Factores asociados a la aparición de mediastinitis en revascularizacion miocárdica

Objetivos: La mediastinitis se presenta hasta en el 4% de los pacientes sometidos a revascularización miocárdica, con un mortalidad hospitalaria reportada del 14 al 47%, generando aumento en los costos de atención, deterioro de la calidad de vida y la sobrevida a largo plazo del enfermo; su etiología es multifactorial. El objetivo de este estudio fue determinar cuáles antecedentes clínicos del paciente y factores relacionados con el procedimiento quirúrgico se asocian con la aparición mediastinitis. Métodos: Diseño de casos y controles anidado en una cohorte histórica de pacientes sometidos a revascularización miocárdica en el periodo de enero de 2005 a julio de 2011. Los pacientes con mediastinitis se compararon con un grupo control sin mediastinitis tomados del mismo grupo de riesgo en una relación 1:4, y pareados por fecha de cirugía. El diagnóstico de mediastinitis se hizo con criterios clínicos, de laboratorio y hallazgos quirúrgicos. Resultados: Se identificaron 30 casos en ese periodo. Los factores asociados a la aparición del evento fueron: Diabetes Mellitus OR 2,3 (1.1- 4,9), uso de circulación extracorpórea OR 2,4 (1,1 -5.5), tiempo de perfusión OR 1,1 (1,1 – 1.3) y pacientes mayores de 70 años OR 1.1 (1,2-1-4). Conclusiones: La mediastinitis sigue siendo una complicación de baja prevalencia con consecuencias devastadoras. El impacto clínico y económico de esta complicación debe obligar a los grupos quirúrgicos a crear estrategias de prevención con base en el conocimiento de los factores de riesgo de su población.

Simulação do escoamento monofásico em um estágio de uma bomba centrífuga utilizando técnicas de fluidodinâmica computacional

Oil production and exploration techniques have evolved in the last decades in order to increase fluid flows and optimize how the required equipment are used. The base functioning of Electric Submersible Pumping (ESP) lift method is the use of an electric downhole motor to move a centrifugal pump and transport the fluids to the surface. The Electric Submersible Pumping is an option that has been gaining ground among the methods of Artificial Lift due to the ability to handle a large flow of liquid in onshore and offshore environments. The performance of a well equipped with ESP systems is intrinsically related to the centrifugal pump operation. It is the pump that has the function to turn the motor power into Head. In this present work, a computer model to analyze the three-dimensional flow in a centrifugal pump used in Electric Submersible Pumping has been developed. Through the commercial program, ANSYS® CFX®, initially using water as fluid flow, the geometry and simulation parameters have been defined in order to obtain an approximation of what occurs inside the channels of the impeller and diffuser pump in terms of flow. Three different geometry conditions were initially tested to determine which is most suitable to solving the problem. After choosing the most appropriate geometry, three mesh conditions were analyzed and the obtained values were compared to the experimental characteristic curve of Head provided by the manufacturer. The results have approached the experimental curve, the simulation time and the model convergence were satisfactory if it is considered that the studied problem involves numerical analysis. After the tests with water, oil was used in the simulations. The results were compared to a methodology used in the petroleum industry to correct viscosity. In general, for models with water and oil, the results with single-phase fluids were coherent with the experimental curves and, through three-dimensional computer models, they are a preliminary evaluation for the analysis of the two-phase flow inside the channels of centrifugal pump used in ESP systems

Survival Analysis of Patients with Heart Failure: Implications of Time-Varying Regression Effects in Modeling Mortality

Background: Several models have been designed to predict survival of patients with heart failure. These, while available and widely used for both stratifying and deciding upon different treatment options on the individual level, have several limitations. Specifically, some clinical variables that may influence prognosis may have an influence that change over time. Statistical models that include such characteristic may help in evaluating prognosis. The aim of the present study was to analyze and quantify the impact of modeling heart failure survival allowing for covariates with time-varying effects known to be independent predictors of overall mortality in this clinical setting. Methodology: Survival data from an inception cohort of five hundred patients diagnosed with heart failure functional class III and IV between 2002 and 2004 and followed-up to 2006 were analyzed by using the proportional hazards Cox model and variations of the Cox's model and also of the Aalen's additive model. Principal Findings: One-hundred and eighty eight (188) patients died during follow-up. For patients under study, age, serum sodium, hemoglobin, serum creatinine, and left ventricular ejection fraction were significantly associated with mortality. Evidence of time-varying effect was suggested for the last three. Both high hemoglobin and high LV ejection fraction were associated with a reduced risk of dying with a stronger initial effect. High creatinine, associated with an increased risk of dying, also presented an initial stronger effect. The impact of age and sodium were constant over time. Conclusions: The current study points to the importance of evaluating covariates with time-varying effects in heart failure models. The analysis performed suggests that variations of Cox and Aalen models constitute a valuable tool for identifying these variables. The implementation of covariates with time-varying effects into heart failure prognostication models may reduce bias and increase the specificity of such models.

