bluuebunny/crossref_metadata_2025 huggingface dataset:
Job Analysis and Student Assessment Tool: Perfusion Education Clinical Preceptor
Authors: Riley Jeffrey B.
Published: July 2023

The perfusion education system centers on the cardiac surgery operating room and the perfusionist teacher who serves as a preceptor for the perfusion student. One method to improve the quality of perfusion education is to create a valid method for perfusion students to give feedback to clinical teachers. The preceptor job analysis consisted of a literature review and interviews with preceptors to list their critical tasks, critical incidents, and cognitive and behavioral competencies. Behaviorally anchored rating traits associated with the preceptors’ tasks were identified. Students voted to validate the instrument items. The perfusion instructor rating instrument with a 0–4, “very weak” to “very strong” Likert rating scale was used. The five preceptor traits for student evaluation of clinical instruction (SECI) are as follows: The clinical instructor (1) encourages self-learning, (2) encourages clinical reasoning, (3) meets student’s learning needs, (4) gives continuous feedback, and (5) represents a good role model. Scores from 430 student–preceptor relationships for 28 students rotating at 24 affiliate institutions with 134 clinical instructors were evaluated. The mean overall good preceptor average (GPA) was 3.45 ± 0.76 and was skewed to the left, ranging from 0.0 to 4.0 (median = 3.8). Only 21 of the SECI relationships earned a GPA <2.0. Analyzing the role of the clinical instructor and performing SECI are methods to provide valid information to improve the quality of a perfusion education program.
Oxygenation Failure During Cardiopulmonary Bypass Prompts New Safety Algorithm and Training Initiative
Authors: Webb David P. , Deegan Robert J. , Greelish James P. , Byrne John G.
Published: July 2023

Developing new strategies to improve patient safety and risk reduction is fundamental to hospital and patient success. Currently, there is a tendency in hospital safety management to focus solely on human error rather than organizational and educational causes that contribute to medical accidents. Although health care providers are the primary safety systems in medical facilities, there must be a more global, perhaps automated, approach using modern technology to prevent or reduce medical mishaps. Herein, we present an oxygenation failure with root cause analysis that prompted a new oxygenation safety algorithm and multi-service training initiative.
In Vitro Drug Adsorption and Plasma Free Hemoglobin Levels Associated With Hollow Fiber Oxygenators in the Extracorporeal Life Support (ECLS) Circuit
Authors: Preston Thomas J. , Hodge Ashley B. , Riley Jeffrey B. , Leib-Sargel Cheryl , Nicol Kathleen K.
Published: July 2023

The purpose of this study was to identify the percentage of fentanyl or morphine sulfate lost from adhesion to either the polyvinylchloride (PVC) tubing or the surface of two different hollow fiber oxygenators used in current extracorporeal life support circuits and to identify any difference in the plasma free hemoglobin (PFH) levels generated when using these oxygenator and/or drug combinations. For each drug examined, six simple circuits were assembled; for each drug, two circuits contained tubing without an oxygenator (control), two circuits contained the Jostra Quadrox D (Maquet Cardiopulmonary, AG Hirrlingen, Germany), and two circuits contained the Terumo Baby Rx (Terumo Cardiovascular Systems Corp., Ann Arbor, MI). Fentanyl or morphine sulfate was added to yield initial circuit concentrations equal to 1430 ng/mL, respectively. Throughout the 6-hour in vitro testing, samples to evaluate the drug and PFH levels were drawn at various time intervals. Significance in this study is defined as p < .05. Fentanyl’s initial adsorption seems to be 80% in circuits without oxygenators, 86% in the circuits containing the Quadrox D oxygenator, and 83% in the circuits with the Baby Rx oxygenator. Morphine sulfate seems to be initially adsorbed at a rate of 40% in all circuits and does not seem to be adsorbed by either of the tested oxygenators. The PFH levels were significantly (p < .05) elevated in the fentanyl circuits. The type of oxygenator does not seem to play a significant role in drug adsorption. During this in vitro study, the majority of both drugs were lost to the PVC tubing. The type of oxygenator did not seem to significantly affect PFH. However, fentanyl in any combination or alone was associated with increased PFH levels.
An Analysis of Perfusion Technology Preadmission Factors Effects on Academic Success, Perfusion Certification Achievement, and Career Placement
Authors: Palmer David A.
Published: July 2023

This retrospective study was designed to evaluate the contribution of grade point average (GPA) and the Wechsler Adult Intelligence Scale-Revised (WAIS-R) practical scores toward predicting perfusion academic success, career placement as a clinical perfusionist, and certification success or failure. The files of 95 students enrolled in the perfusion technology program at Carlow University-University of Pittsburgh Medical Center School of Cardiovascular Perfusion (CARLOW-UPMC) from 1995 through 2005 were reviewed to obtain admission and academic data. The independent variables used were WAIS-R practical results of the picture completion (PC), picture arrangement (PA), block design (BD), object assembly (OA) and digit symbol (DS) tests, undergraduate grade point average (UGPA), science grade point average (SGPA), and anatomy and physiology grade point average (APGPA). The dependent variables used were perfusion grade point average (PGPA), career placement status as a clinical perfusionist (CAREER), and success or failure on the American Board of Cardiovascular Perfusion (ABCP) certification examination. The research plan consisted of logistic and multiple linear regression analyses to determine which of the WAIS-R and GPA independent variables were significantly associated with the dependent variables. UGPA, SGPA, and APGPA all correlate at the 5% level with success achieving high PGPA. WAIS-R measures were not significant indicators of academic success. PGPA, UGPA, SGPA, and APGPA did not significantly correlate with any of the tested WAIS-R scores. PC, BD, and OA scores correlate well with CAREER. OA and DS scores correlate at thep= 0.05 level with ABCP certification success.
Cannulae and Cell Saver Design: Do They Make a Difference?
Authors: Stump David A.
Published: July 2023

