Spontaneous resolution of an intrapericardial thrombus as a complication of pericardiocentesis in a neonate

We present the case of a premature neonate with pericardial effusion secondary to extravasation of total parenteral nutrition from a mispositioned/migrated umbilical venous catheter. Emergency pericardiocentesis was complicated by an intrapericardial thrombus, which was managed conservatively with spontaneous resolution within 24 hours. This case illustrates that the rare complication of an intrapericardial thrombus after pericardiocentesis can be successfully managed conservatively with close monitoring in haemodynamically stable paediatric patients.

A new recumbirostran 'microsaur' from the lower Permian Bromacker locality, Thuringia, Germany, and its fossorial adaptations

Several recumbirostran 'microsaurs' are known from early Permian sites across Germany, including the Tambach Formation in Thuringia, central Germany. The only 'microsaur' thus far described from the Tambach Formation was the ostodolepid recumbirostran Tambaroter carrolli. However, there is also the documented presence of an undescribed recumbirostran 'microsaur' at the well-known Bromacker locality. The Bromacker locality is highly recognized and best known for its very diverse and extremely well-preserved terrestrial tetrapod assemblage combined with the co-occurrence of an exceptional vertebrate ichnofossil record. Here we describe a second new recumbirostran taxon from the Tambach Formation, which is also the first from the Bromacker locality itself. Phylogenetic analysis indicates that the new taxon, Bromerpeton subcolossus gen. et sp. nov., is a brachystelechid recumbirostran, a group also known elsewhere in Germany. The following features differentiate Bromerpeton from the other members of the clade: the presence of 13 maxillary teeth, narrow postorbitals that do not substantially contribute to the postorbital region of the skull, the frontal does not contribute to the orbital margin, and the presence of five manual digits. This new recumbirostran 'microsaur' further adds to the unique ecosystem that is preserved at the Bromacker locality, granting us a better understanding of what was living underfoot the larger more well-known animals at the locality. Likewise, it expands our understanding of the evolution of recumbirostran 'microsaurs', especially with regards to digit and limb reduction within the clade.

Failure of Tricuspid Annuloplasty for Functional Tricuspid Regurgitation: Impact of Patient's Body Size

Tricuspid repair is recommended for significant functional tricuspid regurgitation (FTR) or tricuspid annulus (TA) dilation, based on TA >40 mm or >21 mm/m². The concordance between both TA dimensions related to the patient's body size has not been investigated. Patients who underwent rigid ring tricuspid annuloplasty for FTR between 2009 and 2017 were included. Assuming equality between both TA diameter criteria, patients were divided per body surface area (BSA): group 1 = BSA ≤1.9 m² and group 2 = BSA >1.9 m². The primary outcome was TR recurrence at 5 years. Tricuspid annuloplasty was performed in 186 patients (group 1: 130 patients [69.9%]; group 2: 56 patients [30.1%]). Group 1 comprised more female (70.8% to 23.2%, p <0.001) and older patients (77.1 ± 9.3 years; 74.2 ± 8.2 years, p = 0.048). Group 1 had a smaller absolute TA diameter (group 1: 45.3 ± 5.2 mm; group 2: 48.2 ± 5.6 mm, p <0.001), whereas the indexed TA size was inversely higher (group 1: 26.3 ± 3.4 mm/m²; group 2: 24.2 ± 2.7 mm/m², p <0.001). The tenting height was comparable (group 1: 7.8 ± 3.0 mm; group 2: 8.0 ± 2.7 mm, p = 0.714). The median ring size was 30 (interquartile range 28 to 32) and 32 (interquartile range 30 to 34) for groups 1 and 2, respectively (p <0.001). TR recurrence at 5 years was noticed in 20.2% and 6.5% of group 1 and 2 (p = 0.035). Indexed TA diameter (hazard ratio 1.43, 95% confidence interval 1.10 to 1.87, p = 0.008) and tenting height (hazard ratio 5.52, 95% confidence interval 1.87 to 14.57, p = 0.002) were independent predictors of TR recurrence. In conclusion, when the absolute TA diameter is used as the primary criterion, smaller patients are at a higher risk for TR recurrence by having a proportionally larger TA at the time of repair. An individualized approach guided by patient's body size might be more appropriate to indicate FTR correction to adjust for the annuloplasty sizing method.

Long-term follow-up of atrioventricular valve function in Fontan patients: effect of atrioventricular valve surgery

OBJECTIVES

The aim of this study was to evaluate the relationship between atrioventricular valve and ventricular function in Fontan survivors, including the effect of atrioventricular valve surgery.

METHODS

Analysis focused on transplant-free survival and the need for atrioventricular valve surgery in single ventricle patients after Fontan completion. Longitudinal echocardiographic examination of long-term valve and ventricular function was performed.

