Krishnah G. Bellam, Sharif A. Sabe, Nicholas R. Huang, Nishanth Chalasani, Dwight Douglas Harris, Noah Feldman, Phillip R. Schmitt, Anthony Harwell, Frank W. Sellke, Afshin Ehsan
Background and Aim of the Study. While several studies have suggested a relationship between adverse postoperative outcomes and systemic lupus erythematosus (SLE) in major surgical settings, no study to date has explored postoperative outcomes of SLE patients undergoing coronary artery bypass grafting (CABG). This study aimed to compare the characteristics and outcomes of SLE patients compared to non-SLE patients undergoing CABG. Methods. We utilized the Nationwide Inpatient Sample (NIS) data from 2008–2018 for CABG patients ≥18 years old. Patients were divided into two groups based on SLE status (confirmed SLE diagnosis or no SLE present). Primary outcomes were in-hospital mortality, favorable discharge, and length of stay (LOS). Secondary outcomes included acute kidney injury (AKI), acute liver injury (ALI), hemodialysis, acute myocardial infarction (AMI), and cardiogenic shock. Patient characteristics including age, sex, race, and preexisting comorbidities were considered. Multivariable models, adjusting for confounding variables, were utilized. Results. Data from a total of 352,772 patients who underwent CABG were analyzed. 980 patients had a diagnosis code for SLE. SLE and non-SLE patients had similar rates of in-hospital mortality (OR = 0.92, [0.63–1.35]), nonhome discharge (OR = 1.09, [0.95–1.24]), and LOS (OR = 1.02, [0.99–1.06]). SLE patients developed AKI at a higher rate (OR = 1.50, [1.05–1.48]) and ALI at a lower rate (OR = 0.35, [0.16–0.74]). Both groups had similar rates of hemodialysis (OR = 1.19, [0.98–1.44]), AMI (OR = 0.93, [0.81–1.06]), and cardiogenic shock (OR = 0.8, [0.61–1.05]). Conclusion. These findings suggest that SLE patients undergoing CABG have similar mortality, discharge disposition, and LOS compared to non-SLE patients. However, SLE patients are at increased risk of AKI and decreased risk of ALI than non-SLE patients. These associations warrant further investigation to elucidate their physiologic basis.
{"title":"Hepatic and Renal Outcomes in Systemic Lupus Erythematosus Patients following Coronary Artery Bypass Grafting: A Study from the National Inpatient Sample","authors":"Krishnah G. Bellam, Sharif A. Sabe, Nicholas R. Huang, Nishanth Chalasani, Dwight Douglas Harris, Noah Feldman, Phillip R. Schmitt, Anthony Harwell, Frank W. Sellke, Afshin Ehsan","doi":"10.1155/2023/8846398","DOIUrl":"https://doi.org/10.1155/2023/8846398","url":null,"abstract":"Background and Aim of the Study. While several studies have suggested a relationship between adverse postoperative outcomes and systemic lupus erythematosus (SLE) in major surgical settings, no study to date has explored postoperative outcomes of SLE patients undergoing coronary artery bypass grafting (CABG). This study aimed to compare the characteristics and outcomes of SLE patients compared to non-SLE patients undergoing CABG. Methods. We utilized the Nationwide Inpatient Sample (NIS) data from 2008–2018 for CABG patients ≥18 years old. Patients were divided into two groups based on SLE status (confirmed SLE diagnosis or no SLE present). Primary outcomes were in-hospital mortality, favorable discharge, and length of stay (LOS). Secondary outcomes included acute kidney injury (AKI), acute liver injury (ALI), hemodialysis, acute myocardial infarction (AMI), and cardiogenic shock. Patient characteristics including age, sex, race, and preexisting comorbidities were considered. Multivariable models, adjusting for confounding variables, were utilized. Results. Data from a total of 352,772 patients who underwent CABG were analyzed. 980 patients had a diagnosis code for SLE. SLE and non-SLE patients had similar rates of in-hospital mortality (OR = 0.92, [0.63–1.35]), nonhome discharge (OR = 1.09, [0.95–1.24]), and LOS (OR = 1.02, [0.99–1.06]). SLE patients developed AKI at a higher rate (OR = 1.50, [1.05–1.48]) and ALI at a lower rate (OR = 0.35, [0.16–0.74]). Both groups had similar rates of hemodialysis (OR = 1.19, [0.98–1.44]), AMI (OR = 0.93, [0.81–1.06]), and cardiogenic shock (OR = 0.8, [0.61–1.05]). Conclusion. These findings suggest that SLE patients undergoing CABG have similar mortality, discharge disposition, and LOS compared to non-SLE patients. However, SLE patients are at increased risk of AKI and decreased risk of ALI than non-SLE patients. These associations warrant further investigation to elucidate their physiologic basis.","PeriodicalId":15367,"journal":{"name":"Journal of Cardiac Surgery","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2023-12-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138586081","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
B. Provost, Emmanuelle Fournier, Sebastien Hascoët, E. Le Bret, R. Roussin, J. Zoghbi, E. Belli
Objectives. Aortic coarctation in neonates remains a clinical challenge. Low weight, arch hypoplasia and ductal dependence have been identified as risk factors for recurrent coarctation. We hypothesized that a tailored surgical technique may prevent recurrence. Methods. Retrospective evaluation of neonates treated for coarctation through thoracotomy was done. No primary percutaneous procedure was performed and repairs through sternotomy were excluded. Aortic hypoplasia was defined as a ratio arch diameter (mm)/patient’s weight (kg) < 1. Extended end-to-end anastomosis (EEEA), subclavian flap (Waldhausen) and Amato aortoplasty were performed. Mortality and recurrent obstruction requiring re-intervention were assessed. Results. Records of 340 consecutive patients (2003–2019) were analyzed. Preoperative median age and weight were, respectively, 10 days (1–30) and 3080 grams (1400–5180). Arch hypoplasia was documented in 31 patients (9.1%). Prostaglandin was infused in 220 (65.3%). Critical preoperative status was documented in 35 (10.8%). EEEA repair was performed in 273 (80.3%), Waldhausen was performed in 42 (12.4%), and Amato was performed in 25 (7.4%). The last two were more likely to be performed in the presence of arch hypoplasia ( p < 0.0001). Hospital mortality occurred in 2 patients (0.6%). Thirty-six procedures (31 percutaneous/5 surgical) were performed for recurrent arch obstruction in 33 patients. Three late deaths occurred. Low-weight, hypoplastic arch, and ductal dependency did not influence the outcome. All survivors were free from residual coarctation at a mean follow-up of 3.6 ± 3.4 years postoperatively. Conclusions. Surgical repair remains the procedure of choice for neonatal coarctation. A tailored approach using alternative techniques seemed to offer comparable results even in presence of associated risk factors.