In the evolution of cardiopulmonary bypass (CPB), it is becoming increasing obvious that minimizing microembolization is critical in protecting the brain. Every component of the CPB circuit and ancillary apparatus must be evaluated and, if necessary, re-engineered with the reduction of microemboli a major focus. Cardiotomy suction has been identified as a major source of lipid microemboli. However, is the alternative blood treatment apparatus, the cell saver, capable of reducing the lipid embolic load and are all cell savers equally efficient? In the event that microemboli do make it to the aorta, is it possible to divert them away from the brain to more robust vascular beds through clever design of the aortic cannula? Is the venous cannula a source of microgaseous emboli? The answer is yes to both questions. Emboli can be directed away from the brain by the positioning and design of the aortic cannula and the venous cannulae may be a source of gaseous microemboli delivered to the oxygenator by the venous line but careful practice will prevent this type of embolic formation.
Deformable Emboli and Inflammation: Temporary or Permanent Damage?
Authors: Stump David A.
Published: July 2023

Neurologic sequelae after cardiopulmonary bypass have a multi-factorial etiology. Although it is typically thought that a neurologic dysfunction means a focal lesion, symptoms of a brain disorder can be initiated by metabolic disruption such as from hyper- or hypoglycemia, hypercalcemia, renal and hepatic injury, fatigue, and anesthesia. However, one of the most important causes of acute neurologic dysfunction is edema. Brain swelling is associated with the systemic inflammatory response and the passage of deformable microemboli. The larger question is whether acute symptoms associated with brain swelling because of a breakdown of the blood-brain barrier contributes to a long-term negative outcome caused by cell loss.
Pharmacologic Neuroprotection: The Search Continues
Authors: Grocott Hilary P.
Published: July 2023

Dozens of drugs have been studied in an attempt to mitigate the adverse cerebral consequences of cardiac surgery. The targets for these drugs have focused on pathways identified through the cascade of events that occurs once cerebral ischemia is initiated. In addition, inflammatory targets specific to cardio-pulmonary bypass have also been addressed. Although no drugs are yet approved as specific neuroprotective agents, trials continue of increasingly unique targets, with fewer unwanted side effects and acting through novel mechanisms of action. This review summarizes the past, present, and future of pharmacologic neuroprotection for cardiac surgery.
Twenty Years Trying to Protect the Brain: What Do We Know?
Authors: Stump David A.
Published: July 2023

Thirty-five years ago at the Nixon Watergate hearings, a young attorney named Fred Thompson, current US presidential candidate, asked “What did the President know and when did he know it?” A couple of word changes and this question would be appropriate to ask any number of surgical specialties regarding negative neurologic outcomes. Even today, some specialties are in denial about impaired brain function after surgical intervention. Fortunately, the cardiac surgery community has been in the forefront in efforts to protect the brain.
Lusitrophic Effects of Dobutamine in Young and Aged Mice In Vivo
Authors: Hirleman Emily D. , Yu Qianli , Larson Douglas F.
Published: July 2023

Aged individuals have impaired diastolic relaxation–lusitropic function. Dobutamine, a selective B1-adrenergic agonist, is used to augment systolic cardiac function at the termination of cardiopulmonary bypass (CPB). However, our question is whether dobutamine will also enhance the lusitropic function in the aged individual. The myocyte mechanism for the rate of ventricular relaxation is dependent on the velocity of calcium removal from the myocyte contractile elements by sarcoplasmic reticulum (SR) Ca2+–ATPase (SERCA2a), which is regulated by an inhibitory protein, phospholamban (PLB). Ventricular tissues harvested from young (4 month) and aged (20 months) mice were analyzed to compare the protein levels of SERCA2a and PLB with immunoblot and gene expression for PLB with reverse-transcriptase-polymerase chain reaction. The molecular analyses were compared with in vivo left ventricular function in the young and old mice before and during an intravenous infusion of dobutamine (5 μg/kg/min). The SERCA2a levels were not different between the groups; however, there was a 2-fold increase in PLB in the aged group compared with the young group (p< .05). The gene expression for PLB was increased by 5-fold in the aged group compared with the young group (p< .01). There were significant differences between the young and aged groups related to the lusitropic parameters, tau (τ) and dP/dtmin, and dobutamine infusion increased these parameters in the aged group to that of the young group. This report supports the concept that altered PLB levels correspond with the respective lusitropic function and that dobutamine administration in the aged group increased lusitropic function that was comparable with the young group. Because the patient population requiring CPB is aging, these data suggest that the use of dobutamine at the terminal phase of CPB is warranted to increase systolic and diastolic function.
A Novel Calculation to Estimate Blood Volume and Hematocrit During Bypass
Authors: Trowbridge Cody , Stammers Alfred , Klayman Myra , Brindisi Nicholas
Published: July 2023

