Recommendations for Candidates for Hybrid Coronary Revascularization Versus Conventional Coronary Revascularization [2, 21]
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\r\n\tThis book intends to provide the reader with a comprehensive overview of the current epidemiology, valuable information in relation to the management of specific poisoning agents, and important evidence-based developments in the toxicology field, with special focus on children, who are a more vulnerable population for severe poisonings. Its aim is to be a practical handbook to aid health care professionals involved in individual care of patients poisoning.
The optimal revascularization strategy for patients with multi-vessel coronary artery disease remains controversial. The advent of percutaneous coronary intervention (PCI) has challenged the superiority of coronary artery bypass graft (CABG) surgery for multi-vessel disease as PCI offers a less invasive option with faster recovery time and lower risk. Despite a survival benefit in high-risk groups and superior long-term freedom from revascularization, trends continue to move toward increasing percutaneous approaches. In the late 1990s, an integrated approach, now referred to as “hybrid coronary revascularization” (HCR), was pioneered combining CABG and PCI to offer appropriate patients a less invasive option for revascularization while still capitalizing on the superior patency rates of the left internal mammary artery (LIMA) to left anterior descending (LAD) artery bypass. The technology has evolved tremendously since the introduction of HCR with some LIMA-LAD grafts now performed completely robotically. As HCR evolves, questions regarding indications, optimal surgical technique, timing, and outcomes as well as cost-benefit analysis continue to permeate current practice and will define the future of HCR in the algorithm of coronary revascularization.
CABG has long been the established standard of care to treat left main or three vessel coronary artery disease [1]. The therapeutic benefit of this approach lies in the LIMA-LAD revascularization. Patency rates of this anastomosis lie between 95%–98% at 10 years [2]. Radial arterial conduits have been explored as another option for total arterial revascularization; however, results do not compare with the long-term patency of LIMA utilization [3]. Saphenous vein grafts (SVG) also do not provide the same longevity of the LIMA-LAD revascularization. Failure of SVG is multifactorial including technical failure within 30 days, neo-intimal hyperplasia at 1–24 months, and atherosclerotic degeneration beyond 2 years. Patient risk factors such as hyperlipidemia and ongoing tobacco are also associated with accelerated graft failure. Failure rates are estimated as high as 10%–15% at 1 year after CABG with almost 50% total graft occlusion at 10 years [4]. Despite this high failure rate, SVG remain the most commonly used conduit for CABG surgery.
PCI has challenged the superiority of CABG surgery for multi-vessel disease. The use of drug-eluting stents (DES) in particular has provided a less invasive option for revascularization with faster return to normal activities and lower risk of complications. Restenosis rates and stent thrombosis of DES in non-LAD lesions are markedly lower than non-LAD SVG with rates less than 10% and 1%, respectively [5]. In addition, stenting of SVG after thrombosis introduces technical changes with higher peri-procedural rates of complications and in-hospital mortality than stenting of native arteries [4, 6]. Despite data that suggests improved outcomes with many patients including diabetics and those with left main and complex multi-vessel coronary artery disease (CAD) [2], trends continue toward increased PCI over CABG.
The strategy of HCR attempts to capitalize on the superior LIMA-LAD patency rates as well as the minimally invasive PCI approach thus eliminating the need for additional venous or arterial conduits. Patients with multi-vessel disease with significant proximal LAD disease with other lesions suitable for PCI in the left main, left circumflex, or right coronary artery territories are appropriate candidates for HCR [7]. In addition, patients with lack of suitable conduits, prior sternotomy, severe ascending aortic disease, or coronary arteries not amenable for bypass may be suitable HCR candidates. Patients generally not deemed HCR candidates and thus deferred to conventional CABG include those with chronic total occlusions, highly calcified segments, and diffusely diseased and bifurcation coronary lesions [7]. Table 1 summarizes the clinical and angiographic findings that should be taken into consideration when discussing the option for HCR. Discussions regarding treatment options are best facilitated by a multi-disciplinary approach including both an interventional cardiologist and cardiac surgeon.
\n\t\t\t | PCI | \n\t\t\tCABG | \n\t\t\tHCR | \n\t\t
\n\t\t\t\tAngiographic Characteristics\n\t\t\t | \n\t\t\t\n\t\t\t | \n\t\t\t | \n\t\t |
Unprotected Left Main Disease | \n\t\t\tno | \n\t\t\tyes | \n\t\t\tyes | \n\t\t
Intra-myocardial LAD | \n\t\t\tyes | \n\t\t\tno | \n\t\t\tno | \n\t\t
Complex LAD lesion | \n\t\t\tno | \n\t\t\tyes | \n\t\t\tyes | \n\t\t
Complex non-LAD lesions | \n\t\t\tno | \n\t\t\tyes | \n\t\t\tno | \n\t\t
\n\t\t\t\tComorbidities\n\t\t\t | \n\t\t\t\n\t\t\t | \n\t\t\t | \n\t\t |
Advanced Age | \n\t\t\tyes | \n\t\t\tno | \n\t\t\tyes | \n\t\t
LVEF <30% | \n\t\t\tno | \n\t\t\tyes | \n\t\t\tyes | \n\t\t
Diabetes mellitus | \n\t\t\tno | \n\t\t\tyes | \n\t\t\tyes | \n\t\t
Renal insufficiency | \n\t\t\tno | \n\t\t\tyes | \n\t\t\tyes | \n\t\t
Severe chronic lung disease | \n\t\t\tyes | \n\t\t\tno | \n\t\t\tno | \n\t\t
Prior left thoracotomy | \n\t\t\tyes | \n\t\t\tyes | \n\t\t\tno | \n\t\t
Prior sternotomy | \n\t\t\tyes | \n\t\t\tno | \n\t\t\tyes | \n\t\t
Limited vascular access | \n\t\t\tno | \n\t\t\tyes | \n\t\t\tno | \n\t\t
Lack of available conduits | \n\t\t\tyes | \n\t\t\tno | \n\t\t\tyes | \n\t\t
Severe aortic calcification | \n\t\t\tyes | \n\t\t\tno | \n\t\t\tyes | \n\t\t
Contraindication for dual anti-platelet therapy | \n\t\t\tno | \n\t\t\tyes | \n\t\t\tno | \n\t\t
Minimally invasive cardiac surgery seeks to eliminate two invasive components of conventional CABG: cardiopulmonary bypass (CBP) and sternotomy. The development of stabilizer technology in the early 1990s made available off-pump CABG with the potential advantages of less blood loss, lower incidence of neurologic complications, and less pulmonary complications [8]. In conjunction with sternal sparing incisions as well as robotic techniques, a minimally invasive off-pump option for LIMA-LAD revascularization offers the key to optimizing the HCR option. The techniques described below and in Table 2 discuss the current options for minimally invasive surgical approaches to LIMA-LAD revascularization highlighting key features of the various techniques.