RESULTS

Fontan completion was performed in 113 patients, having a right univentricular morphology in 33.6%, a left ventricle morphology in 62.8% and ambiguous in 3.6%. Perioperative mortality was 2.7% (n = 3). Within a median follow-up of 16.3 years (interquartile range 10.6-23.6), transplant-free survival was 96.1 ± 1.9% and 90.4 ± 5.8% at 10-25 years. Twenty AV valve procedures were performed in 14 (12.4%) children, respectively, pre-Fontan (n = 10), per-Fontan (n = 8) and post-Fontan (n = 2), resulting in a cumulative incidence of AV valve surgery is 5.7 ± 2.2% and 12.3 ± 3.2% at 1-5 years. Atrio-ventricular valve function deteriorated over time [hazard ratio (HR) 1.112, 95% confidence interval (CI) 1.089-1.138, P < 0.001], without difference for valve morphology (P = 0.736) or ventricular dominance (P = 0.484). AV valve dysfunction was greater in patients requiring AV valve surgery (HR 20.383, 95% CI 6.223-36.762, P < 0.001) but showed a comparable evolution since repair to those without valve surgery (HR 1.070, 95% CI 0.987-1.160, P = 0.099). Progressive time-related ventricular dysfunction was observed (HR 1.141, 95% CI 1.097-1.182, P < 0.001), significantly less in left ventricle-dominance (HR 0.927, 95% CI 0.860-0.999, P = 0.047) but more after AV valve surgery (HR 1.103, 95% CI 1.014-1.167, P = 0.022).

CONCLUSIONS

In a homogeneously treated Fontan population, 25-year transplant-free survival is encouraging. Atrio-ventricular valve surgery was necessary in 12.4%, resulting mostly in a durable valve function. However, a slow time-related decline of atrioventricular valve function as of ventricular function is worrisome, evoking a role for additional heart failure therapy.

Evaluating student's ability to assess treatment claims: validating a German version of the Claim Evaluation Tools

BACKGROUND

The Claim Evaluation Tools measure the ability to assess claims about treatment effects. The aim of this study was to adapt the German item sets to the target group of secondary school students (aged 11 to 16 years, grade 6 to 10) and to validate them accordingly. The scale's reliability and validity using Rasch's probabilistic test theory should be determined.

METHODS

We conducted a sequential mixed-method study comprising three stages: contextualisation and adaption of the items (stage 1), piloting of the item sets using qualitative interviews (stage 2) and a construct validation by testing the unidimensional Rasch scalability for each item set after data collection in one secondary school in Germany and two secondary schools in Austria. We explored summary and individual fit statistics and performed a distractor analysis (stage 3).

RESULTS

Secondary school students (n = 6) and their teachers (n = 5) participated in qualitative interviews in Germany. The qualitative interviews identified the need for minor modifications (e.g. reducing thematic repetitions, changing the order of the items). The data of 598 German and Austrian secondary school students were included to test for Rasch scalability. Rasch analyses showed acceptable overall model fit. Distractor analyses suggested that model fit could be improved by simplifying the text in the scenarios, removing and editing response options of some items.

CONCLUSION

After the revision of some items, the questionnaires are suitable to evaluate secondary school students' ability to assess health claims. A future goal is to increase the pool of items being translated and tested.

Impact of mean perfusion pressure and vasoactive drugs on occurrence and reversal of cardiac surgery-associate acute kidney injury: A cohort study

PURPOSE

Low cardiac output and kidney congestion are associated with acute kidney injury after cardiac surgery (CSA-AKI). This study investigates hemodynamics on CSA-AKI development and reversal.

MATERIALS AND METHODS

Adult patients undergoing cardiac surgery were retrospectively included. Hemodynamic support was quantified using a new time-weighted vaso-inotropic score (VIS_AUC), and hemodynamic variables expressed by mean perfusion pressure and its components. The primary outcome was AKI stage ≥2 (CSA-AKI ≥2) and secondary outcome full AKI reversal before ICU discharge.

RESULTS

3415 patients were included. CSA-AKI ≥2 occurred in 37.4%. Mean perfusion pressure (MPP) (OR 0.95,95%CI 0.94-0.96, p < 0.001); and central venous pressure (CVP) (OR 1.17, 95%CI 1.13-1.22, p < 0.001) are associated with CSA-AKI ≥2 development, while VIS_AUC/h was not (p = 0.104). Out of 1085 CSA-AKI ≥2 patients not requiring kidney replacement therapy, 76.3% fully recovered of AKI. Full CSA-AKI reversal was associated with MPP (OR 1.02 per mmHg (95%CI 1.01-1.03, p = 0.003), and MAP (OR = 1.01 per mmHg (95%CI 1.00-1.02), p = 0.047), but not with VIS_AUC/h (p = 0.461).

CONCLUSION

Development and full recovery of CSA-AKI ≥2 are affected by mean perfusion pressure, independent of vaso-inotropic use. CVP had a significant effect on AKI development, while MAP on full AKI reversal.

