Outcome of aortic surgery in patients with Loeys-Dietz syndrome primarily treated as having Marfan syndrome†

OBJECTIVES Loeys-Dietz syndrome (LDS) is characterized by acute aortic dissection (AAD) at aortic diameters below thresholds for intervention in patients with Marfan syndrome (MFS). The aim was to evaluate the outcome of LDS patients primarily treated as having MFS. METHODS We analysed 68 consecutive patients who underwent surgery between 1995 and 2007 under the assumption of having MFS before retrospectively being screened for LDS when genetic testing became available. These patients were followed up until 2013, and underwent a total of 115 aortic surgeries. RESULTS Genetic testing was performed in 76% of the patients. Sixty per cent of these patients were positive for FBN1 mutations associated with MFS, 20% had no FBN1 mutation and 17% harboured TGFBR1/2 mutations associated with LDS. Mean follow-up was 12.7 ± 7 years. All-cause 30-day, 6-month and 1-year mortality rates were 2.9, 4.4 and 7.3%, respectively. Interestingly, initial presentation with AAD did not differ between LDS and MFS (33 vs 37%, P = 0.48) nor did long-term mortality compared with MFS patients (11 vs 16%, P = 1.0) or within MFS subgroups (FBN1 positive 13%, P = 1.0; FBN1 negative 10%, P = 1.0; not tested 25%, P = 0.62). There was no difference in the need for secondary total arch replacement between LDS and MFS patients (11 vs 14%, P = 1.0), nor within MFS subgroups (FBN1 positive 16%, P = 1.0; FBN1 negative 10%, P = 1.0; not tested 13%, P = 1.0). Total aortic replacement became necessary in 22% of LDS compared with 12% of MFS patients (P = 0.6) and did not differ significantly between MFS subgroups. CONCLUSIONS Although early surgical intervention in LDS is warranted to avoid AAD, the current data suggest that once the diseased segment is repaired, there seems to be no additional burden in terms of mortality or reoperation rate compared with that in MFS patients, with or without confirmed FBN1 mutatio

Should aortic arch replacement be performed during initial surgery for aortic root aneurysm in patients with Marfan syndrome?†

OBJECTIVES The aim of this study was to investigate whether total arch replacement (TAR) during initial surgery for root aneurysm should be routinely performed in patients with Marfan syndrome (MFS). METHODS Retrospective analysis of 94 consecutive MFS patients fulfilling Ghent criteria who underwent 148 aortic surgeries and were followed at this institution during the past 16 years. RESULTS The mean follow-up interval was 8.8 ± 7 years. Initial presentation was acute aortic dissection (AAD) in 35% of patients (76% Type A and 24% Type B) and aneurismal disease in 65%. TAR was performed in 8% of patients during initial surgery for AAD (otherwise a hemi-arch replacement was performed) and 1.6% in elective root repair. Secondary TAR had to be performed in only 3% of patients without, but in 33% following AAD (33% Type A and 33% Type B; P = 0.0001). Thirty-day, 6-month, 1-year and overall mortalities were 3.2, 5.3, 6.4 and 11.7%, respectively. Operative and 30-day mortalities in secondary aortic arch replacement were zero. Secondary TAR after AAD did not increase the need for the replacement of the entire thoracoabdominal aorta during follow-up compared with patients without secondary TAR (37 vs 40%, P = 1.0). CONCLUSIONS MFS patients undergoing elective root repair have small risk of reinterventions on the aortic arch, and primary prophylactic replacement does not seem to be justified. In patients with AAD, the need for reinterventions is precipitated by the dissection itself and not by limiting the procedure to the hemi-arch replacement in the emergency setting. Limiting surgery to the aortic root, ascending aorta and proximal aortic arch is associated with low mortality in MFS patients presenting with AA

Correction: (TIMP2) x (IGFBP7) as early renal biomarker for the prediction of acute kidney injury in aortic surgery (TIGER). A single center observational study.

[This corrects the article DOI: 10.1371/journal.pone.0244658.]