\n\t\t\t | \n\t\t\t\tThoracic Access\n\t\t\t | \n\t\t\t\n\t\t\t\tLIMA Harvest\n\t\t\t | \n\t\t\t\n\t\t\t\tAnastomosis\n\t\t\t | \n\t\t\t\n\t\t\t\tSingle Lung ventilation\n\t\t\t | \n\t\t\t\n\t\t\t\tCPB\n\t\t\t | \n\t\t\t\n\t\t\t\tAdvantages/Disadvantages\n\t\t\t | \n\t\t
OPCAB (Off-pump CABG) | \n\t\t\tMidline Sternotomy | \n\t\t\tDirect Vision | \n\t\t\tDirect vision with stabilizers | \n\t\t\tNot Required | \n\t\t\tNo | \n\t\t\tAvoids risks associated with CBP | \n\t\t
MIDCAB (Minimally invasive direct coronary artery bypass grafting) | \n\t\t\tLeft-sided thoracotomy or lower partial sternotomy | \n\t\t\tDirect Vision | \n\t\t\tDirect Vision | \n\t\t\tImproves exposure but not required | \n\t\t\tNot required but can be performed by femoral cannulation | \n\t\t\tAvoids aortic cross-clamping and manipulation | \n\t\t
Endo-ACAB (Endoscopic atraumatic coronary artery bypass graft surgery) | \n\t\t\tLimited rib sparing left-sided thoracotomy | \n\t\t\tRobotic or Thoracoscopic | \n\t\t\tHand-Sutured | \n\t\t\tRequired when robot is used | \n\t\t\tNot required | \n\t\t\tDecreased morbidity from thoracotomy incision yet allows for hand-sewn anastomosis | \n\t\t
TECAB (Totally endoscopic coronary artery bypass graft surgery) | \n\t\t\tThoracoscopic | \n\t\t\tRobotic | \n\t\t\tRobotic intracorporeal anastomosis | \n\t\t\tRequired | \n\t\t\tNot required | \n\t\t\tMinimally invasive, however very technically challenging | \n\t\t
Surgical Techniques Used for LAD Revascularization During Hybrid Coronary Revascularization
MIDCAB: Minimally invasive direct coronary artery bypass(MIDCAB) grafting refers to an off-pump minimally invasive LIMA-LAD revascularization performed through a small left-sided thoracotomy in the fourth or fifth interspace. Costal cartilage removal or rib disarticulation is sometimes necessary for visualizing. Cardiac stabilization and LAD harvest is performed directly through the wound and does not require endoscopic or robotic skills to master the LAD harvest. Surgeon comfort with off-pump techniques is critical as well as experience with sternal sparing incisions. Single-lung ventilation is optimal for exposure; however chest cavity insufflation is not necessary. A slightly larger thoracotomy incision can allow exposure for harvest of bilateral internal mammary arteries.
Large series published since 1994 have validated short-term LAD-LIMA patency rates of this technique at 95%–97% [8]. The advantage of this technique lies in the avoidance of CBP and aortic manipulation as an off-pump strategy; however, no data exists to suggest differences in post-operative pain or pulmonary complications from conventional CABG [8]. MIDCAB may have decreased bleeding and infection rates compared to traditional sternotomy, however the need for a thoracotomy incision for the technique has prompted further exploration into various thoracoscopic and robotic techniques to capitalize on the advantages of minimally invasive strategies as discussed in the following.
Endo-ACAB: Endoscopic atraumatic coronary artery bypass (Endo-ACAB) refers to the thoracosocpic or robotic identification of the LAD with LIMA mobilization without violating the integrity of the chest wall (Figure 1). A directed, non-rib spreading or limited rib spreading thoracotomy is then employed for a hand-sewn LIMA-LAD anastomosis on the beating heart. Robotic LIMA mobilization requires single-lung ventilation and insufflation to create space in the anterior mediastinum to facilitate LIMA harvest. After the LIMA is taken down, a pericardial incision is made for identification of the LAD. A small (4–5cm) anterior thoracotomy without disarticulation of costal cartilage is then made to introduce an endoscopic stabilizer via an arm port, which allows for LAD stabilization and hand-sewn anastomosis.
EndoCab technique as described above.
Multiple case series have reported excellent LIMA-LAD patency rates with thoracoscopic Endo-ACAB approaches. In new smaller series with robotic Endo-ACAB approaches, routine post-operative angiography has demonstrated no decline in LIMA-LAD patency rates. In Kiaii’s series of 58 patients who underwent one-stage robotic Endo-ACAB HCR, the average length of stay in the ICU and hospital were 1 and 4 days, respectively, leading the authors to suggest benefit to patients in terms of post-operative surgical morbidity and recovery time using more minimally invasive technology [9].
TECAB: Totally endoscopic coronary artery bypass grafting (TECAB) utilizes a robotically sewn, intracorporeal anastomosis, which negates the need for even a small thoracotomy. This technique was first explored on an arrested heart during CBP; however, the associated complications of CPB have led most robotic surgeons to employ an off-pump TECAB. The operation itself is technically challenging without widespread adoption of this technique owning to the need for robotic technology and surgeon expertise.
One of the largest series published in 2012 reported on 226 patients with 5-year outcomes [10]. Perioperative results were consistent with the standards of open CABG. The authors report a dramatically decreased time to recovery owning to the lack of need for sternal precautions. In the 10 cases requiring conversion to thoracotomy, these patients averaged 2- day longer hospital stays with increased ventilator time and return to normal activities [10]. Overall results in other case series support the safety and feasibility of this technique; however, Harskamp reports that only approximately one-third of HCRs from 2011–2013 reported in the Society of Thoracic Adult Cardiac Database utilize robotic technology [11]. Expansion of the TECAB approach is currently limited by the cost and learning curve associated with the implementation of robotic technology.
