Soft tissue injury events associated with neural integrity monitoring endotracheal tubes: A MAUDE database analysis

OBJECTIVE

Neural integrity monitoring (NIM) endotracheal tubes are widely used to provide intraoperative monitoring of the recurrent laryngeal nerve during certain neck surgeries, especially thyroidectomy, in order to reduce the risk of nerve injury and subsequent vocal fold paralysis. The unique design of NIM tubes and the increased technical skill required for correct placement compared to standard endotracheal tubes may increase the risk of upper aerodigestive tract soft tissue injury. This study aims to describe adverse events related to NIM endotracheal tubes.

STUDY DESIGN

Retrospective cross-sectional study.

SETTING

The US Food and Drug Administration's MAUDE database (2010-2022); (Manufacturer and User Facility Device Experience).

METHODS

The MAUDE database was queried for reports of adverse events that resulted in patient soft tissue injury involving the use of endotracheal tubes approved by the Food and Drug Administration.

RESULTS

There were 28 reported soft tissue injuries, with all events being related to the NIM EMG family of endotracheal tubes manufactured by Medtronic Xomed, Inc. Overall, 24 were categorized as device-related adverse events, and 4 were unspecified in the event description. The most common soft tissue injuries were edema (n = 7) and perforation (n = 7), each accounting for 25 % of adverse events. The second most common injury type was laceration (n = 4), representing 14 % of all adverse events. Overall, 9 patients (32 %) in our cohort required a surgical intervention to treat their injuries, which consisted of 6 tracheotomies and 3 instances of suture repair.

CONCLUSIONS

The most commonly reported types of soft tissue injury included edema and perforation, followed by laceration. Increased awareness of device-related patient injuries associated with NIM endotracheal tubes can be used to better inform surgeons and anesthesiologists during the process of intubation and surgical decision-making.

State of the Art in Robotic Surgery with Hugo RAS System: Feasibility, Safety and Clinical Applications

Since its introduction in the early 2000s, robotic surgery has represented a significative innovation within a minimally invasive surgery approach. A variety of robotic platforms have been made available throughout the years, and the outcomes related to those platforms have been described in the literature for many types of surgeries. Medtronic's HugoTM RAS system is one of the newest robotic generations launched, but because of its recent placing on the field, comprehensive clinical data are still lacking. The aim of the present state of the art is to address the current literature concerning the use of the HugoTM RAS robot in order to report its feasibility, safety and clinical applications in different surgical branches. Two reviewers independently conducted a search on the "PubMed" electronic database, using the keywords "Hugo" and "Hugo RAS". After the initial screening of 35 results, a total of 15 articles concerning the Hugo RAS system were selected for the review, including both oncological and benign surgery. Patients' demographic and baseline data were compared including, when available, docking system times, complications and oncological outcomes in the fields of urologic, gynecologic and general surgery. With reference to urological procedures, a total of 156 robot-assisted radical prostatectomies, 10 robot-assisted partial nephrectomies, and 5 robot-assisted adrenalectomies were performed, involving a total of 171 patients. The surgical branch in which the Hugo system found its major application was urology, which was followed by gynecology and general surgery. The Hugo RAS system by Medtronic represents an innovative and safe surgical platform, with excellent perspective for the future and different clinical applications in many surgical branches. More studies are needed to validate the safety and results from this new robotic platform.

Clinical evaluation of two adult oxygenator systems in terms of mortality and major adverse events

PURPOSE

The primary aim of this study was to examine the effects of two oxygenator systems on major adverse events and mortality.

METHODS

A total of 181 consecutive patients undergoing coronary artery bypass grafting in our clinic were retrospectively analyzed. The patients were divided into two groups according to the oxygenator used: Group M, in which a Medtronic Affinity (Medtronic Operational Headquarters, Minneapolis, MN, USA) oxygenator was used, and Group S, in which a Sorin Inspire (Sorin Group Italia, Mirandola, Italy) oxygenator was used.

