Flap Monitoring Techniques: A Review.

Postoperative tissue flap vitality monitoring enables early detection of clinical complications, allowing for intervention. Timely re-operation can prevent the need for extensive correction procedures, thus reducing healthcare costs and hospitalization time. Statistics show that monitoring can increase the success rate of flap survival to 95% or higher. However, despite the significant progress in monitoring techniques, major and minor complications, leading to the loss of the flap, still occur. This clinical application review aims to provide a comprehensive overview of the recent advancements and findings in flap surgery reconstructions, transplants, and systems for their postoperative assessment. The literature from the years 1925 to 2024 has been reviewed to capture previous and current solutions for monitoring flap vitality. Clinically acclaimed methods and experimental techniques were classified and reviewed from a technical and clinical standpoint. Physical examination, metabolism change, ultrasound method, and electromagnetic (EM) radiation-based measurement methods were carefully evaluated from the perspective of their considered applications. Guidelines aiding engineers in the future design and development process of monitoring systems were proposed. This paper provides a comprehensive overview of the monitoring techniques used in postoperative flap vitality monitoring. It also gives an overview of each approach and potential ways for future development.

Non-Contact Monitoring of ECG in the Home Environment-Selecting Optimal Electrode Configuration.

Capacitive electrocardiography (cECG) is most often used in wearable or embedded measurement systems. The latter is considered in the paper. An optimal electrocardiographic lead, as an individual feature, was determined based on model studies. It was defined as the possibly highest value of the R-wave amplitude measured on the back of the examined person. The lead configuration was also analyzed in terms of minimizing its susceptibility to creating motion artifacts. It was found that the direction of the optimal lead coincides with the electrical axis of the heart. Moreover, the electrodes should be placed in the areas preserving the greatest voltage and at the same time characterized by the lowest gradient of the potential. Experimental studies were conducted using the developed measurement system on a group of 14 people. The ratio of the R-wave amplitude (as measured on the back and chest, using optimal leads) was less than 1 while the SNR reached at least 20 dB. These parameters allowed for high-quality QRS complex detection with a PPV of 97%. For the "worst" configurations of the leads, the signals measured were practically uninterpretable.

Coupling between Blood Pressure and Subarachnoid Space Width Oscillations during Slow Breathing.

The precise mechanisms connecting the cardiovascular system and the cerebrospinal fluid (CSF) are not well understood in detail. This paper investigates the couplings between the cardiac and respiratory components, as extracted from blood pressure (BP) signals and oscillations of the subarachnoid space width (SAS), collected during slow ventilation and ventilation against inspiration resistance. The experiment was performed on a group of 20 healthy volunteers (12 females and 8 males; BMI=22.1±3.2 kg/m2; age 25.3±7.9 years). We analysed the recorded signals with a wavelet transform. For the first time, a method based on dynamical Bayesian inference was used to detect the effective phase connectivity and the underlying coupling functions between the SAS and BP signals. There are several new findings. Slow breathing with or without resistance increases the strength of the coupling between the respiratory and cardiac components of both measured signals. We also observed increases in the strength of the coupling between the respiratory component of the BP and the cardiac component of the SAS and vice versa. Slow breathing synchronises the SAS oscillations, between the brain hemispheres. It also diminishes the similarity of the coupling between all analysed pairs of oscillators, while inspiratory resistance partially reverses this phenomenon. BP-SAS and SAS-BP interactions may reflect changes in the overall biomechanical characteristics of the brain.

Impact of slow breathing on the blood pressure and subarachnoid space width oscillations in humans.