Graft Assessment: Off-pump (OP) and minimally invasive techniques for LAD-LIMA grafting have appropriately been scrutinized with regard to patency rate outcomes compared to the classical on-pump CABG via a midline sternotomy. The recent Randomized On/Off Bypass (ROOBY) trial as well as other smaller trails have demonstrated that the patency rates of LIMA-LAD grafts between off-pump coronary artery bypass (OPCAB) and conventional CABG were similar (95.3 and 96.2, respectively) [12]. As the HCR approach relies upon the durability and integrity of this anastomosis, the ability of the surgeon to assess the LIMA-LAD graft intra-operatively becomes increasingly important. In fact, the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) recommends graft evaluation before leaving the operating room [13].
Graft assessment includes the traditional methods such as inspection, palpation, electrocardiography (ECG), and echocardiography (ECHO). Other methods include conventional coronary angiography, which is the gold standard, transit-time flow measurement (TTFM), and intra-operative fluorescence imaging (IFI). As the causes of early graft failure are often technical, this technology seeks to eliminate these errors by objectively evaluating graft function. Certainly, a clear advantage of single stage HCR with CABG followed by PCI lies in the opportunity for angiographic graft assessment with readily available operative access for reintervention; however, when angiographic assessment is not available, the most commonly utilized technique among cardiovascular surgeons over the last decade has become TTFM. Retrospective studies have demonstrated the ability of TTFM to detect grafts with impaired flow thus predicting graft failure within 6 months after CABG [14]; however, little is known about how TTFM relates to long-term graft patency and patient survival.
TTFM relies on the principles of transit-time ultrasound technology. The surgeon can obtain both quantitative data of average blood flow volume and several calculated derivatives of the flow of blood in the graft displayed in waveform. TTFM cannot, however, differentiate physiologic conditions accounting for low blood flow versus technical quality of a surgical anastomosis. While clear cut-off values for graft revision have not been set, a mean flow <15ml min -1 for grafts to the left coronary system and less than 20ml min -1 for grafts to the right coronary system were predictive of failure. A pulsatility index (PI) greater than 0.5 is predictive of graft failure. Another important value is the diastolic flow percentage (DF%) or diastolic flow divided by total flow through the graft. This value should be greater than 50% for all grafts and territories and ideally greater than 65%. When the PI and DF% both demonstrate adequate measurements, the graft can be objectively presumed adequate [15]. Figure 2 demonstrates the intra-operative TTFM tracings utilizing the MediStim ASA technology, which is one of the more commonly utilized flowmeters.
Transit Time Flow Assessment.
HCR began in the 1990s as a staged procedure with LIMA-LAD revascularization performed first followed by PCI. The use of DESs and anti-platelet therapy as well as the use of hybrid operating room suites has introduced questions as to the most optimal timing for open and PCI revascularization. Currently, three options for timing strategies exist: PCI followed by CABG, CABG followed by PCI, and one-stage hybrid HCR. Each option introduces different benefits and challenges, and at this time no clear consensus exists on the optimal strategy for timing of revascularization (Table 3). Patient characteristics, operator skill, and availability of facilities should be considered when choosing the most appropriate approach.
\n\t\t\t\tOne-Stage HCR\n\t\t\t | \n\t\t\t\n\t\t\t\tTwo-Stage HCR\n\t\t\t | \n\t\t\t\n\t\t |
\n\t\t\t\tSimultaneous CABG and PCI\n\t\t\t | \n\t\t\t\n\t\t\t\tCABG then PCI\n\t\t\t | \n\t\t\t\n\t\t\t\tPCI then CABG\n\t\t\t | \n\t\t
\n\t\t\t\tAdvantages:\n\t\t\t | \n\t\t\t\n\t\t\t\tAdvantages:\n\t\t\t | \n\t\t\t\n\t\t\t\tAdvantages:\n\t\t\t | \n\t\t
Ability to study LIMA-LAD graft | \n\t\t\tAbility to study LIMA-LAD graft | \n\t\t\tPre-operative angiographic imaging of LIMA size | \n\t\t
Protected LAD to allow PCI to high-risk non-LAD lesions | \n\t\t\tProtected LAD to allow PCI to high-risk non-LAD lesions | \n\t\t\tLower risk of ischemia during CABG given non-LAD territory revascularization | \n\t\t
Single anesthetic exposure | \n\t\t\tReduced risk of post-surgical bleedingas no need for anti-platelet therapy post CABG | \n\t\t\tUseful in acute coronary syndromeswith non-LAD culprits | \n\t\t
Can convert to conventional CABG if PCI fails | \n\t\t\tAfter LIMA-LAD revascularization, asymptomatic patients may require no further intervention | \n\t\t\tIf stents unsuccessful, conventional CABG has to be subsequently performed | \n\t\t
Single procedure reduces cost and hospital length of stay | \n\t\t\t\n\t\t\t | \n\t\t |
\n\t\t\t\tDisadvantages:\n\t\t\t | \n\t\t\t\n\t\t\t\tDisadvantages:\n\t\t\t | \n\t\t\t\n\t\t\t\tDisadvantages:\n\t\t\t | \n\t\t
Requires hybrid suite | \n\t\t\tRisk of ischemia during CABG in non-LAD lesions | \n\t\t\tNo ability to angiographically evaluate LIMA-LAD anastomosis | \n\t\t
Increased risk of post-operative bleeding due to need for anti-platelet after surgery | \n\t\t\tUnsuccessful PCI may lead to need for surgical reintervention | \n\t\t\tIncreased peri-operative bleeding due to need for anti-platelet therapy | \n\t\t
Risk of stent thrombosis due to post-operative inflammatory state | \n\t\t\t\n\t\t\t | Potential for LAD territory ischemia between stages | \n\t\t
CKD patients exposed to dual nephrotoxic insults with surgery and PCI contrast use | \n\t\t\t\n\t\t\t | Higher risk of stent thrombosis due to inflammatory response of CABG and potential need to hold anti-platelet therapy | \n\t\t
High degrees of coordination needed between teams | \n\t\t\t\n\t\t\t | \n\t\t |
Advantages and Disadvantages of One and Two-Staged HCR Procedures
One-Stage HCR: Simultaneous CABG and PCI: The advent of hybrid operating room suites has introduced the option for simultaneous CABG and PCI. This approach allows for complete revascularization before leaving the operating room. Routine imaging of the LIMA-LAD anastomosis is also available before chest closure. More aggressive percutaneous approaches can be taken to otherwise challenging lesions given the safety net of open revascularization options. The patient benefits from a single anesthetic exposure and decreased hospitalization time. One ongoing concern however is the post-operative risk of bleeding given the need for dual anti-platelet therapy after DES placement in conjunction with incomplete heparin reversal. Concerns also exist regarding the relationship of the inflammatory response in the post-operative setting and risk for acute stent thrombosis.