Patient blood volume impacts most facets of perfusion care, including volume management, transfusion practices, and pharmacologic interventions Unfortunately, there is a wide variability in individual blood volumes, and experimental measurement is not practical in the clinical environment. The purpose of this study was to evaluate a mathematical algorithm for estimating individual blood volume. After institutional review board approval, volumetric and transfusion data were prospectively collected for 165 patients and applied to a series of calculations. The resultant blood volume estimate (BVE) was used to predict the first and last bypass hematocrit. The estimated hematocrits using both BVE and 65 mL/kg were compared with measured hematocrits using the Pearson moment correlation coefficient and the Bland Altman measures of accuracy and precision. There was a wide range of BVE (minimum, 35 mL/kg; mean ± SD, 64 ± 22 mL/kg; maximum, 129 mL/kg). Using BVE, the estimated hematocrit was similar to the measured first (24.7 ± 6.4% vs. 24.5 ± 6.2%, r = 0.9884, p > .05) and last (24.5 ± 5.9% vs. 25.1 ± 5.7%, r = 0.9001, p > .05) bypass hematocrit. Using 65 mL/kg resulted in a larger difference between estimated and measured hematocrits for the first (25.6 ± 4.5% vs. 24.5 ± 6.2%, r = 0.6885, p = .030) and last (23.8 ± 3.6% vs. 25.1 ± 5.7%, r = 0.5990, p = .001) bypass hematocrits. Compared with using 65 mL/kg for blood volume, the BVE allowed for a more precise estimated hematocrit during CPB.
Characteristics of Uncontrolled Hemorrhage in Cardiac Surgery
Authors: Trowbridge Cody , Stammers Alfred , Klayman Myra , Brindisi Nicholas , Woods Edward
Published: July 2023

Patients with uncontrolled hemorrhage require massive transfusion therapy and consume a large fraction of blood bank resources. Institutional guidelines have been established for treatment, but early identification and prevention in susceptible patients remains challenging. Uncontrolled hemorrhage was defined as meeting institutional guidelines for recombinant FVIIa administration. Patients who received rFVIIa were compared with patients who did not require the therapy but who were operated on during the same time period. After institutional review board approval, demographic, operative, and transfusion data were analyzed from a prospective database. Patients receiving rFVIIa were more likely to undergo multiple procedures (2.6 ± 0.8 vs. 1.8 ± 0.8; p < .001); aortic surgery (59% vs. 11%; p < .005); have a higher Cleveland Clinic Clinical Severity score (7.8 ± 2.7 vs. 5.5 ± 4.0; p < .005); require longer bypass (265 ± 92 min vs. 159 ± 63 min; p < .001), cross-clamp (182 ± 68 min vs. 112 ± 56 min; p < .001), and circulatory arrest (15 ± 24 minvs.2±7 min; p < .05) times; and require more autotransfusion (2580 ± 1847 mL vs. 690 ± 380 mL; p < .05). Uncontrolled hemorrhage is associated with more complex surgery requiring longer bypass times and more autotransfusion.
Does a Delay in Performing an Activated Clotting (ACT) Test Really Matter? A Study in Nonheparinized Blood and a Single ACT Machine
Authors: Philip Bridget M. , Brock-Utne John G. , Lemmens Harry J.M. , Jaffe Richard A. , Shuttleworth Paul E.
Published: July 2023

Activating clotting time (ACT) is a point-of-care, blood clotting test used to monitor anticoagulation. Recently, institutional requirements have required that ACT testing be completed outside the operating room with trained, certified personnel other than anesthesia staff. For this reason, in this study, we looked at whether a delay in processing an ACT makes a significant difference to the ACT results. Twenty patients between 18 and 65 years of age consented to the study, each undergoing non-cardiac surgery, with no intraoperative administration of heparin. The study was approved by our Institutional Review Board. A blood sample was taken from the patient’s arterial line in the operating room. Immediately afterward, 1 mL was placed into each of two ACT cartridges and the measurement was done in a Medtronic ACT2 machine. The first ACT value was 126.9 ± 14.5 seconds. The ACT value at −30 minutes was 108.3 ± 20.3 seconds (p< .0001). The time between the first and last measurements was 29.4 ± 3.0 minutes. The results suggest that the ACT values decrease over time between sampling all measurements. At −30 minutes, the ACT values average 15% less than the control measurements. Therefore, it would seem prudent to determine ACT values immediately in the operating room without any delay, using point-of-care testing.
Platelet Hyperreactivity in Response to On- and Off-pump Coronary Artery Bypass Grafting
Authors: Bochsen Louise , Rosengaard Lisbeth Bredahl , Nielsen Allan Bybeck , Steinbrüchel Daniel A. , Johansson Pär I.
Published: July 2023

Hypercoagulability has been reported after off-pump coronary artery bypass grafting (OPCAB) compared with patients undergoing standard coronary artery bypass grafting (CABG) with cardiopulmonary bypass. The aim of this study was to evaluate the changes in platelet reactivity in response to cardiac surgery, both OPCAB and CABG. Platelet reactivity was monitored pre- and postoperatively (days 1 and 4) in elective OPCAB (n = 29) and CABG (n = 24) patients using the maximal amplitude (MA) parameter obtained with thrombelastography. Platelet reactivity was also examined at 1 month in 30 of the 53 patients. Twenty-three percent of the patients (12/53) had a preoperative MA value above normal reference value (MA > 69 mm). By postoperative day 4, 88% of the patients presented with an MA > 69 mm, and significant increases in MA were shown in both groups (p < .0001). Of the 30 patients examined at 1 month after surgery, 75% of the patients with high preoperative MA (6/8) remained at this level. In contrast, only 4.5% of patients with normal preoperative MA (1/22) presented with high MA at day 30. MA has previously been shown to correlate with the incidence of thrombotic and ischemic complications and this study identified 23% of patients needing coronary bypass surgery to be at high risk for recurrent ischemic events at 1 month after surgery, based on the MA. These results suggest that a more aggressive antithrombotic treatment might be warranted for patients undergoing coronary artery bypass grafting, both OPCAB and CABG, presenting with a high MA pre- and post-surgery.
Optimizing Circuit Design Using a Remote-mounted Perfusion System
Authors: Kulat Bradley , Zingle Neale
Published: July 2023