{"title":"Aortic Coarctation Associated with Distal Aortic Arch Hypoplasia in Neonates Can Be Effectively Repaired through Left Thoracotomy","authors":"B. Provost, Emmanuelle Fournier, Sebastien Hascoët, E. Le Bret, R. Roussin, J. Zoghbi, E. Belli","doi":"10.1155/2023/5599161","DOIUrl":"https://doi.org/10.1155/2023/5599161","url":null,"abstract":"Objectives. Aortic coarctation in neonates remains a clinical challenge. Low weight, arch hypoplasia and ductal dependence have been identified as risk factors for recurrent coarctation. We hypothesized that a tailored surgical technique may prevent recurrence. Methods. Retrospective evaluation of neonates treated for coarctation through thoracotomy was done. No primary percutaneous procedure was performed and repairs through sternotomy were excluded. Aortic hypoplasia was defined as a ratio arch diameter (mm)/patient’s weight (kg) < 1. Extended end-to-end anastomosis (EEEA), subclavian flap (Waldhausen) and Amato aortoplasty were performed. Mortality and recurrent obstruction requiring re-intervention were assessed. Results. Records of 340 consecutive patients (2003–2019) were analyzed. Preoperative median age and weight were, respectively, 10 days (1–30) and 3080 grams (1400–5180). Arch hypoplasia was documented in 31 patients (9.1%). Prostaglandin was infused in 220 (65.3%). Critical preoperative status was documented in 35 (10.8%). EEEA repair was performed in 273 (80.3%), Waldhausen was performed in 42 (12.4%), and Amato was performed in 25 (7.4%). The last two were more likely to be performed in the presence of arch hypoplasia (\u0000 \u0000 p\u0000 \u0000 < 0.0001). Hospital mortality occurred in 2 patients (0.6%). Thirty-six procedures (31 percutaneous/5 surgical) were performed for recurrent arch obstruction in 33 patients. Three late deaths occurred. Low-weight, hypoplastic arch, and ductal dependency did not influence the outcome. All survivors were free from residual coarctation at a mean follow-up of 3.6 ± 3.4 years postoperatively. Conclusions. Surgical repair remains the procedure of choice for neonatal coarctation. A tailored approach using alternative techniques seemed to offer comparable results even in presence of associated risk factors.","PeriodicalId":15367,"journal":{"name":"Journal of Cardiac Surgery","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2023-12-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138590603","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
V. Bui, Dang Nguyen, Alejandro Pizano, Heath Rutledge-Jukes, Chibuikem S. Iheagwaram, S. Bajaj, D. Van, Nam Hoai Nguyen, T. Theologou, A. Akbar, D. Vervoort, A. Harky, D. H. Nguyen
Purpose. Minimally invasive mitral valve repair (MIMVR) has been demonstrated to be safe and effective, but technical difficulty, outcome variation, and lack of standardized protocols undermine the utility of artificial chordae. This study aims to analyze the midterm outcomes of repair using artificial chordae through right minithoracotomy. Methods. A retrospective cohort study was conducted on consecutive patients who underwent MIMVR using artificial chordae at a single center in Vietnam between April 2016 and April 2022. Valve repairs were separated into two groups based on a previously validated complexity score: simple repair (Group 1) and intermediate-to-complex repair (Group 2). Demographic variables, comorbidities, operative characteristics, surgical outcomes, and follow-up data on survival and mitral regurgitation (MR) grade were analyzed. The learning curve was assessed by comparing the number of procedures with operation time and aorta cross-clamp time. Primary endpoints included survival and freedom from recurrent MR at four years. Results. Ninety patients were identified, including 41 simple and 49 intermediate-to-complex repairs. The mean age was 50.5 ± 12.9 years. Both groups had similar preoperative characteristics. The perioperative and postoperative outcomes were favorable, with no cases requiring mitral valve replacement. The median follow-up time was 30.3 months (18.2–40.4), and there were two (2.2%) cardiac deaths, with one in each group. The Kaplan–Meier survival estimates for Groups 1 and 2 at 12 and 24 months were 97% vs. 100% and 97% vs. 96%, respectively (95% CI = 0.05–12.2, P = 0.850 ), and estimates for freedom from recurrent MR were 97% vs. 92% and 97% vs. 88%, respectively (95% CI = 0.49–12.0, P = 0.260 ). There was a negative association between the volume of operations and the duration of operation and aortic cross-clamp time, leading to shorter durations. Conclusion. Based on our single-center experience, MIMVR using artificial chordae via right mini-thoracotomy can be safely and effectively performed in resource-limited countries for patients with MR. This approach has been shown to be applicable for a range of MR complexities, from simple to intermediate-to-complex MV repairs, and has demonstrated promising results in terms of midterm freedom from MR recurrence.
