注意:以下协议遵循我们的内部指引及批准本部门的椅子标准操作程序。相同的方案经我们的机构审查委员会和用于发表在以前的论文8的研究。 1.预超声波扫描准备<ol><li>放置在患者中使用可选的提高压头的床仰卧位置或担架舒适如果病人是醒着。 </li><li>定位超声波机与operator&#39;s位置和穿刺部位，以防止operator&#39;s头部或身体扭动看到显示一条线。打开超声波机并连接微型凸超声探头。 </li><li>选择一个预先设定的允许深部组织穿透， 例如，设置探测到8 MHz或更低。使用在皮肤上酒精消毒超声探头的声耦合。 </li></ol>在我CVC 2.超声波扫描nsertion站点和上腔静脉<ol><li>放置在微凸超声波探头上的穿刺部位。 注意:B（正当性）-mode短轴视图和平面外穿刺技术是优选的。调整增益，深度和焦点位置，以便获得最佳的图像。 </li><li>通过施加压力来测试压缩性和排除血栓在穿刺部位确认静脉。使用彩色血流多普勒，如果有不确定性。将超声探头集中检测到潜在的血栓。 </li></ol> 3.锁骨上窝超声查看<ol><li>放置超声探头在右锁骨上窝，得到颈内静脉和锁骨下静脉的汇合，以检测潜在的血栓的图。改变增益，深度和集中使用超声波机的旋钮。 注意:设置增益足够高回声血管壁和低回声血管腔之间的区别。集深度（10-12厘米），以具有SVC和r的完整视图飞行肺动脉（RPA）。将焦点设置到RPA的水平。 </li><li>使用超声波机的旋钮来获得头臂静脉汇合处的视图增加深度（4-6厘米）。这也将对应的上腔静脉的开始。调整深度的超声探头（10-12厘米），成角，以获得上腔静脉，相邻的升主动脉和右肺动脉的完整纵向视图。 注:探头频率将由超声波机根据成像深度调整。 </li><li>评价头臂静脉和上腔静脉进行静脉血栓。打开超声波探头90°顺时针，得到上腔静脉的矢状图。观察右肺动脉中的下腔静脉的短轴背侧。此外，观察肺静脉远端右肺动脉的短轴图。使用可选的多普勒确认上腔CAV一。 </li></ol> 4.超声引导下静脉穿刺<ol><li> CVC准备工具包和礼服用无菌袍和手套。皮肤消毒用酒精湿巾和应用无菌单。将超声探头进入无菌盖。超声引导静脉穿刺所用的非镇静，以及在麻醉患者中进行。 注:对于非镇静患者静脉穿刺前局部浸润麻醉，强烈推荐。 </li><li>获得静脉的超声波视图被穿刺。右利手操作者使用连接于在右手注射器和在左手超声波探头的针头。 </li><li>执行超声引导下静脉穿刺。 注:出平面和平面技术都是合适的。 </li><li>以下静脉穿刺，通过针插入导丝。在这一点上，静脉的长轴视图可以确认在静脉内的导引线。 </li></ol> 5.超声引导Guidewi再进步<ol><li>切换超​​声探头右手。通过调节深度获得的上腔静脉的看法和聚焦超声图像（ 图3A和补充视频环）的位置。 注意:这必须是一个协助人或由运营商自己做，如果超声机器用无菌盖操作。超声波探头的角度需要在相对于颈部的小角度。 </li><li>前进用左手的导线。不引入导线太远进入上腔静脉，因为这将使得难以识别导丝尖。前进右肺动脉（ 图3B）的上壁部及交叉时可视化的导线的J-小费。 </li><li>如果超声波束不能与J尖端和右肺动脉对齐，使用升主动脉为地标。打开超声波探头90°顺时针获得的矢状图上腔静脉。以这种观点，确认导丝位置相对于右肺动脉中的短轴观察到的。 </li></ol> 6.测量插入深度<ol><li>使用中央静脉导管以测量导线的插入深度。为了做到这一点，校准20厘米标记的CVC和导丝并读取厘米在静脉穿刺部位的标记。 注:导线具有标记，10％，20厘米，在位置指示的J-尖叶远侧内腔。这些标记可能会根据不同的制造商。要小心，不要动导丝。 注:按照标准的医院协议，包括皮肤和静脉，插入CVC超过导丝，愿望和冲洗和缝合扩张这个角度上，完整的布局。 </li></ol> 7.肺超声<ol><li>在围手术期，在患者进行肺超声检查排除气胸以下CVC位置。 注:此过程已经由利希滕斯坦等11。 </li><li>将超声波探头中的所有四个象限前胸部的两侧，以获得图中B模式为肺滑动和M模式为海滨标志。最好使用线性超声探头。对于肥胖患者，用超声波探头具有较高的渗透， 如弧形阵列或微凸探头。 </li></ol> 8.中心静脉导管改过来导丝注:在导线CVC变化是单个贡献者导管相关血流感染，应该避免。患者的机械并发症有关的CVC插入或有限静脉通路的高风险，过导线CVC变化仍可以被认为是12。 <ol><li>如果放错了地方的中心静脉导管（未使用超声引导下的尖端位置法），获得超锁骨视图推进导引线到正确的位置。在无菌条件下，引入一个导线插入错位中心静脉导管的远端内腔。变化的CVC超过超声引导导丝工作在非镇静的病人，以及在麻醉的患者。 <ol><li>拉回中心静脉导管。可视化从thesupraclavicular窝观点导丝。 </li><li>推进导丝插入在上腔静脉的正确位置。引入新的中心静脉导管在导丝。 </li><li>按照标准的医院协议这一点上，整个程序。 </li></ol></li></ol>

