Conventionally, in order to immobilize the surgical field and to protect the heart, a heart-lung machine is used to oxygenate and transport blood during cardioplegic arrest. ‘Beating heart’ CABG may have a potential for improved patient-reported outcomes, possibly due to a lower incidence of neurological adverse effects believed to be associated with extracorporeal circulation. Between 1999 and 2002, 120 patients were randomly assigned to on-pump or off-pump CABG, and the patients responded to questionnaires before and 3, 6 and 12 months after surgery. Additionally, measurements of cardiac and cognitive function, and magnetic resonance imaging of the brain were entered in regression analyses with patient-reported outcomes. The experimental study demonstrated a benefit of surgical intervention but no significant difference in favour of on- or off-pump surgery. In descriptive and predictive studies, change in physical health was associated with separate contributions from change in exercise capacity and symptom relief, while mental health was associated with preoperative and change in cognitive function. A disadvantage to physical health at three months after surgery was suggested for on-pump patients with preoperative evidence of cerebral ischemic lesions. A methodological study supported that overall quality of life may be a cause as well as a consequence of general health perceptions. This thesis is significant for patient counselling before and after surgery, both in selection of surgical method and for understanding the variation in individual outcomes after CABG. Furthermore, common and unidirectional models appear inadequate to study the causal relationships between cardiac surgery and overall quality of life.

References:

Dissertation:
1) "Patient-reported outcomes after on-pump and off-pump coronary artery bypass surgery", avhandling for graden ph.d. (philosophiae doctor) ved Institutt for sykehusmedisin, Medisinsk fakultet, Universitetet I Oslo, januar 2010.

Published articles:
2) Mathisen L, Lingaas PS, Andersen MH, Hol PK, Fredriksen PM, Sundet K, Rokne B, Wahl AK, Fosse E. Changes in cardiac and cognitive function and self-reported outcomes at one year after coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2009 Dec 15. [Epub ahead of print]

3) Mathisen L, Andersen MH, Veenstra M, Wahl AK, Hanestad BR, Fosse E. Quality of life can both influence and be an outcome of general health perceptions after heart surgery. Health Qual Life Outcomes. 2007 May 24;5:27.

4) Mathisen L, Andersen MH, Hol PK, Tennøe B, Lund C, Russell D, Lundblad R, Halvorsen S, Wahl AK, Hanestad BR, Fosse E. Preoperative cerebral ischemic lesions predict physical health status after on-pump coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2005 Dec;130(6):1691-7.

Mathisen L, Andersen MH, Hol PK, Lingaas PS, Lundblad R, Rein KA, Tønnessen TI, Mørk BE, Svennevig JL, Wahl AK, Hanestad BR, Fosse E. Patient-reported outcome after randomization to on-pump versus off-pump coronary artery surgery. Ann Thorac Surg. 2005 May;79(5):1584-9.

In ten pigs inflatable vascular occluders and ultrasound devices measuring blood flow were placed around the HA and PV. Blood sampling catheters were placed in the PV, hepatic vein and carotid artery. IscAlert™ (diameter < 1 mm) and Neurotrend® sensors measuring real-time PCO2 conductimetrically and PCO2, PO2 and pH optically, respectively, as well as microdialysis probes were placed in the liver. IscAlert™ sensors were placed between loops of small intestine reflecting intestinal PCO2 and microdialysis probes in the intestinal lumen. Subjects were assigned to either full occlusion of the HA and PV followed by gradual occlusion of both or to gradual occlusion of HA and PV followed by total occlusion of both.

Gradual as well as full occlusion of HA and PV led to significant increases of intrahepatic PCO2. This was accompanied by a significant decrease of PO2 and pH both intrahepatically and in the hepatic vein, but not in arterial blood. Microdialysis revealed minor elevation of lactate and glycerol during HA occlusion and significant elevation during occlusion of the PV or both. Intestinal PCO2 rose significantly upon occlusion of the PV accompanied by a significant rise of lactate and glycerol in the intestinal lumen.

Even a gradual occlusion of one vessel leads to detectable changes in liver metabolism. Intrahepatic PCO2 measurement reliably identifies these changes. Intestinal PCO2 increases only during PV occlusion, likely reflecting venous ischemia in the intestine. A combination of intrahepatic and intestinal PCO2 measurement reliably diagnoses the affected vessel, depicts the severity of the occlusion and emerges as a clinical tool enabling early intervention.

