A comparison of the several synthetic methods of IONPs with advantages and disadvantages.
\r\n\tEven though video surveillance systems have been part an integral part of the public and security sectors for decades, there is a significant interest in them outside of those industries. This interest is largely due to increased crime rates and security threats all around the globe, which are driving a continuous growth of the video surveillance market. According to a recent report, the video surveillance market was valued at $29.98 billion in 2016 and is expected to reach a value of $72.19 billion by 2022. This market potential is also propelled by recent advances in Artificial Intelligence and Computer Vision research fields—boosting the intelligence, scalability, and accuracy of intelligent video surveillance solutions.
\r\n\r\n\tThe book's goal is to provide a game-changing and cross-disciplinary forum that brings together experts from academia, industry, and government to advance the frontiers of theories, methods, systems, and applications.
",isbn:"978-1-80356-342-8",printIsbn:"978-1-80356-341-1",pdfIsbn:"978-1-80356-343-5",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,isNomenclature:!1,hash:"4d13a124dd9eb965b2e6958786b710cb",bookSignature:"Dr. Pier Luigi Mazzeo",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11548.jpg",keywords:"Hardware and Software Architectures, Privacy in Surveillance, Cybersecurity for Surveillance, Biometrics, Activity and Interaction Analysis, Cognitive Dynamic Systems and Bio-Inspired Methods, Human-Computer Interfaces, Visualization Algorithms, Classification and Recognition, Sensors, Communications and Networked Sensing, Distributed Camera Networks and Smart Cameras",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 17th 2022",dateEndSecondStepPublish:"March 17th 2022",dateEndThirdStepPublish:"May 16th 2022",dateEndFourthStepPublish:"August 4th 2022",dateEndFifthStepPublish:"October 3rd 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"2 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Artificial Intelligence and Computer Vision enthusiastic researcher at Institute of Applied Science and Intelligent Systems in Lecce (Italy) with more than one hundred publications in his referred research fields.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"17191",title:"Dr.",name:"Pier Luigi",middleName:null,surname:"Mazzeo",slug:"pier-luigi-mazzeo",fullName:"Pier Luigi Mazzeo",profilePictureURL:"https://mts.intechopen.com/storage/users/17191/images/system/17191.jpeg",biography:"Pier Luigi Mazzeo obtained an MSc in Computer Science from the University of Salento, Lecce, Italy, in 2001. Since then, he has been working on several research topics regarding artificial intelligence and computer vision. Dr. Mazzeo joined the Italian National Research Council of Italy (CNR) as a researcher\nin 2002. He is currently involved in projects for algorithms for video object tracking, face detection and recognition, facial expression recognition, deep neural networks, and machine learning. He has authored and co-authored 100 publications, including more than fifteen papers published in international journals and book chapters. He has also co-authored five national and international patents. Dr. Mazzeo acts as a reviewer for several international journals and for some book publishers. 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From chapter submission and review to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"314",title:"Regenerative Medicine and Tissue Engineering",subtitle:"Cells and Biomaterials",isOpenForSubmission:!1,hash:"bb67e80e480c86bb8315458012d65686",slug:"regenerative-medicine-and-tissue-engineering-cells-and-biomaterials",bookSignature:"Daniel Eberli",coverURL:"https://cdn.intechopen.com/books/images_new/314.jpg",editedByType:"Edited by",editors:[{id:"6495",title:"Dr.",name:"Daniel",surname:"Eberli",slug:"daniel-eberli",fullName:"Daniel Eberli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"57",title:"Physics and Applications of Graphene",subtitle:"Experiments",isOpenForSubmission:!1,hash:"0e6622a71cf4f02f45bfdd5691e1189a",slug:"physics-and-applications-of-graphene-experiments",bookSignature:"Sergey Mikhailov",coverURL:"https://cdn.intechopen.com/books/images_new/57.jpg",editedByType:"Edited by",editors:[{id:"16042",title:"Dr.",name:"Sergey",surname:"Mikhailov",slug:"sergey-mikhailov",fullName:"Sergey Mikhailov"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1373",title:"Ionic Liquids",subtitle:"Applications and Perspectives",isOpenForSubmission:!1,hash:"5e9ae5ae9167cde4b344e499a792c41c",slug:"ionic-liquids-applications-and-perspectives",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/1373.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"69811",title:"Chemical Synthesis and Characterization of Luminescent Iron Oxide Nanoparticles and Their Biomedical Applications",doi:"10.5772/intechopen.88165",slug:"chemical-synthesis-and-characterization-of-luminescent-iron-oxide-nanoparticles-and-their-biomedical",body:'\nOver the past few decades, magnetic nanoparticles (MNPs) have attracted tremendous attention due to their unique and tunable chemical and physical properties. Magnetic nanoparticles can selectively target specific biological surfaces of interest owing to the arrangement in dipoles in the absence and presence of an external magnetic field. Iron oxide nanoparticles (IONPs) are one of the mostly used MNPs since they are nontoxic and biodegradable, being promising candidates for use in biology and medicine for example imaging [1, 2], siRNA and drug delivery [3, 4], cell tracking [5], magnetic separation [6, 7] hyperthermia [8, 9], and bio- and chemo-sensoring and [10] biomedical applications. Moreover, IONPs are mostly used as magnetic resonance imaging (MRI) probes to differentiate between normal and cancerous cells for diagnosis [11, 12]. Moreover, magnetic imaging has no practical depth limitation for imaging, however spatial resolution is poor and multiple imaging is problematic. To improve the versatility and efficiency in numerous technologies, the development of hybrid magnetic nanoparticles combining both fluorescent and magnetic properties magnetic are being developed [13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23]. The combination of MRI and fluorescent spectroscopy in one nanocomposite opens up unique multimodal properties to monitor complementary information in biological applications such as in multimodal biological imaging, drug delivery systems and medical diagnostics. Despite many problems related to the synthesis of hybrid magnetic-fluorescent nanoparticles, major advances in recent years have been made in this field. For the synthesis, both physical and chemical techniques have been used for the synthesis of IONPs; still, the chemical approach are easier to control the NPs, such as the co-precipitation, thermal decomposition, hydrothermal synthesis, microemulsion, and sol-gel and polyol methods. Of all these approaches, the chemical approach, particularly co-precipitation method is discussed in Section 2. As Fe3O4 NPs are the mostly used IONPs, in this section we focus on the chemical synthesis of Fe3O4 NPs. Also, covered in this section is the synthesis of fluorescent-magnetic nanocomposite material, using InP/ZnSe NPs as fluorophore. The syntheses of fluorescent-magnetic nanoparticles are challenging due to chemical stability and the aggregation of the nanoparticles in solution caused by electron transfer interactions between the particles. The main challenge associated is to overcome the quenching of the luminescence of the fluorophore when it is on the particle surface of the magnetic core. This can be due to the electron and energy transfer between the fluorophore and the magnetic nanoparticles [24, 25, 26]. The easiest and most commonly used method to overcome this hurdle is to isolate the magnetic core from the fluorescent molecule. This can be achieved by coating the magnetic nanoparticle with a shell before it is attached to the fluorescent structure or by placing a spacer between the two molecules. These solutions lead to most luminescent magnetic nanoparticles to have a core-shell structure [15]. The shell needs to have specific properties namely: non-toxic or harmful to human tissue, should not cause the body to emit an immune response, to avert or reduce agglomeration and reduce non-specific interactions with proteins, cells and other components of biological media. Hence, Section 3 covers several procedures for the functionalization and formation of the fluorescent-magnetic nanocomposite material to overcome these challenges. In Section 4, the biomedical applications of IONPs including MRI, magnetic hyperthermia, magnetic targeting, and cell tracking, with focus on diagnosis for breast cancer treatment are reviewed.
\nNanocomposite material with dual or multiple properties have shown extensive potential to improve the performance of current cancer diagnostic tools and/or therapy, for biosensor applications,
In this experiment the synthesis of the multifunctional material will be synthesized via the process seen in Figure 1. From the diagram the end product, the nanocomposite material, the QDs are expected to cluster around the MNPs.
\nExperimental schematic of the synthesis of the magnetic-luminescent nanomaterial.
In order to synthesize the Fe3O4-InP/ZnSe bifunctional nanocomposite material, the luminescent InP/ZnSe nanocrystals were prepared separately from the Fe3O4 magnetic nanoparticles. Once both the MNPs and QDs nanomaterials are synthesized they are both will be functionalized with a compound containing a thiol group. The MNPs and QDs were functionalized with dimercaptosuccinic acid (DMSA) and mercaptopropionic acid (MPA), respectively. Using thiol chemistry, the QDs will directly combine to the surface of the MNPs (as seen in Figure 1).
\nIn this chapter, we discuss the general and recent progress of different chemical synthetic pathways for IONPs (Fe3O4). Their small and controllable sizes, easily functionalized, as well as the ability to be manipulated by external magnetic forces [15], are all attractive properties for various applications including biomedical pursuits. The properties of MNPs strongly depended on the synthesis route. Consequently, the controllable synthesis of monodispersed IONPs is critical for controlling their size distribution, structural defects, surface chemistry, and magnetic behavior for application in specific biomedical field. The synthesis of shape-controlled, stable, biocompatible, and monodispersed IONPs have drawn much effort over recent years. IONPs have been produced by various chemical, physical and biological methods which have both advantages and disadvantages (Table 1). Chemical synthesis offers significant advantages over other methods, as it is a facile, cost-effective method with ease of control over the NPs characteristics. These methods include thermal decomposition, co-precipitation, microemulsion, hydrothermal synthesis, and sol-gel and polyol methods, also shown in Table 1 [32]. Of these methods, co-precipitation is the mostly used as it tends to be green, simple and effective with low production cost, high reproducibility and high yields in one synthesis [27]. Hence, it is of interest, and discussed in detail in section below.
\nCo-precipitation method is the preferred choice among studied synthetic methods for the preparation of Fe3O4 NPs. It is a simple and classical approach to follow as it is simple, convenient, cheap with high reproducibility, solubility and scalability for large scale production. However, due to the high influence of kinetic factors on the growth of Fe3O4 NPs, such as low reaction temperatures, this resulted in formation of irregularly shaped NPs with broad size distribution. This is the best method for the synthesis of water soluble magnetic nanoparticles. However, it has major drawbacks of broad particle size distribution [27, 33]. In 1982, Rene Massart prepared the first superparamagnetic iron oxide NPs, magnetite (Fe3O4), [17] via an alkaline precipitation of FeCl3 and FeCl2 mixture in a molar ratio of 1:2 [17]. The NPs were some-like spherical shaped, with diameter in broad size range around 8 nm. Hence, a size selection process using NaCl as an extra electrolyte was used to selectively decrease the electrostatic repulsions between NPs. This caused aggregation and formation of larger colloidal particles in the supernatant with a diameter of about 7 nm [18]. Hence, O2-bearing atmospheres is required for subsequent reactions to form maghemite (Fe2O3) or ferric hydroxide (Fe(OH)3) [27, 30, 31], due to the sensitivity and instability of magnetite as it is prone to oxidation [34]. In most cases, the co-precipitation method involves some form of mixing Fe2+/Fe3+ salt solutions in an alkaline medium at standard or elevated temperatures under inert (N2 or Ar) atmospheres to avoid the possible oxidation of Fe2+ into Fe3+ [35]. Most papers apply temperatures between 60 and 80°C, some at even higher temperatures [36]. The alkaline solutions commonly used are sodium hydroxide, potassium hydroxide and ammonium hydroxide. The co-precipitation method consists of two major steps—the first is the occurrence of a short nucleation burst at critical supersaturation is reached, and the second involves the slow nucleation growth via diffusion of the solute to the nanocrystal [15]. To obtain monodispersed Fe3O4 NPs, these two stages must be kept separate and the Fe2+/Fe3+ must be fixed at 1:2 molar ratio. Large amounts of monodispersed IONPs can be easily synthesized by changing certain reaction parameters for example the pH, temperature, ionic strength, composition of iron salts, ratio of ferrous to ferric iron and the type of the base and salt precursors [27]. Depending on the parameters, the particle size can be tuned in size range of 2–15 nm [27] with superparamagnetic properties. In most cases, the particle size increase as reaction time and temperate increase, the faster reaction rate results in formation of monomeric generation of NPs. Moreover, the pH value has shown an important role in controlling the size and stability [16]. Studies have shown that the pH must be kept in the range of 8–14 for monodispersed IONPs. A decrease in the pH value results in the decrease of the diameter or dissolution of the NPs, while increase in pH value show NP tendency to oxidate.