<ol>
	<li>Troianos, C. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Special+articles:+guidelines+for+performing+ultrasound+guided+vascular+cannulation:+recommendations+of+the+American+Society+of+Echocardiography+and+the+Society+Of+Cardiovascular+Anesthesiologists.">Special articles: guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society Of Cardiovascular Anesthesiologists.</a> Anesth Analg. 114 (1), 46-72 (2012).</li><li>Cavanna, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound-guided+central+venous+catheterization+in+cancer+patients+improves+the+success+rate+of+cannulation+and+reduces+mechanical+complications:+a+prospective+observational+study+of+1,978+consecutive+catheterizations.">Ultrasound-guided central venous catheterization in cancer patients improves the success rate of cannulation and reduces mechanical complications: a prospective observational study of 1,978 consecutive catheterizations.</a> World J Surg Oncol. 8 (91), (2010).</li><li>Wirsing, M., Schummer, C., Neumann, R., Steenbeck, J., Schmidt, P., Schummer, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Is+traditional+reading+of+the+bedside+chest+radiograph+appropriate+to+detect+intraatrial+central+venous+catheter+position.">Is traditional reading of the bedside chest radiograph appropriate to detect intraatrial central venous catheter position.</a> Chest. 134 (3), 527-533 (2008).</li><li>Ender, J., Erdoes, G., Krohmer, E., Olthoff, D., Mukherjee, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transesophageal+echocardiography+for+verification+of+the+position+of+the+electrocardiographically-placed+central+venous+catheter.">Transesophageal echocardiography for verification of the position of the electrocardiographically-placed central venous catheter.</a> J Cardiothorac Vasc Anesth. 23 (4), 457-461 (2009).</li><li>Pittiruti, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+intracavitary+ECG+method+for+positioning+the+tip+of+central+venous+catheters:+results+of+an+Italian+multicenter+study.">The intracavitary ECG method for positioning the tip of central venous catheters: results of an Italian multicenter study.</a> J Vasc Access. 13 (3), 357-365 (2012).</li><li>Matsushima, K., Frankel, H. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bedside+ultrasound+can+safely+eliminate+the+need+for+chest+radiographs+after+central+venous+catheter+placement:+CVC+sono+in+the+surgical+ICU+(SICU).">Bedside ultrasound can safely eliminate the need for chest radiographs after central venous catheter placement: CVC sono in the surgical ICU (SICU).</a> J Surg Res. 163 (1), 155-161 (2010).</li><li>Matsushima, K., Frankel, H. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Detection+of+central+venous+catheter+insertion-related+complication+using+bedside+ultrasound:+the+CVC+sono.">Detection of central venous catheter insertion-related complication using bedside ultrasound: the CVC sono.</a> J Trauma. 70 (6), 1561-1563 (2011).</li><li>Kim, S. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+confirmation+of+central+venous+catheter+position+via+a+right+supraclavicular+fossa+view+using+a+microconvex+probe:+A+observational+pilot+study.">Ultrasound confirmation of central venous catheter position via a right supraclavicular fossa view using a microconvex probe: A observational pilot study.</a> Eur J Anaesthesiol. , (2013).</li><li>Lanspa, M. J., Fair, J., Hirshberg, E. L., Grissom, C. K., Brown, S. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound-guided+Subclavian+Vein+Cannulation+Using+a+Micro-Convex+Ultrasound+Probe.">Ultrasound-guided Subclavian Vein Cannulation Using a Micro-Convex Ultrasound Probe.</a> Ann Am Thorac Soc. 11 (4), 583-586 (2014).</li><li>Weber, S. U., Kim, S. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+right+supraclavicular+ultrasound+view+for+real-time+ultrasound-guided+definite+placement+of+a+central+venous+catheter+with+a+microconvex+transducer.">The right supraclavicular ultrasound view for real-time ultrasound-guided definite placement of a central venous catheter with a microconvex transducer.</a> Eur J Anaesthesiol. 31 (3), 173-174 (2014).</li><li>Lichtenstein, D. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+diagnosis+of+occult+pneumothorax.">Ultrasound diagnosis of occult pneumothorax.</a> Crit Care Med. 33 (6), 1231-1238 (2005).</li><li>Garnacho-Montero, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Risk+factors+and+prognosis+of+catheter-related+bloodstream+infection+in+critically+ill+patients:+a+multicenter+study.">Risk factors and prognosis of catheter-related bloodstream infection in critically ill patients: a multicenter study.</a> Intensive Care Med. 34 (12), 2185-2193 (2008).</li><li>Schummer, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intra-atrial+ECG+is+not+a+reliable+method+for+positioning+left+internal+jugular+vein+catheters.">Intra-atrial ECG is not a reliable method for positioning left internal jugular vein catheters.</a> Br J Anaesth. 91 (4), 481-486 (2003).</li></ol>

