Aortic valve stenosis: Treatments options in elderly high-risk patients

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Minimally invasive aortic valve surgery

Aortic valve disease is a prevalent disorder that affects approximately 2% of the general adult population. Surgical aortic valve replacement is the gold standard treatment for symptomatic patients. This treatment has demonstrably proven to be both safe and effective. Over the last few decades, in an attempt to reduce surgical trauma, different minimally invasive approaches for aortic valve replacement have been developed and are now being increasingly utilized. A narrative review of the literature was carried out to describe the surgical techniques for minimally invasive aortic valve surgery and report the results from different experienced centers. Minimally invasive aortic valve replacement is associated with low perioperative morbidity, mortality and a low conversion rate to full sternotomy. Long-term survival appears to be at least comparable to that reported for conventional full sternotomy. Minimally invasive aortic valve surgery, either with a partial upper sternotomy or a right anterior minithoracotomy provides early- and long-term benefits. Given these benefits, it may be considered the standard of care for isolated aortic valve disease

Thermofluid-dynamic assessment of the EU-DEMO divertor single-circuit cooling option

Until 2019, the thermo-hydraulic development of the EU-DEMO divertor was based on the “double-circuit” concept, in which two independent cooling circuits served by two different Primary Heat Transfer Systems were used to cool the Plasma-Facing Components (PFC) and the Cassette Body (CB). During the Divertor Final Design Review Meeting, held in May 2020, the possibility to adopt a single cooling circuit to serve both components was suggested. This new cooling circuit was originally conceived with the aim of simplifying remote maintenance, with potential benefits for some aspects of safety and balance of plant design and integration. During the years from 2020 to 2022, in the framework of the Work Package DIV 1 - “Divertor Cassette Design and Integration” of the EUROfusion action, University of Palermo and ENEA carried out a research campaign focussed on the preliminary thermofluid-dynamic assessment of this new concept, highlighting its strengths and weaknesses. The research campaign was carried out following a theoretical–computational approach based on the finite volume method and adopting the commercial computational fluid-dynamic code ANSYS-CFX. The steady-state thermal-hydraulic performances of the single-circuit DEMO divertor concept were assessed in terms of coolant pressure drop and flow velocity distribution, mainly in order to check coolant aptitude to provide a uniform and effective cooling to CB, shielding liner, reflector plates, PFCs and the newly introduced neutron shields to improve the shielding of the vacuum vessel. Moreover, the margin against critical heat flux distributions among the plasma-facing channels were assessed by adopting appropriate correlations, to check the compliance with the applicable constraints. Models, loads and boundary conditions assumed for the analyses are herewith reported and critically discussed, together with the main results obtained

Divertor of the European DEMO: Engineering and technologies for power exhaust

In a power plant scale fusion reactor, a huge amount of thermal power produced by the fusion reaction and external heating must be exhausted through the narrow area of the divertor targets. The targets must withstand the intense bombardment of the diverted particles where high heat fluxes are generated and erosion takes place on the surface. A considerable amount of volumetric nuclear heating power must also be exhausted. To cope with such an unprecedented power exhaust challenge, a highly efficient cooling capacity is required. Furthermore, the divertor must fulfill other critical functions such as nuclear shielding and channeling (and compression) of exhaust gas for pumping. Assuring the structural integrity of the neutron-irradiated (thus embrittled) components is a crucial prerequisite for a reliable operation over the lifetime. Safety, maintainability, availability, waste and costs are another points of consideration. In late 2020, the Pre-Conceptual Design activities to develop the divertor of the European demonstration fusion reactor were officially concluded. On this occasion, the baseline design and the key technology options were identified and verified by the project team (EUROfusion Work Package Divertor) based on seven years of R&D efforts and endorsed by Gate Review Panel. In this paper, an overview of the load specifications, brief descriptions of the design and the highlights of the technology R&D work are presented together with the further work still needed

Surgical management of moderate ischemic mitral valve regurgitation: Where do we stand?

Ischemic mitral regurgitation (IMR) represents a common complication after myocardial infarction. The valve is anatomically normal and the incompetence is the result of papillary muscles displacement and annular dilatation, causing leaflets tethering. Functionally the leaflets present a restricted systolic motion due to tethering forces that displaces the coaptation surface toward the left ventricle apex. The patients present poor left ventricular function at the time of surgery and the severity of the mitral regurgitation increases the risk of mortality. Currently there is general agreement to treat surgically severe IMR nevertheless strong evidences for patient with moderate insufficiency remains poor and proper treatment debated. The most effective surgical approach for the treatment of IMR remains debated. Some authors demonstrated that coronary artery bypass graft (CABG) alone is beneficial in patients with IMR. Conversely, in most patients, moderate IMR will persist or worsen after CABG alone which translate in higher long-term mortality as a function of residual mitral regurgitation severity. A probable reason for this unclear surgical management of functional MR is due to the contemporary suboptimal results of reparative techniques. The standard surgical treatment of chronic IMR is CABG associated with undersized annuloplasty using complete ring. Though, the recurrence of mitral regurgitation remains high (> 30%) because of continous left ventricle remodeling. To get better long term results, in the last decade, several subvalvular procedures in adjunct to mitral anuloplasty have been developed. Among them, surgical papillary muscle relocation represents the most appreciated option capable to restore normal left ventricle geometry. In the next future new preoperative predictors of increased mitral regurgitation recurrence are certainly needed to find an individual time period of treatment in each patient with moderate IMR