Evaluation of a forest parameterization to improve boundary layer flow simulations over complex terrain. A case study using WRF-LES V4.0.1

We evaluate the influence of a forest parametrization on the simulation of the boundary layer flow over moderate complex terrain in the context of the Perdigão 2017 field campaign. The numerical simulations are performed using the Weather Research and Forecasting model in large eddy simulation mode (WRF-LES). The short-term, high-resolution (40 m horizontal grid spacing) and long-term (200 m horizontal grid spacing) WRF-LES are evaluated for an integration time of 12 h and 1.5 months, respectively, with and without forest parameterization. The short-term simulations focus on low-level jet events over the valley, while the long-term simulations cover the whole intensive observation period (IOP) of the field campaign. The results are validated using lidar and meteorological tower observations. The mean diurnal cycle during the IOP shows a significant improvement of the along-valley wind speed and the wind direction when using the forest parametrization. However, the drag imposed by the parametrization results in an underestimation of the cross-valley wind speed, which can be attributed to a poor representation of the land surface characteristics. The evaluation of the high-resolution WRF-LES shows a positive influence of the forest parametrization on the simulated winds in the first 500 m above the surface

Effect of Perioperative Lipid Status on Clinical Outcomes after Cardiac Surgery

Abstract Patients undergoing cardiac surgery are at increased cardiovascular risk, which includes altered lipid status. However, data on the effect of cardiac surgery and cardiopulmonary bypass (CPB) on plasma levels of key lipids are scarce. We investigated potential effects of CPB on plasma lipid levels and associations with early postoperative clinical outcomes. This is a prospective bio-bank study of patients undergoing elective cardiac surgery at our center January to December 2019. The follow-up period was 1 year after surgery. Blood sampling was performed before induction of general anesthesia, upon weaning from cardiopulmonary bypass (CPB), and on the first day after surgery. Clinical end points included the incidence of postoperative stroke, myocardial infarction, and death of any cause at 30 days after surgery as well as 1-year all-cause mortality. A total of 192 cardiac surgery patients (75% male, median age 67.0 years (interquartile range 60.0–73.0), median BMI 26.1 kg/m2 (23.7–30.4)) were included. A significant intraoperative decrease in plasma levels compared with preoperative levels (all p < 0.0001) was observed for total cholesterol (TC) (Cliff’s delta d: 0.75 (0.68–0.82; 95% CI)), LDL-Cholesterol (LDL-C) (d: 0.66 (0.57–0.73)) and HDL-Cholesterol (HDL-C) (d: 0.72 (0.64–0.79)). At 24h after surgery, the plasma levels of LDL-C (d: 0.73 (0.650.79)) and TC (d: 0.77 (0.69–0.82)) continued to decrease compared to preoperative levels, while the plasma levels of HDL-C (d: 0.46 (0.36–0.55)) and TG (d: 0.40 (0.29–0.50)) rebounded, but all remained below the preoperative levels (p < 0.001). Mortality at 30 days was 1.0% (N = 2/192), and 1-year mortality was 3.8% (N = 7/186). Postoperative myocardial infarction occurred in 3.1% of patients (N = 6/192) and postoperative stroke in 5.8% (N = 11/190). Adjusting for age, sex, BMI, and statin therapy, we noted a protective effect of postoperative occurrence of stroke for pre-to-post-operative changes in TC (adjusted odds ratio (OR) 0.29 (0.07–0.90), p = 0.047), in LDL-C (aOR 0.19 (0.03–0.88), p = 0.045), and in HDL-C (aOR 0.01 (0.00–0.78), p = 0.039). No associations were observed between lipid levels and 1-year mortality. In conclusion, cardiac surgery induces a significant sudden drop in levels of key plasma lipids. This effect was pronounced during the operation, and levels remained significantly lowered at 24 h after surgery. The intraoperative drops in LDL-C, TC, and HDL-C were associated with a protective effect against occurrence of postoperative stroke in adjusted models. We demonstrate that the changes in key plasma lipid levels during surgery are strongly correlated, which makes attributing the impact of each lipid to the clinical end points, such as postoperative stroke, a challenging task. Large-scale analyses should investigate additional clinical outcome measures