\nThis can be prevented by using a surfactant on the surface of Fe3O4 NPs which cause repulsive force between radical ions. In addition, the surfactant not only protects the surface of Fe3O4 NPs, but can also control the size of NPs. In a paper Gao et al. synthesized Fe3O4 NPs using an aqueous solution of FeSO4.4H2O, NaNO3, NaOH, and citrate as the surfactant [19]. The diameter range was tuned from 20 to 40 nm by changing Fe2+ concentration. In another paper, Kumar et al. report on an environmentally benign, non-toxic and cost-effective method for the success synthesis of spherical shaped Fe3O4 NPs.
\nBlackberry leaf (ABL) extract is used as capping agent, and added to a solution of FeSO4.7H2O, using NaOH to adjust the pH to 10–11, the solution was gradually heated between 75 and 80°C. The obtained Fe3O4 NPs had a size range of 54.5 ± 24.6 nm diameter [40]. In our group, Kiplagat et al. synthesized bare and meso-2,3-dimercaptosuccinic acid (DMSA) capped Fe3O4 (as shown in Figure 2). We prepared bare iron oxide nanoparticles following a simple co-precipitation method by dissolving salts of Fe3+ and Fe2+ with a molar ratio of 1:2 at the pH of 12 in ultra-pure water at 50°C [41]. The DMSA capped iron oxide nanoparticles were prepared by dispersing IONPs in toluene and dimethylsulfoxide solution. The diameter of the bare IONPs range from 6 to 13 nm and the average size of 8.5 nm, whereas the DMSA capped IONPs size distribution range from 9 to 16 nm with an average diameter of 10.25 nm as shown histograms in Figure 2. The average size of DMSA capped iron oxide nanoparticles increased slightly compared to the bare iron oxide nanoparticles. Consequently, in our study we found that the synthesis of highly crystalline and monodispersed Fe3O4 NPs was not as easy to achieve. The capping of the iron oxide nanoparticles with the DMSA resulted to partial agglomeration as seen Figure 2(a) and (c). We speculate that the presence of two thiol functional groups in DMSA lead to coupling the nanoparticles, thus the tendency to agglomerate. Similar observations were made by Kumar et al. [40] where they noted that functionalization with ABL led to partial aggregation and broader particle size distribution of IONPs. The use of suitable capping ligands is a widely used to improve their biocompatibility and stability [27, 44], however various approaches are being employed to avoid aggregation of these magnetic nanoparticles that restricts their applications.
\nTEM and EDX of bare and DMSA capped irregularly spherical shaped Fe3O4 nanoparticles synthesized by co-precipitation method (insets: histograms showing size distribution).
In Figure 3, we show the XRD patterns of bare and DMSA capped iron oxide nanoparticles. The XRD pattern was matched with JCPDS no. 00-039-1346 and 00-019-0629 for maghemite (α-Fe2O3) and magnetite (Fe3O4), respectively. Our iron oxide nanoparticles were found to be maghemite. This might be due to the IONPS tendency to undergo oxidation as mentioned earlier [27, 30, 31, 35, 36]. A comparison chart of different coated IONPs and nanocomposites, including their characteristics such as the capping agent, physicochemical and magnetometric properties are shown in Table 2. The main of objective was to provide a facile method of preparing Fe3O4 NPs and its corresponding nanocomposites, to overcome the drawbacks of the prior research, particularly a process with less chemical reagents, carried out at standard reaction conditions.
\nXRD pattern for bare and DMSA capped iron oxide nanoparticles.
Techniques | \nAdvantages | \nDrawbacks | \n
---|---|---|
Chemical | \n||
Microemulsion | \nPrecise control over shape and size and high surface area-to-volume ratio | \nComplex, low yields | \n
Co-precipitation | \nSimple, convenient, very effective, cheap, standard ambient conditions | \nBroad size distribution and poor shape control | \n
Sonochemical | \nEasy with narrow size distribution | \nNo control over shape and medium yield | \n
Hydrothermal | \nEase of control over size and shape. High efficiency | \nHigh pressure and high reaction temperature | \n
Polyol and sol-gel | \nFacile with precise control over size and their internal structure | \nComplicated and high pressures | \n
Electrochemical decomposition | \nGood control over particle size | \nVery low reproducibility, rough and amorphous impurities final product | \n
Thermal decomposition | \nMonodispersed NPs, excellent shape and size control | \nOnly dissolves in non-polar solvents | \n
Physical | \n||
Electron beam lithography | \nGood control over inter-particle spacing | \nCostly and use extremely complex apparatus | \n
Gas phase deposition | \nEasy | \nPoor control over size | \n
Aerosol | \nRelatively narrow size range | \nComplex | \n
Biological | \n||
Bacteria-mediated | \nCheap, good reproducibility and scalability, and high yields | \nTedious, laborious | \n
Type of IONPs | \nSynthetic method | \nCoating | \nPhysicochemical properties | \nMagnetometric properties (SQUID) | \nApplication | \nReference | \n
---|---|---|---|---|---|---|
MnFe2O4\n | \nThermal decomposition | \n1,2-Hexadecanediol, dodecanoic acid, dodecylamine | \nSpherical shape; 12 nm | \nMs = 298 K, Tb = 43.2 emu/g (SQUID) | \nMultimode imaging probes | \nLim et al. [26] | \n
Fe3O4\n | \nThermal decomposition of iron oleate in NaCl | \nOleic acid | \nOctapodes; 20–30 nm | \nMs = 51–71 emu/g, Tb = 240–290 K (SQUID) | \nMagnetic resonance imaging | \nZhao et al. [37] | \n
Fe3O4\n | \nCo-precipitation | \nDMSA | \nNearly spherical, 1.4–6.5 nm | \nMs = 51.7 emu/g, Tb = 298 K (VSM) | \nLymphoma treatment | \nSong et al. [38, 39] | \n
Fe3O4\n | \nGreen method | \nAndean blackberry leaf (ABL) extract | \nSpherical shape, 54.5 ± 24.6 nm | \nN/A | \nDegradation of organic dyes, antioxidant | \nKumar et al. [40] | \n
Fe3O4\n | \nCo-precipitation | \nDMSA | \nSpherical shape, 9–16 nm | \nMs = 43.2 emu/g (SQUID) | \nBreast cancer treatment | \nKiplagat et al. [41] | \n
InP-Fe3O4\n | \nCo-precipitation | \nDMSA | \nAgglomerated, unable to obtain particles | \nMs = 6.03 emu/g (SQUID) | \nBreast cancer treatment | \nKiplagat et al. [41] | \n
Core-shell Fe3O4@SiO2@Au | \nThermal decomposition, sol-gel and oil-in-water technique | \nCetyltrimethylammonium bromide (CTAB) | \nSpherical shape, 100–110 nm | \nMs = 50–46 emu/g, Tb = 298 K (SQUID) | \nPhotoacoustic and magnetic resonance imaging detection | \nMonaco et al. [42] | \n
FemOn-SiO2\n | \nCo-precipitation | \nSilica | \nIrregular nanoflakes; 98–101 nm | \nMs = 11 emu g−1 (VSM) | \nCytotoxicity | \nToropova et al. [43] | \n
SiO2-FemOn | \nCo-precipitation | \nSilica | \nCore-shell structure; 98–101 nm | \nMs = 37.2 emu g−1 (VSM) | \nCytotoxicity | \nToropova et al. [43] | \n
A comparison of several methods of the organic and inorganic coated IONPs, and their corresponding characteristics.
Ms = saturation magnetization; Tb = blocking temperature; Dc = critical size; and Hc = coercivity field.
On the other hand, another class of nanomaterials is quantum dots. Quantum dots (QDs) are inorganic fluorescent semiconductor nanoparticles with dimensions in the range of 1–10 nm. The QDs are usually composed of atoms from groups II–VI, III–V, or IV–VI [45]. The nanometer dimensions of the QDs causes a confinement of electron and hole carriers at dimensions smaller than the bulk Bohr excitation radius; this causes phenomenon, called quantum confinement, to occur in these nanoparticles. The QDs have tunable energy, optical and electronic properties which are done by either managing the QDs size or composition. QDs may be produced via various methods. These methods include but not limited to colloidal synthesis, plasma synthesis, self-assembly, and electrochemical assembly. However, to be able to tune the QDs to a have desired properties and to produce high quality QDs colloidal synthetic methods are the easiest and the most explored. Since there are several different types of QDs in exists, for simplicities sake this study will focus on InP.
\nA colloidal synthetic approach to manufacture QDs can either be achieved by a heating-up technique or rapid hot injection method. The heating up method is a batch process and is achieved by adding all the desired chemicals to a reaction vessel at relatively low temperatures or at room temperature, followed by rapidly heating the entire reaction up to a desired temperature that allows for crystal growth to occur. Khanna et al. [46] directly synthesized indium phosphide (InP) nanoparticles by heating a solution of indium powder in n-trioctylphosphine (TOP). The reaction was carried out under an argon atmosphere. The raw materials, the reaction time and temperature were varied to determine which reaction conditions would create the finest results. In addition, their research demonstrated that with high temperatures in conclusion with, short reaction times and a low amount of TOP leads to InP nanoparticles with small particle sizes and less impurity. The formation of the InP is caused by the catalytic activity of indium nanoparticles attempting to reduce C-P bonds found in TOP. The synthesis method is considered to be simple, low cost and avoids the use of hazardous and expensive raw materials.
\nTo obtain QDs via the rapid hot injection technique, a main reaction is heated to a desired temperature and room temperature precursors are added to the reaction by rapidly being injected into the reaction. The quick addition of the precursors causes the reaction to supersaturate thus allowing for nucleation to occur. The reaction temperature when the cooler precursor is added, the addition of the precursor also causes the reaction to become diluted. The lowered temperature and the lowered concentration of the reaction materials prevent further nucleation, but nanocrystal growth still occurs. The work of Lui and co-workers used a reduction colloidal approach Lui and co-workers [47] were able to synthesize high quality InP NCs. The synthesis required the use of octadecene as a solvent and stearic acid as a capping ligand. These were heated in the presence of indium acetate, under an inert atmosphere for 30 min. After being heated a PCl3-precursor was added to the solution at 40°C. The temperature was then elevated to allow the growth of the InP core. By varying the reaction time and the temperature the study showed how the NC growth could be tuned to a desired size and size distribution. Upon further investigation it was demonstrated that, using a HF post-production treatment, the photoluminescence could be vastly enhanced. The research conducted confirms that InP NCs can be synthesized without the use of the hazardous and expensive material P(TMS)3.