The aim of the study was to assess cardiac and respiratory blood pressure (BP) and subarachnoid space (SAS) width oscillations during the resting state for slow and fast breathing and breathing against inspiratory resistance. Experiments were performed on a group of 20 healthy volunteers (8 males and 12 females; age 25.3 ± 7.9 years; BMI = 22.1 ± 3.2 kg/m2). BP and heart rate (HR) were measured using continuous finger-pulse photoplethysmography. SAS signals were recorded using an SAS monitor. Oxyhaemoglobin saturation (SaO2) and end-tidal CO2 (EtCO2) were measured using a medical monitoring system. Procedure 1 consisted of breathing spontaneously and at controlled rates of 6 breaths/minute and 6 breaths/minute with inspiratory resistance for 10 minutes. Procedure 2 consisted of breathing spontaneously and at controlled rates of 6, 12 and 18 breaths/minute for 5 minutes. Wavelet analysis with the Morlet mother wavelet was applied for delineation of BP and SAS signals cardiac and respiratory components. Slow breathing diminishes amplitude of cardiac BP and SAS oscillations. The overall increase in BP and SAS oscillations during slow breathing is driven by the respiratory component. Drop in cardiac component of BP amplitude evoked by slow-breathing may be perceived as a cardiovascular protective mechanism to avoid target organ damage. Further studies are warranted to assess long-term effects of slow breathing.

A wearable system developed to monitor people suffering from vasovagal syncope.

A wearable system for monitoring non-invasively signals invaluable when examining person suffering from vasovagal syncope is presented in the paper. Following signals are continuously recorded: electrocardiogram, photopletysmogram, impedance cardiogram and electrodermal resistance.

Electrodes array for contactless ECG measurement of a bathing person - a sensitivity analysis.

An applicability of a remote (contactless) electrocardiogram (ECG) measurements in a bathtub is presented in the paper. Possibility of ECG measurements in shallowly filled tube with a water was examined. A bathing person was, both, sitting and lying during experiments performed. The problem became non-trivial when the bathing person was moving in reference to a fixed set of electrodes and located at the longer walls of the bathtub. However, the results obtained indicate that the sensitivity of a developed electrode array could enable such measurements. However, a spatial sensitivity distribution determines, both, the recorded ECG signal parameters and quality.

Can we rely on the pulse transit time - pressure relationship - models comparison.

An unobtrusive, noninvasive and continuous pressure measurement is invaluable however, still being under research and development. There are many attempts proposing an appropriate relationship between pulse pressure velocity and pressure. Fifteen different formulas, both theoretical and experimental, describing relation between blood pressure and cross-sectional area of the vessel were examined. Using these formulas the relation between blood pressure and pulse transit time were derived. The results obtained show variety of dependences. For some of them an explicit derivation was not possible due to non-linear characteristics of the models. It follows from the study performed that depending on the assumptions accepted, even using the same approach, one can obtain contradictory results.

Respiratory signal of bathing person - preliminary study.

The scope of this paper is analysis of applicability of modern biomedical acquisition system installed in bathtub towards reception of respiratory signals of bathing person. An analysis of the possibility of such measurement is shown as well as preliminary results.

Coupling of Blood Pressure and Subarachnoid Space Oscillations at Cardiac Frequency Evoked by Handgrip and Cold Tests: A Bispectral Analysis.

The aim of the study was to assess blood pressure-subarachnoid space (BP-SAS) width coupling properties using time-frequency bispectral analysis based on wavelet transforms during handgrip and cold tests. The experiments were performed on a group of 16 healthy subjects (F/M; 7/9) of the mean age 27.2 ± 6.8 years and body mass index of 23.8 ± 4.1 kg/m2. The sequence of challenges was first handgrip and then cold test. The handgrip challenge consisted of a 2-min strain, indicated by oral communication from the investigator, at 30% of maximum strength. The cold test consisted of 2 min of hand immersion to approximately wrist level in cold water of 4 °C, verified by a digital thermometer. Each test was preceded by 10 min at baseline and was followed by 10-min recovery recordings. BP and SAS were recorded simultaneously. Three 2-min stages of the procedure, baseline, test, and recovery, were analyzed. We found that BP-SAS coupling was present only at cardiac frequency, while at respiratory frequency both oscillators were uncoupled. Handgrip and cold test failed to affect BP-SAS cardiac-respiratory coupling. We showed similar handgrip and cold test cardiac bispectral coupling for individual subjects. Further studies are required to establish whether the observed intersubject variability concerning the BP-SAS coupling at cardiac frequency has any potential clinical predictive value.

A Meta-Analysis of Pulse Arrival Time Based Blood Pressure Estimation.