There is a considerable amount of literature published on the detrimental effects of banked blood exposure in cardiac surgery. Likewise, in an effort to minimize blood exposure, many of these articles involve modifications to the heart-lung machine or its components to reduce priming volumes, therefore decreasing the need for banked blood administration caused by hemodilution. In this study, using Terumo’s System 1 Advanced Heart-Lung machine, all the pump heads were remotely mounted off the pump base closer to the patient and to all the pump components. For example, cardioplegia, ultrafiltration, and vent and cardiotomy lines are now close to the oxygenator and to the patient, minimizing any excess tubing length. Cardiopulmonary bypass (CPB) blood use and priming volumes were compared before and after changing from a fixed perfusion system to a remote-mounted perfusion system using the same disposables and protocols. The mean differences of pump prime and CPB blood use were compared in four weight classes. In the 8- to 12-kg class, blood use was reduced from 1.84 ± 0.55 to 1.10 ± 0.36 units. Priming volume was reduced from 751.2 ± 68.4 to 360.4 ± 51.7 mL. In the 13- to 20-kg class, blood use was reduced from 1.80 ± 0.42 to 1.04 ± 0.28 units. Priming volume was reduced from 829.6 ± 69.6 to 476.± 81.4 mL. In the 21- to 40-kg class, blood use was reduced from 1.60 ± 0.57 to 0.92 ± 0.49 units. Priming volume was reduced from 994.0 ± 137.2 to 713.6 ± 121.8 mL. In the 41+-kg class, blood use was reduced from 1.62 ± 0.88 to 0.42 ± 0.54 units. Priming volume reduced from 1306.3 ± 112.9 to 875.5 ± 96.6 mL. In conclusion, using a remote-mounted perfusion system resulted in reducing priming volumes and also significantly decreased the need for banked blood, subsequently saving the patient excessive exposure to banked blood.
Massive Carbon Dioxide Gas Embolism: A Near Catastrophic Situation Averted by Use of Cardiopulmonary Bypass
Authors: Mohamed Hasratt , Zombolas Theodore , Schultz John , Krzyzewski Mike , Metcalf Randy , Yuskevich Brian , Ginsburg Edo
Published: July 2023

Endovascular vein harvesting is used as a less invasive method when compared to the standard open surgical method of dissecting and procurement of the greater saphenous vein. The benefits include smaller incision, decreased blood loss, less pain, decreased transfusion, decreased risk of infection and enhanced epidermal cosmetics. However, endovascular vein harvesting does have a learning curve to master the technique and although endovascular vein harvesting is the preferred standard of practice over the open surgical technique, it does have inherent potential complications. During endovascular vein harvesting, there is a potential for the patient’s circulatory system to collapse which can be identified initially through hemodynamic monitoring, blood gas results, and vigilance through clinical observation. The suspected source of the crisis was confirmed when the surgeon cannulated the right atrium, where a massive gas source that (appeared pressurized) escaped upon incision of the right atrial appendage. Cardiopulmonary bypass (CPB) was utilized to support the patient and rectify the impending catastrophic event. Once full CPB was attained, we achieved hemodynamic stability and eventually all blood gases were normalized. Massive CO2 embolism is a life threatening emergency which must be identified and corrected instantaneously. CPB was the modality used to salvage this situation. Attention to the set-up of the EVH equipment, use of the transesophageal echocardiography, cerebral cximetry, vigilance and cooperation of all disciplines in the OR are definite recommendations to prevent such an occurrence. Experience gained by the perfusion team with a previous case was applied and helped to solve the immediate problems presented in this case.
Perfusion Preservation of the Donor Heart: Basic Science to Pre-Clinical
Authors: Rivard Andrew L. , Gallegos Robert , Ogden Irene M. , Bianco Richard W.
Published: July 2023

As a consequence of technology improvements and refinement, perfusion of the donor heart has moved from the research laboratory to clinical studies. Multiple investigators are currently leading pre-clinical trials of devices using perfusion preservation, and one device is now in European clinical trials. One major problem with the donor heart is the high metabolism relative to other organs, and depletion of ATP leads rapidly to acidosis and necrosis of the myocardium. Two techniques in development to address the issue are normothermic and hypothermic perfusion. This review examines the current issues regarding donor heart preservation and techniques of pre-clinical evaluation necessary for regulatory approval.
Concomitant Repair of Mitral Valve Papillary Muscle Rupture and Tricuspid Valve Avulsion in a Pediatric Patient after a Motor Vehicle Collision
Authors: Hodge Ashley , Forbus Geoff , Hsia Tain Yen
Published: July 2023

We report the case of an 8-year-old patient with severe acute mitral regurgitation and tricuspid regurgitation after a motor vehicle collision caused by traumatic injuries of the supporting structures of both valves. An echocardiogram showed avulsion of the posteromedial papillary muscle of the mitral valve and a severely prolapsed anterior tricuspid valve leaflet. In addition, there was a near-complete defect in the left ventricular side of the interventricular septum, with diffuse hematoma of the akinetic septal muscle. After emergency mitral and tricuspid valve repairs, consisting of re-implantation of the posteromedial papillary muscle and anterior tricuspid leaflet chordal support, the patient completely recovered with no residual valvular pathology.
Anesthetic Vaporizer Mount Malfunction Resulting in Oxygenation Failure after Initiating Cardiopulmonary Bypass: Specific Recommendations for the Pre-Bypass Checklist
Authors: Gautam Nischal K. , Schmitz Michael L. , Zabala Luis M. , White Michael W. , Mckamie Wesley A. , Lutz Alyssa , Johnson Charles E.
Published: July 2023