Two-Stage: PCI Followed by CABG: This option confers several advantages. In revascularizing the non-LAD lesion first and thus providing collateralization, the potential risks of ischemia during LAD occlusion are minimized. PCI firstly also provides the interventional cardiologist a safety net should revascularization be unsuccessful percutaneously. The most important benefit of this approach occurs in the setting of acute coronary syndrome with a non-LAD culprit. The acutely affected lesion may be stented followed by LAD revascularization at a later time. This strategy does however introduce the difficulty of the need for anti-platelet therapy with DES. Even brief discontinuation of anti-platelet therapy can risk stent thrombosis; however this must be weighed with intra-operative bleeding risk. Investigation is underway regarding the use of newer anti-platelet agents and potential decreased bleeding risk. It again should be noted that the pro-inflammatory trauma from surgery could also put new stents at risk for thrombosis.
Two-Stage: CABG Followed by PCI: This strategy has become the most widely adopted one for HCR. With PCI post-CABG, the concern for surgical bleeding while on anti-platelet therapy is negated. Like hybrid HCR, LIMA-LAD graft patency can be confirmed during PCI angiography. Pre-PCI protection of the LAD also provides the interventional cardiologist the option to approach lesions that would perhaps have otherwise been at higher risk. This includes both left main lesions and diagonal bifurcation lesions [8]. For the minimally invasive surgeon, the unrevascularized collateral lesions could manifest as intra-operative ischemia. Careful attention must be paid to hemodynamics during insufflation, and the use of peripheral CPB should be considered if needed. In the scenario of a PCI complication or failure, this approach could necessitate a return to the operating room with emergent CABG. The optimal time frame for PCI following CABG remains unclear. Some teams opt for PCI during the index hospitalization and thus avoid patient discharge with an incomplete revascularization, however other teams propose a more extended period of waiting from 1 to several weeks. Economic factors also become an increasing concern given questions of reimbursement.
Overall, no clear optimal timing strategy has been clearly defined. While some studies demonstrate increased post-operative bleeding risks on dual-anti-platelet therapy, others suggest that the minimally invasive surgical approaches negate this risk traditionally associated with sternotomy. Harskamp’s analysis of recent STS data suggests that the need for post-operative transfusion was actually lower in the one-stage procedure group with comparable reoperation for bleeding [11]. This analysis also reports that patients undergoing one-stage procedures were more likely to have peripheral vascular disease and stroke history compared to other groups [11]. Further studies are needed to outline the specific clinical scenarios and patient characteristics, which should dictate the timing of CABG and PCI. Certainly, cost analysis and patient preferences will also factor into future decision-making regarding timing strategies.
Anti-platelet management: As discussed, the use of anti-platelet therapy is a complicated balance of post-surgical bleeding versus risk of acute stent thrombosis. Currently, no guidelines exist to define the optimal strategy. This question of anti-platelet therapy poses two questions regarding the order of staging as well as timing of initiation of therapy. Different authors have reported their experience with varying strategies and outcomes. In cases of two staged procedures with CABG first, most authors performed CABG on aspirin alone followed by a second anti-platelet agent greater than 4 h post-operatively after ensuring that there were no bleeding complications [16]. In the two stage procedures, which performed PCI first, anti-platelet therapy was begun before PCI and continued uninterrupted during CABG. In one-stage procedures, the most common strategies administered anti-platelet therapy after undergoing the LIMA-LAD graft, just before its completion, or immediately after PCI. Others administered anti-platelet therapy at the induction of anesthesia or in the pre-operative area owning to the fact that maximal platelet inhibition occurs 4–24 h after administration [16]. None of these strategies differed in reported rate of acute stent thrombosis [5]. In some studies, the rate of blood transfusion was actually lower in the HCR group as was the need for reoperation for bleeding [11]. Newer anti-platelet agents that are more potent and have a faster onset of action and reversal have also been employed; however, there is currently no data to support the use of these new agents in HCR.
Multiple case series from single institution experiences have been published on HCR since the first report in 1996. This includes a population of over 3,000 patients [16]. Data from these series suggest that in experienced hands, the safety profile of HCR is excellent. Multiple studies comparing outcomes after HCR versus CABG and multi-vessel disease have also been published (Table 4). Among cohort studies, the single-stage HCR was most commonly employed. Across these studies, age averaged around 60 years with a male predominance. Left ventricular ejection fraction (LVEF) was preserved or mildly reduced in the majority of patients. With the exception of data from Leacche et al., overall in-hospital mortality, stroke and reoperation for bleeding rates were comparable and low [0% to 2.6%). The outlier reported by Leacche et al. was among the high SYNTAX-HCR group with a reported in-hospital mortality of 23% leading the authors to suggest that HCR should be approached with caution in patients with high (≥33] SYNTAX scores [17]. These reports collectively suggest that HCR may be a comparable option to CABG in patients with non-LAD lesions accessible by PCI.
Harskamp et al. published a meta-analysis in 2014 reporting clinical outcomes after HCR in 1,190 patients in single-center registries [18]. This study incorporated six observational studies (one case control and five propensity adjusted) that included adjustments for differences in baseline characteristics. Comparisons of individual components showed no differences in all-cause mortality, MI, or stroke at one year follow-up (odds ratio: 0.49; 95% confidence interval: 0.2 -1.24; p=0.13), however the HCR group demonstrated a higher repeat revascularization rate compared with CABG. These findings were irrespective of the order in which LIMA-LAD graft and PCI were performed.