The authors declare that they have no competing financial interests.

这个程序允许超声引导下静脉穿刺，并通过正确的supraclaviculare窝视图实时中心静脉导管尖端位置的可视化。与肺部超声扫描相结合，这种方法可以取代胸片确认导管尖端位置，排除气胸的。 这是至关重要的超声波训练有素的操作员熟悉由锁骨上窝视图中提供的超声解剖和正确识别解剖标志。此外，关键的是要调整超声波探头的角度相对于所述颈部以一个可与小的探针来最好?...

中心静脉导管（CVC）尖端位置已得到证实，因为错位导管可导致外伤和血管内皮细胞及血管壁的侵蚀，随后可能致命的心包填塞1。此外，CVC在上部上腔静脉（SVC）可以挑起血栓事件，特别是在癌症患者。同样是在相反的头臂静脉或颈内静脉（IJV）2如此错位CVC。 几种方法已被建立，以确认在​​较低的SVC CVC尖端位置。胸片历来进行的床边方法，以可视化的CVC尖端和排除气胸。然而，附加地暴露于辐射和成本，胸片为前端位置和气胸灵敏度的精度受到质疑，专门为病人在仰卧位3。计算机断层扫描是非常准确和灵敏为CVC吨IP位置和气胸，分别。然而，成本和暴露于辐射并不能证明这种方法对CVC提示确认的唯一指标。经食管超声心动图（TEE）是非常准确的尖端位置，但适应症TEE仅限于患者心脏病理4。心内心电图（ECG）是一个准确的方法，但依赖于P波心律5。 胸骨旁和肋下超声视图被提出来验证CVC末端的位置，但成功取决于导线的深插入到右心房。阴性结果不排除错位导管6,7。右锁骨上窝超声观点在心力衰竭诊断目的已经完全描述。在中试研究中，我们已经证明，这种观点也可安全地用于右颈内静脉的静脉穿刺和CVC导丝随后CVC PL精确定位acement实时8。右锁骨上窝超声视图可以建立与一个microconvex探针相比，线性探针8-10，其具有小尺寸，深pentetration和，但足够的分辨率为静脉穿刺的优点。 所提出的过程有可视静脉穿刺和引导线前进以实时的无菌区域内的单个超声探头的优点。式CVC插入长度不必进行事后更正和额外的操作和潜在的污染源被阻止。在肺超声排除气胸相结合，提出的方法有更换胸片为CVC末端位置确认和排除气胸，降低成本和暴露于辐射和增加任何医院环境患者的舒适度势，其中超声机配备有microconvex超声探头是AVAilable。