Clipping of an Aortopulmonary Window in a Small Neonate With Bronchial Bleeding: A Simple Solution for a Complex Condition

Although the conventional treatment of aortopulmonary (AP) window consists of reconstructive surgery with the use of cardiopulmonary bypass (CPB), some conditions like low birth weight or active respiratory tract bleeding may lead to diverting therapeutic options. We present a case of a premature 1.9 kg neonate with severe pulmonary arterial hypertension based on the association of an AP window and large patent ductus arteriosus. Because of intrabronchial hemorrhage, a conservative strategy was chosen excluding the need for heparinization and CPB. Through median sternotomy, the ductus arteriosus and AP window were clipped, effectively occluding both shunts. The postoperative course was uneventful with a rapid decrease of pulmonary artery pressure. Although classical surgical reconstruction is still advocated as primary therapy, this case illustrates the suitability of an alternative approach without the need for CPB and full heparinization in a patient with an increased risk of bleeding complications.

The Effect of Discontinuing Continuous Glucose Monitoring in Adults With Type 2 Diabetes Treated With Basal Insulin

OBJECTIVE

To explore the effect of discontinuing continuous glucose monitoring (CGM) after 8 months of CGM use in adults with type 2 diabetes treated with basal without bolus insulin.

RESEARCH DESIGN AND METHODS

This multicenter trial had an initial randomization to either real-time CGM or blood glucose monitoring (BGM) for 8 months followed by 6 months in which the BGM group continued to use BGM (n = 57) and the CGM group was randomly reassigned either to continue CGM (n = 53) or discontinue CGM with resumption of BGM for glucose monitoring (n = 53).

RESULTS

In the group that discontinued CGM, mean time in range (TIR) 70-180 mg/dL, which improved from 38% before initiating CGM to 62% after 8 months of CGM, decreased after discontinuing CGM to 50% at 14 months (mean change from 8 to 14 months -12% [95% CI -21% to -3%], P = 0.01). In the group that continued CGM use, little change was found in TIR from 8 to 14 months (baseline 44%, 8 months 56%, 14 months 57%, mean change from 8 to 14 months 1% [95% CI -11% to 12%], P = 0.89). Comparing the two groups at 14 months, the adjusted treatment group difference in mean TIR was -6% (95% CI -16% to 4%, P = 0.20).

CONCLUSIONS

In adults with type 2 diabetes treated with basal insulin who had been using real-time CGM for 8 months, discontinuing CGM resulted in a loss of about one-half of the initial gain in TIR that had been achieved during CGM use.

Reappraisal of lung manifestations in the setting of Fontan circulation

Fontan circulation is a well-established palliation in patients with functional single ventricles. Absence of a sub-pulmonary pumping chamber creates a unique physiology in which blood flow is mainly guided by negative intrathoracic and elevated central venous pressures. Various pulmonary anatomic or pathophysiologic changes can jeopardize optimal Fontan circulation. Long-term survival of patients who have undergone the contemporary total cavopulmonary connection is satisfactory. Thorough literature review in conjunction with accumulated clinical experience can lead clinicians to extract conclusions regarding Fontan and lung interactions indicating the purpose of this review.

QRS Duration During Follow-Up of Tetralogy of Fallot: How Valuable is it? Analysis of ECG Changes in Relation to Pulmonary Valve Implantation

Long-term results after tetralogy of Fallot (TOF) repair are determined by the extent of right ventricular remodeling to chronic pulmonary regurgitation entailing progressive RV dysfunction and a risk of developing ventricular arrhythmia. Pulmonary valve replacement (PVR) can alleviate this burden. As a predictor of ventricular arrhythmia, QRS duration remains a strong parameter in this decision. We performed a retrospective analysis of all PVR patients between 2005 and 2018, studying the time evolution of electrocardiographic parameters before and after PVR through linear mixed model analysis. 42 TOF patients underwent PVR. The median timespan between primary repair and PVR was 18 years (IQR 13-30). The indication for PVR was primarily based on the association of exercise intolerance (67%) and significant RV dilation on cMRI (median RVEDVi 161 ml/m² IQR 133-181). Median QRS length was 155 ms (IQR 138-164), 4 (10%) patients had a QRS > 180 ms. QRS duration increased significantly before PVR, but barely showed regression after PVR. Changes of QRS duration after PVR were independent of RV dilation. In conclusion, when the decision for PVR in TOF patients is primarily based on RV volume and/or function threshold, QRS duration > 180 ms is rarely observed. In contrast with the significant increase of QRS duration before PVR, QRS length regression appears to be independent of the extent of RV dilation or QRS > 160 ms. Considering that the decision for PVR is based on mechanical RV characteristics, the utility of serial follow-up of QRS duration in contemporary operated TOF patients becomes questionable in absence of clinical arguments for ventricular arrhythmia.