Modern technologic advances in medicine have allowed commonly used machines to perform safely with very low risk and a high degree of success. To detect or prevent poten-tial malfunctions, professionals routinely perform pre-use checks for equipment such as anesthesia machines and cardiopulmonary bypass (CPB) machines. These machine checklists are not only critical for a safe operation but also have large impacts on outcomes. For example, when malfunctions are encountered that could have potential negative ramifications or adverse outcomes, multi-approach strategies should be used to identify rectifiable causes and find solutions that are practical. This information can be used to promulgate safe practice guidelines. This case report identifies a machine-based contributing factor to precipitous hypoxia on initiation of bypass in one of our patients. After a detailed approach to identify preventable root causes, we made simple additions to our pre-bypass checklist and recom mend these changes to other institutions.
A Review of Antiplatelet Drugs, Coronary Artery Diseases and Cardiopulmonary Bypass
Authors: Ren Yajun , Patel Kirti , Crane Terry
Published: July 2023

Platelets play a major role in the thromboembolic diseases and upon vascular injury, especially arterial vascular injury. These platelets rapidly adhere to the exposed subendothelial area, where they become activated by contacting with stimulants. Antiplatelet therapy remains extremely important in treatment and prophylaxis of arterial thromboembolic disorders such as coronary arterial diseases and stroke. The antiplatelet drugs (APDs) are among the most widely used in the world. Based on the molecular targets, APDs are classified as Thromboxane A2 pathway blockers, ADP receptor antagonists, GPIIa/IIIb antagonists, adenosine reuptake inhibitors, phosphodiesterase inhibitors, thrombin receptor inhibitors, and others. Coronary artery bypass graft (CABG) surgery is an important therapeutic approach to treat coronary artery disease. Long-term success after CABG depends on the patency of the bypass vessels. Since platelets play a crucial role in the pathogenesis of thrombosis in the blood vessels, APDs are broadly used to reduce serious cardiovascular events. Platelets also are an integral part of inflammation and APDs have demonstrated to reduce the inflammation mediators in the healthy volunteers and coronary artery disease patients; it will be an interesting topic to determine if platelet inhibition will attenuate CPB-induced systemic inflammatory response syndrome. Due to concerns of post-op bleeding with use of APDs, it is a common practice to withhold APDs prior to surgery; however, recent studies have demonstrated that continuation of APDs prior to surgery (even until the day of surgery) does not increase the risk of post-op bleeding. With extensive use of APDs in cardiovascular thromboembolic events, APD resistance becomes problematic in clinical antiplatelet therapy. Since there is no standardized or universal definition available to quantify APDs resistance, a clinically meaningful definition of APD resistance needs to be developed based on data linking laboratory tests to clinical outcomes in patients.
An In-Vitro Comparison between Hemobag® and Non-Hemobag® Ultrafiltration Methods of Salvaging Circuit Blood Following Cardiopulmonary Bypass
Authors: Delaney Ed , Rosinski David , Ellis Harvey , Samolyk Keith A. , Riley Jeffrey B.
Published: July 2023

Ultrafiltration of the residual cardiopulmonary bypass circuit blood has become one of the most advantageous procedures to maximize autologous whole blood recovery and coagulation management in cardiovascular surgery. In this invitro study, the Hemobag® technique (HB) was compared to the most common non-Hemobag® method (NHB) of hemoconcentrating residual circuit blood. The residual bovine blood from 10 identical extracorporeal circuits was processed by the recirculating HB technique or by a venous reservoir NHB concentration method. Blood component concentrations and hemolysis levels were measured before and after processing. The HB method yielded significantly higher hemoglobin, hematocrit, fibrinogen, albumin, and total protein levels in the final product. There was no significant difference in final product platelet and white blood cell counts, or hemolysis index. HB processing times were substantially shorter at all residual circuit volumes tested. The HB technique resulted in significantly less wasted red blood cells at the end of processing. The recirculating HB method to process residual extracorporeal circuit blood is consistent and superior to the most common single pass concentrating method.
Evaluation of Quadrox-i® Adult Hollow Fiber Oxygenator with Integrated Arterial Filter
Authors: Guan Yulong , Su Xiaowei , McCoach Robert , Wise Robert , Kunselman Allen , Ündar Akif
Published: July 2023

Gaseous microemboli (GME) remain a challenge for cardiopulmonary bypass procedures in adult as well as pediatric cardiac surgery patients. The present study tested the effectiveness of a new adult membrane oxygenator in models both with and without an integrated arterial filter to evaluate GME trapping capability and determine membrane pressure drops at various flow rates and temperatures. The experimental circuit included a RotaFlow centrifugal blood pump, Quadrox-i® (n= 8) or Quadrox® (n= 8) adult microporous membrane oxygenator, and Sorin adult tubing package. A Sorin Cardiovascular® VVR® 4000i venous reservoir served as pseudo-patient. The circuit was primed with 900 mL heparinized human red blood cells and 300 mL Lactated Ringer’s solution. The final hematocrit was 36%. Tests were performed at different flow rates (4 L/min, 5 L/min, and 6 L/min) and temperatures (35° and 30°). Five mL of bolus air was injected into the venous line over 15 seconds using a syringe connected to a 3/8 × 1/2 luer connector. The Quadrox-i® adult microporous membrane oxygenator with integrated arterial filter had a similar pressure drop at 4 L/min and 35°C compared with Quadrox® membrane oxygenator whereas it had higher pressure drops at 5 L/min and 6 L/min (p<.001). Quadrox-i® adult microporous membrane oxygenator reduced the total emboli count and total emboli volume delivered to the pseudo-patient at all flow rates (p<.001). The emboli handling of Quadrox-i® adult microporous membrane oxygenator was not affected by flow rate and temperature. Compared with the traditional Quadrox® oxygenator, Quadrox-i® adult microporous membrane oxygenator with integrated arterial filter and Softline coating has improved GME handling capacity.
Evaluation of Basic Perfusion Techniques, ECCSIM-Lite Simulator
Authors: Tokumine Asako , Ninomiya Shinji , Tokaji Megumi , Kurosaki Tatsuya , Tomizawa Yasuko
Published: July 2023

