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OBJECTIVES:Intravascular ultrasound imaging (IVUS) is limited by the size of the imaging catheter. To facilitate imaging before and during interventions, a 30-MHz ultrasonic imaging device was developed that is the same dimension as a 0.018-inch guide wire. The purpose of this study was to evaluate the clinical feasibility of this device. METHODS AND RESULTS:The imaging core was tested in 8 patients with the use of a monorail guiding sheath that was advanced through a 7F catheter. In addition, after coronary interventions, the standard guide wire was removed, the imaging core was placed inside a compatible balloon, and imaging was performed. In 4 patients, imaging was also performed with a standard 3.2F IVUS catheter. The lumen-plaque interface and the media-plaque interface were clearly visualized in all patients. There was no detectable loss in image quality between the new imaging device and the larger IVUS catheter, and measurements of lumen cross-sectional area were not statistically different. CONCLUSIONS:Improvements in manufacturing technology have permitted the development of a mechanically rotating ultrasound imaging core 0.018 inches in diameter. It is compatible with current balloon catheters without degradation of image quality.

BackgroundThe placement of stents in coronary arteries has been shown to reduce restenosis in comparison to balloon angioplasty. However, clinical use of intracoronary stents is impeded by the risk of subacute stent thrombosis and complications associated with the anticoagulant regimen. To reduce these complications, the hypothesis that systemic anticoagulation is not necessary when adequate stent expansion is achieved was prospectively evaluated on a consecutive series of patients who received intracoronary stents.Methods and resultsFrom March 1993 to January 1994, 359 patients underwent Palmaz-Schatz coronary stent insertion. After an initial successful angiographic result with < 20% stenosis by visual estimation had been achieved, intravascular ultrasound imaging was performed. Further balloon dilatation of the stent was guided by observation of the intravascular ultrasound images. All patients with adequate stent expansion confirmed by ultrasound were treated only with antiplatelet therapy (either ticlopidine for 1 month with short-term aspirin for 5 days or only aspirin) after the procedure. Clinical success (procedure success without early postprocedural events) at 2 months was achieved in 338 patients (94%). With an inflation pressure of 14.9 +/- 3.0 atm and a balloon-to-vessel ratio of 1.17 +/- 0.19, optimal stent expansion was achieved in 321 of the 334 patients (96%) who underwent intravascular ultrasound evaluation, with these patients receiving only antiplatelet therapy after the procedure. Despite the absence of anticoagulation, there were only two acute stent thromboses (0.6%) and one subacute stent thrombosis (0.3%) at 2-month clinical follow-up. Follow-up angiography at 3 to 6 months documented two additional occlusions (0.6%) at the stent site. At 6-month clinical follow-up, angiographically documented stent occlusion had occurred in 5 patients (1.6%). At 6-month clinical follow-up, there was a 5.7% incidence of myocardial infarction, a 6.4% rate of coronary bypass surgery, and a 1.9% incidence of death. Emergency intervention (emergency angioplasty or bailout stent) for a stent thrombosis event was performed in 3 patients (0.8%). The overall event rate was relatively high because of intraprocedural complications that occurred in 16 patients (4.5%). Intraprocedural complications, however, decreased to 1% when angiographically appropriately sized balloons were used for final stent dilations. There was one ischemic vascular complication that occurred at the time of the procedure and one ischemic vascular complication that occurred at the time of angiographic follow-up. By 6 months, repeat angioplasty for symptomatic restenosis was performed in 47 patients (13.1%).ConclusionsThe Palmaz-Schatz stent can be safely inserted in coronary arteries without subsequent anticoagulation provided that stent expansion is adequate and there are no other flow-limiting lesions present. The use of high-pressure final balloon dilatations and confirmation of adequate stent expansion by intravascular ultrasound provide assurance that anticoagulation therapy can be safely omitted. This technique significantly reduces hospital time and vascular complications and has a low stent thrombosis rate.

