Minimally Invasive Valve Sparing Aortic Root Replacement in a Patient With Marfan Syndrome

<div>Minimally invasive valve sparing aortic root replacement in a patient with Marfan syndrome is feasible and provides an excellent outcome in a young patient.</div><div><p>Preoperative computed tomography of the chest showed an aortic root dilatation at the sinuses of Valsalva, which measured 5.5 cm. Transesophageal echocardiogram (TEE) demonstrated a trileaflet aortic valve with moderate aortic valve insufficiency. A 6 cm upper partial sternotomy incision extending to the right fourth intercostal space was performed. The aorta was transected 1 cm cephalad from the sinotubular junction. The aortic root was circumferentially mobilized to the level of the aortoventricular junction. The left and right coronary buttons were created and the noncoronary sinus was excised. A circumferential series of 2-0 Ethibond pledgeted annular sutures were placed through the annulus from beneath the aortic valve in a clockwise fashion, beginning at the noncoronary (NC)/left coronary (LC) commissure. These sutures were placed in a horizontal plane formed by the base of the interleaflet triangles between the NC and LC commissures, with exceptions of LC/NC and right coronary/NC areas.</p><p>The precise height of each commissure was measured, transposed onto the graft, and the graft was trimmed in these areas. The subvalvular annular sutures were passed through the aortic graft. The graft was positioned and fastened with an automated suture fastener device. The commissures were secured at the appropriate height within the graft with 4-0 pledgeted polypropylene suture. Subsequently, the circumference of the aortic valve apparatus was secured to the graft with running 4-0 polypropylene sutures. The competency of the aortic valve was reassessed. The left and right coronary anastomoses were performed using button technique. Finally, the distal anastomosis was completed. Postoperative TEE showed excellent hemodynamics, and the patient had an uneventful hospital course.</p><p>Minimally invasive valve sparing root replacement is beneficial in a patient with Marfan syndrome because the procedure eliminates the defective tissue, preserves the aortic valve, decreases trauma to an abnormal sternum, and provides an excellent overall result in a young patient.</p></div

Modeling of interference microscopy beyond the linear regime

© The Authors. Coherence scanning interferometry (CSI), a type of interference microscopy, has found broad applications in the advanced manufacturing industry, providing high-accuracy surface topography measurement. Enhancement of the metrological capability of CSI for complex surfaces, such as those featuring high slopes and spatial frequencies and high aspect-ratio structures, requires advances in modeling of CSI. However, current linear CSI models relying on approximate surface scattering models cannot accurately predict the instrument response for surfaces with complex geometries that cause multiple scattering. A boundary elements method is used as a rigorous scattering model to calculate the scattered field at a distant boundary. Then, the CSI signal is calculated by considering the holographic recording and reconstruction of the scattered field. Through this approach, the optical response of a CSI system can be predicted for almost any arbitrary surface geometry

Surface measuring coherence scanning interferometry beyond the specular reflection limit

The capability of optical surface topography measurement methods for measurement of steep and tilted surfaces is investigated through modelling of a coherence scanning interferometer. Of particular interest is the effect on the interference signal and measured topography when tilting the object at angles larger than the numerical aperture slope limit (i.e. the specular reflection limit) of the instrument. Here we use theoretical modelling to predict the results across a range of tilt angles for a blazed diffraction grating. The theoretically predicted interference patterns and surface height measurements are then verified directly with experimental measurements. Results illustrate the capabilities, limitations and modelling methods for interferometers to measure beyond the specular reflection limit

Determination of the lateral resolution of an interference microscope using a micro-scale sphere

Determination of the lateral resolution of an interference microscope using a micro-scale spher