\nCreating a complex system like this presents a few complications. The fabrication of such a system would require several synthesis and purifications steps, which is time consuming and expensive. Also having a magnetic element in the presence of a fluorescent compound reduces the photoluminescence and could quench the fluorophore [47, 48, 49, 50]. There is currently very little information for possible alternatives to the first problem; the second is usually solved by encasing the MNP’s in silica or polymer [24]. In the research conducted by Hong et al. [50], the layer-by-layer (LbL) approach was used to synthesize the magnetic-luminescent nanocomposite. LbL approach is based on the electrostatic attraction of oppositely charged species. In this synthesis, MNPs were used as a template for the multiple deposition of CdTe QDs. The MNPs were synthesized using the co-precipitation of ferric chloride and ferrous chloride. While TGA-capped CdTe QDs were prepared by the addition of Cd2+ into a solution of NaHTe in the presence of TGA. Using LbL they were able to fabricate Fe3O4/PEn/CdTe and Fe3O4(PE3/CdTe)n nanocomposite material by varying the number of deposition cycles of polyelectrolyte layers. The polyelectrolyte phases allowed for increased PL intensity while maintaining strong magnetic properties.
\nThe synthesis described by Gua et al. [51], demonstrated the synthesis of a multifunctional system by integrated materials, with luminescent and magnetic properties, into microspheres of quantum dots (QD) with a cross-linked polymer shell. They basically synthesized iron oxide magnetic nanoparticles (MNP) via a co-precipitation method and thiol-capped cadmium telluride (CdTe) by hydrothermal route. The MNP were incorporated into a silica sphere via the Stӧber method and the QDs added. These conjugated moieties were capped using a template polymerization. Their technique provides many advantages including the formation of a robust luminescent shell with multicolor bar codes which is generated by the aggregation of the thiol-capped CdTe on the silica particles. The outer shell not only protects the CdTe shells from damage, but also facilitates the covalent bonding of the ligands to the nanoparticles.
\nThe synthesis described by Liu et al. [48], demonstrates the synthesis of a magnetic-luminescent MNP-QD nanocomposite via electrostatic interactions. The two major problems that occur is (i) the close interactions of the QDs and MNPs, when they are embedded in a matrix, material causes photobleaching; (ii) while the layer-by-layer process takes an extremely long time and a lot of effort. In this experiment first CdSe QDs are synthesized via the hydrothermal route. While the MNPs are separately prepared using the co-precipitation of Fe2+ and Fe3+ salts, followed by a silica coating by means of the Stӧber method, and finally functionalizing the silica coated MNPs with 3-aminopropyltrimethoxysilane (APTS). The final MNPs were added to a solution of CdSe QDs. The new solution was sonicated and stirred for 6 hours at room temperature. The nanocomposite material was collected and separated by magnetic decantation. The luminescent-magnetic nanomaterial was spherical and had a diameter between 95 and 105 nm. The MNP-QD interactions caused a decrease in the PL intensity. The Ms of the silica-MNPs was 5.4 emu g−1 and the 3.8 emu g−1 for the nanocomposite.
\nThe increase attention of multifunctional nanomaterial has led Nai-Qiang et al. [52] to develop a method to synthesize a nanocomposite composed of MNPs and QD material. The synthesis started the QDs and MNPs were prepared separately. The Mn-doped ZnS QDs synthesis began with a solution of Zn(NO3)2, manganese acetate and 3-mercaptopropionic acid (MPA) being mixed together. After the mixture undergone a dilution, an adjustment of the pH, and purging the air with N2, NaS2 was injected into the solution. The MNPs were synthesized via the co-precipitation of FeCl3 and FeSO4. The MNPs were then coated with SiO2 using the Stӧber method, finally the coated MNPs were modified with APTS. Using electrostatic interactions, the MNP-QD linkage was able to occur after 6 hours of rapid stirring. The nanocomposite material XRD pattern was a combination of the SiO2-MNP and Mn-doped QD patterns. The TEM results measured the nanocomposite material to be 100–130 nm in size and spherical. The SQUID analysis showed a decrease of from 54 to 7 emu g−1 once the MNPs were coated with SiO2 and the nanocomposite was also roughly 7 emu g−1.
\nDue to the great potential surrounding multifunctional nanomaterial, there is a desire to create a fast, simple and large-scale synthesis of the nanocomposite material. Microwave irradiation (MWI) been successful in synthesizing various nanostructures that Zedan et al. [53] attempted to use the design to develop a novel synthesis of the magnetic-luminescent nanocomposite material. Using microwave synthesis, the Fe3O4 and CdSe NCs were prepared separately and to create the nanocomposite material a seed-mediated approach was used. The Fe3O4 NCs were used as seeds and CdSe semiconductor material was allowed to grow around the nanoparticle under MWI. The TEM images of the nanocomposite material confirmed that they maintained the core-shell morphology, were spherical and 10–15 nm in size. The XRD pattern of the nanocomposite material showed the material having good crystallinity. The nanocomposite material maintained the same emission and adsorption peaks as the CdSe QDs. Also changing the irradiation time provides the nanocomposite material with tunable optical properties and the ability to control the luminescent shell’s thickness.
\nAs mentioned previously the synthesis of such a material is very complex, Cho et al. [54] tried to optimize the synthesis of MNP-QD hybrid system by using a direct nucleation route. The multifunctional nanomaterial was prepared by first synthesizing the iron oxide NCs via the thermal decomposition of FeO(OH) with oleic acid as a surfactant in octadecene. The MNPs which formed were then purified and dispersed in hexane. The synthesis of the complex was created during the synthesis of cadmium selenide (CdSe) QDs via the high temperature decomposition method. Before the nucleation of the CdSe was allowed to take place, a solution of MNPs was injected into the solution, causing the QD to directly bind onto the MNP. The complex was monodispersed, crystalline, with an excitation of 575 nm and emission of 604 nm, and a quantum yield of 5%. The synthesis conditions were then varied in order to optimize the multifunctional nanomaterial produced. By varying the temperatures, injection rate and surfactant composition, created changes in the nanomaterials size, photoluminescence and morphology.
\nFor this study magnetic-luminescent multifunctional nanocomposite material was synthesized. Following the work of Wang et al. [55], the QDs and MNPs were prepared separately. For the Fe3O4 MNP synthesis the co-precipitation method was chosen. The QDs were synthesized using the rapid hot injection method, we used InP\\ZnSe because the study by Brunetti et al. [56] demonstrated that the In-based core-shell QDs are safer for
The synthesized iron oxide magnetic-luminescent nanocomposite, was characterized using high resolution transmission electron microscopy (HR-TEM), photoluminescence (PL), and superconducting quantum interference device (SQUID) analysis.
\nThe multifunctional nanocomposite material was synthesized using a partial ligand exchange. Using the partial ligand exchange method multifunction nanoclusters are formed; this occurred due to using InP\\ZnSe in excess. The choice to use excess QDs was an attempt to reduce the quenching of fluoresce quantum dots caused by the MNPs. As seen by the HR-TEM image (Figure 3) the use of the InP/ZnSe in large excess compared to a number of MNPs led to enormous particle crowding. This crowding scenario makes it difficult to determine the average size of nanocomposite particles since the quantum dots filled the spaces between the MNPs.
\nThe PL spectrum the MNP-QD nanocomposite confirms that the composite was successfully formed. In this study, it was discovered that in spite of the high ratio of the QDs to MNPs, the black MNPs quenched the fluorescing capability of the QDs, the lowered intensity is observed in the PL spectrum (Figure 4). The quenching could be possibly due to energy transfer process resulting from contact between the quantum dots and the surface of the iron oxide particles.
\nMNPs-QDs nanocomposite.
It is also clear that the absorption peak red shifted to 676 nm. This observation was also sufficient evidence for the successful formation of the nanocomposite, as the red shift emission observed in this study is most likely caused by the modification at the surface of the QDs brought by hydrophilic ligands and also immobilization of the MNPs (Figure 5).
\nPL spectra of InP/ZnSe nanocrystals dispersed in hexane (A) PL spectra of α-Fe2O3-InP/ZnSe nanocomposite dispersed in PBS (B) [
The nanocomposite material maintained its magnetic properties after the MNPs were conjugated to the QDs as shown by, Figure 6, the magnetization curve. Saturation magnetization of Fe3O4-InP/ZnSe core-shell nanocomposite ∼5.7 emu/g. After the MNP’s were conjugated to the QD’s the saturation magnetization is now a 10% fraction of the original MNPs.
\nMagnetization curves of the MNPs and the nanocomposite material.
The nanocomposites were exposed to both MCF-12A and KMST 6 cell lines. The cytotoxicity of the nanocomposite is presented in Figure 7 below.
\nCytotoxicity of the iron oxide-InP/ZnSe nanocomposite [
As shown by the Figure 7 the cell viability was greater than 90% for all concentrations of the nanocomposite. The findings suggest that the nanocomposites are less toxic.
\nIncreasing attention has been drawn to the synthesis of MNPs for various applications. Magnetic nanomaterials have been observed to possess several distinctive characteristics, these unique capabilities have inspired many ideas in a wide range of biomedical applications [34, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68]. These applications include, [34, 63, 64, 65, 66, 67, 68, 69, 70, 71], target drug delivery [72], magnetic resonance imaging (MRI) contrasting agent [73, 74], cancer and tumor diagnosis and treatment [75]. Magnetic nanoparticles have demonstrated that they can be manipulated with an external magnetic field and thus to some extent be controlled to successfully reach a specific site of interest in a biological system. It has also been discovered that passing an alternating magnet field over magnetic nanomaterials causes them to heat up; this property makes them very attractive for therapies like hyperthermia, a treatment of cancer that requires selective heating to destroy cancer cells. This property also makes them promising for drug release treatment. Studies have also concluded that superparamagnetic nanoparticles can also improve magnetic resonance imaging (MRI) results. In MRI, aqueous dispersions of superparamagnetic IONPs have shown to be promising contrast agents, since it provides high-resolution images. This characteristic makes it possible to use IONPs as vector in a tracking device for gene and drug delivery. However, most methods require the use of superparamagnetic magnetite with particle size smaller than 20 nm [76]. Over recent years, MNPs have drawn a great deal of interest in cancer treatment, particularly IONPs. Studies have proved that IONPs can easily move into the cells with low cytotoxicity. They possess novel magnetic properties for drug delivery, cell targeting, imaging, tissue engineering and magnetofection. Cancer is known as one of the major causes of death worldwide and survival rates are still significantly low. Great research efforts have been devoted to improving the sensitivity and accuracy of diagnostic treatment for earlier detection and high efficiency, however treatment options not as effective. Recently explored magnetic-fluorescing nanoparticles can be used as simple, efficient and multifunctional diagnostic tool based on MRI [77]. The fluorescent NP emits at certain wavelength appropriate for visual imaging using fluorescence imaging microscopy. The multifunctional nanocomposite will simultaneously allow optical tracking as well as magnetic manipulation of biological processes [78]. Fluorescent-magnetic nanoparticles can be treated as bimodal probes useful for studies of the biological objects using both MRI and fluorescence detection. Bimodal imaging agents serving both for MRI and fluorescence imaging are of special interest. Therefore, we provide a brief introduction on the applications IONPs and fluorescent-IONPs in biomedicine, particularly as contrast agents for MRI diagnosis.