<table border="0" cellpadding="0" cellspacing="0" width="1058">
	<tbody>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">Name of Material/ Equipment</td>
			<td style="width:93px;">Company</td>
			<td style="width:119px;">Catalog Number</td>
			<td style="width:631px;">Comments/Description</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">skin desinfection</td>
			<td style="width:93px;">Ecolab</td>
			<td align="right" style="width:119px;">2686556</td>
			<td>Skinsept G</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;">8C-RS microconvex probe</td>
			<td style="width:93px;">GE Healthcare</td>
			<td style="width:119px;">8C-RS</td>
			<td>Any ultrasound machine equipped with a microconvex ultrasound probe should be suitable for this method</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">Logiq e ultrasound machine</td>
			<td style="width:93px;">GE Healthcare</td>
			<td style="width:119px;">Logiq e</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">CVC Kit</td>
			<td style="width:93px;">Teleflex Medical</td>
			<td style="width:119px;">OW-15802-E</td>
			<td>8 Fr. 2 Lumen Blue-Flex tip catheter</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">Sterile gloves</td>
			<td style="width:93px;">Protexix</td>
			<td style="width:119px;">2D72NT70X</td>
			<td>LatexMicro</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">Sterile gown</td>
			<td style="width:93px;">Medline</td>
			<td style="width:119px;">OP9512CE</td>
			<td>OPS Advanced</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">sterile ultrasound probe cover</td>
			<td style="width:93px;">CIVCO</td>
			<td style="width:119px;">610-637</td>
			<td>CIV-Fle Transducer Cover; sterile 8.9 x 91.5 cm</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">suture</td>
			<td style="width:93px;">Ethicon</td>
			<td style="width:119px;">EH7723</td>
			<td>Ethibond</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">12L-RS linear ultrasound probe</td>
			<td style="width:93px;">GE Healthcare</td>
			<td style="width:119px;"></td>
			<td>any linear ultrasound probe is suitable for lung ultrasound</td>
		</tr>
	</tbody>
</table>

the supraclavicular fossa ultrasound view for central venous catheter placement and catheter change over guidewire

锁骨上窝超声视图可用于中心静脉导管（CVC）的位置很有用。颈内静脉（IJV）或锁骨下静脉的静脉穿刺是用微凸超声波探头进行的，使用具有10MHz的探针频率新生儿腹部​​预设在10-12厘米的深度。下列插入导线插入静脉中，探针被移动到右锁骨上窝，以获得上腔静脉（SVC），右肺动脉和升主动脉的图。根据实时超声图，导线和它的J-尖端可视化并向前推到下的SVC。插入深度使用中心静脉导管导丝痕读取。 CVC然后插入下面的皮肤和静脉扩张。锁骨上窝的看法是右颈内静脉插入CVC最合适的。如果其他插入位点都选择了右锁骨上窝应该是无菌区之内。在国际合资扫描，brachiocephaliÇ静脉和SVC可静脉穿刺前显露显著血栓形成。错放的CVC可以与实时超声引导下通过导丝技术的变化进行校正。在诊断肺部超声扫描相结合，这一技术有可能取代胸片确认CVC末端位置，排除气胸的。此外，这种观点是有利的患者的非对 - 波心律是帧内心脏心电图（ECG）是不适合的CVC尖端位置的确认是可行的。该方法的限制是缺乏微凸探针的可用性和需要进行培训。

在先前发表的研究报告，胸片在以下超声引导CVC放置8所有患者获得。相对于胸部X光片隆突CVC末端位置由放射科医生谁证实了CVC在较低SVC在所有调查的患者正确的位置进行分析。在90％的情况下，CVC末端是内隆突为35毫米的距离。在17％的CVC末端是如上所述，在19％时的电平，并在64％的隆突下方。在4％的CVC末端是超过55毫米以下刘嘉玲（ 图1-2）。 <p class="jove_content" fo:keep-toge...

Watch this Scientific Journal Video about The Supraclavicular Fossa Ultrasound View for Central Venous Catheter Placement and Catheter Change Over Guidewire at JoVE.com

The Supraclavicular Fossa Ultrasound View for Central Venous Catheter Placement and Catheter Change Over Guidewire

总体目标是使临床医生通过上腔静脉的下部的右锁骨上窝以便插入实时超声引导下中央静脉导管。这种观点是不同的导管插入位点有用的，血栓检测错位导管插入和超声引导下修正前。

锁骨上窝超声显示为中心静脉导管放置和导管改过来导丝

The supraclavicular fossa ultrasound view can be useful for central venous catheter (CVC) placement. Venipuncture of the internal jugular veins (IJV) or ...