Minimally Invasive Stage I Elephant Trunk and Aortic Valve Repair

<p><b>Case Presentation </b></p> <p>A 70-year-old woman presented with a symptomatic aortic aneurysm and mild-to-moderate central aortic regurgitation. Preoperative CT-C showed enlargement of her ascending and descending aorta and her aortic arch. Her aortic root was not dilated. Transesophageal echocardiogram demonstrated a trileaflet aortic valve with mild-to-moderate central aortic regurgitation and preserved ejection fraction.<br></p> <p><b>Procedure</b></p> <p>The patient underwent a “J-type” partial upper sternotomy with extension into the right fourth intercostal space. Her right axillary artery was exposed. A 10 mm graft was anastomosed at this site. Long femoral venous cannulation was accomplished via the right common femoral vein utilizing the Seldinger technique and transesophageal guidance.</p><p>Cardiopulmonary bypass was initiated, the aorta was cross-clamped, antegrade Custodial cardioplegia was administered, and a pulmonary artery vent was placed. The proximal aorta was transected and aortic valve repair was accomplished with subcommissural annuloplasty at the left noncoronary commissure. Upon reaching 20^oC, deep hypothermic circulatory arrest was initiated.</p><p>The base of the innominate artery was clamped, and antegrade cerebral perfusion was initiated. The innominate, left carotid, and left subclavian arteries were divided. The aortic arch was divided immediately proximal to the origin of the left subclavian artery. A selective antegrade perfusion catheter was advanced into the left carotid artery. The limbs of a 12 x 8 x 8 mm trifurcation graft were anastomosed to the innominate, left carotid, and left subclavian arteries. Upon completion, the main limb of the trifurcation graft was de-aired and clamped, maintaining antegrade cerebral perfusion.</p><p>A 24 mm graft was invaginated into the proximal descending thoracic aorta. The distal anastomosis was completed. The proximal aspect of the invaginated graft was recovered, and a graft-to-graft anastomosis was performed with the trifurcation graft. Full systemic blood flow was reinstituted. The graft was then anastomosed at the sinotubular junction. The patient was separated from cardiopulmonary bypass. She has subsequently made a full recovery.</p> <p><b>Conclusion</b></p> <p>Minimally invasive techniques can be effectively applied to complex cardiac and aortic procedures. The use of a trifurcation graft in total arch replacement allows for early antegrade cerebral perfusion, and it simplifies the visualization and management of anatomic variants. <br></p

Additional file 1: Figure S1. of The health and wellbeing of Australian farmers: a longitudinal cohort study

Directed Acyclic Graph for Farming and Mental Health Outcomes. Figure S2. Directed Acyclic Graph for Farming and Physical Health Outcomes. Figure S3. Directed Acyclic Graph for Farming and Wellbeing. Figure S4. Directed Acyclic Graphs for Farming and Visits to the Doctor. Figure S5. Directed Acyclic Graph for Farming and Seeking Help from a Mental Health Professional. Table S1. DIRECT effect. Longitudinal analysis over 5 years for Physical health outcomes and GP service use. Farmers v’s Non-Farm workers. Results show Beta values for continous variables and odds ratios for dichotomous variables (95 % Confidence Intervals). Table S2. DIRECT effect. Longitudinal analysis over 5 years for Wellbeing, Mental health outcomes and Visiting a Mental Health Professional. Farmers v’s Non-Farm workers. Results show Beta values for continuous variables and odds ratios for dichotomous variables (95 % Confidence Intervals). (PDF 667 kb

Two-Stage Repair of a DeBakey Type I Aortic Dissection Using the Elephant Trunk Technique

