Diving dinosaurs? Caveats on the use of bone compactness and pFDA for inferring lifestyle.

The lifestyle of spinosaurid dinosaurs has been a topic of lively debate ever since the unveiling of important new skeletal parts for Spinosaurus aegyptiacus in 2014 and 2020. Disparate lifestyles for this taxon have been proposed in the literature; some have argued that it was semiaquatic to varying degrees, hunting fish from the margins of water bodies, or perhaps while wading or swimming on the surface; others suggest that it was a fully aquatic underwater pursuit predator. The various proposals are based on equally disparate lines of evidence. A recent study by Fabbri and coworkers sought to resolve this matter by applying the statistical method of phylogenetic flexible discriminant analysis to femur and rib bone diameters and a bone microanatomy metric called global bone compactness. From their statistical analyses of datasets based on a wide range of extant and extinct taxa, they concluded that two spinosaurid dinosaurs (S. aegyptiacus, Baryonyx walkeri) were fully submerged "subaqueous foragers," whereas a third spinosaurid (Suchomimus tenerensis) remained a terrestrial predator. We performed a thorough reexamination of the datasets, analyses, and methodological assumptions on which those conclusions were based, which reveals substantial problems in each of these areas. In the datasets of exemplar taxa, we found unsupported categorization of taxon lifestyle, inconsistent inclusion and exclusion of taxa, and inappropriate choice of taxa and independent variables. We also explored the effects of uncontrolled sources of variation in estimates of bone compactness that arise from biological factors and measurement error. We found that the ability to draw quantitative conclusions is limited when taxa are represented by single data points with potentially large intrinsic variability. The results of our analysis of the statistical method show that it has low accuracy when applied to these datasets and that the data distributions do not meet fundamental assumptions of the method. These findings not only invalidate the conclusions of the particular analysis of Fabbri et al. but also have important implications for future quantitative uses of bone compactness and discriminant analysis in paleontology.

Thrust production and chordal flexion of the flukes of bottlenose dolphins performing tail stands at different efforts.

Dolphins have become famous for their ability to perform a wide variety of athletic and acrobatic behaviors including high-speed swimming, maneuverability, porpoising and tail stands. Tail stands are a behavior where part of the body is held vertically above the water's surface, achieved through thrust produced by horizontal tail fluke oscillations. Strong, efficient propulsors are needed to generate the force required to support the dolphin's body weight, exhibiting chordwise and spanwise flexibility throughout the stroke cycle. To determine how thrust production, fluke flexibility and tail stroke kinematics vary with effort, six adult bottlenose dolphins (Tursiops truncatus) were tested at three different levels based on the position of the center of mass (COM) relative to the water's surface: low (COM below surface), medium (COM at surface) and high (COM above surface) effort. Additionally, fluke flexibility was measured as a flex index (FI=chord length/camber length) at four points in the stroke cycle: center stroke up (CU), extreme top of stroke (ET), center stroke down (CD) and extreme bottom of stroke (EB). Video recordings were analyzed to determine the weight supported above the water (thrust production), peak-to-peak amplitude, stroke frequency and FI. Force production increased with low, medium and high efforts, respectively. Stroke frequency also increased with increased effort. Amplitude remained constant with a mean 33.8% of body length. Significant differences were seen in the FI during the stroke cycle. Changes in FI and stroke frequency allowed for increased force production with effort, and the peak-to-peak amplitude was higher compared with that for horizontal swimming.

Spin-leap performance by cetaceans is influenced by moment of inertia.