The Early Permian Bolosaurid Eudibamus cursoris: Earliest Reptile to Combine Parasagittal Stride and Digitigrade Posture During Quadrupedal and Bipedal Locomotion

A comprehensive description of the holotype skeleton is presented here for the first time of the lower Permian (Artinskian) reptile Eudibamus cursoris from the Bromacker locality of Germany since the brief description of the holotype in 2000. The holotype is essentially complete and is the only known bolosaurid represented by a well-preserved articulated skeleton. Included in the description here is a superbly preserved, partial, articulated second specimen of E. cursoris discovered at the same locality that includes a short portion of the vertebral column associated with the pelvis and right hindlimb. Descriptions of the holotype and new specimen add substantially to features of the skull and postcranium that not only confirm a bolosaurid assignment, but also add significantly to an already long list of structural features supporting an ability unique among Paleozoic vertebrates to reach relatively high bipedal and quadrupedal running speeds employing a parasagittal stride and digitigrade stance with the limbs held in a near vertical posture. Structural differences between the two specimens are restricted to the tarsi and are attributed to different ontogenetic stages of ossification, with the holotype representing a more juvenile individual, and the larger second specimen representing a more mature animal.

Repeat aortic valve surgery: contemporary outcomes and risk stratification

OBJECTIVES

Redo aortic valve surgery (rAVS) is performed with increasing frequency, but operative mortality is usually higher compared to that associated with primary aortic valve surgery. We analysed our patients who had rAVS to determine the current outcomes of rAVS as a surgical benchmark in view of the growing interest in transcatheter valve techniques.

METHODS

We retrospectively reviewed 148 consecutive patients [median age 67.7 years (interquartile range 54.9-77.6); 68.2% men] who underwent rAVS following aortic valve replacement (81.6%), aortic root replacement (15%) or aortic valve repair (3.4%) between 2000 and 2018.

RESULTS

Indications for rAVS were structural valve dysfunction (42.7%), endocarditis (37.8%), non-structural valve dysfunction (17.7%) and aortic aneurysm (2.1%). Valve replacement was performed in 69.7%, and 34 new root procedures were necessary in 23%. Early mortality was 9.5% (n = 14). Female gender [odds ratio (OR) 6.16], coronary disease (OR 4.26) and lower creatinine clearance (OR 0.95) were independent predictors of early mortality. Follow-up was 98.6% complete [median 5.9 (interquartile range 1.7-10.9) years]. Survival was 74.1 ± 3.7%, 57.9 ± 5.1% and 43.8 ± 6.1% at 5, 10 and 14 years, respectively. Cox regression analysis revealed female gender [hazard ratio (HR) 1.73], diabetes (HR 1.73), coronary disease (HR 1.62) and peripheral vascular disease (HR 1.98) as independent determinants of late survival.

CONCLUSIONS

Despite many urgent situations and advanced New York Heart Association functional class at presentation, rAVS could be performed with acceptable early and late outcomes. Risk factors for survival were female gender, coronary disease and urgency. In this all-comers patient cohort needing rAVS, only a minority would eventually qualify for transcatheter valve-in-valve procedures.

Heart transplantation complicated by COVID-19 infection

The influence of Coronavirus-2019 (COVID-19) on heart transplantation is considerable. Reports of COVID-19 infection in recently transplanted patients are scarce. We present a 60-year-old male patient with COVID-19 infection, diagnosed 6 days after transplantation. His clinical course revealed 2 phases. Initially, there were mild respiratory symptoms for which he was treated with remdesivir and noninvasive respiratory support. In a second phase with clinical deterioration on postoperative day 22, further respiratory decline led to the administration of convalescent plasma, with satisfactory response and further improvement of his condition.

Effect of Continuous Glucose Monitoring on Glycemic Control in Patients With Type 2 Diabetes Treated With Basal Insulin: A Randomized Clinical Trial

IMPORTANCE

Continuous glucose monitoring (CGM) has been shown to be beneficial for adults with type 2 diabetes using intensive insulin therapy, but its use in type 2 diabetes treated with basal insulin without prandial insulin has not been well studied.

OBJECTIVE

To determine the effectiveness of CGM in adults with type 2 diabetes treated with basal insulin without prandial insulin in primary care practices.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted at 15 centers in the US (enrollment from July 30, 2018, to October 30, 2019; follow-up completed July 7, 2020) and included adults with type 2 diabetes receiving their diabetes care from a primary care clinician and treated with 1 or 2 daily injections of long- or intermediate-acting basal insulin without prandial insulin, with or without noninsulin glucose-lowering medications.

INTERVENTIONS

Random assignment 2:1 to CGM (n = 116) or traditional blood glucose meter (BGM) monitoring (n = 59).

MAIN OUTCOMES AND MEASURES

The primary outcome was hemoglobin A1c (HbA1c) level at 8 months. Key secondary outcomes were CGM-measured time in target glucose range of 70 to 180 mg/dL, time with glucose level at greater than 250 mg/dL, and mean glucose level at 8 months.