Intracoronary stents can be implanted with a low incidence of stent thrombosis (< 1%) when the stent procedure is guided by intravascular ultrasound. The long-term clinical and angiographic effects, however, have not been reported. This study assesses the 6 month clinical and angiographic results of a consecutive series of patients with intravascular ultrasound guided Palmaz-Schatz stent deployment that were not treated with subsequent anticoagulation after a successful stent implantation procedure. From March, 1993 to April 1994, 411 patients underwent Palmaz-Schatz stent implantation. There were 26 patients that had uncomplicated Palmaz-Schatz stent implantation that were treated with a standard anticoagulation regimen that are not evaluated in this study. Thus, this study includes an assessment of 385 patients that had either a successful intravascular ultrasound guided stent implantation procedure and did not receive post procedure anticoagulation or had a procedural complication. Procedural success was achieved in 369 patients (96%). Clinical success (procedure success without early post procedure event) was achieved in 363 patients (94%). There were 2 acute stent thrombosis events (0.5%) and 1 subacute stent thrombosis (0.3%) in the group of 369 patients with 454 lesions treated without anticoagulation. At 6 month clinical follow-up the incidence of myocardial infarction was 4.9% and the rate of coronary bypass surgery was 6.2%. There was a 2.1% incidence of death. Emergency intervention (emergency angioplasty or bailout stent implantation was necessary in 3 patients (0.8%). The total incidence of repeat percutaneous intervention was 11.4%. By 6 months clinical follow-up, major events had occurred in 19.2% of patients. The angiographic lesion restenosis rate, according to 50% diameter stenosis criteria, was 19%. The incidence of restenosis per patient was 22%. In conclusion, intravascular ultrasound guided Palmaz-Schatz can be performed without subsequent anticoagulation with a low incidence of stent thrombosis and acceptable clinical and angiographic outcome at 6 month clinical follow-up.

ObjectivesThis study was designed to evaluate the changes in intrastent and angiographic dimensions when intravascular ultrasound imaging is used to direct the deployment of balloon-expandable Palmaz-Schatz stents in coronary arteries and saphenous vein grafts.BackgroundIntravascular ultrasound provides more information than angiography in the imaging of intravascular structures. Previous studies have shown that obtaining a larger lumen (greater "acute gain") with coronary interventions such as stenting leads to less restenosis and subacute thrombosis. It is not clear whether the information obtained by intravascular ultrasound can be used to obtain a greater acute gain in lumen dimensions.MethodsForty consecutive patients undergoing Palmaz-Schatz stent implantation had intravascular ultrasound imaging performed after a good angiographic appearance was obtained. If the stent did not appear adequately expanded by intravascular ultrasound, or if the struts were poorly apposed to the arterial wall, further stent dilation with larger balloons or higher pressure inflations were performed. Twenty-nine patients had subsequent intravascular ultrasound imaging. Intrastent diameters and areas were compared from the initial to the final intravascular ultrasound studies.ResultsOf the 40 patients studied, only 5 (13%) had an adequate result by intravascular ultrasound despite an acceptable angiographic appearance in all patients. Six additional patients did not undergo subsequent intravascular ultrasound imaging. The other 29 patients all demonstrated a significant increase in intrastent minimal diameter (mean 19%), major diameter (11%) and cross-sectional area (34%) (p < 0.001 for all measurements).ConclusionsThe use of intravascular ultrasound imaging in the deployment of balloon-expandable Palmaz-Schatz stents leads to a significant increase in intrastent dimensions (greater "acute gain").

The purpose of this study was to prospectively test the hypothesis that systemic anticoagulation is not needed following coronary stenting when adequate stent expansion is achieved and documented and other flow limitations eliminated. Intravascular ultrasound (IVUS) was used to confirm adequate stent expansion, which was defined as good plaque compression together with the achievement of an intrastent lumen cross-sectional area (CSA) that was greater than 40% of the average reference vessel CSA. In this prospective study, Palmaz-Schatz coronary stenting was performed on 343 lesions in 263 consecutive patients. Primary stenting was successful in 254 patients (96.6%) and 332 lesions (96.8%). All patients with successful primary stenting underwent IVUS imaging except nine patients (13 lesions) that did not have an IVUS evaluation for technical reasons and three patients (4 lesions) in which IVUS was unsuccessful. The initial IVUS performed after achieving an acceptable angiographic result revealed inadequate stent expansion in 191 patients (79%) and 244 lesions (77%). After further dilatation, final adequate stent expansion was accomplished in 230 patients and 301 lesions. These patients were treated with Ticlopidine 250 mg twice per day for 2 months and did not receive postprocedure anticoagulation. There was one acute stent thrombosis (0.3%) that occurred in a lesion with slow flow and an inadequately expanded stent. There was no subacute stent thrombosis and no bleeding or vascular complications. We conclude that when adequate stent expansion is achieved and confirmed and other flow limiting lesions eliminated, that systemic anticoagulation after the stent procedure is not necessary.