The study contributes to our understanding of organising, learning, change and innovation. The specific contributions are developed in the five papers which drew from different theoretical approaches. Several of the papers critically addressed the role of communities of practice in innovation, which is an area that thus far has been under-researched. Specifically, they underscore how power relations both within and across communities of practice become challenged during innovation. In fact, it is argued that during radical innovation, it is no longer given who the master and the apprentice is. In general, the papers emphasise the ongoing, multilevel activities that are important for overcoming different boundaries to develop and stabilise new medical knowing in practice. A major and important challenge is that it is insufficient to establish links between different practices if the organizational and institutional context reinforces the tendency to distinguish between these practices. It also pointed out that the linear approach to innovation is highly problematic, since these processes are not linear or rational, and an innovation is not a "thing" with a constant characteristic that can easily be moved from one context to another. Instead, innovations are very dynamic, contingent and political.
1. opponent was Professor Maxine Robertson, Queen Mary University of London, School of Business and Management, London, England. 2. opponent was Professor Odd Nordhaug, Dept. of Strategy and Management, University of Bergen.
3. member of the Committee was Associated Professor Lars Erik Kjekshus, Health Management and Health Economics at University of Oslo. Leader of the dissertation was Professor Jan Ludvig Svennevig, Dept. of Thorasic Surgery, Faculty Division Rikshospitalet, University of Oslo.

The installed HIFU device at Rikshospitalet [Figure 2] uses an array of 256 ultrasounds transducers to produce a continuous focused beam with 10000-15000 stronger power than imaging ultrasounds [Figure 3]. The ultrasound focus point is continuously moved to ensure a volumetric heating of target tissues [4]. Patient sonication is controlled in real-time by MRI temperature monitoring [5] to ensure that only target tissue is heated and neither excessive heating nor cavitation is produced [Figure 4, Figure 5].

First eligible patients will hopefully be treated at the Interventional Centre from November/December this year [6].
Other application of MRgHIFU are being investigated worldwide [7] for tumour ablation in breast , liver, prostate etc. A very novel application of MRgHIFU is the development of targeted drug delivery [8] where encapsulated drug is selectively released in a specific target zone using only HIFU to destroy the capsule structure.

The Interventional Centre at Rikshospitalet is starting intensive research work using this novel technique. Researchers and medical staff from the Interventional Centre and many other departments at Oslo University Hospital are involved together in a truly multidisciplinary environment. Collaboration agreement between Rikshospitalet and Philips Healthcare is also established.

References

[1] http://www.apptech.philips.com/healthcare/projects/high_intensity_focused_ultrasound.html

[2] Cline HE, Schenck JF, Hynynen K, et al. MR-guided focused ultrasound surgery. J Comput Assist Tomogr 1992;16(6):956–65.

[3] Jolesz FA, Hynynen K,  et al. MR Imaging–Controlled Focused Ultrasound Ablation: A Noninvasive Image-Guided Surgery. Magn Reson Imaging Clin N Am 2005;13 :545–560.

[4] Mougenot C, Salomir R, Palussie`re J, Grenier N, Moonen CTW. Automatic spatial and temporal temperature control for MR-guided focused ultrasound using fast 3D MR thermometry and multispiral trajectory of the focal point. Magn Reson Med 2004;52:1005–1015.

[5] Arora D, Minor MA, Skliar M, Roemer RB. Control of thermal therapies with moving power deposition field. Phys Med Biol 2006;51:1201–1219.

[6] Volumetric MRgHIFU with real-time feedback submission for FDA approval by Philips Healthcare in progress.

[7] Grenier N, Quesson B, de Senneville BD, Trillaud H, Couillaud F, Moonen C. Molecular MR imaging and MR-guided ultrasound therapies in cancer. JBR-BTR. 2009;92(1):8-12 (Review)

[8] Dromi S, Frenkel V et al. Pulsed-high intensity focused ultrasound and low temperature-sensitive liposomes for enhanced targeted drug delivery and antitumor effect. Clin Cancer Res. 2007;13(9):2722-7