RESULTS

Among 175 randomized participants (mean [SD] age, 57 [9] years; 88 women [50%]; 92 racial/ethnic minority individuals [53%]; mean [SD] baseline HbA1c level, 9.1% [0.9%]), 165 (94%) completed the trial. Mean HbA1c level decreased from 9.1% at baseline to 8.0% at 8 months in the CGM group and from 9.0% to 8.4% in the BGM group (adjusted difference, -0.4% [95% CI, -0.8% to -0.1%]; P = .02). In the CGM group, compared with the BGM group, the mean percentage of CGM-measured time in the target glucose range of 70 to 180 mg/dL was 59% vs 43% (adjusted difference, 15% [95% CI, 8% to 23%]; P < .001), the mean percentage of time at greater than 250 mg/dL was 11% vs 27% (adjusted difference, -16% [95% CI, -21% to -11%]; P < .001), and the means of the mean glucose values were 179 mg/dL vs 206 mg/dL (adjusted difference, -26 mg/dL [95% CI, -41 to -12]; P < .001). Severe hypoglycemic events occurred in 1 participant (1%) in the CGM group and in 1 (2%) in the BGM group.

CONCLUSIONS AND RELEVANCE

Among adults with poorly controlled type 2 diabetes treated with basal insulin without prandial insulin, continuous glucose monitoring, as compared with blood glucose meter monitoring, resulted in significantly lower HbA1c levels at 8 months.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03566693.

ACARPA, a rare case of ALCAPA

An anomalous circumflex coronary artery arising from the right pulmonary artery is very rare. Clinical presentation varies from absence of symptoms to arrhythmia and sudden cardiac death. Since prevalence is very low, no definite therapy has been delineated yet. A 19-year-old patient, previously treated for a vascular ring and mitral valve stenosis, was diagnosed with this anomaly through echocardiography revealing collateral coronary flow, with confirmation of this coronary anomaly on subsequent computed tomography examination. To alleviate the burden for arrhythmia in this young patient, he was successfully treated with surgical reimplantation followed by an uneventful recovery.

Analysis of the recovery phase after maximal exercise in children with repaired tetralogy of Fallot and the relationship with ventricular function

Background

Few studies demonstrate delayed recovery after exercise in children and adults with heart disease. We assess the recovery patterns of gas exchange parameters and heart rate (HR) in children with repaired Tetralogy of Fallot (rToF) compared to healthy peers and investigate the correlation with ventricular function and QRS duration.

Methods

45 children after rToF and 45 controls performed a maximal incremental cardiopulmonary exercise test. In the subsequent recovery period, patterns of VO₂, VCO₂ and HR were analysed. Half-life time (T_1/2) of the exponential decay and drop per minute (Rec_min) were compared between groups. In the rToF group, correlations were examined between the recovery parameters and QRS-duration and ventricular function, described by fractional shortening (FS) and tricuspid annular plane systolic excursion (TAPSE) measured at baseline prior to exercise.

Results

Recovery of VO₂ and VCO₂ was delayed in rToF patients, half-life time values were higher compared to controls (T_1/2VO₂ 52.51 ±11.29 s vs. 44.31 ± 10.47 s; p = 0.001 and T_1/2VCO₂ 68.28 ± 13.84 s vs. 59.41 ± 12.06 s; p = 0.002) and percentage drop from maximal value was slower at each minute of recovery (p<0.05). Correlations were found with FS (T_1/2VO₂: r = -0.517; p<0.001; Rec_1minVO₂: r = -0.636, p<0.001; Rec_1minVCO₂: r = -0.373, p = 0.012) and TAPSE (T_1/2VO₂: r = -0.505; p<0.001; Rec_1minVO₂: r = -0.566, p<0.001; T_1/2VCO₂: r = -0.466; p = 0.001; Rec_1minVCO₂: r = -0.507, p<0.001), not with QRS-duration. No difference was found in HR recovery between patients and controls.

Conclusions

Children after rToF show a delayed gas exchange recovery after exercise. This delay correlates to ventricular function, demonstrating its importance in recovery after physical activity.

Right superior vena cava draining into the left atrium in a patient with sinus venosus defect

Right superior vena cava draining into the left atrium is an extremely rare anomaly of systemic venous return. It can be isolated or it can be associated with other congenital heart defects, thus clinical presentation may vary. A case of a 9-year-old asymptomatic patient with sinus venous defect and bilateral superior vena cava with the right-sided draining into the left atrium is described.

Pediatric lung transplantation: Results of volume reduction in smaller children

Pediatric LTX is challenged by the scarcity of suitable donor organs. To alleviate the problem of size matching, volume reduction of the donor is a possible option. Previous reports address mostly older teenagers, and data about younger patients are lacking. The purpose of this study was to investigate whether trimming had influence on the morbidity and mortality in slightly younger recipients, operated in a single center. Between 2015 and 2018, 20 patients were transplanted at the GOSH London. The mean age was 11.5 (±4.6) years. Nine patients underwent volume reduction prior to transplantation (T group). The other patients received classical bilateral LTX (NT group). Ischemia times were longer in the T group, but this difference was not statistically significant. We observed no 30-day mortality. Hospital survival in the T group was 78% vs 90% in the NT group. After almost 3 years, mortality in the T group was 22% vs 28% in the NT group. None of these differences was statistically significant. The mean duration of MV, intensive care stay, and hospital stay were 11.5, 19.9, and 44.8 days, respectively. Results were equal in terms of morbidity, defined as respiratory and neurological complications or the need for ECMO. Results show that volume reduction prior to LTX is a feasible option, even in smaller children. While awaiting long-term results, accepting larger donor organs could be a strategy to further reduce waiting list time and subsequently lower the mortality on the waiting list.