Mechanical circulatory support as a bridge to heart transplantation: what remains? Long-term emotional sequelae in patients and spouses

Implantation of a ventricular assist device (VAD) reduces short-term mortality and morbidity and provides patients with reasonable quality of life even though it may also be a long-lasting emotional burden. This study was conducted to analyze the long-time emotional consequences of VAD implantation, followed by heart transplantation in patients and spouses.

Everolimus immunosuppression in de novo heart transplant recipients: What does the evidence tell us now?

The efficacy of everolimus with reduced cyclosporine in de novo heart transplant patients has been demonstrated convincingly in randomized studies. Moreover, everolimus-based immunosuppression in de novo heart transplant recipients has been shown in two randomized trials to reduce the increase in maximal intimal thickness based on intravascular ultrasound, indicating attenuation of cardiac allograft vasculopathy (CAV). Randomized trials of everolimus in de novo heart transplantation have also consistently shown reduced cytomegalovirus infection versus antimetabolite therapy. In maintenance heart transplantation, conversion from calcineurin inhibitors to everolimus has demonstrated a sustained improvement in renal function. In de novo patients, a renal benefit may only be achieved if there is an adequate reduction in exposure to calcineurin inhibitor therapy. Delayed introduction of everolimus may be appropriate in patients at high risk of wound healing complications, e.g. diabetic patients or patients with ventricular assist device. The current evidence base suggests that the most convincing reasons for use of everolimus from the time of heart transplantation are to slow the progression of CAV and to lower the risk of cytomegalovirus infection. A regimen of everolimus with reduced-exposure calcineurin inhibitor and steroids in de novo heart transplant patients represents a welcome addition to the therapeutic armamentarium.

Physiologic and hematologic concerns of rotary blood pumps: what needs to be improved?

Over the past few decades, advances in ventricular assist device (VAD) technology have provided a promising therapeutic strategy to treat heart failure patients. Despite the improved performance and encouraging clinical outcomes of the new generation of VADs based on rotary blood pumps (RBPs), their physiologic and hematologic effects are controversial. Currently, clinically available RBPs run at constant speed, which results in limited control over cardiac workload and introduces blood flow with reduced pulsatility into the circulation. In this review, we first provide an update on the new challenges of mechanical circulatory support using rotary pumps including blood trauma, increased non-surgical bleeding rate, limited cardiac unloading, vascular malformations, end-organ function, and aortic valve insufficiency. Since the non-physiologic flow characteristic of these devices is one of the main subjects of scientific debate in the literature, we next emphasize the latest research regarding the development of a pulsatile RBP. Finally, we offer an outlook for future research in the field.

Reliability of lithium dilution cardiac output in anaesthetized sheep

BACKGROUND: Cardiac output (CO) measurement with lithium dilution (COLD) has not been fully validated in sheep using precise ultrasonic flow probe technology (COUFP). Sheep generate important cardiovascular research models and the use of COLD has become more popular in experimental settings. METHODS: Ultrasonic transit-time perivascular flow probes were surgically implanted on the pulmonary artery of 13 sheep. Paired COLD readings were taken at six time points, before and after implantation of a left ventricular assist device (LVAD) and compared with COUFP recorded just after lithium injection. RESULTS: The mean COLD was 5.7 litre min(-1) (range 3.8-9.6 litre min(-1)) and mean COUFP 5.9 litre min(-1) (range 4.0-9.2 litre min(-1)). The bias (standard deviation) was 0.3 (1.0) litre min(-1) [5.1 (16.9)%] and limits of agreement (LOA) were -1.7 to 2.3 litre min(-1) (-28.8 to 39.0%) with a percentage error (PE) of 34.4%. Data to assess trending [rate (95% confidence intervals)] included a 78 (62-93)% concordance rate in the four-quadrant plot (n=27). In the half moon polar plot (n=19), the mean polar angle was +5°, the radial LOA were -49 to +35° and 68 (47-89)% of data points fell within 22.5° of the mean polar angle. Both tests indicated moderate to poor trending ability. CONCLUSION: COLD is not precise when evaluated against COUFP in sheep based on the statistical criteria set, but the results are comparable with previously published animal studies. KEYWORDS:

Review of recent results using computational fluid dynamics simulations in patients receiving mechanical assist devices for end-stage heart failure

Many end-stage heart failure patients are not eligible to undergo heart transplantation due to organ shortage, and even those under consideration for transplantation might suffer long waiting periods. A better understanding of the hemodynamic impact of left ventricular assist devices (LVAD) on the cardiovascular system is therefore of great interest. Computational fluid dynamics (CFD) simulations give the opportunity to study the hemodynamics in this patient population using clinical imaging data such as computed tomographic angiography. This article reviews a recent study series involving patients with pulsatile and constant-flow LVAD devices in which CFD simulations were used to qualitatively and quantitatively assess blood flow dynamics in the thoracic aorta, demonstrating its potential to enhance the information available from medical imaging.

The use of recombinant activated factor VII for refractory bleeding post complex cardiothoracic surgery

We reviewed the outcome following use of recombinant activated factor VII (rVIIa) in patients with major bleeding post cardiothoracic surgery in our unit between January 2002 and July 2004. The unit consists of 16 cardiothoracic intensive care beds in a public metropolitan teaching hospital which serves as a referral centre for heart and lung transplant surgery Patients with refactory bleeding following cardiothoracic surgical procedures who were treated with rVIIa were identified. A total of 12 episodes of rVIIa use were recorded in ten patients, including three episodes with ventricular assist devices, and 5 heart and/or lung transplants. The median dose used was 85 mu g/kg. Chest tube drainage decreased in all patients following administration of rVIIa; median chest tube drainage decreased front 445 ml/h to 171 ml/h (P=0.03). Despite cessation of bleeding, mortality was high, when rVIIa was used after more than 24 hours. In six episodes, despite early rVIIa use (within six hours), continued bleeding necessitated return to theatre, where a surgical source of bleeding was found. In this small retrospective study, rVIIa significantly reduced bleeding that was refractory to standard blood product transfusion. In this series of patients., those that did not respond to rVIla early in the postoperative phase were found to have a surgical source of bleeding.

Simulação do escoamento monofásico em um estágio de uma bomba centrífuga utilizando técnicas de fluidodinâmica computacional

Oil production and exploration techniques have evolved in the last decades in order to increase fluid flows and optimize how the required equipment are used. The base functioning of Electric Submersible Pumping (ESP) lift method is the use of an electric downhole motor to move a centrifugal pump and transport the fluids to the surface. The Electric Submersible Pumping is an option that has been gaining ground among the methods of Artificial Lift due to the ability to handle a large flow of liquid in onshore and offshore environments. The performance of a well equipped with ESP systems is intrinsically related to the centrifugal pump operation. It is the pump that has the function to turn the motor power into Head. In this present work, a computer model to analyze the three-dimensional flow in a centrifugal pump used in Electric Submersible Pumping has been developed. Through the commercial program, ANSYS® CFX®, initially using water as fluid flow, the geometry and simulation parameters have been defined in order to obtain an approximation of what occurs inside the channels of the impeller and diffuser pump in terms of flow. Three different geometry conditions were initially tested to determine which is most suitable to solving the problem. After choosing the most appropriate geometry, three mesh conditions were analyzed and the obtained values were compared to the experimental characteristic curve of Head provided by the manufacturer. The results have approached the experimental curve, the simulation time and the model convergence were satisfactory if it is considered that the studied problem involves numerical analysis. After the tests with water, oil was used in the simulations. The results were compared to a methodology used in the petroleum industry to correct viscosity. In general, for models with water and oil, the results with single-phase fluids were coherent with the experimental curves and, through three-dimensional computer models, they are a preliminary evaluation for the analysis of the two-phase flow inside the channels of centrifugal pump used in ESP systems

A quasi stationary approach to drying kinetics of cylindrical food particulates in a heat pump asisted fluid bed dryer

Experiments were undertaken to study drying kinetics of moist cylindrical shaped food particulates during fluidised bed drying. Cylindrical particles were prepared from Green beans with three different length:diameter ratios, 3:1, 2:1 and 1:1. A batch fluidised bed dryer connected to a heat pump system was used for the experimentation. A Heat pump and fluid bed combination was used to increase overall energy efficiency and achieve higher drying rates. Drying kinetics, were evaluated with non-dimensional moisture at three different drying temperatures of 30, 40 and 50o C. Numerous mathematical models can be used to calculate drying kinetics ranging from analytical models with simplified assumptions to empirical models built by regression using experimental data. Empirical models are commonly used for various food materials due to their simpler approach. However problems in accuracy, limits the applications of empirical models. Some limitations of empirical models could be reduced by using semi-empirical models based on heat and mass transfer of the drying operation. One such method is the quasi-stationary approach. In this study, a modified quasi-stationary approach was used to model drying kinetics of the cylindrical food particles at three drying temperatures.