Cetaceans are capable of extraordinary locomotor behaviors in both water and air. Whales and dolphins can execute aerial leaps by swimming rapidly to the water surface to achieve an escape velocity. Previous research on spinner dolphins demonstrated the capability of leaping and completing multiple spins around their longitudinal axis with high angular velocities. This prior research suggested the slender body morphology of spinner dolphins together with the shapes and positions of their appendages allowed for rapid spins in the air. To test whether greater moments of inertia reduced spinning performance, videos and biologging data of cetaceans above and below the water surface were obtained. The principal factors affecting the number of aerial spins a cetacean can execute were moment of inertia and use of control surfaces for subsurface corkscrewing. For spinner dolphin, Pacific striped dolphin, bottlenose dolphin, minke whale and humpback whale, each with swim speeds of 6-7 m s-1, our model predicted that the number of aerial spins executable was 7, 2, 2, 0.76 and 1, respectively, which was consistent with observations. These data implied that the rate of subsurface corkscrewing was limited to 14.0, 6.8, 6.2, 2.2 and 0.75 rad s-1 for spinner dolphins, striped dolphins, bottlenose dolphins, minke whales and humpback whales, respectively. In our study, the moment of inertia of the cetaceans spanned a 21,000-fold range. The greater moments of inertia for the last four species produced large torques on control surfaces that limited subsurface corkscrewing motion and aerial maneuvers compared with spinner dolphins.

Patterns of Electrocardiographic Abnormalities in Children with Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HCM), a common cardiomyopathy in children, is an important cause of morbidity and mortality. Early recognition and appropriate management are important. An electrocardiogram (ECG) is often used as a screening tool in children to detect heart disease. The ECG patterns in children with HCM are not well described.ECGs collected from an international cohort of children, and adolescents (≤ 21 years) with HCM were reviewed. 482 ECGs met inclusion criteria. Age ranged from 1 day to 21 years, median 13 years. Of the 482 ECGs, 57 (12%) were normal. The most common abnormalities noted were left ventricular hypertrophy (LVH) in 108/482 (22%) and biventricular hypertrophy (BVH) in 116/482 (24%) Of the patients with LVH/BVH (n = 224), 135 (60%) also had a strain pattern (LVH in 83, BVH in 52). Isolated strain pattern (in the absence of criteria for hypertrophy) was seen in 43/482 (9%). Isolated pathologic Q waves were seen in 71/482 (15%). Pediatric HCM, 88% have an abnormal ECG. The most common ECG abnormalities were LVH or BVH with or without strain. Strain pattern without hypertrophy and a pathologic Q wave were present in a significant proportion (24%) of patients. Thus, a significant number of children with HCM have ECG abnormalities that are not typical for "hypertrophy". The presence of the ECG abnormalities described above in a child should prompt further examination with an echocardiogram to rule out HCM.

Rationale and Design of the Multicenter Catheter Ablation of Ventricular Tachycardia Before Transcatheter Pulmonary Valve Replacement in Repaired Tetralogy of Fallot Study.

Patients with repaired tetralogy of Fallot are at elevated risk for ventricular arrhythmia and sudden cardiac death. Over the past decade, the pathogenesis and natural history of ventricular tachycardia has become increasingly understood, and catheter ablation has emerged as an effective treatment modality. Concurrently, there has been great progress in the development of a versatile array of transcatheter valves that can be placed in the native right ventricular outflow tract for the treatment of long-standing pulmonary regurgitation. Although such valve platforms may eliminate the need for repeat cardiac operations, they may also impede catheter access to the myocardial substrates responsible for sustained macro-reentrant ventricular tachycardia. This manuscript provides the rationale and design of a recently devised multicenter study that will examine the clinical outcomes of a uniform, preemptive strategy to eliminate ventricular tachycardia substrates before transcatheter pulmonary valve implantation in patients with tetralogy of Fallot.

Thrust generation and propulsive efficiency in dolphin-like swimming propulsion.

Given growing interest in emulating dolphin morphology and kinematics to design high-performance underwater vehicles, the current research effort is dedicated to studying the hydrodynamics of dolphin-like oscillatory kinematics in forward propulsion. A computational fluid dynamics method is used. A realistic three-dimentional surface model of a dolphin is made with swimming kinematics reconstructed from video recording. The oscillation of the dolphin is found to enhance the attachment of the boundary layer to the posterior body, which then leads to body drag reduction. The flapping motion of the flukes is found to generate high thrust forces in both the downstroke and the upstroke, during which vortex rings are shed to produce strong thrust jets. The downstroke jets are found to be on average stronger than the upstroke jet, which then leads to net positive lift production. The flexion of the peduncle and flukes is found to be a crucial feature of dolphin-like swimming kinematics. Dolphin-inspired swimming kinematics were created by varying the flexion angle of the peduncle and flukes, which then resulted in significant performance variation. The thrust benefits and propulsive efficiency benefits are associated with a slight decrease and slight increase of the flexion of the peduncle and flukes, respectively.