The paper presents a preliminary meta-analysis of the sample correlation between pulse arrival time (PAT) and blood pressure (BP). The aim of the study was to verify sample correlation coefficient between PAT and BP using an affine model $ BP = a . PAT+b $ for systolic and diastolic blood pressure. The databases included in the search were the IEEE Xplore Digital Library, Springer Link and Google Scholar. Only papers from 2005 to 2017 wereincluded into analysis. The random-effects model was considered. The resulting sample correlation coefficient was equal to -0.82 (95 % CI; -0.89, -0.72) for systolic blood pressure and -0.64 (95% CI, -0.74 -0.51) for diastolic one. Egger's regression test showed that there was no evidence of publication bias. Obtained 95% CI intervals for sample correlation coefficients for SBP and DBP are almost separate, which may indicate different relation between PAT and BP for systolic and diastolic pressure.

A body position influence on ECG derived respiration.

An influence of a human body position on ECG derived respiration (EDR) signal is presented in the paper. Examinations were performed during deep, suspended and normal breathing for eight people in four different body positions. EDR and thoracic impedance signals were compared using correlation and standard deviation coefficients. Obtained results have shown that it is possible to monitor breath activity of people being in different position, however a precise interpretation of the obtained signal is limited.

A novel sensor for measuring temperature profile during the thermoablation.

A novel approach for monitoring a temperature distribution inside a tissue during thermoablation is presented in the paper. A thermal profile is measured using a set of serially connected thermistors each bypassed by a capacitor. This technique allows a two-wire and simultaneous multi-point measurements using a multi-frequency measurement of electrical impedance. It is shown that application signals of appropriately selected frequency allows simultaneous measurement of temperature at five distinct points. This technique can be utilized in the assisting of a thermoablation process, and in other applications based on resistive or capacitive sensors.

Sympathetic Activation Does Not Affect the Cardiac and Respiratory Contribution to the Relationship between Blood Pressure and Pial Artery Pulsation Oscillations in Healthy Subjects.

INTRODUCTION: Using a novel method called near-infrared transillumination backscattering sounding (NIR-T/BSS) that allows for the non-invasive measurement of pial artery pulsation (cc-TQ) and subarachnoid width (sas-TQ) in humans, we assessed the influence of sympathetic activation on the cardiac and respiratory contribution to blood pressure (BP) cc-TQ oscillations in healthy subjects. METHODS: The pial artery and subarachnoid width response to handgrip (HGT) and cold test (CT) were studied in 20 healthy subjects. The cc-TQ and sas-TQ were measured using NIR-T/BSS; cerebral blood flow velocity (CBFV) was measured using Doppler ultrasound of the left internal carotid artery; heart rate (HR) and beat-to-beat mean BP were recorded using a continuous finger-pulse photoplethysmography; respiratory rate (RR), minute ventilation (MV), end-tidal CO2 (EtCO2) and end-tidal O2 (EtO2) were measured using a metabolic and spirometry module of the medical monitoring system. Wavelet transform analysis was used to assess the relationship between BP and cc-TQ oscillations. RESULTS: HGT evoked an increase in BP (+15.9%; P<0.001), HR (14.7; P<0.001), SaO2 (+0.5; P<0.001) EtO2 (+2.1; P<0.05) RR (+9.2%; P = 0.05) and MV (+15.5%; P<0.001), while sas-TQ was diminished (-8.12%; P<0.001), and a clear trend toward cc-TQ decline was observed (-11.0%; NS). CBFV (+2.9%; NS) and EtCO2 (-0.7; NS) did not change during HGT. CT evoked an increase in BP (+7.4%; P<0.001), sas-TQ (+3.5%; P<0.05) and SaO2(+0.3%; P<0.05). HR (+2.3%; NS), CBFV (+2.0%; NS), EtO2 (-0.7%; NS) and EtCO2 (+0.9%; NS) remained unchanged. A trend toward decreased cc-TQ was observed (-5.1%; NS). The sas-TQ response was biphasic with elevation during the first 40 seconds (+8.8% vs. baseline; P<0.001) and subsequent decline (+4.1% vs. baseline; P<0.05). No change with respect to wavelet coherence and wavelet phase coherence was found between the BP and cc-TQ oscillations. CONCLUSIONS: Short sympathetic activation does not affect the cardiac and respiratory contribution to the relationship between BP-cc-TQ oscillations. HGT and CT display divergent effects on the width of the subarachnoid space, an indirect marker of changes in intracranial pressure.