目的。微创二尖瓣修复(MIMVR)已被证明是安全有效的，但技术上的困难、结果的变化和缺乏标准化的方案削弱了人工二尖瓣的实用性。本研究旨在分析经右小开胸人工索修复术的中期结果。方法。2016年4月至2022年4月在越南的一个中心对使用人工脊索进行MIMVR的连续患者进行了回顾性队列研究。根据先前验证的复杂性评分，将瓣膜修复分为两组:简单修复(组1)和中度至复杂修复(组2)。统计变量、合并症、手术特征、手术结果、生存和二尖瓣反流(MR)等级的随访数据进行分析。通过比较手术次数与手术时间和主动脉交叉夹夹时间来评估学习曲线。主要终点包括4年生存率和无复发MR。结果。确定了90例患者，包括41例简单修复和49例中到复杂修复。平均年龄50.5±12.9岁。两组术前特征相似。围手术期和术后结果良好，没有病例需要二尖瓣置换术。中位随访时间为30.3个月(18.2-40.4个月)，有2例(2.2%)心源性死亡，每组1例。第1组和第2组在12个月和24个月时的Kaplan-Meier生存估计分别为97%对100%和97%对96% (95% CI = 0.05-12.2, P = 0.850)，无复发MR的估计分别为97%对92%和97%对88% (95% CI = 0.49-12.0, P = 0.260)。手术量与手术时间和主动脉交叉夹夹时间呈负相关，导致手术时间缩短。结论。根据我们的单中心经验，在资源有限的国家，通过右小开胸使用人工索的MIMVR可以安全有效地治疗MR患者。这种方法已被证明适用于一系列MR复杂性，从简单到中等到复杂的MV修复，并且在中期免于MR复发方面显示出令人满意的结果。
{"title":"Minimally Invasive Mitral Valve Repair with Artificial Chordae: Insights from a 6-Year Single-Center Study","authors":"V. Bui, Dang Nguyen, Alejandro Pizano, Heath Rutledge-Jukes, Chibuikem S. Iheagwaram, S. Bajaj, D. Van, Nam Hoai Nguyen, T. Theologou, A. Akbar, D. Vervoort, A. Harky, D. H. Nguyen","doi":"10.1155/2023/5510950","DOIUrl":"https://doi.org/10.1155/2023/5510950","url":null,"abstract":"Purpose. Minimally invasive mitral valve repair (MIMVR) has been demonstrated to be safe and effective, but technical difficulty, outcome variation, and lack of standardized protocols undermine the utility of artificial chordae. This study aims to analyze the midterm outcomes of repair using artificial chordae through right minithoracotomy. Methods. A retrospective cohort study was conducted on consecutive patients who underwent MIMVR using artificial chordae at a single center in Vietnam between April 2016 and April 2022. Valve repairs were separated into two groups based on a previously validated complexity score: simple repair (Group 1) and intermediate-to-complex repair (Group 2). Demographic variables, comorbidities, operative characteristics, surgical outcomes, and follow-up data on survival and mitral regurgitation (MR) grade were analyzed. The learning curve was assessed by comparing the number of procedures with operation time and aorta cross-clamp time. Primary endpoints included survival and freedom from recurrent MR at four years. Results. Ninety patients were identified, including 41 simple and 49 intermediate-to-complex repairs. The mean age was 50.5 ± 12.9 years. Both groups had similar preoperative characteristics. The perioperative and postoperative outcomes were favorable, with no cases requiring mitral valve replacement. The median follow-up time was 30.3 months (18.2–40.4), and there were two (2.2%) cardiac deaths, with one in each group. The Kaplan–Meier survival estimates for Groups 1 and 2 at 12 and 24 months were 97% vs. 100% and 97% vs. 96%, respectively (95% CI = 0.05–12.2, \u0000 \u0000 P\u0000 =\u0000 0.850\u0000 \u0000 ), and estimates for freedom from recurrent MR were 97% vs. 92% and 97% vs. 88%, respectively (95% CI = 0.49–12.0, \u0000 \u0000 P\u0000 =\u0000 0.260\u0000 \u0000 ). There was a negative association between the volume of operations and the duration of operation and aortic cross-clamp time, leading to shorter durations. Conclusion. Based on our single-center experience, MIMVR using artificial chordae via right mini-thoracotomy can be safely and effectively performed in resource-limited countries for patients with MR. This approach has been shown to be applicable for a range of MR complexities, from simple to intermediate-to-complex MV repairs, and has demonstrated promising results in terms of midterm freedom from MR recurrence.","PeriodicalId":15367,"journal":{"name":"Journal of Cardiac Surgery","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2023-12-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138595115","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background. Limited randomized controlled studies showed that thoracoscopic surgical left atrial ablation was not superior to catheter ablation (CA) in patients with persistent atrial fibrillation (PerAF). Right atrium might play an important role in triggering and maintaining atrial fibrillation (AF) in patients with PerAF. This study aimed to compare the efficacy of thoracoscopic surgical biatrial ablation versus CA in patients with PerAF. Methods. Patients with PerAF underwent thoracoscopic surgical biatrial ablation or CA were included in this study. Propensity score matching (1 : 2) was applied to select patients in CA group and surgical ablation (SA) group. The primary endpoint was to compare the probability of freedom from atrial tachyarrhythmias between SA and CA. Atrial tachyarrhythmia recurrence was defined as any atrial tachyarrhythmias longer than 30 s documented by 24-hour Holter monitoring after the 3-month blanking period. Results. After propensity score matching, 51 patients in surgical biatrial ablation group and 102 patients in CA group were enrolled (mean left atrial diameter: 45.8 mm). The probability of freedom from atrial tachyarrhythmias on antiarrhythmia drugs was 62.7%, 60.6%, and 60.6% in SA group and 42.0%, 39.6%, and 36.7% in CA group at 12, 24, and 36 months, respectively ( p = 0.011), and off antiarrhythmia drugs were 56.9%, 52.5%, and 52.5% in SA group and 36.0%, 31.4%, and 27.5% in CA group at 12, 24, and 36 months, respectively ( p = 0.007). After adjustment of age, sex, left atrial diameter, and AF duration history, multivariable Cox regression analysis suggested that SA procedure was an independent factor to reduce the risk of atrial tachyarrhythmia recurrence (HR: 0.589, 95% CI 0.370–0.937, p = 0.025). Conclusion. Compared with CA, thoracoscopic surgical biatrial ablation might achieve superior effectiveness for patients with PerAF.