RESULTS

Group S consisted of 89 patients, whereas Group M included 92 patients. No statistically significant differences were found between the two groups in terms of age (p = .112), weight (p = .465), body surface area (p = .956), or gender (p = .484). There was no statistically significant difference in hemorrhage on the first or second postoperative day (p = .318 and p = .455, respectively). No statistically significant differences were observed in terms of red blood cell (p = .468), fresh frozen plasma (p = .116), or platelet concentrate transfusion (p = .212). Infections, wound complications, and delayed sternal closure were significantly more common in Group M (p = .006, p = .023, and p = .019, respectively). Extracorporeal membrane oxygenators and intra-aortic balloon pumps were required significantly more frequently in Group S (p = .025 and p = .013, respectively). Major adverse events occurred in 16 (18%) patients in Group S and 14 (15.2%) patients in Group M (p = .382). Mortality was observed in six (6.7%) patients in Group S and three (3.3%) patients in Group M (p = .232). No statistically significant difference was found between the two groups in terms of length of hospital stay (p = .451).

CONCLUSION

The clinical outcomes of the two oxygenator systems, including mortality, major adverse events, hemorrhage, erythrocyte and platelet transfusions, and length of hospital stay, were similar.

Surgical placement of implantable cardiac loop recorders in great apes

Cardiovascular disease is the leading cause of morbidity and mortality in zoologically managed adult great apes, accounting for 29%-77% of adult deaths in the North American population depending on the species. In an effort to better understand the underlying causes of heart disease, implantable loop recorders (ILRs) have been used in some cases to monitor great apes with suspected or known cases of arrhythmia. This is a 10-year review of the Great Ape Heart Project's experience of implanting 21 ILRs in 7 gorillas (Gorilla gorilla gorilla; 9 total ILR devices), 5 chimpanzees (Pan troglodytes, 11 total ILR devices), and 1 orangutan (Pongo abelii, 1 ILR device) in an effort to develop effective methods for surgical implantation and remote collection of the data for analysis.

Comparison of Cgmanalysis, a Free Open-Source Continuous Glucose Monitoring Data Management and Analysis Software, with Commercially Available CGM Platforms: Data Standardization for Diabetes Technology Research

Background: Cgmanalysis is an open-source software based on the R programming language for data management and descriptive analysis of data from continuous glucose monitoring (CGM). We sought to validate the summary measures calculated by cgmanalysis against the results from proprietary software associated with four CGM commercially available models. Methods: Two weeks of data from 188 patients with type 1 diabetes using commercially available CGMs. Freestyle Libre Gen 1 (n = 53), Medtronic Guardian 3 (n = 52), Dexcom G6 reported by Dexcom Clarity (n = 48), and Dexcom G6 reported by Tandem (n = 35) were analyzed using proprietary software and cgmanalysis. Agreement was assessed using scatterplots, Bland-Altman plots, and equivalence tests. Results: Good agreement was obtained for all glycemic summary measures for all CGMs assessed. None of the differences between the cgmanalysis package and the manufacturers' software were outside the prespecified bounds of equivalence. Conclusions: Cgmanalysis is a validated open-source software to analyze commercially available CGM data and can be used to standardize diabetes technology research.

Gender Differences after Transcatheter Aortic Valve Replacement (TAVR): Insights from the Italian Clinical Service Project