\nIONPs possess unique physicochemical characteristics, as well as superparamagnetic with high surface area, non-toxicity, and biocompatibility [15]. IONPs have effectively been applied in various in biomedical applications [34, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68], since they can selectively target a specific biological unit by applying an external magnetic field. Iron oxide nanoparticles of the type, Fe3O4, have shown to be promising candidate as a contrast agent for magnetic resonance imaging. This is due to superparamagnetic or paramagnetism which creates an outer magnetic field around itself when exposed to an external magnetic field; this permits the increase of image resolution and decreases aggregation of particles due to fast dephasing of the spins through a so-called magnetic susceptibility effect. This enhances the signal intensity to help distinguish between healthy and unhealthy cells [79, 80, 81]. Studies have reported IONPs as promising MRI contrast agents for in vivo rat studies.
\nIn of the studies, rats were anesthetized and subcutaneous injection containing 2.5 mg (Fe3O4)/kg body weight of Fe3O4 samples was given every 6 hours into the right hand of the animal. MRI scans taken after every 6 hours showed accumulation occurred on the lymph nodes, however none was noticed on the left-hand side. The study proved successful imaging of lymphatic system using iron oxide as a contrast agent [82]. At present, numerous studies are still undergoing clinical trials and only two types of dextran-capped IONPs have been clinically approved as MRI contrast agents, highlighted in Table 3 [83]. These two are commonly known as, Ferucarbotran (Resovist) with particle size of about 60 nm, and Ferumoxides (Feridex in America and Endorem in Europe) have a broader particle size distribution between 120 and 180 nm (Table 3) [82, 83].
\nNames | \nCompany | \nApplications | \nRelaxometric properties | \nCoating agent | \nHydrodynamic size (nm) | \n
---|---|---|---|---|---|
Clariscan ferristene | \nGE Healthcare | \nOral GI imaging | \nN/A | \nSulfonated styrenedivinylbenzene copolymer | \n3500 | \n
Ferumoxsil AMI-121 | \nGuerbet, advanced magnetics | \nOral GI imaging | \nN/A | \nSilicon | \n300 | \n
Ferumoxides AMI-25 | \nGuerbet, advanced magnetics | \nLiver imaging, cellular labeling | \nr1 = 10.1 r2 = 120 | \nDextran T10 | \n120–180 | \n
Lumirem/Gastromark Ferucarbotran SHU-555A | \nSchering | \nLiver imaging, cellular labeling | \nr1 = 9.7 r2 = 189 | \nCarboxydextran | \n60 | \n
Ferumoxytol code 7228 | \nAdvanced magnetics | \nMacrophage imaging blood pool agent, cellular labeling | \nr1 = 15 r2 = 89 | \nCarboxylmethyldextran | \n30 | \n
Endorem/feridex ferumoxtran-10 AMI-227 | \nGuerbet, advanced magnetics | \nMetastatic lymph node imaging | \nr1 = 9.9 r2 = 65 | \nDextran T10, T1 | \n15–30 | \n
Resovist SHU-555C Supravist | \nSchering | \nBlood pool agent, cellular labeling | \nr1 = 10.7 r2 = 38 | \nCarboxydextran | \n21 | \n
Feruglose NC100150 | \nGE Healthcare (discontinue) | \nBlood pool agent | \nN/A | \nPEGylated starch | \n20 | \n
VSOP-C184 | \nFerropharm | \nBlood agent, cellular labeling | \nr1 = 14 r2 = 33.4 | \nCitrate | \n7 | \n
Characteristics of SIONPs agents undergoing clinical investigation clinical or commercial investigation.
Data edited from [82].
Over the years, scientists have shown that one way to improve on current nanomaterials was to combine two or more desired physical properties into one structure. The wish sparked many research ventures into the synthesis or assembly of these type multifunctional materials, also how many entities is effective and which areas could benefit most from these nanocomposites. Incorporation of a fluorescent material within a magnetic NP might modify its band gap energy as well as the luminescence properties [84]. Such multimodal properties are highly desirable specifically in the biomedical diagnosis and therapy [85, 86]. This nanocomposite would not only be improving current applications, but find better ways to achieve a desired outcome. These magnetic-fluorescent nanocomposites could be multimodal assays for in vitro- and in vivo-bioimaging applications such as MRI and fluorescence microscopy [27]. Other exciting applications of these nanocomposites include cell tracking, cytometry and magnetic separation, which could be easily controlled and monitored using fluorescent or confocal microscopy and molecular resonance imaging (MRI) [24, 87, 88]. They could also be used as bimodal agents for cancer therapy, additionally encompassing hyperthermic and photodynamic properties [89]. These fluorescent-magnetic nanocomposites can also be utilized as a multimodal therapeutic and diagnostic tool that can simultaneously locate, diagnose and treat various diseases [90, 91, 92]. In another study, Mandal et al. prepared multifunctional nanobiocomposite for targeted drug delivery in cancer therapy. Iron oxide nanoparticle of 15 nm in diameter was used as a contrast agent to enhance MRI and the anticancer drug gemcitabine. In vitro studies between treated and untreated cancer cell lines showed black spots on the gastric cancer cell lines that were treated with the nanobiocomposites whereas no reduction in the signal of the untreated cells. The study concluded that the iron oxide nanobiocomposite can act as contrast agent in MRI and also as a targeted drug delivery system in vivo using rats as an animal model [89]. In similar study, Ahmed et al. prepared the thiol capped-CdTe QDs coated with CTAB. The nanocomposites showed distinct magnetic and fluorescent properties even after isolation with a magnet it still maintained good PL intensity. The nanocomposite was conjugated to antibodies for the imaging of the colon carcinoma cells. No green fluorescence was observed on the surface of the cells. In vitro studies showed low toxicity at 64 fold dilutions. This demonstrated their potential as probes for imaging and ultimately provides a new class of multimodal diagnostics NPs for the complex biological systems [93, 94]. Hence, we focus on the developments of magnetic-fluorescent nanocomposites and their biological applications specifically, multimodal imaging for breast cancer diagnostics.
\nBiological imaging or bioimaging is defined as the study of biological processes at the cellular and/or and subcellular level. Several biological imaging techniques have been developed with different in principles and equipment such as optical bioluminescence, optical fluorescence, ultrasound imaging, MRI, single-photon-emission computed tomography (SPECT), and positron emission tomography (PET), X-ray, thermal imaging, X-ray computed tomography (CT), hyperspectral imaging, and magnetic resonance imaging (MRI) [82]. Over three decades, these techniques have continuously had rapid developments and incremental improvements due to their wide application various biological fields. Multimodal magnetic nanoparticles have significant features as they could act as imaging probes and drug delivery systems. These NPs offer unique characteristic as a dual contrast agent that can combine fluorescent microscopy and MRI. Both techniques are well studied, MRI have been widely applied for in vivo imaging diagnosis, meanwhile fluorescence microscopy are mostly applied for in vitro imaging. Optical imaging is a promising tool as it provides better spatial resolution and performance in sensibility for in vitro imaging, however tissue penetration is limited to few millimeters. Moreover, MRI provides excellent spatial resolution and deep tissue contrast for better in vivo imaging. The amalgamation fluorescent microscopy and MRI opens new possibilities of rapid analysis for diagnosis of diseases and pathogens. In recent years, significant advances have been made in development of fluorescent magnetic nanoparticles as multimodal agents by using magnetic contrast agents. Zhang et al. prepared fluorescent mesoporous silica coated-iron oxide nanoparticles of \n
Cytotoxicity studies of bare and functionalized iron oxide nanoparticles using MCF-12A and KMST 6 cell lines.
We were able to successfully synthesize iron oxide magnetic nanoparticles using the co-precipitation method. The synthesized nanoparticles were then functionalized with DMSA.
\nWe were also able to successfully synthesize InP/ZnSe nanocrystals using the hot injection method. The synthesized nanocrystals were capped with oleic acid, which was the stabilizing agent in the nanocrystals’ synthesis. The InP/ZnSe then underwent a ligand exchange and thus the oleic acid capped QDs were replaced with MPA capped QDs.
\nThe ultimate objective of the study was realized when we successfully fabricated a magnetic-luminescent bifunctional nanocomposite material was prepared using thiol-chemistry, this allowed the direct combination of the QDs and MNPs. The nanocomposite material was characterized and observed to exhibit both magnetic and luminescent properties. The SQUID analysis showed that the Fe3O4-InP/ZnSe nanocomposite material has a magnetic saturation of 6.03 emu/g. The PL studies demonstrated that the nanocomposite material had a fluorescence of approximately 40,000 arbitrary units. The nanocomposite material had significantly lower magnetic and fluorescence properties in comparison to their pure forms.
\nTo conclude the study we carried out extensive in vitro cytotoxicity study to evaluate the toxicity of the iron oxide nanoparticles, functionalized iron oxide nanoparticles, InP/ZnSe nanocrystals, and Fe2O3-InP/ZnSe nanocomposite. The KMST 6 and MCF-12A cell lines were exposed to increasing concentration of the nanoparticles. The cells were incubated with the nanoparticles for 24 hours and the cell viability was determined using MTT assay. The cell viability for all types of the nanomaterials was greater than 90% using both MCF-12A and KMST6 cell lines. This suggested that the particles are safe hence not limiting their biological applications and also safe in regard to handling.
\nThere is no universally accepted definition of ischemic cardiomyopathy (ICM). However, the term ischemic cardiomyopathy generally refers to significantly impaired left ventricular function (left ventricular ejection fraction [LVEF] ≤35–40%) that results from coronary artery disease (CAD) [1, 2, 3]. In 2002, Felker et al. suggested that the symptomatic patients with LVEF ≤40% and presence of left main or proximal left anterior descending coronary artery stenosis ≥75% or two or more epicardial coronary artery stenosis ≥75% or a prior history of coronary artery revascularization [percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)] or prior history of myocardial infarction should only be classified as having ICM [3].
Ischemic heart disease is a global pandemic, and its incidence continues to increase. In an estimate, 125 million people across the globe suffer from ischemic heart disease. In the United States itself, every year 720,000 people develop their first myocardial infarction (MI) resulting in hospitalization and/or death [4, 5]. Thirty-five percent of the patients who experience coronary event in a given year die due to it; and each death is associated with an average of 16 years of lost life. Patients who survive after the myocardial infarction are at an increased risk of developing ICM and eventually heart failure (HF). Etiopathogenesis of heart failure is multifactorial; however, ischemic cardiomyopathy is the single most common cause of heart failure. More than 64.3 million people across the world and 6 million people in the United States currently experience HF [3, 6]. In addition to increase in human toll, the estimated cost of HF exceeds $60 billion each year [7, 8].
In patients with coronary artery disease, rupture of atherosclerotic plaque followed by in situ thrombus formation leads to sudden cessation of coronary blood flow. If the coronary blood flow is not established early enough either by spontaneous, pharmacological, or interventional recanalization, the death of ischemic myocytes ensues. With time, dead myocytes are replaced with fibrous tissue. Once the amount of scarred myocardium is significant enough after single or multiple episodes of MI, the left ventricle remodels with dilatation, regional deformation, and decrease in overall contractility. Remodeling and alteration of LV geometry especially the inferior wall may also lead to papillary muscle malalignment and mitral regurgitation (MR). Left ventricle volume overloading due to chronic MR in association with poor left ventricular contractility sets up a vicious cycle of worsening LV remodeling and MR [9].