背景。有限的随机对照研究显示，在持续性心房颤动（PerAF）患者中，胸腔镜手术左心房消融并不优于导管消融（CA）。右心房可能在触发和维持持续性心房颤动（PerAF）患者的心房颤动（AF）中扮演重要角色。本研究旨在比较胸腔镜手术双心房消融与 CA 在 PerAF 患者中的疗效。方法。本研究纳入了接受胸腔镜手术双腔消融或 CA 的 PerAF 患者。采用倾向评分匹配法（1:2）选择 CA 组和手术消融（SA）组患者。研究的主要终点是比较 SA 和 CA 两种消融术后患者摆脱房性快速性心律失常的概率。房性快速性心律失常复发的定义是，3个月空白期后，24小时Holter监测记录到的任何超过30秒的房性快速性心律失常。结果经过倾向评分匹配后，51 名患者入选手术双心房消融组，102 名患者入选 CA 组（平均左心房直径：45.8 毫米）。12、24和36个月时，SA组患者服用抗心律失常药物后摆脱房性快速性心律失常的概率分别为62.7%、60.6%和60.6%，CA组患者分别为42.0%、39.6%和36.7%（P = 0.在12、24和36个月时，SA组停用抗心律失常药物的比例分别为56.9%、52.5%和52.5%，CA组分别为36.0%、31.4%和27.5%（P = 0.007）。在对年龄、性别、左心房直径和房颤持续时间史进行调整后，多变量考克斯回归分析表明，SA 手术是降低房性快速性心律失常复发风险的独立因素（HR：0.589，95% CI 0.370-0.937，P = 0.025）。结论与CA相比，胸腔镜外科双心房消融术对PerAF患者可能会取得更好的疗效。
{"title":"Thoracoscopic Surgical Biatrial Ablation vs. Catheter Ablation in Patients with Persistent Atrial Fibrillation","authors":"Chunyu Yu, Haojie Li, Shuo Yuan, Lihui Zheng, Ling-min Wu, Ligang Ding, Yan Yao, Zhe Zheng","doi":"10.1155/2023/9463793","DOIUrl":"https://doi.org/10.1155/2023/9463793","url":null,"abstract":"Background. Limited randomized controlled studies showed that thoracoscopic surgical left atrial ablation was not superior to catheter ablation (CA) in patients with persistent atrial fibrillation (PerAF). Right atrium might play an important role in triggering and maintaining atrial fibrillation (AF) in patients with PerAF. This study aimed to compare the efficacy of thoracoscopic surgical biatrial ablation versus CA in patients with PerAF. Methods. Patients with PerAF underwent thoracoscopic surgical biatrial ablation or CA were included in this study. Propensity score matching (1 : 2) was applied to select patients in CA group and surgical ablation (SA) group. The primary endpoint was to compare the probability of freedom from atrial tachyarrhythmias between SA and CA. Atrial tachyarrhythmia recurrence was defined as any atrial tachyarrhythmias longer than 30 s documented by 24-hour Holter monitoring after the 3-month blanking period. Results. After propensity score matching, 51 patients in surgical biatrial ablation group and 102 patients in CA group were enrolled (mean left atrial diameter: 45.8 mm). The probability of freedom from atrial tachyarrhythmias on antiarrhythmia drugs was 62.7%, 60.6%, and 60.6% in SA group and 42.0%, 39.6%, and 36.7% in CA group at 12, 24, and 36 months, respectively ( p = 0.011), and off antiarrhythmia drugs were 56.9%, 52.5%, and 52.5% in SA group and 36.0%, 31.4%, and 27.5% in CA group at 12, 24, and 36 months, respectively ( p = 0.007). After adjustment of age, sex, left atrial diameter, and AF duration history, multivariable Cox regression analysis suggested that SA procedure was an independent factor to reduce the risk of atrial tachyarrhythmia recurrence (HR: 0.589, 95% CI 0.370–0.937, p = 0.025). Conclusion. Compared with CA, thoracoscopic surgical biatrial ablation might achieve superior effectiveness for patients with PerAF.","PeriodicalId":15367,"journal":{"name":"Journal of Cardiac Surgery","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2023-11-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139269276","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
N. Pandey, Mumun Sinha, M. Verma, S. Ramakrishnan, Sanjeev Kumar, Priya Jagia
Aim. The present study sought to characterize the pulmonary arterial morphology and pulmonary blood supply in patients of tetralogy of Fallot and pulmonary atresia (TOF-PA) on CT angiography. Materials and Methods. We retrospectively reviewed our departmental database to identify patients with TOF-PA evaluated using CT angiography. The images were analysed to detect the presence of main and branch pulmonary arteries and pulmonary arterial confluence, presence of major aortopulmonary collateral arteries (MAPCAs), laterality and relation with pulmonary arterial morphology, and presence of patent arterial duct and associated intra- and extracardiac anomalies. Results. TOF-PA was identified in 177 patients (114 (64.4%) males; median age: 9 months). Pulmonary arteries were confluent in 142/177 (80.2%) patients. According to Somerville classification, type II pulmonary atresia was the most frequent pattern seen in 127/177 (71.8%). Based on McGoon’s ratio, pulmonary arteries were adequate for surgery in 123/177 (69.5%) patients. Patent arterial duct was present in 84/177 (47.5%) patients while MAPCAs were present in 124 (70.1%) patients, of which 72/124 (58.1%) patients had at least 1 essential MAPCA supplying either lung. According to Congenital Heart Surgeons’ Society classification, type B pulmonary arterial anatomy was the most prevalent, seen in 103/177 (57.6%) patients. Conclusion. TOF-PA is associated with marked morphologic variability in the pulmonary arterial arborization to supply the lungs. Cardiac CT angiography can accurately delineate the pulmonary arterial morphology, sources of pulmonary blood supply, and associated cardiovascular anomalies in patients with TOF-PA which aids in planning appropriate surgical management including decisions regarding the need for unifocalization of MAPCAs.