Background: Despite being essential in patients with acute respiratory distress syndrome (ARDS), mechanical ventilation (MV) may cause lung injury and hemodynamic instability. Mechanical power (MP) may describe the net injurious effects of MV, but whether it reflects the hemodynamic effects of MV is currently unclear. We hypothesized that MP is also associated with cardiac output (CO) and pulmonary blood flow (PBF)., Methods: 24 anesthetized pigs with experimental acute lung injury were ventilated for 18 h according to one of three strategies: 1) Open lung approach (OLA), 2) ARDS Network high-PEEP/F I O 2 strategy (HighPEEP), or 3) low-PEEP/F I O 2 strategy (LowPEEP). Total MP was assessed as the sum of energy dissipated to overcome airway resistance and energy temporarily stored in the elastic lung tissue per minute. The distribution of pulmonary perfusion was determined by positron emission tomography. Regional PBF and MP, assessed in three iso-gravitational regions of interest (ROI) with equal lung mass (ventral, middle, and dorsal ROI), were compared between groups., Results: MP was higher in the LowPEEP than in the OLA group, while CO did not differ between groups. After 18 h, regional PBF did not differ between groups. During LowPEEP, regional MP was higher in the ventral ROI compared to OLA and HighPEEP groups (2.5 ± 0.3 vs. 1.4 ± 0.4 and 1.6 ± 0.3 J/min, respectively, P < 0.001 each), and higher in the middle ROI compared to the OLA group (2.5 ± 0.4 vs. 1.6 ± 0.5 J/min, P = 0.04). MP in the dorsal ROI did not differ between groups (1.4 ± 0.9 vs. 1.4 ± 0.5 vs. 1.3 ± 0.8 J/min, P = 0.916). Total MP was independently associated with CO [0.34 (0.09, 0.59), P = 0.020]. Regional MP was positively associated with PBF irrespective of the regions [0.52 (0.14, 0.76), P = 0.01; 0.49 (0.10, 0.74), P = 0.016; 0.64 (0.32, 0.83), P = 0.001 for ventral, middle, and dorsal ROI, respectively]. Subgroup analysis revealed a significant association of MP and CO only in the OLA group as well as a significant association between MP with regional PBF only in the HighPEEP group., Conclusion: In this model of acute lung injury in pigs ventilated with either open lung approach, high, or low PEEP tables recommended by the ARDS network, MP correlated positively with CO and regional PBF, whereby these clinically relevant lung-protective ventilation strategies influenced the associations., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Zhang, Wittenstein, Braune, Theilen, Maiello, Benzi, Bluth, Kiss, Ran, Koch, Rocco, J. Schultz, Kotzerke, Gama De Abreu, Huhle and Scharffenberg.)

Background: Identification of lung parenchyma on computer tomographic (CT) scans in the research setting is done semi-automatically and requires cumbersome manual correction. This is especially true in pathological conditions, hindering the clinical application of aeration compartment (AC) analysis. Deep learning based algorithms have lately been shown to be reliable and time-efficient in segmenting pathologic lungs. In this contribution, we thus propose a novel 3D transfer learning based approach to quantify lung volumes, aeration compartments and lung recruitability., Methods: Two convolutional neural networks developed for biomedical image segmentation (uNet), with different resolutions and fields of view, were implemented using Matlab. Training and evaluation was done on 180 scans of 18 pigs in experimental ARDS ( u 2 Net Pig ) and on a clinical data set of 150 scans from 58 ICU patients with lung conditions varying from healthy, to COPD, to ARDS and COVID-19 ( u 2 Net Human ). One manual segmentations (MS) was available for each scan, being a consensus by two experts. Transfer learning was then applied to train u 2 Net Pig on the clinical data set generating u 2 Net Transfer . General segmentation quality was quantified using the Jaccard index ( JI ) and the Boundary Function score ( BF ). The slope between JI or BF and relative volume of non-aerated compartment ( S JI and S BF , respectively) was calculated over data sets to assess robustness toward non-aerated lung regions. Additionally, the relative volume of ACs and lung volumes (LV) were compared between automatic and MS., Results: On the experimental data set, u 2 Net Pig resulted in JI = 0.892 [0.88 : 091] (median [inter-quartile range]), BF = 0.995 [0.98 : 1.0] and slopes S JI = -0.2 {95% conf. int. -0.23 : -0.16} and S BF = -0.1 {-0.5 : -0.06}. u 2 Net Human showed similar performance compared to u 2 Net Pig in JI , BF but with reduced robustness S JI = -0.29 {-0.36 : -0.22} and S BF = -0.43 {-0.54 : -0.31}. Transfer learning improved overall JI = 0.92 [0.88 : 0.94], P < 0.001, but reduced robustness S JI = -0.46 {-0.52 : -0.40}, and affected neither BF = 0.96 [0.91 : 0.98] nor S BF = -0.48 {-0.59 : -0.36}. u 2 Net Transfer improved JI compared to u 2 Net Human in segmenting healthy ( P = 0.008), ARDS ( P < 0.001) and COPD ( P = 0.004) patients but not in COVID-19 patients ( P = 0.298). ACs and LV determined using u 2 Net Transfer segmentations exhibited < 5% volume difference compared to MS., Conclusion: Compared to manual segmentations, automatic uNet based 3D lung segmentation provides acceptable quality for both clinical and scientific purposes in the quantification of lung volumes, aeration compartments, and recruitability., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Maiello, Ball, Micali, Iannuzzi, Scherf, Hoffmann, Gama de Abreu, Pelosi and Huhle.)