<p>A 65-year-old man, who had a previous type A aortic dissection in 2011, developed a pseudoaneurysm at the proximal and distal aortic anastomoses of this prior ascending aortic repair. At the time of previous aortic repair, he had also undergone a mechanical aortic valve replacement. Echocardiogram demonstrated moderate paravalvular regurgitation of the aortic valve.<br></p><p>He underwent reoperative aortic root and total arch replacement with stage I elephant trunk procedure, which was followed a year later by an open thoracoabdominal aortic replacement (a stage II elephant trunk repair). A composite valve graft comprised of a 25 mm valve and 30 mm graft was created and used to replace the dilated aortic root. During the first stage elephant trunk procedure, the aortic arch was replaced using deep hypothermic circulatory arrest and antegrade cerebral perfusion. The innominate and left carotid arteries were transected 1 cm above their origins and serially anastomosed to the limbs of a trifurcation graft. Selective antegrade perfusion was subsequently instituted via the main limb of the trifurcation graft. The aortic arch was then transected proximal to the origin of the left subclavian artery. The septum was excised for a distance of 20 cm. A 26 mm graft was invaginated into itself, was placed into the proximal descending thoracic aorta, and the distal anastomosis was completed. The main limb of the trifurcation graft was anastomosed to the 26 mm graft in end-to-side fashion, and the 26 mm graft was anastomosed to the composite valve graft. The third limb of the trifurcation graft was anastomosed to the left subclavian artery underneath the clavicle. The patient was weaned from cardiopulmonary bypass. His postoperative course was uneventful. The patient was discharged on the eighth postoperative day.</p><p>During routine follow-up one year later, computed tomography angiogram demonstrated a dilation of the type II thoracoabdominal aortic aneurysm, from 4.6 cm to 5.6 cm. The authors proceeded with the second stage elephant trunk repair. The left common femoral artery and vein were exposed and cannulated for cardiopulmonary bypass. A standard left thoracoabdominal incision was performed. The patient was placed on partial cardiopulmonary bypass. A retroperitoneal plane was developed, and the entire aorta was exposed. Proximal and distal clamps were applied just distal to the left subclavian artery and middescending aorta, respectively. The aorta was opened and all intercostal arteries were ligated. The prior elephant trunk was identified and anastomosed to a 30 mm graft in an end-to-end fashion. The aortic cross-clamp was repositioned from the middescending aorta to below the renal arteries. The abdominal aorta was opened, and distal thoracic arteries were ligated. Selective cold blood perfusion at a rate of 300 cc/min was continuously delivered to the celiac, superior mesenteric, and right and left renal arteries. The main limb of a bifurcation graft was beveled and anastomosed around the celiac, superior mesenteric, and right renal arteries. The second limb of the bifurcation graft was anastomosed to the left renal artery in end-to-end fashion. The distal anastomosis was performed. The main limb of the bifurcation graft was attached to the 30 mm graft in end-to-side fashion. The patient was weaned off partial cardiopulmonary bypass without difficulty. The patient was discharged on postoperative day eight without complications. He continues to progress well in follow-up visits.</p><p>A two-stage repair of a DeBakey type I aortic dissection using the elephant trunk technique is a feasible therapeutic option in a complex high-risk patient.</p

Additional file 1: of Fitness consequences of altered feeding behavior in immune-challenged mosquitoes

Additional details of model development, simplification, parameterization, and analysis. (PDF 374 kb

Additional file 2: of Fitness consequences of altered feeding behavior in immune-challenged mosquitoes

Tables S1-S7. This file contains additional data on feeding treatment complience and details of model outputs. (DOCX 503 kb

Protocol to improve hypertension management in a VA outpatient clinic

This 20-week quality improvement study describes implementation of a hypertension identification and management program with use of a standardized oscillometric blood pressure (BP) measurement protocol, provider education, and audit/feedback of hypertension control in a Veterans Affairs primary care clinic. A total of 692 male Veterans ages 18-85 years with treated hypertension and at least one clinic visit in the previous year were included for analysis. Mean age was 69.7 years (standard deviation 7.6) and race and ethnicity were 42.0% White, 29.1% Black and 3.0% Hispanic. Prior to program implementation, clinic BP was measured using the auscultatory method with a manual syphgmomanometer. Baseline BP measurements demonstrated bias as determined by terminal digit preference for digits 0 and 8 in 29.5% and 25.2% of systolic (SBP) and 31.6% and 21.8% of diastolic BP measurements, respectively (p < 0.001). Post-implementation of the standardized oscillometric BP measurement protocol, digit preference was eliminated. Protocol compliance was 89.1% at 5 weeks and 92.4% at 20 weeks. Overall average SBP was significantly higher in the post-implementation period compared to average SBP in the 12-month pre-implementation period (137.4 [Standard Deviation (SD) 17.4] vs. 126.3 [SD 15.3]; P < 0.001). Uncontrolled hypertension, (BP ≥ 140/90 mmHg), increased from 17.8% at baseline to 41.8% post-implementation while provider therapeutic inertia declined from 84.5% at baseline to 55.8% after 20 weeks. This study shows that terminal digit preference is reduced with implementation of standardized oscillatory BP measurement and a quality improvement program can reduce therapeutic inertia of hypertension treatment