The scope of the present consortium is to provide technology and training for the integration of ultrasound and biophotonics based imaging guidance with magnetic resonance imaging (MRI), Computed Tomography (CT) and Positron Emission Tomography (PET) to define the specs of an Integrated Interventional Imaging Operating System (III OS) aimed at minimal invasive treatment of common life-threatening disorders, e.g., cancer, cardiovascular disease and structural heart defects. Effective therapy of these conditions will require a range of safe surgical and interventional devices used with the necessary visualization and tracking under real-time image guidance. The consortium includes a critical mass of industrial and university research institute partners with high expertise in design, development, and manufacture of these devices and instruments. To ensure medical the safety and economical usability of the system and to allow an optimal integration into the future hospital workflow, 6 university hospitals will contribute their clinical and administrative expertise to the consortium in the fields of Interventional Radiology/Cardiology, Anaesthesia, Oncology, General and Cardiovascular Surgery and preclinical Image guided procedures. The consortium of the IIIOS research and training process includes two Biomedical Technology Societies: DGBMT and SMIT&MEDIS Foundation in Rumania providing expert networking and conference organization. The Associated Partners involved in the consortium and will play a key role in the exchange of knowledge and expertise to the new member states of the EU through hosting conferences such SMIT 2009 in Sinaia (www.smit2009.com).
Project Objectives:
The project level objective is the development of the “Integrated Interventional Imaging Operating System”.  The partner level objectives will be verified through the publication of new advances in the following;
The consortium:
1(Coord’or) University of Dundee UNIVDUN UK
2 The University Court of St.Andrews USTAN UK
3 The Interventional Centre, Oslo University Hospital - Rikshospitalet RH-IVS NOR
4 Norwegian University of Science and Technology NTNU NOR
5 University of Homburg Saar UHS GER
6 Delft University of Technology UAD NETH
7 MR Comp GmbH MRC GER
8 University of Luebeck UOL GER
9 Masaryk University ICRC CZ 10 GE Medical systems GE FRA

Modern medicine is irreversibly shifting towards less invasive surgical procedures. Conventional open surgery approaches are systematically being replaced by interventions that reduce access trauma and thereby minimise pain and hospitalisation periods for patients. The downside of this approach is that it is highly demanding for the interventionalist, entailing unacceptable risks for the patient. In the perspective of patient safety, SCATh aims at minimizing these drawbacks specifically for a series of new and promising catheterization procedures. These procedures have the common denominator of dealing with cardiovascular disease, the main cause of death in the EU. SCATh will provide the interventionalist with visual and haptic tools for robust and accurate catheter
guidance, which will be developed through novel approaches, by fusing preoperative patient-specific anatomical and mechanical models and intra-operative data streams from in situ sensors. By complementing and augmenting the skills of the interventionalist, patient safety will drastically increase and at the same time, potentially life-threatening complications which result from poor or damaging (xray,use of contrast agents) visualisation or poor surgical technique can be avoided.
The new concept for tracking, sensing, modelling and manipulation of the surgical environment will be integrated with existing technological state-of-the-art in close cooperation with clinical experts and industrial partners, both in the design and in the evaluation phases. The common efforts delivered during this project will result in a demonstrator applied to a carefully selected set of catheter procedures. Moreover, many of the technological advancements created during SCATh touch upon minimally invasive surgical procedures in general.
The main objective of SCATh is therefore:
The creation of an ICT platform that closes the existing gap between the reality of the catheter inside the cardiovascular system and the manner in which this reality is presented and made accessible to the interventionalist.
Among the main advantages of the envisioned approach are:

1.  Better, more detailed real-time information of the catheter and its local environment.
2.  Reduced mental load on the interventionalist.
3.  Improved manoeuvrability of the catheter and control by the interventionalist.
4.  Faster observation (2) of adverse events and better response (2,3) to such events.
5.  Reduced dependency on visualisation techniques that are harmful for the patient and/or the
interventionalist or that put large stress upon the health care system in terms of expenditure.

Partners are:
1 Katholieke Universiteit Leuven KUL Belgium
2 Centro Investigation Biomedico En Red GBT-UPM Spain
3 The Interventional Centre, Oslo University Hospital IVS Norway
4 Zurich University of Applied Sciences ZHAW Switzerland
5 Imperial College London ICL United Kingdom
6 Technische Universitat Graz, Institut fur Biomechanik TUG Austria
7 Endosense EndoS Switzerland
8 AngioCam GmbH AngioC Germany