Effect of fluid dynamics and device mechanism on biofluid behaviour in microchannel systems: modelling biofluids in a microchannel biochip separator

Biofluid behaviour in microchannel systems is investigated in this paper through the modelling of a microfluidic biochip developed for the separation of blood plasma. Based on particular assumptions, the effects of some mechanical features of the microchannels on behaviour of the biofluid are explored. These include microchannel, constriction, bending channel, bifurcation as well as channel length ratio between the main and side channels. The key characteristics and effects of the microfluidic dynamics are discussed in terms of separation efficiency of the red blood cells with respect to the rest of the medium. The effects include the Fahraeus and Fahraeus-Lindqvist effects, the Zweifach-Fung bifurcation law, the cell-free layer phenomenon. The characteristics of the microfluid dynamics include the properties of the laminar flow as well as particle lateral or spinning trajectories. In this paper the fluid is modelled as a single-phase flow assuming either Newtonian or Non-Newtonian behaviours to investigate the effect of the viscosity on flow and separation efficiency. It is found that, for a flow rate controlled Newtonian flow system, viscosity and outlet pressure have little effect on velocity distribution. When the fluid is assumed to be Non-Newtonian more fluid is separated than observed in the Newtonian case, leading to reduction of the flow rate ratio between the main and side channels as well as the system pressure as a whole.

A microfluidics device to monitor platelet aggregation dynamics in response to strain rate micro-gradients in flowing blood

This paper reports the development of a platform technology for measuring platelet function and aggregation based on localized strain rate micro-gradients. Recent experimental findings within our laboratories have identified a key role for strain rate micro-gradients in focally triggering initial recruitment and subsequent aggregation of discoid platelets at sites of blood vessel injury. We present the design justification, hydrodynamic characterization and experimental validation of a microfluidic device incorporating contraction–expansion geometries that generate strain rate conditions mimicking the effects of pathological changes in blood vessel geometry. Blood perfusion through this device supports our published findings of both in vivo and in vitro platelet aggregation and confirms a critical requirement for the coupling of blood flow acceleration to downstream deceleration for the initiation and stabilization of platelet aggregation, in the absence of soluble platelet agonists. The microfluidics platform presented will facilitate the detailed analysis of the effects of hemodynamic parameters on the rate and extent of platelet aggregation and will be a useful tool to elucidate the hemodynamic and platelet mechano-transduction mechanisms, underlying this shear-dependent process.

Computational Fluid Dynamics Expert System using Artificial Neural Networks

The design of a modern aircraft is based on three pillars: theoretical results, experimental test and computational simulations. As a results of this, Computational Fluid Dynamic (CFD) solvers are widely used in the aeronautical field. These solvers require the correct selection of many parameters in order to obtain successful results. Besides, the computational time spent in the simulation depends on the proper choice of these parameters. In this paper we create an expert system capable of making an accurate prediction of the number of iterations and time required for the convergence of a computational fluid dynamic (CFD) solver. Artificial neural network (ANN) has been used to design the expert system. It is shown that the developed expert system is capable of making an accurate prediction the number of iterations and time required for the convergence of a CFD solver.

Robust multidisciplinary design optimisation using CFD and advanced evolutionary algorithms

Computation Fluid Dynamics (CFD) has become an important tool in optimization and has seen successful in many real world applications. Most important among these is in the optimisation of aerodynamic surfaces which has become Multi-Objective (MO) and Multidisciplinary (MDO) in nature. Most of these have been carried out for a given set of input parameters such as free stream Mach number and angle of attack. One cannot ignore the fact that in aerospace engineering one frequently deals with situations where the design input parameters and flight/flow conditions have some amount of uncertainty attached to them. When the optimisation is carried out for fixed values of design variables and parameters however, one arrives at an optimised solution that results in good performance at design condition but poor drag or lift to drag ratio at slightly off-design conditions. The challenge is still to develop a robust design that accounts for uncertainty in the design in aerospace applications. In this paper this issue is taken up and an attempt is made to prevent the fluctuation of objective performance by using robust design technique or Uncertainty.