Herzchirurgische Strategien im Wandel: Ein Wort der Vorsicht

The introduction of minimally invasive coronary artery bypass surgery has expanded the technical armementarium for operative treatment of coronary artery disease. Minimal access surgery using partial sternotomy or anterior intercostal minimal thoracotomy can be combined with videoscopic techniques or port-access-methods. Either atrio-aortal cannulation, femoro-femoral or jugular-femoral connections to the pump are possible for extracorporal circulation (ECC). Even endoluminar occlusion of the aorta and application of cardioplegia into the aortic root can be considered and applied. Extracorporal circulation has developed into a safe standardized method. As far as pathophysiology is concerned, the decision to use ECC or not is of much more importance than the grade of invasiveness. Fundamentally we therefore need to distinguish between minimally invasive methods with and without ECC. Video-assisted coronary surgery in hearts under hypothermia and fibrillation with ECC is also recommended occasionally. Minimally invasive coronary artery procedures on beating hearts without ECC have to be done in a stabilized and bloodless operative field to allow the construction of high standard anastomoses between bypass grafts and coronary arteries. In practice, silicon occluders, epicardial and myocardial suture occlusion and fixation, mechanical stabilization devices, and pharmacologic induction of bradycardia are used. In principle a skilled surgeon should be familiar with all these methods to select the most suitable solution for the special clinical problem. A final judgement about each method is not possible up to now. High patients numbers have to be recruited in the groups and subgroups due to low mortality (1%) and morbidity (5%), otherwise statistical significance of the results cannot be gained.     

A New Automatically Fixating Stone Basket (2.5 F) Prototype with a Nitinol Spring for Accurate Ureteroscopic Stone Size Measurement

Introduction

Intraoperative assessment of stone size is crucial for the successful and safe extraction of stones. The first automatically fixating measuring stone basket prototype showed a mismatch between the steel spring and the nitinol basket; therefore, to improve this prototype, the steel spring was replaced with a nitinol spring and a modified scale was implemented on the basket handle for accurate intraoperative stone size measurement.

Methods

The proposed tipped basket was composed of nitinol. A standard handle with a spring-supported self-closing mechanism (2.5 F, Urotech^®) was used, and a modified nonlinear millimeter scale was established on the handle. The grasping force was provided by the new nitinol spring mechanism in the handgrip. Various colors associated with the stone size were applied on the scale.

Results

The material difference between the basket and the spring was eliminated. The measuring scale ranged from 2 mm (green) through 5 mm (yellow) to 8 mm (red), and the scale was nonlinear because of the nonlinear relationship between the diameter of the stone and the distance marked on the scale.

Conclusion

The proposed automatically fixating stone basket with a nitinol spring has the potential to improve the safety and effectiveness of endourological stone retrieval. Further validation of this new scale and basket should follow.

     

Coaxial waveguide MRI

As ultrahigh-field MR imaging systems suffer from the standing wave problems of conventional coil designs, the use of antenna systems that generate travelling waves was suggested. As a modification to the original approach, we propose the use of a coaxial waveguide configuration with interrupted inner conductor. This concept can focus the radiofrequency energy to the desired imaging region in the human body and can operate at different Larmor frequencies without hardware modifications, as it is not limited by a lower cut-off frequency. We assessed the potential of the method with a hardware prototype setup that was loaded with a tissue equivalent phantom and operated with imaging areas of different size. Signal and flip angle distributions within the phantom were analyzed, and imaging at different Larmor frequencies was performed. Results were compared to a finite difference time domain simulation of the setup that additionally provides information on the spatial distribution of the specific absorption rate load. Furthermore, simulation results with a human model (virtual family) are presented. It was found that the proposed method can be used for MRI at multiple frequencies, achieving transmission efficiencies similar to other travelling wave approaches but still suffers from several limitations due to the used mode of wave propagation.     