Multiple behaviors for turning performance of Pacific bluefin tuna (Thunnus orientalis).

Tuna are known for exceptional swimming speeds, which are possible because of their thunniform lift-based propulsion, large muscle mass and rigid fusiform body. A rigid body should restrict maneuverability with regard to turn radius and turn rate. To test if turning maneuvers by the Pacific bluefin tuna (Thunnus orientalis) are constrained by rigidity, captive animals were videorecorded overhead as the animals routinely swam around a large circular tank or during feeding bouts. Turning performance was classified into three different types: (1) glide turns, where the tuna uses the caudal fin as a rudder; (2) powered turns, where the animal uses continuous near symmetrical strokes of the caudal fin through the turn; and (3) ratchet turns, where the overall global turn is completed by a series of small local turns by asymmetrical stokes of the caudal fin. Individual points of the rostrum, peduncle and tip of the caudal fin were tracked and analyzed. Frame-by-frame analysis showed that the ratchet turn had the fastest turn rate for all points with a maximum of 302 deg s-1. During the ratchet turn, the rostrum exhibited a minimum global 0.38 body length turn radius. The local turn radii were only 18.6% of the global ratchet turn. The minimum turn radii ranged from 0.4 to 1.7 body lengths. Compared with the performance of other swimmers, the increased flexion of the peduncle and tail and the mechanics of turning behaviors used by tuna overcomes any constraints to turning performance from the rigidity of the anterior body morphology.

Morphological and histochemical characterization of the pectoral fin muscle of batoids.

Batoids differ from other elasmobranch fishes in that they possess dorsoventrally flattened bodies with enlarged muscled pectoral fins. Most batoids also swim using either of two modes of locomotion: undulation or oscillation of the pectoral fins. In other elasmobranchs (e.g., sharks), the main locomotory muscle is located in the axial myotome; in contrast, the main locomotory muscle in batoids is found in the enlarged pectoral fins. The pectoral fin muscles of sharks have a simple structure, confined to the base of the fin; however, little to no data are available on the more complex musculature within the pectoral fins of batoids. Understanding the types of fibers and their arrangement within the pectoral fins may elucidate how batoid fishes are able to utilize such unique swimming modes. In the present study, histochemical methods including succinate dehydrogenase (SDH) and immunofluoresence were used to determine the different fiber types comprising these muscles in three batoid species: Atlantic stingray (Dasyatis sabina), ocellate river stingray (Potamotrygon motoro) and cownose ray (Rhinoptera bonasus). All three species had muscles comprised of two muscle fiber types (slow-red and fast-white). The undulatory species, D. sabina and P. motoro, had a larger proportion of fast-white muscle fibers compared to the oscillatory species, R. bonasus. The muscle fiber sizes were similar between each species, though generally smaller compared to the axial musculature in other elasmobranch fishes. These results suggest that batoid locomotion can be distinguished using muscle fiber type proportions. Undulatory species are more benthic with fast-white fibers allowing them to contract their muscles quickly, as a possible means of escape from potential predators. Oscillatory species are pelagic and are known to migrate long distances with muscles using slow-red fibers to aid in sustained swimming.

Spinosaurus is not an aquatic dinosaur.