the-supraclavicular-fossa-ultrasound-view-for-central-venous-catheter

Research

JoVE Journal

Medicine

18.7K 次观看.  University Hospital Bonn. 总体目标是使临床医生通过上腔静脉的下部的右锁骨上窝以便插入实时超声引导下中央静脉导管。这种观点是不同的导管插入位点有用的，血栓检测错位导管插入和超声引导下修正前。 

视频: The Supraclavicular Fossa Ultrasound View for Central Venous Catheter Placement and Catheter Change Over Guidewire

Remote Magnetic Navigation for Accurate, Real-time Catheter Positioning and Ablation in Cardiac Electrophysiology Procedures

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac substrates such as left atrial flutter. This protocol describes all the clinical and invasive interventional steps performed during a human electrophysiological study and ablation to assess the accuracy, safety and real-time navigation of the Catheter Guidance, Control and Imaging (CGCI) system. Patients who underwent ablation of a right or left atrium flutter substrate were included. Specifically, data from three left atrial flutter and two counterclockwise right atrial flutter procedures are shown in this report. One representative left atrial flutter procedure is shown in the movie. This system is based on eight coil-core electromagnets, which generate a dynamic magnetic field focused on the heart. Remote navigation by rapid changes (msec) in the magnetic field magnitude and a very flexible magnetized catheter allow real-time closed-loop integration and accurate, stable positioning and ablation of the arrhythmogenic substrate.

This report provides a detailed description of a new remote navigation system based on magnetic driven forces, which has been recently introduced as a new robotic tool for human cardiac electrophysiology procedures.

遥控磁导航导管定位准确，实时和心脏电生理消融程序

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac ...

科研

医学

Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and disordered electrical activity in the atria gives rise to palpitations, fatigue, dyspnea, chest pain and dizziness with or without syncope 4, 5. Patients with AF have a five-fold higher risk of stroke 6.
Oral anticoagulation (OAC) with warfarin is commonly used for stroke prevention in patients with AF and has been shown to reduce the risk of stroke by 64% 7. Warfarin therapy has several major disadvantages, however, including bleeding, non-tolerance, interactions with other medications and foods, non-compliance and a narrow therapeutic range 8-11. These issues, together with poor appreciation of the risk-benefit ratio, unawareness of guidelines, or absence of an OAC monitoring outpatient clinic may explain why only 30-60% of patients with AF are prescribed this drug 8.
The problems associated with warfarin, combined with the limited efficacy and/or serious side effects associated with other medications used for AF 12,13, highlight the need for effective non-pharmacological approaches to treatment. One such approach is catheter ablation (CA), a procedure in which a radiofrequency electrical current is applied to regions of the heart to create small ablation lesions that electrically isolate potential AF triggers 4. CA is a well-established treatment for AF symptoms 14, 15, that may also decrease the risk of stroke. Recent data showed a significant decrease in the relative risk of stroke and transient ischemic attack events among patients who underwent ablation compared with those undergoing antiarrhythmic drug therapy 16.
Since the left atrial appendage (LAA) is the source of thrombi in more than 90% of patients with non-valvular atrial fibrillation 17, another approach to stroke prevention is to physically block clots from exiting the LAA. One method for occluding the LAA is via percutaneous placement of the WATCHMAN LAA closure device. The WATCHMAN device resembles a small parachute. It consists of a nitinol frame covered by fabric polyethyl terephthalate that prevents emboli, but not blood, from exiting during the healing process. Fixation anchors around the perimeter secure the device in the LAA (Figure 1). To date, the WATCHMAN is the only implanted percutaneous device for which a randomized clinical trial has been reported. In this study, implantation of the WATCHMAN was found to be at least as effective as warfarin in preventing stroke (all-causes) and death (all-causes) 18. This device received the Conformit&eacute; Europ&eacute;enne (CE) mark for use in the European Union for warfarin eligible patients and in those who have a contraindication to anticoagulation therapy 19.
Given the proven effectiveness of CA to alleviate AF symptoms and the promising data with regard to reduction of thromboembolic events with both CA and WATCHMAN implantation, combining the two procedures is hoped to further reduce the incidence of stroke in high-risk patients while simultaneously relieving symptoms. The combined procedure may eventually enable patients to undergo implantation of the WATCHMAN device without subsequent warfarin treatment, since the CA procedure itself reduces thromboembolic events. This would present an avenue of treatment previously unavailable to patients ineligible for warfarin treatment because of recurrent bleeding 20 or other warfarin-associated problems.
The combined procedure is performed under general anesthesia with biplane fluoroscopy and TEE guidance. Catheter ablation is followed by implantation of the WATCHMAN LAA closure device. Data from a non-randomized trial with 10 patients demonstrates that this procedure can be safely performed in patients with a CHADS2 score of greater than 1 21. Further studies to examine the effectiveness of the combined procedure in reducing symptoms from AF and associated stroke are therefore warranted.