Although serious accidents during extracorporeal circulation are infrequent, potential adverse events with both equipment and operation do still occur and require immediate and well-coordinated responses. Hence, perfusionists need to be well trained in both standard and emergency procedures, and this would be aided by the establishment of an official education and training curriculum. In particular, the establishment of a simulator-based educational program and corresponding evaluation methods will spur development of increasingly medical simulators. Extra-Corporeal Circulation SIMulator (ECCSIM-Lite) was used during repeated sessions of undergraduate students (n= 12) using a simple training scenario. Trainees aimed to maintain reservoir volume around a constant mean, and increase or decrease the arterial flow avoiding rapid variations, and their performance was monitored. Ability to prevent backflow was also recorded as a measure of accomplishment. Skills in performances were evaluated by using a scoring system based on task accomplishment. Accomplishment score was improved in all participants after 1 week of training. Accomplishment scores reflecting ability to maintain flow improved to an average of 78%; in the third and final practice session backflow was prevented in 100% of cases. The average reservoir level maintenance score in the flow-up phase was 75%, in the flow-maintenance phase was 92%, and in the flow-down phase was 58%. During skill training, in which trainees learn methods of avoiding adverse events, the use of simulators combined with tractable skills scores can ease the transition from training session to clinical practice. Use of these training scenarios within a perfusion education system also has the advantage of providing an index of trainees’ current proficiency and improvement by providing tractable skill scores. In conclusion, the use of ECCSIM-Lite simulations, together with evaluation of task accomplishment over repeated training sessions, is an effective method of basic skill training for perfusionists.
Self-priming Hemodynamic Reservoir and Inline Flow Meter for a Cardiopulmonary Bypass Simulation
Authors: Raasch David , Austin Jon , Tallman Richard
Published: July 2023

Simulator exercises are used at Midwestern University to augment academic and laboratory training toward consolidating particular skills, increasing situation awareness, and preparing the student for practice within the team environment of an operating room. This paper describes an enhanced cardiopulmonary bypass simulator consisting of a self-priming hemodynamic reservoir that includes an inline flow meter. A typical cardiopulmonary bypass adult perfusion circuit was assembled using a roller pump console and integrated oxygenator/heat exchanger/reservoir and primed with 2 liters of water. For patient simulation, a soft-sided reservoir bag was mounted onto an inclined platform. A 1-liter soft-sided bag was placed just above the reservoir, providing an overflow reservoir. The priming line extended to the head of the mannequin. The arterial, venous, and suction lines extended through the open chest. The primed perfusion circuit was connected to ports on the filled reservoir bag. To test the patient simulation, the arterial pump output was adjusted to flow rates ranging from 1–7 liters per minute, with a complete interruption (to zero flow) between each test run. An inline flow meter was added to the bypass circuit and an analog to digital converter board was used to pass flow data into the computer-based simulation program. The use of an inclined hemodynamic reservoir bag proved to be self-priming and functional without problems over a wide range of flows tested. By including a reservoir with the mannequin, plus processing and displaying real-time flow data using the CPB-Sim simulation program, a higher fidelity and more realistic simulation experience was created.
Biventricular Pacing in Conjunction with Epicardial Atrial Pacing Adversely Affects Timing of Intra-Aortic Balloon Pump
Authors: Cross David A. , Johnston William E.
Published: July 2023

A case of accidental triggering of an intra-aortic balloon pump during systole is presented. The patient had a cardiac resynchronization therapy device in place preoperatively for heart failure. A temporary epicardial atrial pacing wire was used during separation from cardiopulmonary bypass for rate control. An intra-aortic balloon pump was necessary for separation from bypass. Although the pacemaker functioned properly, the intra-aortic balloon triggered from the atrial pacing spike and was inflated during systole. Pacemaker and intra-aortic balloon electronics and timing settings that caused this are discussed in detail. Suggestions for prevention are presented.
Pediatric Cardiopulmonary Bypass Adaptations for Long-Term Survival of Baboons Undergoing Pulmonary Artery Replacement
Authors: Whittaker Carrie , Grist Gary , Bert Arthur , Brasky Kathleen , Neighbors Stacy , McFall Christopher , Hilbert Stephen L. , Drake William B. , Cromwell Michael , Mueller Barbara , Lofland Gary K. , Hopkins Richard A.
Published: July 2023