Background: TAVR is a safe alternative to surgical aortic valve replacement (SAVR); however, sex-related differences are still debated. This research aimed to examine gender differences in a real-world transcatheter aortic valve replacement (TAVR) cohort. Methods: All-comer aortic stenosis (AS) patients undergoing TAVR with a Medtronic valve across 19 Italian sites were prospectively included in the Italian Clinical Service Project (NCT01007474) between 2007 and 2019. The primary endpoint was 1-year mortality. We also investigated 3-year mortality, and ischemic and hemorrhagic endpoints, and we performed a propensity score matching to assemble patients with similar baseline characteristics. Results: Out of 3821 patients, 2149 (56.2%) women were enrolled. Compared with men, women were older (83 ± 6 vs. 81 ± 6 years, p < 0.001), more likely to present severe renal impairment (GFR ≤ 30 mL/min, 26.3% vs. 16.3%, p < 0.001) but had less previous cardiovascular events (all p < 0.001), with a higher mean Society of Thoracic Surgeons (STS) score (7.8% ± 7.1% vs. 7.2 ± 7.5, p < 0.001) and a greater mean aortic gradient (52.4 ± 15.3 vs. 47.3 ± 12.8 mmHg, p < 0.001). Transfemoral TAVR was performed more frequently in women (87.2% vs. 82.1%, p < 0.001), with a higher rate of major vascular complications and life-threatening bleeding (3.9% vs. 2.4%, p = 0.012 and 2.5% vs. 1.4%, p = 0.024). One-year mortality differed between female and male (11.5% vs. 15.0%, p = 0.002), and this difference persisted after adjustment for significant confounding variables (Adj.HR1yr 1.47, 95%IC 1.18–1.82, p < 0.001). Three-year mortality was also significantly lower in women compared with men (19.8% vs. 24.9%, p < 0.001) even after adjustment for age, STS score, eGFR, diabetes and severe COPD (Adj.HR3yr 1.42, 95%IC 1.21–1.68, p < 0.001). These results were confirmed in 689 pairs after propensity score matching. Conclusion: Despite higher rates of peri-procedural complications, women presented better survival than men. This better adaptive response to TAVR may be driven by sex-specific factors.

Competing Robotic Systems: A Preview

"The new frontier of robotic surgery is well under way. Current research and development is rapidly progressing, allowing for the creation of many new robotic companies. Each company has its own identity and platform for what their vision for the future entails. The competition generated between these companies will shortly be forcing newer, cheaper, more accessible robotic systems worldwide."

Unexpected high failure rate of a specific MicroPort/LivaNova/Sorin pacing lead

BACKGROUND

Pacing leads are the Achilles heel of pacemakers. Most manufacturers report a 3-year survival rate of >99% of their leads. We observed several failures of the Beflex/Vega leads (MicroPort, Shanghai, China; formerly Sorin/LivaNova).

OBJECTIVE

The purpose of this study was to investigate failure rates of Beflex/Vega leads.

METHODS

We analyzed the performance of Beflex/Vega leads implanted at our tertiary referral center. All-cause lead failures (any issues requiring reinterventions such as lead dislocations, cardiac perforations, and electrical abnormalities) were identified during follow-up. The Beflex/Vega lead was compared with a reference lead (CapSureFix Novus 5076, Medtronic, Minneapolis, MN) implanted within the same period and by the same operators.

RESULTS

A total of 585 leads were analyzed (382 Beflex/Vega and 203 CapSureFix Novus 5076 leads). Cumulative failure rate estimates were 5.2%, 6.3%, and 12.4% after 1, 2, and 3 years for the Beflex/Vega lead. This was worse compared to the reference lead (1.5%, 1.5%, 3.7% after 1, 2, and 3 years; P = .001). Early failure manifestations up to 3 months occurred at a similar rate (Beflex/Vega vs CapSureFix Novus 5076 lead: 1.3% vs 0.5% for dislocations; 1.3% vs 1.0% for perforations). During follow-up, electrical abnormalities such as noise oversensing (P = .013) and increased pacing thresholds (P = .003) became more frequent in the Beflex/Vega group. Electrical abnormalities were the most common failure manifestation 3 years after implantation in this group (9.4% vs 2.2% for the CapSureFix Novus 5076).

CONCLUSION

The failure rate of the Beflex/Vega lead of >10% after 3 years was higher than that of a competitor lead. This gives rise to concern since >135,000 such leads are active worldwide.

Evolution and clinical adoption of the Autologs system: An automated analysis for enhanced patient management in MCS

The Medtronic Autologs System allows real-time clinician review of HeartWare HVAD System logfiles, providing supplemental pump data to aid in patient management. In its first year of availability, Autologs generated a 70% increase in logfile submissions, with 73% of all logfile requests being sent to Autologs. Within a month of its launch, Autologs submissions outnumbered the amount of logfiles submitted for manual review. Following the v1.1 release, there was a 20% increase in logfile submissions, with 77% of all logfile requests being Autologs. With the introduction of v1.2, there was another 35% increase in logfile submissions, with nearly 90% of all logfile requests being Autologs. The widespread adoption and utility of the Autologs System highlights the need for clinician access to real-time data analysis in the field of Mechanical Circulatory Support.