The replacement of the dead myocardium with fibrous tissue is the most important mechanism in the development of ICM. Other pathophysiological processes such as myocardial stunning and hibernation that render the viable myocardial cells unable to perform their mechanical work and also contribute to the development of ICM. Both myocardial stunning and hibernation are reversible forms of myocardial contractile dysfunction that have the potential of mechanical work restoration if the blood flow supply can be improved [10]. In any given heart with ICM, all three stages of myocardium, i.e., normal, viable but hypocontractile and scarred myocardium often coexist within a single cross section of LV. Thus, ischemic cardiomyopathy is extremely heterogeneous and particularly challenging for accurate viability assessment with imaging studies [11].
The concept of hibernating myocardium is interesting as well as mysterious. Our present understanding about the hibernating myocardium is limited [12, 13, 14, 15, 16]. Rahimtoola [17] described the hibernating myocardium as “resting left ventricular dysfunction due to reduced coronary blood flow that can be partially or completely reversed by myocardial revascularization and/or by reducing myocardial oxygen demand.” Hibernating myocardium is usually limited to subendocardial tissues. Histologically, in hibernating myocardium, there is loss of contractile proteins and sarcoplasmic reticulum without the change in the cell volume. Presumably, hibernation is a protective dedifferentiation of myocardial cells or switch to a quiescent state of decreased mechanical work in times of chronically decreased oxygen supply [13]. This adaptive mechanism probably allows the myocytes to avoid the ischemic imbalance and remain alive in the milieu of decreased coronary blood flow that would otherwise lead to cell death. Alternative mechanism for ventricular dysfunction in ICM may be myocardial stunning. Myocardial stunning apparently occurs due to repeated episodes of ischemic insult that result in viable but chronically hypocontractile myocardium (i.e., repetitive stunning). Due to extremely low ischemic threshold of the myocytes, any decrease in coronary blood flow during stress leads to ischemia and ischemia–reperfusion changes in the myocytes despite normal or insignificantly decreased resting coronary perfusion [13, 18]. This repetitive stunning of the myocytes results in chronic LV dysfunction. Thus, in patients with ICM, territories with high numbers of cardiomyocytes with excess glycogen reserve and less fibrosis in all probabilities are reversible after revascularization. These myocytes also demonstrate higher blood flow and glucose uptake on positron emission tomography (PET) scan [19].
Patients with ICM present with myriad of signs and symptoms depending upon the severity of heart failure and degree of physiological compensation. Some patients may be asymptomatic or minimally symptomatic with mild anginal chest pain and dyspnea on exertion while other patients may present with overt heart failure symptoms, e.g., dyspnea, orthopnea, poor exercise tolerance, and increased fatigability. Patients usually have a longstanding history of coronary artery disease and a prior history of myocardial infarctions. Physical examination can reveal bibasilar crackles, S3 gallop, displaced apical impulse, carotid bruits, jugular venous distension, positive hepato-jugular reflex, and bilateral lower extremity edema.
In patients with ICM, multivessel disease, low LVEF, and increased LV end-systolic volumes are important prognostic factors. Therefore, all these factors must be taken into consideration when making the difficult decision regarding revascularization. Suitability of the patient for CABG depends upon: A) suitability of the diseased coronary arteries for bypass grafting; B) the amount of viable myocardium present and whether the viable myocardium is present in the territory of CAD; C) severity of right and left heart failure; and D) associated cardiac lesions. All the diagnostic investigations should be directed toward determining whether the patient is a suitable candidate for CABG or not.
Transthoracic echocardiography (TTE): Transthoracic echocardiography is an essential investigation in assessing myocardial viability in a patient with ICM. Echocardiography is useful in evaluating cardiac anatomy, valvular function, ventricular systolic/diastolic function, cardiac wall motion, and pericardial pathology. All this information is useful in diagnosing ischemic cardiomyopathy, especially in patients with HF and other high-risk features.
Coronary angiography: Coronary angiography allows direct visualization of the coronary arteries for assessment of severity of obstruction, collateralization, and the blood flow to the myocardium. Coronary angiography is most important in defining the extent and severity of coronary artery disease and whether the coronaries arteries are suitable for grafting. Computed tomography coronary angiography can also be performed in place of conventional coronary angiography to assess coronary arteries in patients with low to intermediate risk of CAD [20].
Cardiac stress test: There are different stress tests available depending on the patient’s health, functional status, baseline heart rhythm, and exercise tolerance. The goal of these stress tests is to assess for cardiac ischemia and myocardial viability. Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR), dobutamine stress echocardiography, single-photon emission computed tomography (SPECT), and F-18- fluorodeoxyglucose positron emission tomography (FDG-PET) imaging can be used to assess myocardial viability [21]. Dobutamine stress echocardiography is widely used to assess myocardial contractility reserve and viability. With continuous dobutamine infusion, initially myocardial perfusion increases along with increased contractility. However, as the dobutamine dose increases, blood flow cannot be escalated further leading to reduced myocardial contractility. This phenomenon known as biphasic reaction can predict the recovery of the myocardial function after revascularization.
Late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) can detect increase in extracellular space due to myocardial apoptosis and necrosis and can predict the reversibility of the myocardial contractility after successful revascularization while dobutamine stress CMR can detect the ischemic myocardium. In patients with ICM with transmural infarct, minimal LGE (<25%) in dysfunctional myocardial segment indicates a high likelihood of recovery while the chance of recovery is minimal in segments with >50% LGE.13 In segments with 25–50% LGE involvement, the recovery prediction is not consistent [22].
Single-photon emission computed tomography (SPECT) and positron emission tomography (PET) had been widely utilized in the past to assess myocardial viability. Thallium-based SPECT scan demonstrate delayed distribution but has increased risk of ionizing radiations while technetium-based SPECT has less risk of radiation, but it cannot demonstrate a delayed distribution. Another nuclear imaging modality to assess myocardial viability is cardiac PET. PET imaging is based on the principle that in an ICM, ischemic myocardium switches to glucose-based metabolism instead of fatty acids. 18F-fluorodeoxyglucose (18F-FDG) can detect this shift in viable but ischemic myocardium. PET has higher spatial resolution, lower risk of radiation, and better attenuation correction compared with SPECT. PET, however, cannot distinguish between normal and ischemic or hibernating myocardium in patients with insulin resistance, and results may be inaccurate in patients with variable uptake of FDG due to heart failure [23].
Brain natriuretic peptide (BNP) test: BNP is synthesized in the ventricles, and it is secreted when the myocardial muscle has a high wall tension. BNP is an important biomarker for heart failure patients. Increasing trend in BNP suggests worsening of heart failure; however, it cannot detect myocardial ischemia.
Coronary artery bypass grafting for CAD started in the mid-1960s. Since then, numerous clinical trials and studies have tried to address different questions related to the management of CAD. All these trials and studies have established an undisputed role of surgical revascularization in patients with CAD in terms of improved survival, risk of reintervention, and quality of life [24, 25, 26, 27]. Nevertheless, prior to Surgical Treatment for Ischemic Heart Failure (STICH) trial [28], none of the studies specifically addressed the management of patients with ICM. The coronary artery surgery study (CASS) trial registry that followed the patients who were excluded from the main study reported that patients with LVEF <35% had better survival with CABG than with medical therapy, if they had associated three-vessel disease and if the presenting symptom was angina [29]. Similarly, a 25-year observational study involving 1391 patients (medical therapy (n = 1052) or CABG (n = 339)) from Duke Cardiovascular Disease Databank also reported an improved survival with CABG over medical therapy alone after 30 days to more than 10 years in patients with NYHA class ≥II, CAD with at least one vessel stenosis ≥75%, and LVEF <40%. The benefit with CABG was observed irrespective of the extent of coronary artery involvement (P < 0.001) [30].
These observational studies pointed toward the role of CABG in patients with ischemic cardiomyopathy; however, lack of randomized clinical studies in patients with ICM led to different therapeutic approaches driven by the physician bias regarding the potential benefit of myocardial revascularization [9]. The resulting equipoise formed the basis for the multiinstitutional STICH randomized controlled clinical trial [28]. STICH trial was the first and only large-scale randomized clinical trial to compare surgical revascularization with medical therapy in patients with LVEF ≤35% and CAD amenable to CABG. The STICH trial randomly assigned 1212 patients to three groups (medical therapy alone, medical therapy with CABG, and medical therapy with CABG and SVR). To evaluate the superiority of either procedure, two hypotheses were developed. In Hypotheses 1, the investigators evaluated medical therapy against medical therapy with CABG. All patients underwent coronary angiography to define the extent of CAD; patients with critical left main disease or unstable coronary syndromes were excluded from the trial. The primary outcome of the study was all-cause mortality, and secondary outcomes were cardiovascular mortality, combination of all-cause mortality and hospitalization for cardiac causes. At a median follow-up of 56 months, medical therapy plus CABG surgery resulted in a nonsignificant trend toward improvement in the primary outcome (36% vs. 41% with medical therapy alone) as well as significantly lower cardiovascular mortality and improved quality of life (at 4, 12, 24, and 36 months as assessed by the Kansas City Cardiomyopathy Questionnaire) [31]. However, this trial was fraught with certain limitations. First, during the study period, 9% patients in medical therapy plus CABG group crossed over to medical therapy group only while 17% patients in medical therapy alone group crossed over to medical therapy and CABG group. This crossover may have led to a diminished treatment benefit, thereby preventing the primary outcome from reaching statistical significance. Second, the STICH trial was designed to maximize both medical and surgical outcomes using strict criteria for surgical expertise (e.g., documented surgical expertise by volume and outcome criteria) and regular review of both surgical center conduct and intensity of medical therapy. Clinical equipoise had to be present, and both the surgeon and cardiologist had to believe revascularization was technically feasible. Both these issues may limit the generalizability of the trial to routine clinical practice.
In 2016, results of extended follow-up of STICH trial patients, i.e., the STICH Extension Study (STICHES), were published extending the median follow-up to 9.8 years [32]. After 9.8 years, the primary outcome (all-cause mortality) was significantly lower in the medical therapy and CABG group compared with medical therapy alone group (59% vs. 66%; hazard ratio [HR] 0.84; 95% CI, 0.73–0.97). Medical therapy and CABG group also experienced significant reductions in cardiovascular mortality (40.5% vs. 49.3%; HR 0.79; 95% CI, 0.66–0.93) and the combination of all-cause mortality and cardiovascular hospitalization (76.6% vs. 87%; HR 0.72; 95% CI, 0.64–0.82). Another large population based observational study related to CAD with LV systolic dysfunction was reported [33], it is recommended to do CABG and medical therapy for patients with ICM who have coronaries amenable to surgical revascularization.