Monitoring of myocardium state during off-pump coronary artery by-pass grafting.

A measurement technique for evaluation of processes occurring in the myocardium during blood flow arrest is presented. The system is devoted to monitoring the myocardium state during off-pump coronary artery by-pass grafting, i.e. during a surgical operation performed on a beating heart. A substantial part of the system is a probe whose construction is similar to a mechanical stabilizer. Such a stabilizer is used for preventing the myocardium from moving, thus it enables stitching of the graft and artery. In comparison to the commercially available stabilizer the developed probe is enhanced with a set of electrodes. These electrodes enable simultaneous measurements of impedance and electrograms. Examples of recordings made during in vivo studies are also presented. Thus, the proposed method is applicable and potentially very useful in clinical practice.

A modified cardiac stabilizer used for recording electrograms.

Originally, tissue stabilizer has been developed by Medtronic, Inc. It is used to prevent a certain part of myocardium from moving. For example, such an approach is utilized during Coronary Artery Bypass Grafting (CABG). Moreover, medical procedures during such operations involve blood arrest, thus, potentially may involve ischemia of myocardium. A construction of the modified tissue stabilizer used during surgery on a beating heart is presented in the paper. We have developed a stabilizer that aside preventing part of myocardium from moving enables recording of epicardial electrograms. Four electrograms are recorded simultaneously together with one lead of standard ECG as a reference signal. Time relations between electrograms, recorded at four different points surrounding potentially ischemic area, are strongly modified by processes triggered by myocardium ischemia. Aside a construction of the stabilizer the associated measurement system is also presented. Measurement properties of the developed stabilizer and measurement system have been examined during tank studies. Finally, the waveforms obtained during in vivo study are also presented.

A six-ring probe for monitoring conductivity changes.

This paper presents the construction of a six-ring probe for monitoring immittance changes. The spatial sensitivity of the probe is defined. This is used to examine the uniqueness of the probe in terms of its application to monitoring conductivity changes. A spatial distribution of the sensitivity is presented for isotropic and anisotropic cases. The latter case is restricted only to anisotropy met when measuring muscles, i.e. diagonal anisotropy. Theoretical calculations performed using the finite element method were verified experimentally using a specially developed measuring system. An example of in vivo measurements is included.

The contribution of blood-flow-induced conductivity changes to measured impedance.

The paper considers the contribution of conductivity changes undergone in an anisotropical medium to measured resistance. This was achieved by extending the relationship proposed by Geselowitz to anisotropical materials described, therefore, by a conductivity tensor. It was found that each element of a conductivity change tensor contributed to the measured resistance only if a corresponding component of the electrical field was nonzero. Numerical calculations were performed for blood-flow-associated conductivity changes. A special experiment stand was developed which allowed experiments to be performed proving the theoretical results. It was found that the absolute value of resistance change measured in the direction perpendicular to the vessel axis was much smaller than that measured along the vessel axis. The results obtained may explain the fact that the actual change of measured resistance created by changes of conductivity induced by aortic blood flow is lower than expected from simplified models.

An averaging two-electrode probe for monitoring changes in myocardial conductivity evoked by ischemia.

This paper considers the applicability of effective conductivity measurements for monitoring physiological and/or pathological phenomena induced by ischemia in the myocardium. The sensitivity of a probe, calculated by means of the finite element method, to changes in the conductivity of the tissue examined is defined for this purpose. Probes developed by Schafer and collaborators (1995) and in our own departments have been examined on the basis of this sensitivity. Theoretical results were verified experimentally using a tank, enlarged models of the probes, and a specially developed electronic circuit. It follows from this study that the probe developed by Schafer et al. is characterized by positive and negative sensitivity. This can lead to misinterpretation of the measurements obtained. In contrast, the sensitivity of our probe is dominantly positive. An example of the in vivo result obtained during experimentally induced ischemia in a swine heart is included.