Background: Variable pressure support ventilation (vPSV) is an assisted ventilation mode that varies the level of pressure support on a breath-by-breath basis to restore the physiological variability of breathing activity. We aimed to compare the effects of vPSV at different levels of variability and pressure support (Δ P S ) in patients with acute respiratory distress syndrome (ARDS). Methods: This study was a crossover randomized clinical trial. We included patients with mild to moderate ARDS already ventilated in conventional pressure support ventilation (PSV). The study consisted of two blocks of interventions, and variability during vPSV was set as the coefficient of variation of the Δ P S level. In the first block, the effects of three levels of variability were tested at constant Δ P S : 0% (PSV 0% , conventional PSV), 15% (vPSV 15% ), and 30% (vPSV 30% ). In the second block, two levels of variability (0% and variability set to achieve ±5 cmH 2 O variability) were tested at two ΔP S levels (baseline Δ P S and Δ P S reduced by 5 cmH 2 O from baseline). The following four ventilation strategies were tested in the second block: PSV with baseline Δ P S and 0% variability (PSV BL ) or ±5 cmH 2 O variability (vPSV BL ), PSV with ΔP S reduced by 5 cmH 2 O and 0% variability (PSV -5 ) or ±5 cmH 2 O variability (vPSV -5 ). Outcomes included gas exchange, respiratory mechanics, and patient-ventilator asynchronies. Results: The study enrolled 20 patients. In the first block of interventions, oxygenation and respiratory mechanics parameters did not differ between vPSV 15% and vPSV 30% compared with PSV 0% . The variability of tidal volume ( V T ) was higher with vPSV 15% and vPSV 30% compared with PSV 0% . The incidence of asynchronies and the variability of transpulmonary pressure ( P L ) were higher with vPSV 30% compared with PSV 0% . In the second block of interventions, different levels of pressure support with and without variability did not change oxygenation. The variability of V T and P L was higher with vPSV -5 compared with PSV -5 , but not with vPSV BL compared with PSV BL . Conclusion: In patients with mild-moderate ARDS, the addition of variability did not improve oxygenation at different pressure support levels. Moreover, high variability levels were associated with worse patient-ventilator synchrony. Clinical Trial Registration: www.clinicaltrials.gov, identifier: NCT01683669., Competing Interests: MG was granted a patent on the variable pressure support ventilation mode of assisted ventilation (noisy PSV), which has been licensed to Dräger Medical AG (Lübeck, Germany). The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Ball, Sutherasan, Fiorito, Dall'Orto, Maiello, Vargas, Robba, Brunetti, D'Antini, Raimondo, Huhle, Schultz, Rocco, Gama de Abreu and Pelosi.)

Unlabelled: The assessment of defense mechanisms in psychotherapy is currently one of the most used ways to evaluate the effectiveness of psychotherapy. In literature there are few reports on defense mechanisms changes by short-term treatments., Aim: To determine whether the defense mechanisms are changed after twelve sessions of short-term psychotherapy related to psychopathological symptoms, severity and overall functioning., Methods: Twenty patients (12 F and 8 M; age 38.4) affected by anxiety and mood disorders were recruited to the study between November 2008 and July 2009 and were assessed with the Defense Style Questionnaire-88 (DSQ-88), scale Symptom Checklist-90-Revised (SCL-90-R), scale Clinical Global Impression (CGI) and scale Valutazione Globale del Funzionamento (VGF) at the beginning and after short-term psychotherapy. Half the sample also assumed drugs. The treatment was supportive-expressive psychotherapy of Luborsky, a short focal dynamic therapy, characterized by the integration of supportive and expressive techniques., Results: Both patients showed a significant decrease in immature defenses and a significant-increase in mature defenses (p < 0.01). Mature defenses were significantly correlated with severity (r = -0632; p = 0.003) and overall functioning (r = 0529; p = 0.01)., Discussion: Immature and mature defenses seem to be a useful outcome measure in short-term psychotherapy as well as severity and overall functioning and the combined treatment may be most effective in reducing immature defenses.