Repair of pulmonary artery sling with tracheal and intracardiac defects

BACKGROUND

Pulmonary artery sling is commonly associated with tracheal stenosis and intracardiac anomalies. While surgical repair is standardized, coexistent anomalies often determine outcomes. With the paucity of risk stratification, this study aimed to review our experience and stratify risk factors for the surgical outcome of complex pulmonary artery sling repair in the presence of airway or intracardiac lesions.

METHODS

Seventy-nine consecutive children with pulmonary artery sling were evaluated retrospectively following surgical repair. Median age at surgery was 5 months (interquartile range 3-9). Surgical approaches included pulmonary artery sling alone (n = 10), pulmonary artery sling with tracheoplasty (n = 41), and pulmonary artery sling with both intracardiac and tracheal surgery (n = 28).

RESULTS

There were 7 early (8.8%) deaths. Two patients after left pulmonary artery reimplantation needed revision of the anastomosis. The median intensive care and hospital stay were 11 (interquartile range 9.2-24.8) and 17.9 (interquartile range 4.3-19.8) days, and considerably longer when associated tracheal surgery (p = 0.002). Follow-up was complete in 66/69 and 3 (3.8%) children died late: 2.7, 10.2, and 17 months after surgery. Univariate analysis showed abnormal lung and coexisting structural heart disease as risk factors. Multivariate analysis revealed total cardiopulmonary bypass time as an independent predictor of overall mortality.

CONCLUSION

Complex pulmonary artery sling repair can be performed with a good surgical outcomes even when associated with airway malformations or structural heart diseases. Lung abnormality and longer cardiopulmonary bypass time as a surrogate marker of complex surgery, are possible risk factors.

Sensor Measures of Affective Leaning

The aim of this study was to predict self-report data for self-regulated learning with sensor data. In a longitudinal study multichannel data were collected: self-report data with questionnaires and embedded experience samples as well as sensor data like electrodermal activity (EDA) and electroencephalography (EEG). 100 students from a private university in Germany performed a learning experiment followed by final measures of intrinsic motivation, self-efficacy and gained knowledge. During the learning experiment psychophysiological data like EEG were combined with embedded experience sampling measuring motivational states like affect and interest every 270 s. Results of machine learning models show that consumer grade wearables for EEG and EDA failed to predict embedded experience sampling. EDA failed to predict outcome measures as well. This gap can be explained by some major technical difficulties, especially by lower quality of the electrodes. Nevertheless, an average activation of all EEG bands at T7 (left-hemispheric, lateral) can predict lower intrinsic motivation as outcome measure. This is in line with the personality system interactions (PSI) theory of Julius Kuhl. With more advanced sensor measures it might be possible to track affective learning in an unobtrusive way and support micro-adaptation in a digital learning environment.

Acute Type A Aortic Dissection Complicated by COVID-19 Infection

A patient underwent surgery for acute type A aortic dissection. Testing for SARS-CoV-2 was positive. The postoperative course was complicated by a mixed viral and bacterial pneumonia with bilateral infiltration, treated with antibiotics and hydroxychloroquine, without any need for reintubation. The patient recovered and finally could be discharged. This report shows the feasibility for surgical treatment of acute aortic disease in patients with COVID-19.

Deep hypothermic extracorporeal membrane oxygenation cannula exchange in a child with necrotic pneumonia

Necrotizing pneumonia can lead to respiratory insufficiency in previously healthy children. Extracorporeal membrane oxygenation can be used for hemodynamic salvage and subsequent lung rest awaiting recovery. We present a case of a child initially placed on veno-arterial extracorporeal membrane oxygenation and converted to veno-venous extracorporeal membrane oxygenation. This was done under deep hypothermia in the operating theater.

Technical challenges of lung transplantation in children after arterial switch operation

Pulmonary arterial hypertension after arterial switch operation for transposition of the great arteries is rare. Lung transplantation can be the last option in cases of failed medical therapy. We report 2 paediatric patients who underwent lung transplantation for this indication. Altered hilar anatomy, mediastinal adhesions and haemostatic control represent the main technical challenges. Volume-reduction surgery is sometimes necessary to address altered cardiopulmonary relationships while expanding the donor pool.

Ten-year results of aortic valve replacement with first-generation Mitroflow bioprosthesis: is early degeneration a structural or a technical issue?

OBJECTIVES

Concerns have been raised about the durability of the first-generation Mitroflow aortic bioprosthesis (model 12 A-LX) due to the lack of anticalcification treatment. This study reflects a 10-year experience with this prosthesis for aortic valve replacement.