A predominantly fish-eating diet was envisioned for the sail-backed theropod dinosaur Spinosaurus aegyptiacus when its elongate jaws with subconical teeth were unearthed a century ago in Egypt. Recent discovery of the high-spined tail of that skeleton, however, led to a bolder conjecture that S. aegyptiacus was the first fully aquatic dinosaur. The 'aquatic hypothesis' posits that S. aegyptiacus was a slow quadruped on land but a capable pursuit predator in coastal waters, powered by an expanded tail. We test these functional claims with skeletal and flesh models of S. aegyptiacus. We assembled a CT-based skeletal reconstruction based on the fossils, to which we added internal air and muscle to create a posable flesh model. That model shows that on land S. aegyptiacus was bipedal and in deep water was an unstable, slow-surface swimmer (<1 m/s) too buoyant to dive. Living reptiles with similar spine-supported sails over trunk and tail are used for display rather than aquatic propulsion, and nearly all extant secondary swimmers have reduced limbs and fleshy tail flukes. New fossils also show that Spinosaurus ranged far inland. Two stages are clarified in the evolution of Spinosaurus, which is best understood as a semiaquatic bipedal ambush piscivore that frequented the margins of coastal and inland waterways.

Multi-environment robotic transitions through adaptive morphogenesis.

The current proliferation of mobile robots spans ecological monitoring, warehouse management and extreme environment exploration, to an individual consumer's home1-4. This expanding frontier of applications requires robots to transit multiple environments, a substantial challenge that traditional robot design strategies have not effectively addressed5,6. For example, biomimetic design-copying an animal's morphology, propulsion mechanism and gait-constitutes one approach, but it loses the benefits of engineered materials and mechanisms that can be exploited to surpass animal performance7,8. Other approaches add a unique propulsive mechanism for each environment to the same robot body, which can result in energy-inefficient designs9-11. Overall, predominant robot design strategies favour immutable structures and behaviours, resulting in systems incapable of specializing across environments12,13. Here, to achieve specialized multi-environment locomotion through terrestrial, aquatic and the in-between transition zones, we implemented 'adaptive morphogenesis', a design strategy in which adaptive robot morphology and behaviours are realized through unified structural and actuation systems. Taking inspiration from terrestrial and aquatic turtles, we built a robot that fuses traditional rigid components and soft materials to radically augment the shape of its limbs and shift its gaits for multi-environment locomotion. The interplay of gait, limb shape and the environmental medium revealed vital parameters that govern the robot's cost of transport. The results attest that adaptive morphogenesis is a powerful method to enhance the efficiency of mobile robots encountering unstructured, changing environments.

3D visualization processes for recreating and studying organismal form.

The study of biological form is a vital goal of evolutionary biology and functional morphology. We review an emerging set of methods that allow scientists to create and study accurate 3D models of living organisms and animate those models for biomechanical and fluid dynamic analyses. The methods for creating such models include 3D photogrammetry, laser and CT scanning, and 3D software. New multi-camera devices can be used to create accurate 3D models of living animals in the wild and captivity. New websites and virtual reality/augmented reality devices now enable the visualization and sharing of these data. We provide examples of these approaches for animals ranging from large whales to lizards and show applications for several areas: Natural history collections; body condition/scaling, bioinspired robotics, computational fluids dynamics (CFD), machine learning, and education. We provide two datasets to demonstrate the efficacy of CFD and machine learning approaches and conclude with a prospectus.

Fast and Furious: Energetic Tradeoffs and Scaling of High-Speed Foraging in Rorqual Whales.

Although gigantic body size and obligate filter feeding mechanisms have evolved in multiple vertebrate lineages (mammals and fishes), intermittent ram (lunge) filter feeding is unique to a specific family of baleen whales: rorquals. Lunge feeding is a high cost, high benefit feeding mechanism that requires the integration of unsteady locomotion (i.e., accelerations and maneuvers); the impact of scale on the biomechanics and energetics of this foraging mode continues to be the subject of intense study. The goal of our investigation was to use a combination of multi-sensor tags paired with UAS footage to determine the impact of morphometrics such as body size on kinematic lunging parameters such as fluking timing, maximum lunging speed, and deceleration during the engulfment period for a range of species from minke to blue whales. Our results show that, in the case of krill-feeding lunges and regardless of size, animals exhibit a skewed gradient between powered and fully unpowered engulfment, with fluking generally ending at the point of both the maximum lunging speed and mouth opening. In all cases, the small amounts of propulsive thrust generated by the tail were unable to overcome the high drag forces experienced during engulfment. Assuming this thrust to be minimal, we predicted the minimum speed of lunging across scale. To minimize the energetic cost of lunge feeding, hydrodynamic theory predicts slower lunge feeding speeds regardless of body size, with a lower boundary set by the ability of the prey to avoid capture. We used empirical data to test this theory and instead found that maximum foraging speeds remain constant and high (∼4 m s-1) across body size, even as higher speeds result in lower foraging efficiency. Regardless, we found an increasing relationship between body size and this foraging efficiency, estimated as the ratio of energetic gain from prey to energetic cost. This trend held across timescales ranging from a single lunge to a single day and suggests that larger whales are capturing more prey-and more energy-at a lower cost.