The only current randomized control trial comparing HCR and CABG was published in 2014 [19]. Two-hundred consecutive patients from a single institution with angiographically confirmed multi-vessel disease involving the proximal LAD and a significant (>70%) lesion in at least one major non-LAD epicardial vessel amenable to both PCI and CABG were randomized in a 1:1 fashion. The primary endpoint was the evaluation of the safety of HCR. The HCR group (n=98) utilized MIDCAB and cobalt chromium DES with a two-stage HCR with PCI performed within 36 h of initial MIDCAB, versus the conventional CABG group (n=102) in which 85.0% of the procedures were performed off-pump. Pre-operative characteristics were similar. Regarding HCR procedures, 6.1% patients were converted to CABG with no adverse early or late outcomes, and HCR was feasible in 93.9% of patients. At 1 year, the two groups had similar all-cause mortality (CABG 2.9% versus HCR 2%; p=NS) and MACE-free survival rates (CABG 92.2% versus HCR 89.8%; p log-rank =0.54). Larger studies are needed to power conclusions regarding long-term mortality data; however, this study suggests that HCR is feasible and safe.
Harskamp et al. recently published a study of practice patterns and clinical outcomes after HCR, in the United States, using the Society of Thoracic Surgeons Adult Cardiac Surgery Database from July 2011 to March 2013 [11]. This analysis demonstrated that HCR represented 0.48% (n=950; staged=809, concurrent=141) of the total CABG volume (n=198,622) over the studied time. HCR was performed in approximately one-third of participating centers (n=361). Interestingly, patients who underwent HCR had high-risk profiles but less extensive coronary disease. There was no statistically significant association between operative approach and operative mortality when comparing the HCR and conventional CABG treatment groups [11].
Hybrid coronary revascularization has emerged as a promising technique that combines the superior patency of the LIMA-LAD graft with the superior patency of DES to SVG grafts for non-LAD vessels. As with any new technique, ongoing research will benefit from standardized definitions as well as sub-classification for HCR procedures [20]. Current evidence also lacks direction as to which patient population benefits most from HCR. Current data supports HCR as a feasible alternative to CABG, however, the future of these techniques will rely on improved patient satisfaction, recovery, and financial feasibility. Current reported quality of life assessments 1 year post-operatively are remarkably better in patients undergoing HCR versus OPCAB [5]. Likely reasons include decreased post-operative pain and decreased length of intensive care and hospital stay with quicker return to work and normal activities. Cost analysis have been reported both equal and in favor of HCR; however, these analysis did not examine the hidden cost of construction of a cardiac hybrid operating room as well as training of personal [5]. Further studies are needed to firmly establish improved outcomes and financial benefits of HCR before this novel technique establishes itself as a widespread option in the algorithm of coronary revascularization.
Renewable energy is going to be an important source for power generation in the near future, because we can use these resources again and again to produce useful energy. The energy resources are normally classified as fossil resources, renewable, and nuclear energy resources. Different renewable energy resources, like hydropower, wind, solar, biomass, ocean energy, biofuel, geothermal, etc., provide 15–20% of the total world’s energy. The world is going to turn into a global village due to more requirement of energy due to fast growing population, which leads to the use the fossil fuels like coal, gas, and oil to fulfill the energy requirement, which creates unsustainable situations and many problems like depletion of fossil fuels, environmental and geographical conflicts, greenhouse effect, global warming, and fluctuation in fuel prices. Due to environment-friendly and less emission of gases from renewable energy, it is considered as sustainable energy; also supported for the society from each dimensions like economic, social and environmental. “Approximately 1.6 billion people have no access to electricity and about 1.1 billion are without water supply” [1]. Renewable energy resources have an ability to complete the world’s energy demand, protect the environment, and provide energy security. Along with the outstanding advantages of these resources, some shortcomings also exist like the variation of output due to seasonal change, which is the common thing for wind and hydroelectric power plant; hence, special design and consideration are required, which are fulfilled by the hardware and software due to the improvement in computer technology. The main renewable energy sources with their usage in different form are classified in Table 1, and it is expected that renewable energy will be one of the important sources for the future; the world’s renewable energy sources scenario by 2040 is estimated as given in Table 2.
\nEnergy resource | \nEnergy conversion and usage option | \n
---|---|
Hydropower | \nPower generation | \n
Biomass | \nHeat and power generation, pyrolysis, gasification, digestion | \n
Geothermal | \nUrban heating, power generation, hydrothermal, hot rock | \n
Solar | \nSolar home system, solar dryers, solar cookers | \n
Direct solar | \nPhotovoltaic, thermal power generation, water heaters | \n
Wind | \nPower generation, wind generators, windmills | \n
Wave | \nNumerous designs | \n
Tidal | \nBarrage, tidal stream | \n
Main renewable energy sources with their usage form [2].
\n | 2001 | \n2010 | \n2020 | \n2030 | \n2040 | \n
---|---|---|---|---|---|
Total consumption (million tons equivalent) | \n10,038 | \n10,549 | \n11,425 | \n12,352 | \n13,310 | \n
Biomass | \n1080 | \n1313 | \n1791 | \n2483 | \n3271 | \n
Large hydro | \n22.7 | \n266 | \n309 | \n341 | \n358 | \n
Geothermal | \n43.7 | \n86 | \n186 | \n333 | \n493 | \n
Small hydro | \n9.5 | \n19 | \n49 | \n106 | \n189 | \n
Wind | \n4.7 | \n44 | \n266 | \n542 | \n688 | \n
Solar thermal | \n4.1 | \n15 | \n66 | \n244 | \n480 | \n
Photovoltaic | \n0.1 | \n2 | \n24 | \n221 | \n784 | \n
Solar thermal electricity | \n0.1 | \n0.4 | \n3 | \n16 | \n68 | \n
Marine (tidal/wave/ocean) | \n0.05 | \n0.1 | \n0.4 | \n3 | \n20 | \n
Total RES | \n1365,5 | \n1745,5 | \n2964,4 | \n4289 | \n6351 | \n
Renewable energy contribution source (%) | \n13.6 | \n16.6 | \n23.6 | \n34.7 | \n47.7 | \n
Global renewable energy scenario by 2040 [3].