{"title":"Clarifying the Pulmonary Arterial Morphology and Pulmonary Blood Supply in Patients with Tetralogy of Fallot and Pulmonary Atresia on Computed Tomography Angiography","authors":"N. Pandey, Mumun Sinha, M. Verma, S. Ramakrishnan, Sanjeev Kumar, Priya Jagia","doi":"10.1155/2023/5511363","DOIUrl":"https://doi.org/10.1155/2023/5511363","url":null,"abstract":"Aim. The present study sought to characterize the pulmonary arterial morphology and pulmonary blood supply in patients of tetralogy of Fallot and pulmonary atresia (TOF-PA) on CT angiography. Materials and Methods. We retrospectively reviewed our departmental database to identify patients with TOF-PA evaluated using CT angiography. The images were analysed to detect the presence of main and branch pulmonary arteries and pulmonary arterial confluence, presence of major aortopulmonary collateral arteries (MAPCAs), laterality and relation with pulmonary arterial morphology, and presence of patent arterial duct and associated intra- and extracardiac anomalies. Results. TOF-PA was identified in 177 patients (114 (64.4%) males; median age: 9 months). Pulmonary arteries were confluent in 142/177 (80.2%) patients. According to Somerville classification, type II pulmonary atresia was the most frequent pattern seen in 127/177 (71.8%). Based on McGoon’s ratio, pulmonary arteries were adequate for surgery in 123/177 (69.5%) patients. Patent arterial duct was present in 84/177 (47.5%) patients while MAPCAs were present in 124 (70.1%) patients, of which 72/124 (58.1%) patients had at least 1 essential MAPCA supplying either lung. According to Congenital Heart Surgeons’ Society classification, type B pulmonary arterial anatomy was the most prevalent, seen in 103/177 (57.6%) patients. Conclusion. TOF-PA is associated with marked morphologic variability in the pulmonary arterial arborization to supply the lungs. Cardiac CT angiography can accurately delineate the pulmonary arterial morphology, sources of pulmonary blood supply, and associated cardiovascular anomalies in patients with TOF-PA which aids in planning appropriate surgical management including decisions regarding the need for unifocalization of MAPCAs.","PeriodicalId":15367,"journal":{"name":"Journal of Cardiac Surgery","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2023-11-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139275130","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Qi Shi, Jiazhong Tang, Minjie Zhang, Sun Chen, Yurong Wu, Yanan Lu
Objective. The aim of this study is to investigate the predictive value of fetal and neonatal echocardiographic parameters for neonatal coarctation repair in fetuses suspected of coarctation of the aorta (CoA), establish a prediction model for neonatal coarctation repair, and verify its predictive effectiveness and clinical applicability. Methods. From September 2017 to September 2022, fetuses suspected with CoA were enrolled. They were divided into two groups based on the need for neonatal coarctation repair. Fetal and neonatal echocardiographic parameters and clinical characteristics were collected retrospectively. Univariate and multivariate logistic regressions were applied to select significant predictors, which were further used to establish the nomogram prediction model. The area under the curve (AUC) of the receiver operating characteristic (ROC) was employed to quantify its discrimination ability. The calibration curve was drawn for internal verification, and the decision curve analysis (DCA) and clinical impact curve (CIC) were used to evaluate the clinical applicability of the prediction model. Results. This study included 50 infants suspected of CoA prenatally, of which 16 (32%) received aortic coarctation repair in the neonatal period and 34 (68%) did not. Multivariable logistic regression analysis revealed that the fetal echocardiographic parameter aortic isthmus/ductus arteriosus (AoI/DA) diameter ratio and the neonatal echocardiographic parameters such as the distance from left common carotid to left subclavian artery (LCSA) and the diameter of distal transverse aortic arch (DTAA) were independent predictors for neonatal coarctation repair. The ROC curve of the model showed excellent predictive value (AUC = 0.943). The calibration curve of the prediction model exhibited good fitness. The DCA and CIC demonstrated that the model had good clinical utility. Conclusion. The prediction model, which combines the fetal echocardiographic parameter AoI/DA diameter ratio and the neonatal echocardiographic parameters distance of LCSA and DTAA diameter, has an exceptional level of clinical value and prediction accuracy.