Biomechanical energetics of terrestrial locomotion in California sea lions (Zalophus californianus).

Pinnipedia, an order of semi-aquatic marine mammals, adapted a body design that allows for efficient aquatic locomotion but limited terrestrial locomotion. Otariids, like the California sea lion (Zalophus californianus), have enlarged forelimbs and can bring their hindlimbs under the body to locomote quadrupedally on land, but phocids (true seals) have reduced forelimbs and are unable to bring their hindlimbs beneath them during terrestrial locomotion. Because of these differences, phocids are expected to have greater energetic costs when moving on land compared with otariids. The mechanical costs of transport (COT) and power outputs of terrestrial locomotion were first obtained from one male and two female adult California sea lions through video recording locomotion sequences across a level runway. The center of mass, along with six other anatomical points, were digitized to obtain variables such as velocity (V), amplitude of heave (A) and the frequency (f) of oscillations during the locomotion cycle. These variables represent the principal parameters of a biomechanical model that computes the power output of individuals. The three California sea lions in this study averaged a power output of 112.04 W and a COT of 0.63 J kg-1 m-1. This footage was compared against video footage previously recorded of three phocid species (harbor seal, gray seal and northern elephant seal). Power output and mechanical COT were compared for all four pinniped species by tracking the animals' center of mass. The quadrupedal gait of sea lions showed lower vertical displacements of the center of mass, and higher velocities compared with the terrestrial gait of phocids. Northern elephant seals, gray seals and harbor seals showed significantly higher COT and power outputs than the sea lions. California sea lions locomote with lower energetic costs, and thus higher efficiency compared with phocids, proving that they are a mechanically intermediate species on land between terrestrial mammals and phocids. This study provides novel information on the mechanical energy exerted by pinnipeds, particularly California sea lions, to then be used in future research to better understand the limitations of these aquatic mammals.

Slamming dynamics of diving and its implications for diving-related injuries.

In nature, many animals dive into water at high speeds, e.g., humans dive from cliffs, birds plunge, and aquatic animals porpoise and breach. Diving provides opportunities for animals to find prey and escape from predators and is a source of great excitement for humans. However, diving from high platforms can cause severe injuries to a diver. In this study, we demonstrate how similarity in the morphology of diving fronts unifies the slamming force across diving animals and humans. By measuring a time-averaged impulse that increases linearly with the impact height, we are able to estimate the unsteady hydrodynamic forces that an average human body experiences during the slamming phase of a feet-first, hand-first, or head-first dive. We evaluate whether the unsteady forces put the diver at risk of muscle or bone injuries for a particular diving height. Therefore, this study sheds light on a hydrodynamics-based protocol for safe high diving and an evolutionary driver for animal morphology.

Influence of CYP2D6 genetic variation on adverse events with propafenone in the pediatric and young adult population.