The economy of Pakistan has been variable and unstable for a long time, but it started to grow somehow since 1990s. Energy demand also increased, as the economy of the country increased. To fulfill the energy demand, oil, natural gas, and coal are used, but due to limited resources, Pakistan is forced to import oil and gases from U.A.E and Saudi Arabia. The location of Pakistan is very good for getting benefit from the sun to generate power, and there are also some places suitable for wind power generation in Pakistan. However, the main problem to generate power is the funding. The energy overview of Pakistan is given in Figure 1. Ref. [4] addressed the impacts of renewable energy projects (REP) on the community in Australia. The study focused on four major factors impacting REP: social, political, economic, and environmental. According to one prediction, the world’s energy demand will be increased up to 5 times from that of current demand. Currently, three-fourths of that demand is fulfilled by the fossil fuels. On the other hand, the more usage of these resources causes environment pollution and results in more greenhouse effect [5]. For the protection of environment, social development and economics benefits can be get by using renewable energy sources, because there is no requirement of fuel [6]. These resources avoid the fluctuations in prices and importing of fossil fuel. Wind energy has some effects like bird strike and noise etc., which can be mitigated by proper placement of installation. The hydroelectric power may develop slowly with respect to other resources, because a number of people have to leave their homes. But, this may be beneficial for the companies to improve flood control [7]. The increasing global warming effect can easily be prevented with the proper access of renewable energy and by improving the renewable energy technologies [8]. In developing countries like Pakistan, our main focus is to create jobs and the financial development, than focusing on the environment impacts; with the shift of consumers’ attention toward renewable energy, society will be more effective and efficient and enhancement in smart gird system [9].
\nEnergy overview of Pakistan [22].
Renewable energy source will be the best option for minimizing pollution, increasing economy, energy security, and job opportunities; also, poverty will be reduced because mostly poor people rely on the natural resources [10]. It is believed that after 2050, 50% of global energy supply will be generated using renewable energy resources; the magnitude of renewable energy sources is 140 times the worldwide annual energy consumption. Renewable energy resources as “job motor for Germany,” 55% increase in total number of jobs since 2004, reported in a publication from Environmental Ministry (BMU) [11]. Pakistan has abundant renewable energy resources and also shows the potential to overcome the energy demand gap, but it is inhibited by some factors like policy, institutional, regulatory, fiscal, social, economic, technical, industrial, and informational barriers [12]. Globally, around three billion people rely on solid fuel mostly fossil fuel, causing health concerns and diseases like pneumonia, chronic respiratory diseases, and lung cancer. It is found that with the 1% increment of growth there will be an increment in CO2 emission up to 0.84% [13]. Population and GDP per capita have positive impacts on increasing CO2 emission. Government of Pakistan should initiate, in short run, small dams in the northern area and, in long run, big dams and hydro power projects, and for domestic purposes, coal and hydel resources can be used in small scale [14]. With the proper and efficient use of energy, the culture will be developed [15]. Still most of the northern areas of Pakistan are not electrified and we are under the huge crises of electric power; urban and rural areas experienced 10–12 and 16–18 h, respectively, of load shedding, which is caused direct decrement in the overall economics. With solar cell, electricity can be generated but in small amount, which would be useful as backup during load shedding time. In Baluchistan, there is no scope of gird system because of scattered villages; 77% of the population lives in villages and 90% of them do not have electricity [16]. In Pakistan, big cities produce millions of tons of biomass, but lack of technologies to generate electric power from these wastes is one of the biggest barriers for the improvement in renewable energy resources in Pakistan. Pakistan has potential to produce almost 652 million kg of manure per day, only from cattle and buffalo. It can produce 16.6 million m3 biogas daily, and 21 million tons of biofertilizer can be generated per year. That means 20% nitrogen and 66% phosphorous can be provided to the crop fields. Additionally, 3000 MW energy can be generated from sugarcane industries. A 10 m3 biogas unit can save almost 92,062 PKR per year. Finally, the study concluded that biogas energy system has low initial cost, low operating cost, and positive impact on household income. Biogas energy can do good for almost 70% of the country’s population living in rural areas [17]. Nuclear energy can be useful for the development in the long term to meet global increasing demand [18].
\nEvery year, Pakistan spends 3 billion US dollars to import oil to meet the energy requirement, and this ratio is increasing 1% yearly. Decreased efficiencies of thermal plants, periodic changes in water flow, fuel availability, auxiliary consumption and transmission limitations are main cause that Maximum system capability is lower. The main cause of load shedding is the circular debt caused by government institutions, poor revenue collection, insufficient tariff, corruption, losses, theft of electric power, and dispute on tariff with FATA, AJK, and KESC and also due to ignorance of merit, appointments of noneligible employees on political basis, etc. Circular debt can only be improved with the introduction of more and more renewable energy to the national gird [19]. Nonrenewable consumption increases the real GDP rapidly as compared to renewable energy consumption. However, it has 87% variation in carbon dioxide emission, which causes deforestation and dangerous impacts on the human health and the environment. Finally, it was concluded that renewable energy consumption along with nonrenewable energy consumption is the better solution for the GDP growth of the country [20]. It is found that economical, technical, reliability, availability of renewable energy resources, and financial risk are the important factors for selection and ranking of renewable energy technologies. The study prioritizes the renewable energy resources as wind energy, biomass, solar photovoltaic, and solar thermal energy. Further, wind energy and biomass were preferred for power generation in Pakistan [21], and energy review of Pakistan is shown in Figure 1.
\nThese resources also provide social benefits like improvement of health, according to choice of consumer, advancement in technologies, and opportunities for the work, but some basic considerations should be taken for the benefit of humans, for example, climate conditions, level of education and standard of living, and region whether urban or rural from agricultural point of view. Social aspects are the basic considerations for the development of any country. The following social benefits can be achieved by renewable energy systems: local employment, better health, job opportunities, and consumer choice. The study concluded that the total emission reduction is exponentially increasing in different years after the installation of renewable energy projects in remote areas [23]. Social impacts of each resource with its magnitude are listed in Table 3.