Observational studies done in early 2000s focused on the potential benefit of viable myocardium on the patient survival and LV function after the revascularization. Initial potential survival benefit from revascularization in patients with ICM and viable myocardium was reported in a meta-analysis published in 2002. This meta-analysis included 24 nonrandomized viability studies involving 3088 patients with CAD and LV dysfunction who had a mean LVEF of 32% [34]. Patients with myocardial viability had 80% reduction in annual mortality with revascularization (3.2% vs. 16% with medical therapy alone), while there was no significant change in annual mortality with revascularization in patients without myocardial viability (7.7% vs. 6.2% with medical therapy alone). Potential effect of viable myocardium on LVEF was also illustrated in a review published in 2004 that involved 29 observational studies including 758 patients [35]. In this review, LVEF increased after revascularization when myocardial viability was present (37–45%) but did not change significantly in the absence of viability. Further, studies have also demonstrated that 25–30% of the dysfunctional myocardium needs to be viable to result in improvement of LVEF. On the contrary, in a substudy of the STICH trial, 601 of the 1212 patients were evaluated for myocardial viability, and outcomes were analyzed according to those assigned to receive medical therapy plus CABG or medical therapy alone. Study showed minimal improvement in LVEF with revascularization (from 28% pre-CABG to 30% post-CABG). Following adjustment for differences in baseline variables and with follow-up extending beyond 10 years, there was no significant improvement in mortality with medical therapy plus CABG compared with medical therapy alone. Myocardial viability was associated with reduced mortality but did not predict a benefit from revascularization. This raises the question of whether viability assessment is needed prior to surgical revascularization. However, myocardial viability in STICH trial was assessed using stress echocardiography and SPECT radionuclide myocardial perfusion imaging; more contemporary techniques such as CMR and positron emission tomography (PET) were not studied and are an important limitation of the STICH findings [36]. Presence of myocardial viability does lead to improvement in contractility and myocardial thickness following revascularization subject to the presence of at least 25–30% of viable myocardium and scar burden <25% (as detected by LGE-CMR) [37]. However, inconsistencies in the criteria and the methods used to diagnose myocardial viability between various studies have led to blurring of the evidence of benefit of revascularization.
In the absence of firm evidence, routine viability assessment prior to consideration for CABG in patients with ICM is not recommended. However, situations that require greater precision in defining large infarcts either due to associated excessive surgical morbidity (e.g., renal failure) or risk of suboptimal outcome (e.g., evidence of LV remodeling, inability to achieve complete revascularization); viability assessment with more contemporary techniques such as LGE-CMR or FDG-PET may help further refine the potential risks and benefits.
Left ventricular size is an important determinant of outcome after surgical revascularization in patients with ICM. However, our present understanding of impact of preoperative LV size on postoperative LV function and survival is still limited. The impact of left ventricular enlargement on the improvement in LV function after revascularization was illustrated in a review of 61 patients with ischemic heart disease and a mean LVEF of 28%, all of whom had an evidence of substantial myocardial viability [38]. One-third of the patients had no significant improvement in the LVEF (≥5%). The study showed that the patients with a significant improvement in LVEF after CABG had a significantly smaller left ventricular end-systolic volume (LVESV) on preoperative echocardiography than those without improvement (121 mL vs. 153 mL). The observational data are in contrast with the findings from the STICH trial, which found greater benefit with respect to mortality in patients with greater baseline remodeling (e.g., larger left ventricle end-systolic volume index [LVESVI]) [28].
Percutaneous coronary intervention (PCI) is an established treatment for revascularization in acute myocardial infarction. Role of PCI in management of ICM is still unclear due to the lack of well-designed randomized studies. In the lack of randomized controlled study, best available data come from the observational study comparing PCI with CABG in 4616 patients with LVEF ≤35% who were enrolled in New York State registries (1351 underwent PCI with drug eluting stents and 3265 underwent CABG), from which 2126 patients were chosen for evaluation based on propensity score matching [39]. At a median follow-up of 2.9 years, there was no significant difference in mortality between contemporary PCI and CABG (HR 1.01; 95% CI 0.81–1.28). PCI was associated with a greater risk of myocardial infarction (HR 2.16; 95% CI 1.42–3.28) and need for repeat revascularization (HR 2.54; 95% CI 1.88–3.44), but a significantly lower risk of stroke compared with CABG (HR 0.57; 95% CI 0.33–0.97).
In a separate post hoc analysis of AWESOME trial, in which 454 patients who had medically refractory unstable or provocable ischemia were randomized to PCI or CABG. Ninety-four patients had LVEF <35% (mean 25%) [40]. Among patients with LVEF <35%, there was no difference in mortality between CABG and PCI. However, limitation of this trial was that all patients included in the study had angina and acute coronary syndromes and not heart failure.
The mechanism of survival advantage conferred by CABG in patients with heart failure irrespective of myocardial viability still remains speculative, although, post hoc analysis of STICH trial has been able to shed some interesting insight on this topic. In STICH trial, a subanalysis evaluating cause-specific cardiac mortality in patients with ICM demonstrated that sudden cardiac death (SCD) was the most frequent mode of death and outnumbered pump failure deaths by approximately twofold [41]. Further, both SCD and death from HF were significantly reduced after the CABG (as was death from myocardial infarction). Predictors of increased risk of SCD in this analysis were increased LVESVI and elevated BNP level. Interestingly, same variables along with regional myocardial sympathetic denervation were found to be significant risk factors for SCD in patients with ICM in the Prediction of Arrhythmic Events with Positron Emission Tomography (PAREPET) Study [42, 43]. Thus, the survival benefit of CABG in patients with ICM is largely due to the significant effect of revascularization on reducing the death due to arrhythmia with a smaller contribution from reducing the deaths from pump failure and fatal MI.
We suggest the combined CABG and medical therapy instead of medical therapy alone for patients with ICM and CAD that is amenable to surgical revascularization. This suggestion is based primarily on a 7% absolute reduction in overall mortality over 10 years (STICH trial) and superior relief of anginal symptoms following CABG. However, as significant morbidity and early mortality (compared with medical management alone) are associated with CABG in patients with ICM, patients may also reasonably choose medical therapy alone as the initial treatment option. Following initiation of medical therapy, patients should be reevaluated on an ongoing basis for any changes in clinical status or symptoms and consideration for surgical revascularization should be discussed with the patient.
Other clinical features that should be considered while tailoring the decision for any given patient are greater functional capacity (6-minute walk >300 m), greater burden of CAD (e.g., three-vessel disease), coexistent moderate to severe mitral regurgitation (MR), lower ejection fraction (e.g., LVEF <35%), and greater remodeling (e.g., LVESVI >79 mL/m2) (associated with improved outcomes in STICH trial).
Additionally, we do not recommend routine viability assessment prior to consideration for surgical revascularization and consideration should be case-to-case basis especially in patients in whom the risk-to-benefit profile is not as clear (e.g., patients with significantly elevated surgical risk). We believe that viability study may not aid in decision-making; however, the presence of significant viability and < 25–30% scar on LGE-CMR gives reassurance to the surgeon for improved surgical outcome.
Considering the advantage with CABG from the STICHES trial, it seems that patients with suitable targets for revascularization in the setting of an EF < 35% with two or three vessel CAD should be considered for CABG irrespective of the results of viability testing. However, competing risk factors such as severity of heart failure, age of the patient, and risks for noncardiac mortality need to be carefully weighed in considering the recommendation for revascularization and decision should be made on individual basis.
Factors that have been consistently associated with adverse outcomes after CABG for patients with ICM include preoperative renal dysfunction, advanced HF, recent myocardial infarction, and hemodynamic instability. Perioperative shock in this patient population more than doubles the rate of perioperative mortality [44, 45, 46]. Therefore, preoperative optimization of the patient status can improve the patient outcome after the surgery. The specific mode of optimization should be individualized to patients’ needs and driven by their response to initial therapy. If medical therapy alone is ineffective, more invasive measures should be considered. In the preoperative setting, prophylactic intra-aortic balloon pump (IABP) decreases afterload, increases coronary artery perfusion, provides a modest increase in cardiac output [47, 48]. In a variety of analyses, IABP therapy before the operation has been noted to result not only in improved patient condition before CABG, but also in reduced perioperative morbidity and mortality. Two meta-analyses of randomized clinical trials examining the utility of preoperative IABP therapy in patients with ICM demonstrated a strong association between preoperative use of IABP and reduced hospital mortality, lower incidence of low cardiac output syndrome, and shorter duration of ICU stay. Patients with high-risk profile including low LVEF, left main disease >70%, prior heart surgery, poor coronary artery targets, and unstable angina typically benefit from preoperative IABP [47, 48, 49, 50].
In patients who present with cardiogenic shock resulting from acute myocardial infarction or decompensated HF with end-organ dysfunction, IABP may be inadequate for stabilization or preoperative optimization. In these patients, transvalvular devices such as microaxial surgical heart pump can be used. These devices reduce left ventricular end-diastolic pressure (LVEDP) and volume workload and provide the circulatory support necessary to allow native heart recovery. In a recent analysis, the use of these micro-axial pump was associated with reduced mortality, without significant increase in device-related stroke, hemolysis, or limb ischemia [51, 52]. Finally, in patients with cardiogenic shock that is refractory to inotropic support, IABP, and/or microaxial pumps, ventricular assist device (VAD) implantation should be considered [47, 53, 54].
Patients with ICM with cardiogenic shock, who have organ dysfunction at the time of presentation, temporary VAD can be used as bridge to decision. Patients who reverse their organ dysfunction and acidosis after the insertion of temporary MCS and demonstrate an adequate contractile reserve and response to inotropic stimulation can successfully bridge to CABG. This is contingent to good coronary targets and absence of unfavorable anatomic and physiologic profiles [27]. Otherwise, they should be evaluated for heart transplant and should be considered for more durable VAD option as bridge to transplant.
The goal of CABG in patients with ICM is to achieve expeditious and complete revascularization. On-pump arrested-heart CABG is the most commonly used strategy that allows a bloodless and still field that facilitates complete revascularization [55]. Excellent myocardial protection especially right ventricle is paramount in the setting of ischemic cardiomyopathy as myocardial ischemia and injury are poorly tolerated when myocardial reserve is limited [56].
In patients undergoing on-pump CABG, controversy still remains about type of cardioplegic solution, temperature, and route of administration that provides the optimal myocardial protection. This becomes critical in patients with ICM as any amount of further myocardial damage may be deleterious. In a meta-analysis of 12 studies including 2866 patients, lower prevalence of perioperative myocardial infarction was found in patients who received blood cardioplegia [57]. Another meta-analysis of 41 randomized clinical trials (RCT) found that warm cardioplegia did not improve clinical outcomes but was associated with a mild reduction of cardiac enzyme release [58]. Single-dose cardioplegia benefit is limited to a reduction in ischemia and bypass time and does not translate into a major morbidity or mortality advantage [59]. There is no systematic comparison of different routes of cardioplegia administration (i.e., antegrade vs. retrograde vs. combined); however, isolated retrograde cardioplegia should be avoided due to its heterogeneous perfusion and unpredictable right ventricle myocardial protection [60]. On the other hand, retrograde cardioplegia may be useful in adjunct to antegrade cardioplegia in patients with severe CAD and in redo CABG to reach territories not otherwise reachable by antegrade delivery and to flush potential embolic debris from inadvertently manipulated diseased vein grafts [61, 62]. Although data are scarce, it has been reported that antegrade cardioplegia supplemented with venous graft perfusion can significantly improve myocardial protection. The most suitable myocardial protection strategy may be a combination of antegrade, retrograde, and delivery down the vein grafts.
Utilization of off-pump CABG (OPCABG) is limited to few centers and selected patients in the developed countries. There have been no large RCTs comparing on-pump CABG versus OPCABG and small RCTs that did compare these two modalities have reported inferior or non-superior long-term outcome with OPCABG. Most of these studies are limited by smaller sample size, short duration of follow-up, and limited experience of the operator. This is of particular relevance given that OPCABG may lead to inferior long-term outcomes if performed by inexperienced operators and/or accompanied by incomplete revascularization [63]. In a meta-analysis of 23 individual nonrandomized studies published in 2011 that involved 7759 CABG patients with LVEF <40%, 2822 patients underwent OPCABG. Overall early mortality was significantly reduced (odds ratio [OR], 0.64; 95% CI, 0.51–0.81) in OPCABG group. Similar results were observed on subgroup analysis of 1915 patients with LVEF <30% (OR 0.61; 95% CI 0.47–0.80) [64]. A recent meta-analysis published in 2020 comprising 16 studies with 32,354 patients with LV dysfunction (defined as LVEF <40%) also reported a significant reduction in 30-day mortality (OR 0.84; 95% CI 0.73–0.97), perioperative complications, and transfusion requirements with OPCABG [65]. In a report published in 2016 from the Japan Adult Cardiovascular Surgery Database including 918 pairs of propensity-matched CABG patients with LVEF <30%, there was reduced perioperative and 30-day mortality with OPCABG (1.7% vs. 3.7%; P < 0.01) and reduced incidence of mediastinitis, reoperation for bleeding, and need for prolonged ventilation, but there was no difference in incidence of stroke or renal failure compared to on-pump CABG [66].