METHODS

From June 2003 to May 2012, the Mitroflow prosthesis was used for aortic valve replacement in 510 patients, of whom only 467 with complete clinical follow-up were included for analysis. Study end-points were survival and incidence of structural valve degeneration (SVD). Analysis of SVD was based on cumulative incidence function and competing-risk Cox regression.

RESULTS

The mean patient age was 76.4 ± 6.1 years. Valve sizes from 23 to 25 were used in 70.4%, whereas sizes from 19 to 21 were used in only 19.2%, thereby avoiding patient-prosthesis mismatch in 89.1%. Within a median follow-up time of 6.6 years (interquartile range 4.4), a cumulative 2375 patient-years, the survival rate was 86.2%, 67.3% and 33.3% at 1, 5 and 10 years, respectively. The cumulative incidence of SVD, with death as a competing risk, was 0%, 0.7% and 6.2% at 1, 5 and 10 years, respectively. Only age <75 years tended to affect the late hazard of SVD (hazard ratio 0.50, 95% confidence interval 0.23-1.08, P  = 0.08), regardless of valve-specific issues.

CONCLUSIONS

The data do not support the concerns about early accelerated structural degeneration of the first-generation Mitroflow bioprosthesis used for aortic valve replacement in patients older than 75 years. We postulate that limiting the number of small prostheses using a proper implantation technique has enhanced the reduction in risk of significant patient-prosthesis mismatch as the main determinant of early SVD.

Minimally Invasive Repair of Mitral Valve Prolapse and Concomitant Atrial Fibrillation Ablation in a Heart Transplant

Significant mitral valve disease with atrial fibrillation after heart transplantation is unusual. We report the diagnosis and minimally invasive surgical treatment 17 years after transplantation, in which mitral valve repair together with left atrial ablation was performed, resulting in a satisfying clinical and echocardiographic improvement.

Stealth monoolein-based nanocarriers for delivery of siRNA to cancer cells

While the delivery of small interfering RNAs (siRNAs) is an attractive strategy to treat several clinical conditions, siRNA-nanocarriers' stability after intravenous administration is still a major obstacle for the development of RNA-interference based therapies. But, although the need for stability is well recognized, the notion that strong stabilization can decrease nanocarriers' efficiency is sometimes neglected. In this work we evaluated two stealth functionalization strategies to stabilize the previously validated dioctadecyldimethylammonium bromide (DODAB):monoolein (MO) siRNA-lipoplexes. The nanocarriers were pre- and post-pegylated, forming vectors with different stabilities in biological fluids. The stealth nanocarriers' behavior was tested under biological mimetic conditions, as the production of stable siRNA-lipoplexes is determinant to achieve efficient intravenous siRNA delivery to cancer cells. Upon incubation in human serum for 2h, by fluorescence Single Particle Tracking microscopy, PEG-coated lipoplexes were found to have better colloidal stability as they could maintain a relatively stable size. In addition, using fluorescence fluctuation spectroscopy, post-pegylation also proved to avoid siRNA dissociation from the nanocarriers in human serum. Concomitantly it was found that PEG-coated lipoplexes improved cellular uptake and transfection efficiency in H1299 cells, and had the ability to silence BCR-ABL, affecting the survival of K562 cells. Based on an efficient cellular internalization, good silencing effect, good siRNA retention and good colloidal stability in human serum, DODAB:MO (2:1) siRNA-lipoplexes coated with PEG-Cer are considered promising nanocarriers for further in vivo validation.

STATEMENT OF SIGNIFICANCE

This work describes two stealth functionalization strategies for the stabilization of the previously validated dioctadecyldimethylammonium bromide (DODAB):monoolein (MO) siRNA-lipoplexes. These nanocarriers are capable of efficiently incorporating and delivering siRNA molecules to cells in order to silence genes whose expression is implicated in a pathological condition. The main objective was to functionalize these nanocarriers with a coating conferring protection to siRNA in blood without compromising its efficient delivery to cancer cells, validating the potential of DODAB:MO (2:1) siRNA-lipoplexes as therapeutic vectors. We show that the stealth strategy is determinant to achieve a stable and efficient nanocarrier, and that DODAB:MO mixtures have a very promising potential for systemic siRNA delivery to leukemic cells.

A Three-Dimensional Skeletal Reconstruction of the Stem Amniote Orobates pabsti (Diadectidae): Analyses of Body Mass, Centre of Mass Position, and Joint Mobility

Orobates pabsti, a basal diadectid from the lower Permian, is a key fossil for the understanding of early amniote evolution. Quantitative analysis of anatomical information suffers from fragmentation of fossil bones, plastic deformation due to diagenetic processes and fragile preservation within surrounding rock matrix, preventing further biomechanical investigation. Here we describe the steps taken to digitally reconstruct MNG 10181, the holotype specimen of Orobates pabsti, and subsequently use the digital reconstruction to assess body mass, position of the centre of mass in individual segments as well as the whole animal, and study joint mobility in the shoulder and hip joints. The shape of most fossil bone fragments could be recovered from micro-focus computed tomography scans. This also revealed structures that were hitherto hidden within the rock matrix. However, parts of the axial skeleton had to be modelled using relevant isolated bones from the same locality as templates. Based on the digital fossil, mass of MNG 10181 was estimated using a model of body shape that was varied within a plausible range to account for uncertainties of the dimension. In the mean estimate model the specimen had an estimated mass of circa 4 kg. Varying of the mass distribution amongst body segments further revealed that Orobates carried most of its weight on the hind limbs. Mostly unrestricted joint morphology further suggested that MNG 10181 was able to effectively generate propulsion with the pelvic limbs. The digital reconstruction is made available for future biomechanical studies.