The Two‐Energies Turbulence Scheme Coupled to the Assumed PDF Method

An update of the two‐energy turbulence scheme is presented, the 2TE + APDF scheme. The original version of the two‐energy scheme is able to successfully model shallow convection without the need of an additional parameterization for non‐local fluxes. However, the performance of the two‐energy scheme is worse in stratocumulus cases, where it tends to overestimate the erosion of the stable layers. We have identified the causes: the non‐local stability parameter does not consider local stratification, the scheme lacks an internal parameter that could distinguish between a shallow convection regime and a stratocumulus regime, and it uses an inflexible turbulence length scale formulation. To alleviate this problem, we propose several modifications: an update of the stability parameter, a modified computation of the turbulence length scale, and the introduction of the entropy potential temperature to distinguish between a shallow convection and a stratocumulus regime. In addition, the two‐energy scheme is coupled to a simplified assumed probability density function method in order to achieve a more universal representation of the cloudy regimes. The updated turbulence scheme is evaluated for several idealized cases and one selected real case in the ICOsahedral Nonhydrostatic (ICON) modeling framework. The results show that the updated scheme corrects the overmixing problem in the stratocumulus cases. The performance of the updated scheme is comparable to the operational setup, and can be thus used instead of the operational turbulence and shallow convection scheme in ICON. Additionally, the updated scheme improves the coupling with dynamics, which is beneficial for the modeling of coherent flow structures in the atmospheric boundary layer.Plain Language Summary: The two‐energy turbulence scheme parametrizes turbulence and boundary layer clouds in a unified framework. This enables the scheme to be more consistent and more continuous in time and space than the classical combination of separate turbulence and convection schemes. The original version of the scheme tends to overestimate the erosion of the stable layers, particularly in stratocumulus cases. We have identified several reasons for this problem and updated the scheme accordingly. To achieve a more universal representation of the cloudy regimes, the two‐energy scheme has been also coupled to the assumed probability density function (PDF) method. This method is based on assuming the shape of the trivariate PDF of moisture, heat and vertical velocity. The new version of the scheme was implemented into the ICOsahedral Nonhydrostatic (ICON) modeling framework and was tested on several idealized cases and one realistic case. The results show that the updated scheme corrects the overmixing problem in the stratocumulus cases. The performance of the updated scheme is comparable to the operational setup, and can be thus used instead of the operational turbulence and shallow convection scheme in ICON. Additionally, the updated scheme improves the coupling with dynamics, which is beneficial for the modeling of coherent flow structures in the atmospheric boundary layer.Key Points: An update of the two‐energy scheme for the unified parameterization of the turbulence and clouds in the atmospheric boundary layer (ABL) is presented. The performance of the updated scheme is comparable to the operational ICOsahedral Nonhydrostatic configuration. The updated scheme shows the ability to model coherent flow structures in the ABL.Hans Ertel Centre for Weather Research of DWDDeutsche Forschungsgemeinschaft (DFG) http://dx.doi.org/10.13039/501100001659https://zenodo.org/record/822842https://doi.org/10.5281/zenodo.640303

The Quasi-Steady State of the Valley Wind System

The quasi-steady-state limit of the diurnal valley wind system is investigated over idealized three-dimensional topography. Although this limit is rarely attained in reality due to ever-changing forcings, the investigation of this limit can provide valuable insight, in particular on the mass and heat fluxes associated with the along-valley wind. We derive a scaling relation for the quasi-steady-state along-valley mass flux as a function of valley geometry, valley size, atmospheric stratification, and surface sensible heat flux forcing. The scaling relation is tested by comparison with the mass flux diagnosed from numerical simulations of the valley wind system. Good agreement is found. The results also provide insight into the relation between surface friction and the strength of the along-valley pressure gradient.ISSN:2296-646