On-pump beating-heart CABG has been proposed as an alternative strategy to on-pump cardioplegic arrest CABG, particularly in higher-risk patients including patients with impaired LV function [67]. This technique is more of historical significance as it is rarely used nowadays. In a review of 11 studies, comprising two RCTs and nine observational studies comparing on-pump beating-heart CABG and on-pump arrested heart CABG, lower mortality was reported with on-pump beating-heart CABG in five of the nine observational studies while mortality was similar with both techniques in two RCTs. However, due to the lack of randomization and the absence of propensity matching, the possibility of selection bias accounting for the difference in mortality cannot be discounted. Intraoperative myocardial injury with on-pump beating heart may increase due to inadequate coronary perfusion distal to areas of stenosis [68].
In the absence of more definitive evidence about the superiority of one technique of CABG over the other, the operative strategy should be tailored based on patient factors such as extent of CAD and associated comorbidities, surgeon’s expertise and comfort level of the cardiac anesthetist, and center experience. When off-pump technique is used, maintenance of appropriate perfusion pressure and when on-pump CABG is utilized, appropriate myocardial protection is imperative to minimize further myocardial injury.
Presently, use of left internal mammary artery (LIMA) for bypassing left anterior descending coronary artery and reverse saphenous vein grafts for bypassing rest of the coronary arteries is the standard of care across the globe. Evidence from the recent studies has shown the superiority of multi-arterial grafting in improving long-term patient survival after CABG. The impact on survival becomes even more significant with increasing duration of follow-up [69, 70, 71]. The evidence of beneficial effects of multi-arterial grafting in patients with ICM, however, is limited to few studies and a small number of patients [72, 73, 74]. Further, multi-arterial grafting in patients with ICM still remains controversial as the overriding priority in these patients is to mitigate the upfront risk of surgery and avoidance of perioperative myocardial ischemia. In a risk predictive model based on STS database review of patients operated for CABG, the HR for perioperative mortality after isolated CABG was 1.19 (95% CI, 1.17–1.22) for every 10% reduction in LVEF [75], and operative risk was further compounded with the addition of noncardiac organ dysfunction and other comorbidities.
There are four reasons why caution should be used when contemplating multi-arterial grafting in patients with ICM [56]. First, perioperative administration of high doses of vasopressors may be necessary in these patients, and this is an important predisposing factor for the development of spasm in the arterial grafts [76]. Radial and gastroepiploic arteries are particularly vulnerable to spasm compared with IMAs. Second, adequacy of blood flow in a fresh arterial graft may not be as robust as in a vein graft, with the potential for clinically significant perioperative coronary artery hypoperfusion [77, 78, 79]. Third, multi-arterial grafting usually adds to the complexity and length of the operation and prolongs myocardial ischemic time. This may not be well tolerated by the patients with ICM. Fourth, arterial grafts may not be of adequate length in massively dilated hearts, especially if sequential anastomoses are contemplated. A patient-level combined analysis of six RCTs associated radial artery grafts in addition to LIMA with improved clinical outcomes compared with venous grafts [80]. The benefit of radial artery grafting was persistent even on subgroup analysis of patients with severe LV dysfunction (LVEF <35%). However, the number of patients in subgroup were limited (25 (4.7%) and 32 (6.4%) in the radial artery and saphenous vein groups, respectively). The results of other observational studies have yielded mixed results with the use of multi-arterial grafting in patients with ICM [73, 81, 82, 83, 84]. The probable reason is variable cutoff for LVEF with different studies (lowest limit <30%), which adds to uncertainty regarding multi-arterial grafting benefits [85]. Observational evidence also suggests that the benefit of multi-arterial grafting is lost in patients with ICM with limited life expectancy or severe associated comorbidities [83, 86, 87, 88].
We believe that multi-arterial grafting should not be routinely recommended for patients with ICM. Patient selection for multi-arterial grafting should be based on patient factors and surgeon’s experience and comfort. Young patients with compensated HF having good target for bypass may be considered for multi-arterial grafting if the risk–benefit ratio is favorable and prolonged survival is anticipated after revascularization.
Atrial fibrillation (AFib) is present in 5–10% of patients undergoing CABG. It is associated with increased risk of complications including stroke and renal failure, prolonged hospital stay as well as increased mortality despite adjustment for potential confounders [89]. Therefore, current North American and European guidelines for CABG recommend concomitant AFib ablation procedure in symptomatic patients or asymptomatic patients having low operative risk [90, 91]. The evidence supporting the surgical ablation of AFib in patients with ICM undergoing CABG is minimal and limited by selection bias [92]. Theoretically, patients with a reduced ejection fraction would benefit from the restoration of sinus rhythm and atrial contraction [93]. However, concomitant AFib ablation procedure adds to the technical complexity of the surgery and prolongs the duration of aortic cross clamp and cardiopulmonary bypass. Despite this, some studies reported that surgical AFib ablation is safe and effective in patients with heart failure [94, 95].
Up to 10% patients develop chronic moderate or severe MR following acute myocardial infarction. Chronic ischemic mitral regurgitation (CIMR) is associated with an increased incidence of heart failure and increased risk of mortality in patients with LV dysfunction [96]. Furthermore, LV dysfunction can lead to gradual dilatation and geometric change in the left ventricle that results in distortion of the mitral valve and worsening of MR. Although, there is a general consensus to repair or replace the mitral valve in patients with severe CIMR undergoing CABG, the management of moderate (Grade II) mitral regurgitation still remains controversial.
In the Cardiothoracic Surgical Trials Network study, adding surgical mitral valve repair to CABG in patients with moderate CIMR had no significant effect on survival or LV reverse remodeling at 2 years follow-up but was associated with increased duration of hospital stay and morbidity including neurological events and atrial arrhythmias [97]. Smaller RCTs have shown benefit in surrogate outcomes for CABG and mitral valve repair versus CABG alone in patients with moderate CIMR [98, 99]. However, none of the trials has specifically focused on patients with ICM. In patients with severe CIMR, mitral valve replacement has been shown to provide more reliable and durable relief of MR than repair, but without survival benefit [100]. Mitral valve replacement rather than repair is also favored in patients with LV basal aneurysm/dyskinesis or other potential risk factors for recurrent MR after repair, e.g., significant leaflet tethering and/or severe left ventricular dilatation (LV end-diastolic dimension >6.5 cm). Preserving the subvalvular apparatus is also strongly recommended when replacing mitral valve in these patients. Concerns about persistent tethering of the posterior leaflet and recurrent MR after CABG in patients with prior inferior wall MI have prompted some to combine mitral anuloplasty with a subvalvular procedure such as papillary muscle approximation and papillary muscle relocation. All these procedures result in improved echocardiographic and cardiovascular outcomes but fail to influence all-cause mortality or quality of life [101, 102, 103]. Therefore, this remains an area for further study and evaluation.
Tricuspid regurgitation (TR) is an established risk factor in patients undergoing CABG [104]. In patients with CIMR, although progression of unrepaired mild to moderate TR after revascularization is uncommon, presence and progression of moderate or greater TR are associated with increased incidence of clinical events [105]. The underlying etiology of TR in ICM includes tricuspid annular dilatation and leaflet tethering in the setting of RV remodeling due to right ventricle infarction with or without pulmonary hypertension, tricuspid annular dilatation associated with AFib, and iatrogenic or lead related injury to tricuspid leaflets. Current AHA/ACC guidelines assign class I recommendation for tricuspid valve repair at the time of left sided valve surgery for severe TR and class IIa for less than severe TR in the presence of annular dilatation (>4.0 cm) or right-sided HF [106].
Concomitant mitral valve repair can be considered in patients with ICM undergoing CABG in the presence of atrial arrhythmias, left atrial dilation, or in the setting of severe LV dilation. Replacement, rather than repair, should be considered in patients with limited viability in the posterolateral wall of the LV [97]. Tricuspid valve repair should be considered at the time of left sided valve surgery for severe TR and less than severe TR in the presence of annular dilatation (>4.0 cm), right-sided HF or iatrogenic, or lead-related injury to tricuspid leaflets. Severe TR in the presence of significant RV dysfunction is a marker of poor outcome after coronary revascularization and warrants evaluation and consideration for advanced HF therapies.
In patients with ICM, gradual dilatation of LV results in transition from elliptical to a more spherical geometry. This impairs the structure–function relationship of the left ventricle [107]. The concept of surgical ventricular restoration (SVR) procedure for the patients with ICM is more than four decades old; however, the procedure is yet to gain acceptance as not only the procedure is technically challenging but also, no study so far has been able to show consistent benefit with concomitant SVR. Doctrine of SVR operation assumes that resection of scarred myocardium, reducing the ventricular size, and restoring an anatomically elliptical shape can improve the left ventricular function [108]. However, studies so far have not been able to prove this assumption. A randomized study including 137 patients with LVEF <50% and LV end systolic volume index (LVESVI) >80 ml/m2 showed that CABG alone was inferior to CABG with SVR in terms of improvement in LVEF, MR, and NYHA class. However, study was limited to only 2 years of follow-up [109]. Similarly, Prucz et al. reported this result [110]. Both these studies were limited by short duration of follow-up and failed to show any benefit of SVR procedure on survival. Consequently, the STICH trial was conducted to evaluate the long-term outcome of concomitant SVR procedure in patients with LV dysfunction, LV akinesis/dyskinesis, presence of scar, and LV dilatation [111]. To evaluate the benefit of SVR, patients enrolled in STICH trial in CABG arm were divided into two groups (medical therapy with CABG versus medical therapy with CABG and SVR). The study found no difference in mortality between the groups at median follow-up of 48 months (hazard ratio 1.00, 95% CI 0.79–1.26, P = 0.98) [111]. Results of these studies led to abandonment of the SVR procedure by majority surgeons [112].
It still remains uncertain which patients should receive SVR as part of CABG operation and what is its impact on long-term survival and functional outcome [112, 113, 114]. Therefore, consideration for SVR should still be given to patients with true large ventricular aneurysms who present with medically refractory heart failure or ventricular arrhythmias.
Patients with ICM undergoing CABG are at increased risk of postcardiotomy shock and the risk increases further in patients with ischemic MR and/or right ventricular infarct. Patients with postcardiotomy shock who are unable to separate from cardiopulmonary bypass or require high-dose inotropic therapy, MCS should be considered [115].
Intra-aortic balloon pump has been considered as first line therapy for PCS as it is safe, widely available, and easy to place. Intra-aortic balloon pump improves the coronary perfusion, decreases the left ventricular afterload, and improves the cardiac output by 0.5–1 L/min. However, the hemodynamic support provided by an IABP is usually insufficient in reversing cardiogenic shock [116, 117]. In a recent analysis of 4550 patients operated for CABG between 2004 and 2008, 5% patients required an intraoperative or postoperative IABP, with overall mortality of 37%. IABP was equally effective in patients with predominantly right-sided failure with 50% increase in cardiac index and associated mortality of 31%. This study specifically addressed the issue of IABP effectiveness in both right- and left-sided failure [118].