Catheter ablation is combined with placement of the WATCHMAN Left Atrial Appendage Closure Device to prevent ischemic stroke in a patient with non-valvular atrial fibrillation.

结合消融房颤左心耳封堵

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and ...

Non-fluoroscopic Catheter Tracking for Fluoroscopy Reduction in Interventional Electrophysiology

A technological platform (MediGuide) has been recently introduced for non-fluoroscopic catheter tracking. In several studies, we have demonstrated that the application of this non-fluoroscopic catheter visualization system (NFCV) reduces fluoroscopy time and dose by 90-95% in a variety of electrophysiology (EP) procedures. This can be of relevance not only to the patients, but also to the nurses and physicians working in the EP lab. Furthermore, in a subset of indications such as supraventricular tachycardias, NFCV enables a fully non-fluoroscopic procedure and allows the lab staff to work without wearing lead aprons. With this protocol, we demonstrate that even complex procedures such as ablations of atrial fibrillation, that are typically associated with fluoroscopy times of &#62;30 min in conventional settings, can safely be performed with a reduction of &#62;90% in fluoroscopy exposure by the additional use of NFCV.

Radiation exposure is an underestimated risk in complex ablation procedures. Here, we describe a protocol to significantly decrease fluoroscopy time and dosage for both the patient and the lab staff by using a novel non-fluoroscopic catheter visualization system.

非透视导管跟踪透视减少介入电

A technological platform (MediGuide) has been recently introduced for non-fluoroscopic catheter tracking. In several studies, we have demonstrated that ...

Reduction of Iatrogenic Atrial Septal Defects with an Anterior and Inferior Transseptal Puncture Site when Operating the Cryoballoon Ablation Catheter

The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical transseptal puncture site is the fossa ovalis (FO) &#8211; the atrial septum&#8217;s thinnest section. A potentially beneficial transseptal site, for the cryoballoon, is near the inferior limbus (IL). This study examines an alternative transseptal site near the IL, which may decrease the frequency of acute iatrogenic atrial septal defect (IASD). Also, the study evaluates the acute pulmonary vein isolation (PVI) success rate utilizing the IL location. 200 patients were evaluated by retrospective chart review for acute PVI success rate with an IL transseptal site. An additional 128 IL transseptal patients were compared to 45 FO transseptal patients by performing Doppler intracardiac echocardiography (ICE) post-ablation to assess transseptal flow after removal of the transseptal sheath. After sheath removal and by Doppler ICE imaging, 42 of 128 (33%) IL transseptal patients demonstrated acute transseptal flow, while 45 of 45 (100%) FO transseptal puncture patients had acute transseptal flow. The difference in acute transseptal flow detection between FO and IL sites was statistically significant (P &#60;0.0001). Furthermore, 186 of 200 patients (with an IL transseptal puncture) did not need additional ablation(s) and had achieved an acute PVI by a &#8220;cryoballoon only&#8221; technique. An IL transseptal puncture site for cryoballoon AF ablations is an effective location to mediate PVI at all four PVs. Additionally, an IL transseptal location can lower the incidence of acute transseptal flow by Doppler ICE when compared to the FO. Potentially, the IL transseptal site may reduce later IASD complications post-cryoballoon procedures.

The goal of this study is to demonstrate the preferential location of transseptal puncture during a cryoballoon catheter ablation procedure for the treatment of atrial fibrillation.

与前伪劣间隔穿刺网站减少医源性房间隔缺损操作Cryoballoon消融导管时，

The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical ...

Use of a Central Venous Line for Fluids, Drugs and Nutrient Administration in a Mouse Model of Critical Illness

This protocol describes a centrally catheterized mouse model of prolonged critical illness. We combine the cecal ligation and puncture method to induce sepsis with the use of a central venous line for fluids, drugs and nutrient administration to mimic the human clinical setting. Critically ill patients require intensive medical support in order to survive. While the majority of patients will recover within a few days, about a quarter of the patients need prolonged intensive care and are at high risk of dying from non-resolving multiple organ failure. Furthermore, the prolonged phase of critical illness is hallmarked by profound muscle weakness, and endocrine and metabolic changes, of which the pathogenesis is currently incompletely understood. The most widely used animal model in critical care research is the cecal ligation and puncture model to induce sepsis. This is a very reproducible model, with acute inflammatory and hemodynamic changes similar to human sepsis, which is designed to study the acute phase of critical illness. However, this model is hallmarked by a high lethality, which is different from the clinical human situation, and is not developed to study the prolonged phase of critical illness. Therefore, we adapted the technique by placing a central venous catheter in the jugular vein allowing us to administer clinically relevant supportive care, to better mimic the human clinical situation of critical illness. This mouse model requires an extensive surgical procedure and daily intensive care of the animals, but it results in a relevant model of the acute and prolonged phase of critical illness.