\nTechnology | \nImpact | \nMagnitude | \n
---|---|---|
Photovoltaic | \nToxins | \nMinor-Major | \n
Visual | \nMinor | \n|
Wind | \nBird strike | \nMinor | \n
Noise | \nMinor | \n|
Visual | \nMinor | \n|
Hydro | \nDisplacement | \nMinor-Major | \n
Agricultural | \nMinor-Major | \n|
River damage | \nMinor-Major | \n|
Geothermal | \nSeismic activity | \nMinor | \n
Odor | \nMinor | \n|
Pollution | \nMinor-Major | \n|
Noise | \nMinor | \n
Social impacts assessment for different renewable energy sources [7].
It was discovered that renewable energy projects provide benefits in economic point of view because they utilize local labor from rural areas, local material and business, local shareholders, and services of local banks. In addition, the renewable energy projects have facilitated the communities by establishing a trust fund that aims to invest the money earned by selling electricity in local economy. This makes it easy for a few communities to invest money on any small business of their own choice [4]. Biofuel projects created large number of jobs; however, very low jobs were created by solar power plants, as the ratio of people working in different companies increase that will create more jobs for others by using the part of their economy for entertainment, leisure, restaurant, etc. The consumers will be provided with electric power at a low cost as compared to that of conventional energy sources, and overall economy will be enhanced because there will be multiple options to generate power using different renewable energy sources present in that region [23].
\nRenewable energy projects have also contributed in improving environmental impacts such as reduction of carbon dioxide gas, awakening community about the climate change. The study observed very small impacts on the people living in a particular area, tourism, cost of energy supply, and educational impacts. Significant impacts were observed in improvement of life standard, social bonds creation, and community development. They also observed that the renewable energy projects are complex to install and are local environmental and condition sensitive. Their forecasting, execution, and planning require more consideration and knowledge as compared to other projects [4]. The two main aspects of environment are air and water pollution, normally created by the discharged water from houses, industries, and polluted rain, and discharge of used oils and liquids contains poisonous chemicals and heavy metals like mercury, lead, etc. Along with water pollution, natural resources can be maintained and greenhouse effect and air pollution can be mitigated by the proper usage of renewable energy sources [23] as shown in Table 4. Carbon dioxide emission with the generation of electric power using different energy resources is given in Figure 2.
\nCategory of impact | \nRelationship to conventional sources | \nComment | \n
---|---|---|
\n | Exposure to harmful chemicals | \n\n |
Emission of Hg, Cd, and other toxic elements | \nReduced emissions | \nEmission reduced a few hundred times. | \n
Emission of particles | \nReduced emissions | \nMuch less emission. | \n
\n | Exposure to harmful gases | \n\n |
CO2 emission | \nReduced emissions | \nA big advantage. | \n
Acid rain, SO, NOx | \nReduced emissions | \nReduced more than 25 times. | \n
Other greenhouse gases | \nReduced greenhouse gases | \nBig advantage-global warming. | \n
\n | Other | \n\n |
Spouts off fossil fuels | \nTotal or partial elimination of oil spills | \nHeavy fuel oil and other petroleum product spills. | \n
Water quality | \nBetter quality water | \nReduced water pollution. | \n
\n | \n | \n |
Soil erosion | \nSmaller loss of land | \nIn most cases, there is no penetration deep into earth. | \n
Summary of environmental effects [24].
Carbon dioxide equivalent emission during power generation [7].
Various greenhouse gases in atmosphere is being increased by humankind by doing many economic activities. The role of greenhouse gases and current situation are given in Table 5.
\nSubstance | \nAbility to retain infrared radiation compared to CO2 | \nPreindustrial concentration | \nPresent concentration | \nAnnual growth rate (%) | \nShare in greenhouse effect due to human activity | \nShare in greenhouse effect increase due to human activity | \n
---|---|---|---|---|---|---|
Alpha | \n1 | \n275 | \n346 | \n0.4 | \n71 | \n50 ± 5 | \n
Beta | \n25 | \n0.75 | \n1.65 | \n1.0 | \n8 | \n15 ± 5 | \n
Gamma | \n250 | \n0.25 | \n0.35 | \n0.2 | \n18 | \n9 ± 5 | \n
Delta | \n17,500 | \n0 | \n0.00023 | \n5.0 | \n1 | \n13 ± 5 | \n
Epsilon | \n20,000 | \n0 | \n0.00040 | \n5.0 | \n2 | \n13 ± 5 | \n
Role of different substances in greenhouse effect [15].
Solar panels are usually installed at the roofs of the buildings that increase the job opportunities in the PV system fabrication and installation. This increases the regional development and reduces the usage of energy from nonrenewable energy projects. It is very useful at the regions where there is no access of electricity. The major problem with solar system is the high investment and maintenance cost. Biomass energy projects have great contribution in the local job creation and the development of rural areas. Such types of power plants have large opportunities of jobs in construction of plants, management, maintenance of plants, production, and preparation of biomass. Only the noise production and unpleasant smell are the negative impacts of these plants. Fuel cells have slow implementation because of their high cost of plant construction and energy generation. Their construction and operation create jobs in almost all technical activities. In hydro power plants, the major sociopolitical problem is the shifting of the people from the areas where the plant is going to be constructed. These plants provide significant jobs for local community and also play an important role in the economic development of the community. The construction of tidal energy plants has no effect on humans, and they have better contribution in the local and official employment. These plants are very expensive and are not common. Wind energy projects do not have any emigration problem, and they create large number of job opportunities especially for engineers. Geo thermal energy projects provide the following sociopolitical benefits: improvement in the education of local people, improvement in living standards, and improvement in the care of health issues [25].
\nWhen the solar panels are connected to the distribution system, the cost of safety equipment is reduced because their short circuit current is higher than the nominal value. Biomass power plants have the same effects on the gird as do conventional plants. The integration of wind energy plants, tidal energy, and geothermal energy is complex [25].
\nThree case studies were made to investigate the socioeconomic benefits of renewable energy projects, and the three cases were solar, wind, and biofuel energy projects; empirical method was used to collect data. The basic aim of study was to know the contribution of renewable energy projects to local sustainability, which includes social, economic, and environmental, and to identify the socioeconomic benefits of REPs through the concerned community. It was done by doing survey of the communities. Eleven parameters were used including job creation, impacts on education, easy usage of energy, income development, demographic impacts, social bonds creation and community development, usage of native resources, and tourism. They concluded that the impacts of REPs on employment are positive, and indirect employment is high in comparison with the size of community, whereas direct employment is moderate [26].