{"title":"A Prediction Model for Neonatal Coarctation Repair Involving Fetal and Neonatal Echocardiographic Parameters","authors":"Qi Shi, Jiazhong Tang, Minjie Zhang, Sun Chen, Yurong Wu, Yanan Lu","doi":"10.1155/2023/8831107","DOIUrl":"https://doi.org/10.1155/2023/8831107","url":null,"abstract":"Objective. The aim of this study is to investigate the predictive value of fetal and neonatal echocardiographic parameters for neonatal coarctation repair in fetuses suspected of coarctation of the aorta (CoA), establish a prediction model for neonatal coarctation repair, and verify its predictive effectiveness and clinical applicability. Methods. From September 2017 to September 2022, fetuses suspected with CoA were enrolled. They were divided into two groups based on the need for neonatal coarctation repair. Fetal and neonatal echocardiographic parameters and clinical characteristics were collected retrospectively. Univariate and multivariate logistic regressions were applied to select significant predictors, which were further used to establish the nomogram prediction model. The area under the curve (AUC) of the receiver operating characteristic (ROC) was employed to quantify its discrimination ability. The calibration curve was drawn for internal verification, and the decision curve analysis (DCA) and clinical impact curve (CIC) were used to evaluate the clinical applicability of the prediction model. Results. This study included 50 infants suspected of CoA prenatally, of which 16 (32%) received aortic coarctation repair in the neonatal period and 34 (68%) did not. Multivariable logistic regression analysis revealed that the fetal echocardiographic parameter aortic isthmus/ductus arteriosus (AoI/DA) diameter ratio and the neonatal echocardiographic parameters such as the distance from left common carotid to left subclavian artery (LCSA) and the diameter of distal transverse aortic arch (DTAA) were independent predictors for neonatal coarctation repair. The ROC curve of the model showed excellent predictive value (AUC = 0.943). The calibration curve of the prediction model exhibited good fitness. The DCA and CIC demonstrated that the model had good clinical utility. Conclusion. The prediction model, which combines the fetal echocardiographic parameter AoI/DA diameter ratio and the neonatal echocardiographic parameters distance of LCSA and DTAA diameter, has an exceptional level of clinical value and prediction accuracy.","PeriodicalId":15367,"journal":{"name":"Journal of Cardiac Surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135340500","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Objective. Predicting risk factors for acute kidney injury (AKI) after total arch replacement via modified triple-branched stent graft (MTBSG) implantation in patients with acute type A aortic dissection (AAAD) by conducting a nomogram. Methods. We collected the clinical data of 254 patients with AAAD who underwent MTBSG implantation surgery in our center. The independent risk factors of postoperative AKI were screened by univariate and multivariate logistic regression analysis and combined into a nomogram. We use receiver operating characteristic (ROC) curves, decision curve analysis (DCA), clinical impact curve (CIC), and calibration plots to evaluate the accuracy of the nomogram model. Results. Multiple logistic regression analysis showed that the risk factors of AKI after MTBSG implantation were age, malperfusion syndrome, preoperative serum creatinine, cardiopulmonary bypass time, and amount of red blood cell (RBC) transfusion. Based on these five risk factors, we established a nomogram model. The good accuracy and clinical applicability of the model were verified by drawing ROC curve (area under the curve (AUC) = 0.854), DCA curve, CIC curve, and calibration curve. Conclusions. Using perioperative clinical data to establish a nomogram model of AKI in patients with AAAD who received MTBSG implantation can be used as a tool to predict the occurrence of AKI after operation.
{"title":"Prediction of Postoperative Acute Kidney Injury Risk Factors for Acute Type A Aortic Dissection Patients after Modified Triple-Branched Stent Graft Implantation by a Perioperative Nomogram: A Retrospective Study","authors":"Fan Xu, Linfeng Xie, Jian He, Qingsong Wu, Xinfan Lin, Yunnan Hu, Liangwan Chen","doi":"10.1155/2023/3220929","DOIUrl":"https://doi.org/10.1155/2023/3220929","url":null,"abstract":"Objective. Predicting risk factors for acute kidney injury (AKI) after total arch replacement via modified triple-branched stent graft (MTBSG) implantation in patients with acute type A aortic dissection (AAAD) by conducting a nomogram. Methods. We collected the clinical data of 254 patients with AAAD who underwent MTBSG implantation surgery in our center. The independent risk factors of postoperative AKI were screened by univariate and multivariate logistic regression analysis and combined into a nomogram. We use receiver operating characteristic (ROC) curves, decision curve analysis (DCA), clinical impact curve (CIC), and calibration plots to evaluate the accuracy of the nomogram model. Results. Multiple logistic regression analysis showed that the risk factors of AKI after MTBSG implantation were age, malperfusion syndrome, preoperative serum creatinine, cardiopulmonary bypass time, and amount of red blood cell (RBC) transfusion. Based on these five risk factors, we established a nomogram model. The good accuracy and clinical applicability of the model were verified by drawing ROC curve (area under the curve (AUC) = 0.854), DCA curve, CIC curve, and calibration curve. Conclusions. Using perioperative clinical data to establish a nomogram model of AKI in patients with AAAD who received MTBSG implantation can be used as a tool to predict the occurrence of AKI after operation.","PeriodicalId":15367,"journal":{"name":"Journal of Cardiac Surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135870068","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background. The aim of this study was to clarify the incidence and risk factors for acute kidney injury (AKI) in patients undergoing hemiarch replacement (HAR) under moderate hypothermic circulatory arrest (MHCA) with retrograde cerebral perfusion (RCP). Methods. We retrospectively analyzed patients who underwent HAR under MHCA with RCP at our institution between April 2015 and July 2022. Exclusion criteria were preoperative dialysis, single kidney, and lack of preoperative plasma creatinine data. The study endpoint was the incidence of postoperative AKI, defined using the Kidney Disease: Improving Global Outcomes criteria. Multivariate logistic regression analysis was performed to identify the risk factors for postoperative AKI. Results. One hundred and seventy-nine patients were included in this study. The most common indications for HAR were thoracic aortic aneurysm (n = 107) and acute aortic dissection (n = 57). Concomitant procedures, most frequently aortic valve surgery, were performed in 104 (60.5%) patients. Median circulatory arrest time and minimum rectal temperature were 15 minutes (interquartile range, 11 to 19) and 27.4°C (interquartile range, 25.9 to 28.1), respectively. Operative mortality was 1.1%. The incidence of postoperative AKI was 37.8%. Multivariate analysis showed that acute aortic dissection (odds ratio, 4.57; 95% confidence interval (CI), 2.13–10.14; < 0.001) and longer operating time (odds ratio, 1.01; 95% CI, 1.00-1.01; = 0.001) were independent predictors for postoperative AKI. Conclusions. Acute aortic dissection and longer operating time were risk factors for postoperative AKI in patients undergoing HAR under MHCA with RCP. In contrast, neither circulatory arrest time nor minimum rectal temperature was a risk factor for AKI. This may be due to the short duration of circulatory arrest.