This protocol describes a centrally catheterized mouse model of prolonged critical illness. We combine the cecal ligation and puncture method to induce sepsis with the use of a central venous line for fluids, drugs and nutrient administration to mimic the human clinical setting.

在重大疾病的小鼠模型中使用中心静脉导管的流体，药物和营养管理

This protocol describes a centrally catheterized mouse model of prolonged critical illness. We combine the cecal ligation and puncture method to induce ...

Murine Model of Central Venous Stenosis using Aortocaval Fistula with an Outflow Stenosis

Central venous stenosis is an important entity contributing to arteriovenous fistula (AVF) failure. A murine AVF model was modified to create a partial ligation of the inferior vena cava (IVC) in the outflow of the fistula, mimicking central venous stenosis. Technical aspects of this model are introduced. The aorta and IVC are exposed, following an abdominal incision. The infra-renal aorta and IVC are dissected for proximal clamping, and the distal aorta is exposed for puncture. The IVC at the midpoint between the left renal vein and the aortic bifurcation is carefully dissected to place an 8-0 suture beneath the IVC. After clamping the aorta and IVC, an AVF is created by puncturing the infra-renal aorta through both walls into the IVC with a 25 G needle, followed by ligating a 22 G intra-venous (IV) catheter and IVC together. The catheter is then removed, creating a reproducible venous stenosis without occlusion. The aorta and IVC are unclamped after confirming primary hemostasis. This novel model of central vein stenosis is easy to perform, reproducible, and will facilitate studies on AVF failure.

An aortocaval fistula was created by puncturing the murine infra-renal aorta through both walls into the inferior vena cava and was followed by creation of a stenosis in its outflow via partial ligation of the inferior vena cava. This reproducible model can be used to study central venous stenosis.

中央静脉狭窄病的Murine模型,使用具有流出狭窄病的动脉静脉瘘管病

Central venous stenosis is an important entity contributing to arteriovenous fistula (AVF) failure. A murine AVF model was modified to create a partial ...

A Protocol to Set Up Needle-Free Connector with Positive Displacement on Central Venous Catheter in Intensive Care Unit

Needle-free connectors were initially designed and promoted to avoid blood exposure for healthcare workers. Some recent data suggest that the latest generation of connectors (with positive displacement) may be of interest for reducing central venous line infections. We have been using needle-free connectors for several years in our intensive care unit and here we present a protocol for installing these connectors on central venous catheters. After insertion of the catheter and control of the permeability of the lines, the connectors must be purged with 0.9% NaCl before being connected. The connectors replace all disposable caps used on infusion stopcocks and manifolds. All the connectors are changed every 7 days as recommended by the manufacturer (except when there is macroscopic contamination, which requires an immediate change of the connector). Before each injection, the connector must be disinfected for at least 3 seconds with 70% isopropyl alcohol. The connectors must not be disconnected (unless changed), as the injection is done through the device. Setting up the connectors slightly increases the total time required to place the catheter and there is no formal evidence that these connectors reduce the incidence of infectious or thrombotic complications. However, these devices simplify the management of central venous lines and prevent the catheter circuit from &#34;opening&#34; once it has been sterilely installed.

We present a protocol to show the installation of a needle-free connector with positive displacement on a central venous catheter.

在重症监护病房的中央静脉导管上设置无针接头,带正位移

Needle-free connectors were initially designed and promoted to avoid blood exposure for healthcare workers. Some recent data suggest that the latest ...