After examining the notion of time among philosophical and psychological theories and some recent evidences, we propose a concept of time, relating to its objective/subjective difference, from a cognitive-systems process oriented approach, which is a multidisciplinary and evolutionary approach for diagnosis, practice and steps of psychotherapy.

We conducted a prospective observational study to evaluate the indications, technique, in-hospital and 9-month results of consecutive patients treated with rotational atherectomy (RA) in 12 centers during 1 year, as well as their relationship with volume of RA activity. The study included 345 lesions in 289 patients treated (4.4% +/- 2.6% of procedures at the participating centers). The lesions were mostly calcified (63%) and type B2 or C (74%). Procedural success was obtained in 94% of patients, with a major adverse cardiac event (MACE) rate of 4.5%. At 9 months, MACE occurred in 17.3%. Multivariate analysis identified multivessel disease and slow flow as negative predictors of procedural success, whereas balloon pressure

Background: Severe coronary artery disease in patients with a markedly depressed left ventricular function is associated with a poor prognosis. Even though coronary angioplasty (PTCA) has been offered as an alternative to bypass surgery, the role of PTCA in the treatment of patients with severe left ventricular dysfunction has not been well defined. The aim of the present study was to evaluate the immediate and long-term results in patients with severe left ventricular dysfunction < or = 35% who underwent PTCA., Methods: One hundred and twenty-five patients with a left ventricular ejection fraction < or = 35% who underwent PTCA were analyzed., Results: The mean left ventricular ejection fraction was 29.7%. Eighty-seven patients (69.6%) had multivessel disease and 41 (32.8%) had previous coronary artery bypass graft. Intra-aortic balloon pumping was used in 12% of cases. Angiographic success was achieved in 96% of patients. Complete revascularization was achieved in 56 patients (44.8%). Major complications occurred in 4% of the population and 2 patients died (1.6%). During the long-term follow-up re-PTCA due to angiographic restenosis was performed in 41 patients (34%); 12 patients (10.4%) died. The only parameter which significantly correlated with death was the presence of an occluded left anterior descending coronary artery not recanalized neither with PTCA nor with coronary artery bypass graft., Conclusions: These data suggest that PTCA may be an effective treatment for coronary artery disease in patients with left ventricular dysfunction and is associated with high procedural success rate and low complications; however, the long-term follow-up seems not to be influenced by the PTCA procedure.

Iatrogenic acute dissection of the ascending aorta following coronary angiography and percutaneous intervention is rare. Localized aortic dissections have been treated by sealing the entry with a coronary stent. Extensive dissections may require a surgical intervention. We describe a coronary dissection with retrograde extension to the ascending aorta that occurred during angioplasty of the right coronary artery. The extensive dissection, which was limited to the ascending aorta, was successfully treated by stenting of the right coronary artery and monitoring the aortic dissection by means of transesophageal echocardiography.

Background: Intracoronary brachytherapy has significantly reduced the recurrence of in-stent restenosis. The aim of this study was to evaluate the feasibility, safety and efficacy of intracoronary beta-radiation in patients at very high risk for recurrence of in-stent restenosis., Methods: We analyzed 42 patients with 50 lesions submitted to catheter-based beta-radiation (Beta-Cath System, Novoste Corporation, Norcross, GA, USA) for in-stent restenosis. Thirty-eight lesions were at the second restenosis, 8 at the third, and 4 at the fourth; a diffuse pattern was present in 78%., Results: Balloon angioplasty was performed for 30 lesions (60%) and the cutting balloon technique for 20 (40%). In 12 lesions further 14 stents had to be deployed (28%). The delivery catheter was successfully positioned in 96% of the procedures. The mean dwell time was 179 +/- 50 s with a radiation dose ranging from 18.4 to 25.3 Gy, depending on the vessel size. A complete angiographic success without coronary dissection and without any additional stenting after radiation delivery was achieved in 86%. At follow-up (7.2 +/- 2.1 months), the overall restenosis rate was 30.4% (14 lesions). A recurrence was detected in 1/11 lesions with initial focal pattern and in 13/39 lesions with initial diffuse pattern. The restenosis rate was higher in patients in whom a geographic miss had occurred (p < 0.05 vs lesions without geographic miss) and in those in whom a new stent had been deployed (p < 0.05 vs lesions treated without a stent)., Conclusions: Brachytherapy reduces the in-stent restenosis rate in patients who are at very high risk of recurrence. The restenosis pattern, geographic miss and new stent deployment seem to be negative prognostic factors for recurrence of restenosis.