Cardiopulmonary bypass (CPB) protocols of the baboon (Papio cynocephalus anubis) are limited to obtaining experimental data without concern for long-term survival. In the evaluation of pulmonary artery tissue engineered heart valves (TEHVs), pediatric CPB methods are adapted to accommodate the animals’ unique physiology enabling survival up to 6 months until elective sacrifice. Aortic access was by a 14F arterial cannula and atrial access by a single 24F venous cannula. The CPB circuit includes a 3.3 L/min flow rated oxygenator, ¼″ × ⅜″ arterial-venous loop, ⅜″ raceway, and bubble trap. The prime contains 700 mL Plasma-Lyte, 700 units heparin, 5 mL of 50% dextrose, and 20 mg amiodarone. Heparinization (200 u/kg) targets an activated clotting time of 350 seconds. Normothermic CPB was initiated at a 2.5 L/m2/min cardiac index with a mean arterial pressure of 55–80 mmHg. Weaning was monitored with transesophageal echocardiogram. Post-CPB circuit blood was re-infused. Chest tubes were removed with cessation of bleeding. Extubation was performed upon spontaneous breathing. The animals were conscious and upright 3 hours post-CPB. Bioprosthetic valves or TEHVs were implanted as pulmonary replacements in 20 baboons: weight = 27.5 ± 5.6 kg, height = 73 ± 7 cm, body surface area = 0.77 m2± 0.08, mean blood flow = 1.973 ± .254 L/min, core temperature = 37.1 ± .1°C, and CPB time = 60 ± 40 minutes. No acidosis accompanied CPB. Sixteen animals survived, four expired. Three died of right ventricular failure and one of an anaphylactoid reaction. Surviving animals had normally functioning replacement valves and ventricles. Baboon CPB requires modifications to include high systemic blood pressure for adequate perfusion into small coronary arteries, careful CPB weaning to prevent ventricular distention, and drug and fluid interventions to abate variable venous return related to a muscularized spleno-splanchnic venous capacity.
Extracorporeal Life Support for Pandemic Influenza: The Role of Extracorporeal Membrane Oxygenation in Pandemic Management
Authors: DeLaney Ed , Smith Michael J. , Harvey Brian T. , Pelletier Keith J. , Aquino Michael P. , Stone Justin M. , Jean-Baptiste Gerald C. , Johnson Julie H.
Published: July 2023

The recent global threat of a severe pandemic influenza outbreak has suggested that extracorporeal life support will begin to play an evolving role in the care of critically ill influenza stricken patients. The highly communicable attributes of influenza could result in widespread infection and an associated increased need for advanced life support. Supply and demand equilibrium may be abruptly disrupted, and ethical decisions regarding the allocation of life saving resources will inevitably need to be made. Protocol oriented planning, research analysis, and advanced technologies are critical factors in averting catastrophe. This review article details the epidemiology, diagnostic techniques, and interventions for the influenza A virus, including H1N1.
Is There an Association between Hyperglycemia and Clinical Outcome in Adult Patients Receiving Extracorporeal Membrane Oxygenation
Authors: Lou Song , Li Jingwen , Long Cun , Hei Feilong , Yu Kun , Wang Shigang
Published: July 2023

Perioperative hyperglycemia frequently develops in critically ill patients and has been associated with adverse outcome. In this study, we tried to identify whether hyperglycemia was associated with adverse outcome in adult patients receiving extracorporeal membrane oxygenation. From 2004 through 2008, 44 adult patients received extracorporeal membrane oxygenation. Clinical records of these 44 consecutive patients were retrospectively analyzed. Glucose levels were monitored and recorded every 3 hours during the support period. The mean glucose level was computed for all patients for whom data were available within the first 48 hours after extracorporeal membrane oxygenation setup. More than 15% of blood glucose levels above 180 mg/dL were defined as hyperglycemia. Clinical outcomes were compared between patients with and without hyperglycemia. The primary outcome was death from any cause in hospital. A p value < .05 was accepted as significant. The overall survival was 68%. Twenty-eight patients were allocated to group 1 with a mean glucose of 179 ± 40 mg per deciliter. The other 16 patients allocated to group 2 with a mean glucose of 140 ± 16 mg per deciliter. There is no significant difference in the mortality of the two groups. Perioperative complications were also similar between the two groups. Glucose levels were not associated with mortality and complications in adult patients receiving extracorporeal membrane oxygenation.
Unfitted Trefftz discontinuous Galerkin methods for elliptic boundary value problems
Authors: Heimann Fabian , Lehrenfeld Christoph , Stocker Paul , von Wahl Henry
Published: July 2023

We propose a new geometrically unfitted finite element method based on discontinuous Trefftz ansatz spaces. Trefftz methods allow for a reduction in the number of degrees of freedom in discontinuous Galerkin methods, thereby, the costs for solving arising linear systems significantly. This work shows that they are also an excellent way to reduce the number of degrees of freedom in an unfitted setting. We present a unified analysis of a class of geometrically unfitted discontinuous Galerkin methods with different stabilisation mechanisms to deal with small cuts between the geometry and the mesh. We cover stability and derive a-priori error bounds, including errors arising from geometry approximation for the class of discretisations for a model Poisson problem in a unified manner. The analysis covers Trefftz and full polynomial ansatz spaces, alike. Numerical examples validate the theoretical findings and demonstrate the potential of the approach.
Insulin Glargine is More Suitable Than Exenatide in Preventing Muscle
Loss in Non-Obese Type 2 Diabetic Patients with NAFLD
Authors: Liu Lin , Wang Ruwen , Gao Jian , Yan Jianhua , Zhang Jingtian , Zhang Zhitian , Liu Jiaojiao , Lin Huandong , Rao Shengxiang , Yao Xiuzhong , Wu Weiyun , Bian Hua , Wang Xiangyu , Guo Shanshan , Gao Xin , Yan Hongmei
Published: July 2023

Aim This study investigated the effects of insulin glargine and exenatide
on the muscle mass of patients with newly diagnosed type 2 diabetes (T2DM) and
nonalcoholic fatty liver disease (NAFLD).

