaging Protocol to Discriminate Specialized Conduction Tissue During Congenital Heart Surgery. Semin Thorac Cardiovasc Surg 2019; 31:537-546. [PMID: 30738149 DOI: 10.1053/j.semtcvs.2019.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 02/01/2019] [Indexed: 12/20/2022]
Abstract
We performed preclinical validation of intraoperative fiber-optic confocal microscopy (FCM) and assessed its safety and efficacy in an ovine model of the pediatric heart. Intraoperative imaging was performed using an FCM system (Cellvizio, Mauna Kea Technology, Paris, France) with specialized imaging miniprobe (GastroFlex UHD, Mauna Kea Technologies). Before imaging, we applied an extracellular fluorophore, sodium fluorescein, to fluorescently label extracellular space. We imaged arrested hearts of ovine (1-6 months) under cardiopulmonary bypass. Image sequences (1-10 seconds duration) were acquired from regions of the sinoatrial and atrioventricular node, as well as subepicardial and subendocardial working myocardium from atria and ventricle. The surgical process was evaluated for integration of the imaging protocol during the operative procedure. In addition, fluorescein cardiotoxicity studies (n = 3 animals) were conducted by comparing electrocardiogram (PR and QRS intervals) and ejection fraction at baseline and after topical application of fluorescein at 1:10, 1:100, and 1:1000 dilutions on a beating ovine heart. Our studies suggest that intraoperative FCM can be used to identify regions associated with specialized conducting tissue in ovine hearts in situ. The imaging protocol was integrated with conventional open heart surgical procedures with minimal changes to the operative process. Application of fluorescein in varying concentrations did not affect the normalized PR interval, QRS interval, and ejection fraction. These preclinical validation studies demonstrated both safety and efficacy of the proposed intraoperative imaging approach. The studies constitute an important step toward first-in-human clinical trials.
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Affiliation(s)
- Abhijit Mondal
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - John Lackey
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah
| | - Mossab Saeed
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Fei-Yi Wu
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Jordan K Johnson
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
| | - Chao Huang
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah; Comprehensive Arrhythmia and Research Management (CARMA) Center, University of Utah, Salt Lake City, Utah
| | - Frank B Sachse
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
| | - Robert Hitchcock
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah
| | - Aditya K Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah
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Movila A, Kajiya M, Wisitrasameewong W, Stashenko P, Vardar-Sengul S, Hernandez M, Thomas Temple H, Kawai T. Intravital endoscopic technology for real-time monitoring of inflammation caused in experimental periodontitis. J Immunol Methods 2018; 457:26-29. [PMID: 29567043 DOI: 10.1016/j.jim.2018.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/02/2018] [Accepted: 03/12/2018] [Indexed: 12/27/2022]
Abstract
We report a novel method for in situ imaging of microvascular permeability in inflamed gingival tissue, using state-of-the-art Cellvizio™ intravital endoscopic technology and a mouse model of ligature-induced periodontitis. The silk ligature was first placed at the upper left second molar. Seven days later, the ligature was removed, and the animals were intravenously injected with Evans blue. Evans blue dye, which selectively binds to blood albumin, was used to monitor the level of inflammation by monitoring vascular permeability in control non-diseased and ligature-induced experimental periodontitis tissue. More specifically, leakage of Evans blue-bound albumin from the micro-capillary to connective tissue indicates the state of inflammation occurring in the specific site. Evans blue leakage from blood vessels was imaged in situ by directly attaching the endoscope (mini Z tip) of the Cellvizio™ system to the gingival tissue without any surgical incision. Evans blue emission intensity was significantly elevated in gingiva of periodontitis lesions, but not control non-ligature placed gingiva, indicating that this technology can be used as a potential minimally invasive diagnostic tool to monitor the level of inflammation at the periodontal disease site.
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Affiliation(s)
- Alexandru Movila
- The Forsyth Institute, Department of Immunology, Cambridge, MA, USA; Harvard University School of Dental Medicine, Department of Oral Medicine, Infection, and Immunity, Boston, MA, USA; Nova Southeastern University, College of Dental Medicine, Fort Lauderdale, FL, USA.
| | - Mikihito Kajiya
- The Forsyth Institute, Department of Immunology, Cambridge, MA, USA
| | | | - Philip Stashenko
- Harvard University School of Dental Medicine, Department of Oral Medicine, Infection, and Immunity, Boston, MA, USA
| | - Saynur Vardar-Sengul
- Nova Southeastern University, College of Dental Medicine, Fort Lauderdale, FL, USA
| | - Maria Hernandez
- Nova Southeastern University, College of Dental Medicine, Fort Lauderdale, FL, USA
| | - H Thomas Temple
- Nova Southeastern University, College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Toshihisa Kawai
- Nova Southeastern University, College of Dental Medicine, Fort Lauderdale, FL, USA
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