Transcatheter Aortic Valve Replacements: Current Trends and Future Directions

Since the 1960s when the first aortic surgical aortic valve replacement (SAVR) was performed, continuous growth in the field of valvular technology has occurred. Although SAVR remains a lifesaving procedure, minimally invasive transcatheter aortic valve replacement has revolutionized and expanded aortic valve replacement to patients who were not previously SAVR candidates, increasing their quality of life and survival. Since its introduction in the United States in 2011, the technology and practice have rapidly expanded. Hybrid techniques have been developed that combine surgical access to the vasculature with valvular deployment over transcatheter systems. This literature review aims to describe the differences between the current available valve technologies, review approaches to surgical technique, discuss anesthetic considerations, and look forward to future directions, trends, and challenges.

An In-Vitro Study Comparing the GME Handling of Two Contemporary Oxygenators

Gaseous microemboli (GME) are a potential complication of cardiopulmonary bypass (CPB). Though it is difficult to prove that GME is the only major cause of neurological deficits, it may increase the chance of post-operative cognitive dysfunction if not removed. The objectives of this research were to compare LivaNova-Sorin Inspire (Inspire) oxygenator with a Medtronic arterial filter to the Medtronic Fusion (Fusion) oxygenator with and without a Medtronic arterial filter based on each system's ability to handle GME. The Inspire and Fusion systems were evaluated in vitro. GME handling was observed by introducing air in the sampling manifold connected to the venous return at a 60 mL bolus or 1 liter per minute (LPM). The emboli detection and classification (EDAC) system measured GME preand post-oxygenator/arterial filter. The Inspire with a filter was able to remove a statistically significant greater amount of total emboli per second during the 60 mL bolus and 1 LPM tests than the Fusion with and without an arterial filter. The Inspire with an arterial filter was more efficient in removing GME during a 60 mL bolus and 1 LPM than the Fusion and Fusion with an arterial filter. However, the Fusion with an arterial filtered performed better than the Fusion system without the arterial filter.

Effects on radiation oncology treatments involving various neuromodulation devices

OBJECT

Where no society-based or manufacturer guidance on radiation limits to neuromodulation devices is available, this research provides the groundwork for neurosurgeons and radiation oncologists who rely on the computerized treatment plan clinically for cancer patients. The focus of the article is to characterize radiation parameters of attenuation and scatter when an incident therapeutic x-ray beam is directed upon them. At the time of this writing, manufacturers of Neuromodulation products do not recommend direct exposure of the device in the beam nor provide guidance for the maximum dose for these devices.

METHODS

Ten neuromodulation models were chosen to represent the finite class of devices marketed by Medtronic before 2011. CT simulations permitted computer treatment modeling for dose distribution analysis as used routinely in radiation oncology for patients. Phantom case results were directly compared to actual clinical patient cases. Radiation detection measurements were then correlated to computational results. Where the x-ray beam passes through the device and is attenuated, dose reduction was identified with Varian Eclipse computer modeling for these posterior locations.

RESULTS

Although the computer algorithm did not identify physical processes of side-scatter and back-scatter, these phenomena were proven by radiation measurement to occur. In general, the computer results underestimated the level of change seen by measurement.

CONCLUSIONS

For these implantable neurostimulators, the spread in dose changes were found to be -6.2% to -12.5% by attenuation, +1.7% to +3.8% by side-scatter, and +1.1% to +3.1% by back-scatter at 6 MV. At 18 MV, these findings were observed to be -1.4% to -7.0% by attenuation, +1.8% to 5.7% by side-scatter, and 0.8% to 2.7% by back-scatter. No pattern for the behavior of these phenomena was deduced to be a direct consequence of device size.