Dynamic Navigation for Dental Implant Placement

In modern implantology, the application of surgical navigation systems is becoming increasingly important. In addition to static surgical navigation methods, a guide-independent dynamic navigation implant placement procedure is becoming more widespread. The procedure is based on computer-guided dental implant placement utilizing optical control. This work aims to demonstrate the technical steps of a new dynamic computer-aided implant surgery (DCAIS)&#160;system (design, calibration, surgery) and check the accuracy of the results. Based on cone-beam computed tomography (CBCT) scans, the exact positions of implants are determined with dedicated software. The first step of the operation is the calibration of the navigation system, which can be performed in two ways: 1) based on CBCT images taken with a marker or 2) based on CBCT images without markers. Implants are inserted with the aid of real-time navigation according to the preoperative plans. The accuracy of the interventions can be evaluated based on postoperative CBCT images. The preoperative images containing the planned positions of the implants and postoperative CBCT images were compared based on the angulation (degree), platform, and apical deviation (mm) of the implants. To evaluate the data, we calculated the standard deviation (SD), mean, and standard error of the mean (SEM) of deviations within planned and performed implant positions. Differences between the two calibration methods were compared based on this data. Based on the interventions performed so far, the use of DCAIS allows for high-precision implant placement. A calibration system that does not require labeled CBCT recording allows for surgical intervention with similar accuracy as a system that uses labeling. The accuracy of the intervention can be improved by training.

Dynamic computer-aided implant surgery (DCAIS) is a controlled implant surgical placement method performed without a surgical template using optical control. The real-time intraoperative control of movement and position of the surgical device simplifies the procedure and gives more freedom to the surgeon, providing similar precision as static navigation methods.

种植牙的动态导航

In modern implantology, the application of surgical navigation systems is becoming increasingly important. In addition to static surgical navigation ...

A Retrograde Implantation Approach for Peritoneal Dialysis Catheter Placement in Mice

Murine models are employed to probe various aspects of peritoneal dialysis (PD), such as peritoneal inflammation and fibrosis. These events drive peritoneal membrane failure in humans, which remains an area of intense investigation due to its profound clinical implications in managing patients with end-stage kidney disease (ESKD). Despite the clinical importance of PD and its related complications, current experimental murine models suffer from key technical challenges that compromise the models&#39; performance. These include PD catheter migration and kinking and usually warrant earlier catheter removal. These limitations also drive the need for a greater number of animals to complete a study. Addressing these drawbacks, this study introduces technical improvements and surgical nuances to prevent commonly observed PD catheter complications in a murine model. Moreover, this modified model is validated by inducing peritoneal inflammation and fibrosis using lipopolysaccharide injections. In essence, this paper describes an improved method to create an experimental model of PD.

This article describes modifications of a procedure to implant a peritoneal dialysis catheter in a murine model to avoid major technical issues observed with the conventional techniques.

一种小鼠腹膜透析导管放置的逆行植入方法

Murine models are employed to probe various aspects of peritoneal dialysis (PD), such as peritoneal inflammation and fibrosis. These events drive ...

Drug Treatment by Central Venous Catheter in a Mouse Model of Angiotensin II Induced Abdominal Aortic Aneurysm and Monitoring by 3D Ultrasound

Since pharmaceutical treatment options are lacking in the clinical management of abdominal aortic aneurysm (AAA), animal models, in particular mouse models, are applied to advance the understanding of the disease pathogenesis and to identify potential therapeutic targets. Testing novel drug candidates to block AAA growth in these models generally requires repeated drug administration during the time course of the experiment. Here, we describe a compiled protocol for AAA induction, insertion of an intravenous catheter to facilitate prolonged therapy, and serial AAA monitoring by 3D ultrasound. Aneurysms are induced in apolipoprotein E (ApoE) deficient mice by angiotensin II release over 28 days from osmotic mini-pumps implanted subcutaneously into the mouse back. Subsequently, the surgical procedure for external jugular vein catheterization is conducted to allow for daily intravenous drug treatment or repeated blood sampling via a subcutaneous vascular access button. Despite the two dorsal implants, the monitoring of AAA development is readily facilitated by sequential semi-automated 3D ultrasound analysis, which yields comprehensive information on the expansion of aortic diameter and volume and on aneurysm morphology, as illustrated by experimental examples.

This protocol describes the consecutive implantation of an osmotic pump to induce abdominal aortic aneurysm by angiotensin II release in apolipoprotein E (ApoE) deficient mice and of a vascular access port with a jugular vein catheter for repeated drug treatment. Monitoring of aneurysm development by 3D ultrasound is effectively conducted despite dorsal implants.

血管紧张素II诱导的腹主动脉瘤小鼠模型中中心静脉导管的药物治疗及3D超声监测

Since pharmaceutical treatment options are lacking in the clinical management of abdominal aortic aneurysm (AAA), animal models, in particular mouse ...