Advanced fit of the diffusion kurtosis tensor by directional weighting and regularization

The diffusional kurtosis is an indicator for diffusion restrictions in biological tissue. It is observed experimentally that the kurtosis is largest for directions perpendicular to the fiber direction in white matter. The directional dependence of the kurtosis can be described by the diffusion kurtosis tensor. Since the intention of diffusion kurtosis imaging is to detect diffusion restrictions, the fit of the kurtosis tensor should be dominated by directions perpendicular to the fibers. In this work, it is shown that the basic approach, which is solving the occurring linear system by a pseudoinverse matrix, may completely fail in this regard if the diffusion is highly anisotropic. This problem is solved by adapting the weights of the fit--and thus emphasizing directions of restricted water motion--using a direct fit of the kurtosis tensor to the measured kurtosis values. Moreover, due to its large number of degrees of freedom, the kurtosis tensor can assume complicated shapes resulting in a fit which is sensitive to noise. This article demonstrates that the quality of the kurtosis tensor calculation can be further improved if the fit is regularized by suppressing too large and too small kurtosis tensor values and thus restricting the possible tensor shapes.     

Rapid structural change in synaptosomal-associated protein 25 (SNAP25) precedes the fusion of single vesicles with the plasma membrane in live chromaffin cells

The SNARE complex consists of the three proteins synaptobrevin-2, syntaxin, and synaptosomal-associated protein 25 (SNAP25) and is thought to execute a large conformational change as it drives membrane fusion and exocytosis. The relation between changes in the SNARE complex and fusion pore opening is, however, still unknown. We report here a direct measurement relating a change in the SNARE complex to vesicle fusion on the millisecond time scale. In individual chromaffin cells, we tracked conformational changes in SNAP25 by total internal reflection fluorescence resonance energy transfer (FRET) microscopy while exocytotic catecholamine release from single vesicles was simultaneously recorded using a microfabricated electrochemical detector array. A local rapid and transient FRET change occurred precisely where individual vesicles released catecholamine. To overcome the low time resolution of the imaging frames needed to collect sufficient signal intensity, a method named event correlation microscopy was developed, which revealed that the FRET change was abrupt and preceded the opening of an exocytotic fusion pore by ∼90 ms. The FRET change correlated temporally with the opening of the fusion pore and not with its dilation.     

Active microcoil tracking in the lungs using a semisolid rubber as signal source

A new method to localize and track medical devices in air‐filled body cavities is proposed that uses active microcoils with a semisolid filling. In air spaces, e.g., the lung, microcoils require an independent signal source, which should be made of a biocompatible, solid and sterilizable material with a long shelf time. In a measurement of the T₁ and T*₂ and the relative spin density of several semisolid materials, latex was identified as a suitable material from which a prototype catheter was constructed with a microcoil at its tip. In a dual‐echo tracking pulse sequence, the very short T*₂ of the rubber material allowed suppressing the background signal from surrounding tissue with a subtraction technique and additional dephasing gradients. With a roadmapping reconstruction, the microcoil's trajectory could be visualized on a previously acquired reference image set with a tracking rate of up to 60 Hz at a spatial resolution of better than 2mm. In a real‐time tracking implementation, an image update rate of 4 Hz was achieved by combining the tracking with a fast real‐time imaging sequence. Both methods were successfully applied in vivo to track the catheter in the lung of a pig. Magn Reson Med, 2010. © 2010 Wiley‐Liss, Inc.     

Quantitative MR-Spektroskopie: Implementierung und Qualitätssicherung an einem klinischen MR-Tomografen

The aim of this study was the implementation of quantitative MR-Spectroscopy with external reference signals on a Philips Gyroscan Intera 1,5 T MR-Scanner for routine clinical use. We established measurements for quality assurance of the used phantoms and methods. In detail we analyzed the dependence of the signal on concentration and volume as well as on the local variation within the coil and the impact of these factors on quantification. Furthermore we established measurements for routine constancy checks.The method as well as the software for concentration calculation was checked by an in vitro measurement. In a blinded measurement the concentrations of NAA, Cho and Kr in the PTB reference phantom 10614 mM were determined correctly within their error limits.