\nOne of the important assessing factors to generate power from renewable energy sources is the availability and their technical limitation. Each resource has some limitations; photovoltaic has limitation to generate power only because heat energy from sun can only be received during the day time, except cloudy season. For wind turbine, speed should not increase beyond 25 m/s; otherwise, turbine will be damaged. Also, low speed of wind, that is, <3 m/s, will not be sufficient for the generation of electric power. Geothermal has good ability to generate power throughout the day for 24 h but is geography limited according to the presence of resources. Hydro-electric power plants are easy to start, stop, and operate within minutes; hence, they are considered as one of the highest available, reliable, and flexible renewable energy resources. From efficiency point of view, hydroelectric is classified at the top of the list, and then wind energy, photovoltaic, and geothermal are lowest efficient renewable energy resources. Because of availability of cells in different categories, the efficiency of photovoltaic is very much variable [7]. According to the efficiency, different energy sources are categorized in Table 6.
\nTechnique | \nEfficiency | \n
---|---|
Photovoltaic | \n4–22% | \n
Wind | \n24–54% | \n
Hydro | \n>90% | \n
Geothermal | \n10–20% | \n
Coal | \n32–45% | \n
Gas | \n45–53% | \n
Efficiency of electricity generation [7].
The conventional energy resources like oil, gas, and coal are very important for the improvement in economics of a country. A country like Pakistan is fully dependent on the conventional energy sources in spite of knowing its bad effects for health and environment like greenhouse effect, global warming effect, etc. Pakistan is blessed with all the renewable energy sources like hydro, wind, and geothermal, and for solar power generation also, it is a suitable country. But, the main problems to generate power from renewable energy resources are funds and politics. All the factors like emission of greenhouse gases, availability of resources, land requirements, water consumption, social impacts, and price of power generated are taken into consideration for the classification of renewable energy sources. Wind power generation is considered as 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. Biomass is considered suitable for the small-scale industries because of saving of fuel in considerable amount. Local employment, better health, job opportunities, job creation, consumer choice, improvement of life standard, social bonds creation, income development, demographic impacts, social bonds creation, and community development can be achieved by the proper usage of renewable energy system. Along with benefits of renewable energy resources, these are complex to install and are local environmental and conditions sensitive. Their forecasting, execution, and planning require more consideration and knowledge as compared to other projects.
\nThe author thanks the Mehran University of Engineering and Technology, Jamshoro, for providing the necessary facilities for carrying out this research.
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I am also a member of the team in charge for the supervision of Ph.D. students in the fields of development of silicon based planar waveguide sensor devices, study of inelastic electron tunnelling in planar tunnelling nanostructures for sensing applications and development of organotellurium(IV) compounds for semiconductor applications. I am a specialist in data analysis techniques and nanosurface structure. 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After obtaining a Master's degree in Mechanical Engineering, he continued his PhD studies in Robotics at the Vienna University of Technology. Here he worked as a robotic researcher with the university's Intelligent Manufacturing Systems Group as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and most importantly he co-founded and built the International Journal of Advanced Robotic Systems- world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career, since it was a pathway to founding IntechOpen - Open Access publisher focused on addressing academic researchers needs. Alex is a personification of IntechOpen key values being trusted, open and entrepreneurial. Today his focus is on defining the growth and development strategy for the company.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"19816",title:"Prof.",name:"Alexander",middleName:null,surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/19816/images/1607_n.jpg",biography:"Alexander I. Kokorin: born: 1947, Moscow; DSc., PhD; Principal Research Fellow (Research Professor) of Department of Kinetics and Catalysis, N. Semenov Institute of Chemical Physics, Russian Academy of Sciences, Moscow.\r\nArea of research interests: physical chemistry of complex-organized molecular and nanosized systems, including polymer-metal complexes; the surface of doped oxide semiconductors. He is an expert in structural, absorptive, catalytic and photocatalytic properties, in structural organization and dynamic features of ionic liquids, in magnetic interactions between paramagnetic centers. The author or co-author of 3 books, over 200 articles and reviews in scientific journals and books. He is an actual member of the International EPR/ESR Society, European Society on Quantum Solar Energy Conversion, Moscow House of Scientists, of the Board of Moscow Physical Society.",institutionString:null,institution:{name:"Semenov Institute of Chemical Physics",country:{name:"Russia"}}},{id:"62389",title:"PhD.",name:"Ali Demir",middleName:null,surname:"Sezer",slug:"ali-demir-sezer",fullName:"Ali Demir Sezer",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62389/images/3413_n.jpg",biography:"Dr. Ali Demir Sezer has a Ph.D. from Pharmaceutical Biotechnology at the Faculty of Pharmacy, University of Marmara (Turkey). 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Focus of his research activity is drug delivery, physico-chemical characterization and biological evaluation of biopolymers micro and nanoparticles as modified drug delivery system, and colloidal drug carriers (liposomes, nanoparticles etc.).",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"61051",title:"Prof.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"100762",title:"Prof.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"St David's Medical Center",country:{name:"United States of America"}}},{id:"107416",title:"Dr.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Texas Cardiac Arrhythmia",country:{name:"United States of America"}}},{id:"64434",title:"Dr.",name:"Angkoon",middleName:null,surname:"Phinyomark",slug:"angkoon-phinyomark",fullName:"Angkoon Phinyomark",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/64434/images/2619_n.jpg",biography:"My name is Angkoon Phinyomark. I received a B.Eng. degree in Computer Engineering with First Class Honors in 2008 from Prince of Songkla University, Songkhla, Thailand, where I received a Ph.D. degree in Electrical Engineering. My research interests are primarily in the area of biomedical signal processing and classification notably EMG (electromyography signal), EOG (electrooculography signal), and EEG (electroencephalography signal), image analysis notably breast cancer analysis and optical coherence tomography, and rehabilitation engineering. I became a student member of IEEE in 2008. During October 2011-March 2012, I had worked at School of Computer Science and Electronic Engineering, University of Essex, Colchester, Essex, United Kingdom. In addition, during a B.Eng. 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