{"title":"Risk Factors for Acute Kidney Injury after Moderate Hypothermic Circulatory Arrest in Hemiarch Replacement","authors":"Kosaku Nishigawa, Takafumi Hirota, Hideaki Hidaka, Tatsuya Horibe, Jun Takaki, Takashi Yoshinaga, Toshihiro Fukui","doi":"10.1155/2023/6685741","DOIUrl":"https://doi.org/10.1155/2023/6685741","url":null,"abstract":"Background. The aim of this study was to clarify the incidence and risk factors for acute kidney injury (AKI) in patients undergoing hemiarch replacement (HAR) under moderate hypothermic circulatory arrest (MHCA) with retrograde cerebral perfusion (RCP). Methods. We retrospectively analyzed patients who underwent HAR under MHCA with RCP at our institution between April 2015 and July 2022. Exclusion criteria were preoperative dialysis, single kidney, and lack of preoperative plasma creatinine data. The study endpoint was the incidence of postoperative AKI, defined using the Kidney Disease: Improving Global Outcomes criteria. Multivariate logistic regression analysis was performed to identify the risk factors for postoperative AKI. Results. One hundred and seventy-nine patients were included in this study. The most common indications for HAR were thoracic aortic aneurysm (n = 107) and acute aortic dissection (n = 57). Concomitant procedures, most frequently aortic valve surgery, were performed in 104 (60.5%) patients. Median circulatory arrest time and minimum rectal temperature were 15 minutes (interquartile range, 11 to 19) and 27.4°C (interquartile range, 25.9 to 28.1), respectively. Operative mortality was 1.1%. The incidence of postoperative AKI was 37.8%. Multivariate analysis showed that acute aortic dissection (odds ratio, 4.57; 95% confidence interval (CI), 2.13–10.14; <math xmlns=\"http://www.w3.org/1998/Math/MathML\" id=\"M1\"> <mi>P</mi> </math> < 0.001) and longer operating time (odds ratio, 1.01; 95% CI, 1.00-1.01; <math xmlns=\"http://www.w3.org/1998/Math/MathML\" id=\"M2\"> <mi>P</mi> </math> = 0.001) were independent predictors for postoperative AKI. Conclusions. Acute aortic dissection and longer operating time were risk factors for postoperative AKI in patients undergoing HAR under MHCA with RCP. In contrast, neither circulatory arrest time nor minimum rectal temperature was a risk factor for AKI. This may be due to the short duration of circulatory arrest.","PeriodicalId":15367,"journal":{"name":"Journal of Cardiac Surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-10-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136317367","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Alexander Schutz, Zvonimir Krajcer, Qianzi Zhang, Scott A. LeMaire, Katherine G. Dougherty, Juan Carlos Plana, Stephanie A. Coulter, Neil E. Strickman, Guilherme V. Silva, James Anton, Joseph S. Coselli, Ourania Preventza
Background. Monitored anesthesia care (MAC) may offer better outcomes than general anesthesia (GA) in transcatheter aortic valve implantation (TAVI). We compared TAVI outcomes between patients who received MAC versus GA. Methods. We retrospectively reviewed data from all patients (N = 659), as well as 216 propensity-matched patients, who underwent TAVI at our institution during 2014–2019. Results. MAC and GA did not differ significantly in mortality (1.6% MAC vs. 4.2% GA, = 0.05) or stroke (2.2% MAC vs. 2.4% GA, = 0.96); however, median length of stay (LOS) was shorter in the MAC group (2 d MAC vs. 7 d GA, < 0.0001). In propensity-matched patients, mortality (2.8% MAC vs. 4.6% GA, = 0.7) and stroke (3.7% MAC vs. 1.9% GA, = 0.7) did not differ significantly between groups. LOS remained shorter in the MAC group (2 d MAC vs. 7 d GA, < 0.0001). Conclusions. In this large, single-center, retrospective study, MAC was associated with shorter hospital stay after TAVI.