Single-particle tracking for studying nanomaterial dynamics: applications and fundamentals in drug delivery

Many macromolecular therapeutics could potentially treat genetic disorders and cancer. They have, however, not yet reached the clinical stage owing to a lack of suitable carriers that can bring the therapeutics from the administration site to the subcellular site in target cells. One of the reasons that is hindering the development of such carriers is the limited knowledge of their transport dynamics and intracellular processing. Single-particle tracking (SPT) microscopy, thanks to its single molecule sensitivity and its broad applicability, has found its entry in the field of drug delivery to get an answer to these questions. This review aims to introduce the fundamentals of SPT to the drug delivery community and highlight the most recent discoveries obtained with SPT in the field of drug delivery.

Spindle cell sarcoma of the mitral valve: an unusual cause of acute coronary syndrome in a child

We present an unusual case of acute myocardial infarction by embolic obstruction of both the left anterior descending and right coronary arteries in a 14-year-old girl. Echocardiography showed mobile lesions on the mitral valve and into the left ventricular outflow tract with poor left ventricular function, eventually suggesting endocarditis. Successful surgery comprised mitral valve plasty after complete resection of the tumoral lesion, in association with coronary artery embolectomy. Histologic examination revealed a malignant spindle cell sarcoma treated with adjuvant chemotherapy. We emphasize here the differential diagnosis of acute coronary syndrome in children by a rare cardiac tumor.

Meso-Rex shunt using deep femoral vein conduit: first report

The Meso-Rex shunt (MRS) procedure was first described in 1992 by de VILLE et al. for the treatment of extrahepatic portal vein obstruction (EHPVO) in paediatric liver transplant patients. This technique provides more physiological relief of portal hypertension compared to the porto-systemic shunts, which can lead to long-term complications such as hyperammonaemia and hepato-pulmonary syndrome. Different conduits as autologous and cryopreserved veins or prosthetic grafts have been previously reported. We present herein the first case of a MRS using the autologous deep femoral vein in a 17-year-old female patient affected by EHPVO from unknown reasons.

Correlation of dual colour single particle trajectories for improved detection and analysis of interactions in living cells

Interactions between objects inside living cells are often investigated by looking for colocalization between fluorescence microscopy images that are recorded in separate colours corresponding to the fluorescent label of each object. The fundamental limitation of this approach in the case of dynamic objects is that coincidental colocalization cannot be distinguished from true interaction. Instead, correlation between motion trajectories obtained by dual colour single particle tracking provides a much stronger indication of interaction. However, frequently occurring phenomena in living cells, such as immobile phases or transient interactions, can limit the correlation to small parts of the trajectories. The method presented here, developed for the detection of interaction, is based on the correlation inside a window that is scanned along the trajectories, covering different subsets of the positions. This scanning window method was validated by simulations and, as an experimental proof of concept, it was applied to the investigation of the intracellular trafficking of polymeric gene complexes by endosomes in living retinal pigment epithelium cells, which is of interest to ocular gene therapy.

Automatic particle detection in microscopy using temporal correlations

One of the fundamental problems in the analysis of single particle tracking data is the detection of individual particle positions from microscopy images. Distinguishing true particles from noise with a minimum of false positives and false negatives is an important step that will have substantial impact on all further analysis of the data. A common approach is to obtain a plausible set of particles from a larger set of candidate particles by filtering using manually selected threshold values for intensity, size, shape, and other parameters describing a particle. This introduces subjectivity into the analysis and hinders reproducibility. In this paper, we introduce a method for automatic selection of these threshold values based on maximizing temporal correlations in particle count time series. We use Markov Chain Monte Carlo to find the threshold values corresponding to the maximum correlation, and we study several experimental data sets to assess the performance of the method in practice by comparing manually selected threshold values from several independent experts with automatically selected threshold values. We conclude that the method produces useful results, reducing subjectivity and the need for manual intervention, a great benefit being its easy integratability into many already existing particle detection algorithms.

Multiple aneurysms in a patient with aneurysms-osteoarthritis syndrome

The aneurysms-osteoarthritis syndrome (AOS) was recently described and encompasses multiple aneurysms and tortuosity of the great arteries. Most patients have early-onset osteoarthritis. We report the diagnosis, treatment, and follow-up of a patient presenting with bilateral aneurysms of the common iliac arteries and an ascending aortic aneurysm. After proper surgical treatment, genetic studies revealed a causal mutation in the SMAD3 gene.