Impella is a percutaneous or surgically implanted axial-flow device that is used for all types of cardiogenic shock. Impella devices significantly reduce LV end-diastolic pressure and volume, reduce myocardial oxygen demand, and support the systemic perfusion while allowing the heart to recover. EngstrÖm and colleagues [119] reported their experience with Impella 5.0 for treating 46 postcardiotomy shock patients mostly after CABG at three European centers. Half of the patients received an IABP before the Impella placement. Overall survival was 40% at 30 days. More recently, David and colleagues [120] reported on use of the Impella 5.0/Impella LD in 29 patients (40% with isolated CABG) treated for PCS between 2010 and 2015. Mortality was nearly 40%, similar to the aforementioned study. The best results for PCS treatment were reported by Griffith and colleagues [121] in the RECOVER I study, wherein an Impella 5.0 was placed in 16 patients having difficulty weaning from cardiopulmonary bypass. Fifteen patients were successfully supported, with 30-day survival of 94%. Results of this study should however be interpreted carefully as all the patients in the study were on low level of inotropic support before the Impella placement as opposed to the study protocol requirement of high inotropic support prior to Impella placement.
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is second most commonly used device after IABP for postcardiotomy shock. Veno-arterial ECMO significantly unloads the right ventricle, improves the coronary perfusion, and supports the systemic perfusion while allowing the right heart to recover. However, VA-ECMO significantly increases the left ventricular afterload. Therefore, in patients supported with VA-ECMO, it is imperative to maintain left ventricular ejection either spontaneous or with inotropes. Otherwise, left side of the heart should be vented either by atrial septostomy, left atrial/left ventricular vent, or Impella [122]. There are no RCTs regarding the effectiveness of VA-ECMO in PCS, but several retrospective studies have shown 60–70% mortality in patients with PCS despite use of VA-ECMO [122, 123, 124, 125]. In a recent report of the European registry of 781 patients receiving VA-ECMO for PCS, institution of VA-ECMO was associated with increased mortality (odds ratio 1.54; 95% CI, 1.09–2.18), reoperation for bleeding/tamponade (odds ratio, 1.96; 95% CI, 1.37–2.81), and blood transfusion of >9 units (odds ratio, 2.42; 95% CI, 1.59–3.67). The authors also did a systematic review of 2491 patients with PCS who received VA-ECMO and reported 66.6% pooled prevalence of in-hospital/30-day mortality (95% CI, 64.7–68.4%), and lower in-hospital/30-day mortality in patients with peripheral ECMO (risk ratio, 0.92; 95% CI, 0.87–0.98). Switching the patients from central to peripheral cannulation appeared to provide close to a 10% mortality benefit [126]. Finally, studies evaluating the role of LV unloading during VA-ECMO for cardiogenic shock have reported 10–20% mortality benefit with LV unloading with either Impella or IABP [127, 128].
In patients with ICM, the importance of adhering to guideline-directed medical therapy (GDMT), secondary prevention, and cardiac rehabilitation after revascularization cannot be overemphasized [129, 130]. Close follow-up of these patients is recommended for the titration of heart failure medications and continued assessment for needed additional interventions, including device implantation (e.g., automated implantable cardioverter-defibrillator (AICD)/Cardiac resynchronization therapy device (CRT) or advanced surgical therapies for persistent HF. In patients with ICM, initial 90 days after CABG are most vulnerable and associated with several-fold increase in HF-associated rehospitalization and mortality. Thus, these patients should undergo a close clinical monitoring after discharge. Initial post-discharge follow-up should be done at 7–14 days to review the volume status of the patient and titrate guideline-directed medications [131]. Although studies directly evaluating and comparing the impact of GDMT on ICM patients who have or have not undergone CABG are limited, conventional medical opinion supports that GDMT goals for post-CABG patients should not differ from those without CABG. Post hoc analysis has revealed that in patients with ICM, maintenance of optimal medical therapy after discharge is associated with best short-term and long-term outcomes [132].
Patients with ischemic cardiomyopathy and coronary artery disease that is amenable to surgical revascularization should undergo combination of surgical revascularization and medical therapy rather than medical therapy alone. This suggestion is based primarily on the long-term absolute reduction in mortality over the 10 years following CABG balanced against the early mortality risk of CABG. Routine assessment of viability to evaluate advisability of multivessel coronary revascularization to improve total mortality is not recommended. Based on the small but nontrivial early mortality risk associated with CABG surgery as well as other post-CABG morbidities, patients may also reasonably choose medical therapy as the initial treatment option. Revascularization remains an important treatment option for patients with ongoing anginal symptoms despite optimal medical therapy. For such patients, the relative efficacy of percutaneous coronary intervention (PCI) compared with CABG for revascularization is unknown. Nonrandomized registry suggests that there was no difference in mortality between CABG and PCI.
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The social, environmental, and economical problems can be omitted by use of renewable energy sources, because these resources are considered as environment-friendly, having no or little emission of exhaust and poisonous gases like carbon dioxide, carbon monooxide, sulfur dioxide, etc. Renewable energy is going to be an important source for power generation in near future, because we can use these resources again and again to produce useful energy. Wind power generation is considered as having lowest water consumption, lowest relative greenhouse gas emission, and most favorable social impacts. It is considered as one of the most sustainable renewable energy sources, followed by hydropower, photovoltaic, and then geothermal. As these resources are considered as clean energy resources, they can be helpful for the mitigation of greenhouse effect and global warming effect. 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The reported reviewed results in this chapter will be a valuable researchers and practicing engineers involved in the design and development of wind energy systems.",book:{id:"7636",slug:"wind-solar-hybrid-renewable-energy-system",title:"Wind Solar Hybrid Renewable Energy System",fullTitle:"Wind Solar Hybrid Renewable Energy System"},signatures:"Salisu Muhammad Lawan and Wan Azlan Wan Zainal Abidin",authors:[{id:"286205",title:"Dr.",name:"Salisu",middleName:null,surname:"Muhammad Lawan",slug:"salisu-muhammad-lawan",fullName:"Salisu Muhammad Lawan"},{id:"286210",title:"Prof.",name:"Wan Azlan",middleName:null,surname:"Wan Zainal Abidin",slug:"wan-azlan-wan-zainal-abidin",fullName:"Wan Azlan Wan Zainal Abidin"}]},{id:"59381",title:"A Review of Recycling Processes for Photovoltaic Modules",slug:"a-review-of-recycling-processes-for-photovoltaic-modules",totalDownloads:3470,totalCrossrefCites:21,totalDimensionsCites:40,abstract:"The installations of photovoltaic (PV) solar modules are growing extremely fast. As a result of the increase, the volume of modules that reach the end of their life will grow at the same rate in the near future. It is expected that by 2050 that figure will increase to 5.5–6 million tons. Consequently, methods for recycling solar modules are being developed worldwide to reduce the environmental impact of PV waste and to recover some of the value from old modules. Current recycling methods can recover just a portion of the materials, so there is plenty of room for progress in this area. Currently, Europe is the only jurisdiction that has a strong and clear regulatory framework to support the PV recycling process. This review presents a summary of possible PV recycling processes for solar modules, including c-Si and thin-film technologies as well as an overview of the global legislation. So far, recycling processes of c-Si modules are unprofitable but are likely to be mandated in more jurisdictions. There is potential to develop new pathways for PV waste management industry development and offer employment and prospects for both public and private sector investors.",book:{id:"6691",slug:"solar-panels-and-photovoltaic-materials",title:"Solar Panels and Photovoltaic Materials",fullTitle:"Solar Panels and Photovoltaic Materials"},signatures:"Marina Monteiro Lunardi, Juan Pablo Alvarez-Gaitan, José I. Bilbao\nand Richard Corkish",authors:[{id:"233229",title:"Dr.",name:"Richard",middleName:null,surname:"Corkish",slug:"richard-corkish",fullName:"Richard Corkish"},{id:"233231",title:"Ms.",name:"Marina",middleName:null,surname:"Monteiro Lunardi",slug:"marina-monteiro-lunardi",fullName:"Marina Monteiro Lunardi"},{id:"242337",title:"Dr.",name:"Juan Pablo",middleName:null,surname:"Alvarez-Gaitan",slug:"juan-pablo-alvarez-gaitan",fullName:"Juan Pablo Alvarez-Gaitan"},{id:"242338",title:"Dr.",name:"Jose I.",middleName:null,surname:"Bilbao",slug:"jose-i.-bilbao",fullName:"Jose I. Bilbao"}]},{id:"49438",title:"Perovskite Nanomaterials – Synthesis, Characterization, and Applications",slug:"perovskite-nanomaterials-synthesis-characterization-and-applications",totalDownloads:9064,totalCrossrefCites:23,totalDimensionsCites:54,abstract:"Inorganic perovskite-type oxides are fascinating nanomaterials for wide applications in catalysis, fuel cells, and electrochemical sensing. Perovskites prepared in the nanoscale have recently received extensive attention due to their catalytic nature when used as electrode modifiers. The catalytic activity of these oxides is higher than that of many transition metals compounds and even some precious metal oxides. They exhibit attractive physical and chemical characteristics such as electronic conductivity, electrically active structure, the oxide ions mobility through the crystal lattice, variations on the content of the oxygen, thermal and chemical stability, and supermagnetic, photocatalytic, thermoelectric, and dielectric properties.",book:{id:"5063",slug:"perovskite-materials-synthesis-characterisation-properties-and-applications",title:"Perovskite Materials",fullTitle:"Perovskite Materials - Synthesis, Characterisation, Properties, and Applications"},signatures:"Nada F. Atta, Ahmed Galal and Ekram H. El-Ads",authors:[{id:"30072",title:"Prof.",name:"Nada",middleName:null,surname:"F. Atta",slug:"nada-f.-atta",fullName:"Nada F. Atta"},{id:"174033",title:"Prof.",name:"Ahmed",middleName:null,surname:"Galal",slug:"ahmed-galal",fullName:"Ahmed Galal"},{id:"174034",title:"MSc.",name:"Ekram",middleName:null,surname:"El-Ads",slug:"ekram-el-ads",fullName:"Ekram El-Ads"},{id:"176164",title:"MSc.",name:"Ekram",middleName:null,surname:"Ekram H. El-Ads",slug:"ekram-ekram-h.-el-ads",fullName:"Ekram Ekram H. El-Ads"}]}],onlineFirstChaptersFilter:{topicId:"770",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:0,limit:8,total:null},allSeries:{pteSeriesList:[],lsSeriesList:[],hsSeriesList:[],sshSeriesList:[],testimonialsList:[]},series:{item:{id:"25",title:"Environmental Sciences",doi:"10.5772/intechopen.100362",issn:"2754-6713",scope:"
\r\n\tScientists have long researched to understand the environment and man’s place in it. The search for this knowledge grows in importance as rapid increases in population and economic development intensify humans’ stresses on ecosystems. Fortunately, rapid increases in multiple scientific areas are advancing our understanding of environmental sciences. Breakthroughs in computing, molecular biology, ecology, and sustainability science are enhancing our ability to utilize environmental sciences to address real-world problems.
\r\n\tThe four topics of this book series - Pollution; Environmental Resilience and Management; Ecosystems and Biodiversity; and Water Science - will address important areas of advancement in the environmental sciences. They will represent an excellent initial grouping of published works on these critical topics.