Methods We performed a post-hoc analysis of our previously study, a
24-week randomized controlled multicenter clinical trial (ClinicalTrials.gov,
NCT02303730). Seventy-six patients were randomly assigned 1:1 to receive insulin
glargine or exenatide treatment. The changes in psoas muscle area (PMA)
(mm2) were obtained with the cross-sectional Dixonfat magnetic
resonance images at the fourth lumber vertebra.

Results There were no significant differences in age, BMI, gender, and PMA
in insulin glargine and exenatide groups at baseline. After treatment, PMA
tended to increase by 13.13 (–215.52, 280.80) mm2 in the
insulin glargine group and decrease by 149.09 (322.90–56.39)
mm2 in the exenatide group (both p>0.05). Subgroup
analysis showed a 560.64 (77.88, 1043.40) (mm2) increase of PMA in
the insulin group relative to the Exenatide group in patients with
BMI<28 kg/m2 (p0.031) after
adjusting for gender, age, and research center. Interaction analysis showed an
interaction between BMI and treatment (p0.009). However, no interaction
was observed among subgroups with a
BMI≥28 kg/m2 or with different genders
and ages.

Conclusion Compared to exenatide, insulin glargine can relativity increase
PMA in patients with T2DM having BMI<28 kg/m2
and NAFLD.
Adventures in Total Synthesis – The Next Chapter
Authors: Chen David Yu-Kai
Published: July 2023

This account summarizes the author’s endeavors in target-oriented synthesis at Seoul National University since 2011. A collection of the most celebrated molecules in total synthesis are revisited and the author’s solutions to these historical challenges are presented. In particular, the unique perception of their molecular frameworks and unprecedented bond-forming sequences form the basis of the newly developed strategies. Together with a ‘personal touch’ on these selected stories, the author hopes that this account will offer new insights and fresh perspectives for all levels of enthusiasts of target-oriented total synthesis.

1 Introduction

2.1 Synthesis of Strychnine

2.2 Synthesis of Actinophyllic Acid

2.3 Synthesis of Dendrobine

2.4 Synthesis of Communesin

2.5 Synthesis of Morphinans

2.6 Synthesis of Reserpine

2.7 Synthesis of Quinine and Quinidine

2.8 Synthesis of Haouamine

2.9 Future Work

3 Summary and Outlook

4 Abbreviations
Tandem Oxidative Reaction of 1,3-Diarylpropenes and 5-Aminopyrazoles
Authors: Cheng Dongping , Li Jing-Hua , Xu Xiaoliang , Gu Huafang , Xia Hongshuang , Wang Yawei
Published: July 2023

The reaction of 5-aminopyrazoles with 1,3-diarylpropenes mediated by 2,3-dichloro-5,6-dicyano-1,4-benzoquinone, with subsequent intramolecular cyclization and dehydroaromatization in the presence of Cu(OTf)2/tert-butyl hydroperoxide, gave a series of pyrazolo[3,4-b]pyridines in moderate to excellent yields. The reaction has the advantages of high atom economy, a wide substrate scope, and a one-pot procedure.
Liver Biopsy and Pressure Hemodynamics: IR Perspective
Authors: Jain Aakash , Hughes III Joseph A. , Tavri Sidhartha
Published: July 2023

Liver biopsy is important for staging of liver disease and cirrhosis and can be performed by many techniques. While percutaneous biopsy is fast, safe, effective, and widely available, transvenous biopsy, most often performed from the transjugular approach, offers many advantages for selected patients. In the setting of suspected or confirmed portal hypertension, transjugular liver biopsy (TJLB), most commonly performed by interventional radiologists, can be used to simultaneously obtain core biopsies of the liver and measure hemodynamic pressures in the right atrium, hepatic vein, and portal vein to calculate a hepatic venous pressure gradient. TJLB can be performed safely when percutaneous biopsy is contraindicated, including in the setting of ascites, coagulopathy, anticoagulation, and other high-risk bleeding situations. The procedure can be performed in the outpatient setting in a short period of time for most patients and without the use of precious anesthesia resources. Hepatic venography also allows for variant anatomy evaluation that may be important in the diagnosis and planning of future procedures, such as transjugular intrahepatic portosystemic shunt.
A Rare Treatable Complication of Neuroregression in Glutaric Aciduria Type 1 Management: Vitamin B12 Deficiency
Authors: Gowda Vykuntaraju K. , Shamnur Asha , Srinivasan Varunvenkat M. , Vamyanmane Dhananjaya K.
Published: July 2023

Glutaric aciduria type 1 is a rare treatable inborn error of metabolism caused due to deficiency of the enzyme glutaryl-CoA dehydrogenase. A restrictive lysine and tryptophan diet has significantly improved the outcome of presymptomatically diagnosed glutaric aciduria type 1 children. Here we present the case of a 6-month-old male infant with glutaric aciduria type 1 diagnosed based on clinical, biochemical, radiological, and genetically confirmed case on therapy with homemade diet modification. The patient later developed regression of milestones at 16 months of age while on treatment with good compliance. On examination, pallor and hypopigmented sparse hair with knuckle hyperpigmentation were noted. Investigation revealed low vitamin B12 levels. On vitamin B12 supplementation, the child showed significant improvement. A reversible cause needs to be looked for in patients on dietary restriction and formula feeds treated for metabolic disorders.