背景。在经导管主动脉瓣植入术(TAVI)中，麻醉监护(MAC)可能比全身麻醉(GA)提供更好的结果。我们比较了接受MAC和GA治疗的患者的TAVI结果。方法。我们回顾性回顾了2014-2019年期间在我们机构接受TAVI治疗的所有患者(N = 659)以及216名倾向匹配的患者的数据。结果。MAC组和GA组在死亡率(1.6% MAC vs. 4.2% GA, p = 0.05)或卒中(2.2% MAC vs. 2.4% GA, p = 0.96)方面无显著差异;然而，MAC组的中位住院时间(LOS)更短(MAC 2 d vs. GA 7 d, p <0.0001)。在倾向匹配的患者中，死亡率(2.8% MAC vs. 4.6% GA, p = 0.7)和卒中(3.7% MAC vs. 1.9% GA, p = 0.7)组间无显著差异。MAC组的LOS仍较短(MAC 2 d vs. GA 7 d, p <0.0001)。结论。在这项大型、单中心、回顾性研究中，MAC与TAVI术后住院时间缩短有关。
{"title":"General versus Local Anesthesia with Intravenous Sedation in Transcatheter Aortic Valve Implantation","authors":"Alexander Schutz, Zvonimir Krajcer, Qianzi Zhang, Scott A. LeMaire, Katherine G. Dougherty, Juan Carlos Plana, Stephanie A. Coulter, Neil E. Strickman, Guilherme V. Silva, James Anton, Joseph S. Coselli, Ourania Preventza","doi":"10.1155/2023/1379034","DOIUrl":"https://doi.org/10.1155/2023/1379034","url":null,"abstract":"Background. Monitored anesthesia care (MAC) may offer better outcomes than general anesthesia (GA) in transcatheter aortic valve implantation (TAVI). We compared TAVI outcomes between patients who received MAC versus GA. Methods. We retrospectively reviewed data from all patients (N = 659), as well as 216 propensity-matched patients, who underwent TAVI at our institution during 2014–2019. Results. MAC and GA did not differ significantly in mortality (1.6% MAC vs. 4.2% GA, <math xmlns=\"http://www.w3.org/1998/Math/MathML\" id=\"M1\"> <mi>p</mi> </math> = 0.05) or stroke (2.2% MAC vs. 2.4% GA, <math xmlns=\"http://www.w3.org/1998/Math/MathML\" id=\"M2\"> <mi>p</mi> </math> = 0.96); however, median length of stay (LOS) was shorter in the MAC group (2 d MAC vs. 7 d GA, <math xmlns=\"http://www.w3.org/1998/Math/MathML\" id=\"M3\"> <mi>p</mi> </math> < 0.0001). In propensity-matched patients, mortality (2.8% MAC vs. 4.6% GA, <math xmlns=\"http://www.w3.org/1998/Math/MathML\" id=\"M4\"> <mi>p</mi> </math> = 0.7) and stroke (3.7% MAC vs. 1.9% GA, <math xmlns=\"http://www.w3.org/1998/Math/MathML\" id=\"M5\"> <mi>p</mi> </math> = 0.7) did not differ significantly between groups. LOS remained shorter in the MAC group (2 d MAC vs. 7 d GA, <math xmlns=\"http://www.w3.org/1998/Math/MathML\" id=\"M6\"> <mi>p</mi> </math> < 0.0001). Conclusions. In this large, single-center, retrospective study, MAC was associated with shorter hospital stay after TAVI.","PeriodicalId":15367,"journal":{"name":"Journal of Cardiac Surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-10-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136377127","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Aashray K. Gupta, Hugh S. Paterson, Cheng He, Michael P. Vallely, Jayme S. Bennetts
For over forty years, coronary artery bypass grafting (CABG) has been recommended to patients with triple vessel disease (TVD) with the aim of providing a survival benefit compared to medical therapy. Generally, the survival benefit of CABG is determined by (a) the volume of myocardium at risk of infarction according to the extent of coronary artery disease (CAD), (b) the impairment of coronary flow reserve according to severity of coronary stenoses, severity of symptoms, or objective evidence of regional ischemia, and (c) the impairment of myocardial reserve according to left ventricular function and viability. The most frequently used index of survival benefit is the extent of CAD as described by the terms of the left main coronary stenosis and TVD. However, TVD has been inconsistently defined in randomised controlled trials. Furthermore, international guidelines do not provide a specific definition of TVD. This impacts a substantially sized and high-risk population. Here, we argue that the definition of TVD should include diseases in the major artery in each of the three coronary territories in order to estimate the survival benefit provided by CABG.
{"title":"Triple Vessel Coronary Artery Disease Needs a Consistent Definition for Management Guidelines","authors":"Aashray K. Gupta, Hugh S. Paterson, Cheng He, Michael P. Vallely, Jayme S. Bennetts","doi":"10.1155/2023/6653354","DOIUrl":"https://doi.org/10.1155/2023/6653354","url":null,"abstract":"For over forty years, coronary artery bypass grafting (CABG) has been recommended to patients with triple vessel disease (TVD) with the aim of providing a survival benefit compared to medical therapy. Generally, the survival benefit of CABG is determined by (a) the volume of myocardium at risk of infarction according to the extent of coronary artery disease (CAD), (b) the impairment of coronary flow reserve according to severity of coronary stenoses, severity of symptoms, or objective evidence of regional ischemia, and (c) the impairment of myocardial reserve according to left ventricular function and viability. The most frequently used index of survival benefit is the extent of CAD as described by the terms of the left main coronary stenosis and TVD. However, TVD has been inconsistently defined in randomised controlled trials. Furthermore, international guidelines do not provide a specific definition of TVD. This impacts a substantially sized and high-risk population. Here, we argue that the definition of TVD should include diseases in the major artery in each of the three coronary territories in order to estimate the survival benefit provided by CABG.","PeriodicalId":15367,"journal":{"name":"Journal of Cardiac Surgery","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-10-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136063978","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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