Propafenone is an antiarrhythmic drug metabolized primarily by cytochrome P450 2D6 (CYP2D6). In adults, propafenone adverse events (AEs) are associated with CYP2D6 poor metabolizer status; however, pediatric data are lacking. Subjects were tested for 10 CYP2D6 allelic variants and copy number status, and activity scores assigned to each genotype. Seventy-six individuals (median 0.3 [range 0-26] years old) were included. Propafenone AEs occurred in 29 (38%); 14 (18%) required drug discontinuation due to AE. The most common AEs were QRS (n = 10) and QTc (n = 6) prolongation. Those with AEs were older at the time of propafenone initiation (1.58 [0.13-9.92] vs. 0.20 [0.08-2.01] years old; p = 0.042). CYP2D6 activity scores were not associated with presence of an AE (odds ratio [OR] 0.48 [0.22-1.03]; p = 0.055) but with the total number of AE (ß1  = -0.31 [-0.60, -0.03]; p = 0.029), systemic AEs (OR 0.33 [0.13-0.88]; p = 0.022), and drug discontinuation for systemic AEs (OR 0.28 [0.09-0.83]; p = 0.017). Awareness of CYP2D6 activity score and patient age may aid in determining an individual's risk for an AE with propafenone administration.

Bio-Inspired Propulsion: Towards Understanding the Role of Pectoral Fin Kinematics in Manta-like Swimming.

Through computational fluid dynamics (CFD) simulations of a model manta ray body, the hydrodynamic role of manta-like bioinspired flapping is investigated. The manta ray model motion is reconstructed from synchronized high-resolution videos of manta ray swimming. Rotation angles of the model skeletal joints are altered to scale the pitching and bending, resulting in eight models with different pectoral fin pitching and bending ratios. Simulations are performed using an in-house developed immersed boundary method-based numerical solver. Pectoral fin pitching ratio (PR) is found to have significant implications in the thrust and efficiency of the manta model. This occurs due to more optimal vortex formation and shedding caused by the lower pitching ratio. Leading edge vortexes (LEVs) formed on the bottom of the fin, a characteristic of the higher PR cases, produced parasitic low pressure that hinders thrust force. Lowering the PR reduces the influence of this vortex while another LEV that forms on the top surface of the fin strengthens it. A moderately high bending ratio (BR) can slightly reduce power consumption. Finally, by combining a moderately high BR = 0.83 with PR = 0.67, further performance improvements can be made. This enhanced understanding of manta-inspired propulsive mechanics fills a gap in our understanding of the manta-like mobuliform locomotion. This motivates a new generation of manta-inspired robots that can mimic the high speed and efficiency of their biological counterpart.

Scaling of maneuvering performance in baleen whales: larger whales outperform expectations.

Despite their enormous size, whales make their living as voracious predators. To catch their much smaller, more maneuverable prey, they have developed several unique locomotor strategies that require high energetic input, high mechanical power output and a surprising degree of agility. To better understand how body size affects maneuverability at the largest scale, we used bio-logging data, aerial photogrammetry and a high-throughput approach to quantify the maneuvering performance of seven species of free-swimming baleen whale. We found that as body size increases, absolute maneuvering performance decreases: larger whales use lower accelerations and perform slower pitch-changes, rolls and turns than smaller species. We also found that baleen whales exhibit positive allometry of maneuvering performance: relative to their body size, larger whales use higher accelerations, and perform faster pitch-changes, rolls and certain types of turns than smaller species. However, not all maneuvers were impacted by body size in the same way, and we found that larger whales behaviorally adjust for their decreased agility by using turns that they can perform more effectively. The positive allometry of maneuvering performance suggests that large whales have compensated for their increased body size by evolving more effective control surfaces and by preferentially selecting maneuvers that play to their strengths.

Catheter Ablation of Atrial Arrhythmias in Patients Post-Fontan.

Atrial arrhythmias are highly prevalent in the aging Fontan population and contribute importantly to morbidity and mortality. Although the most common arrhythmia is scar-based intra-atrial re-entrant tachycardia, various other arrhythmias may occur, including focal atrial tachycardia, atrioventricular node-dependent tachycardias, and atrial fibrillation. The type and prevalence of atrial arrhythmia is determined, in part, by the underlying congenital defect and variant of Fontan surgery. Although the cumulative incidence of atrial tachyarrhythmias has decreased substantially from the atriopulmonary anastomosis to the more recent total cavopulmonary-connection Fontan, the burden of atrial arrhythmias remains substantial. Management is often multifaceted and can include anticoagulation, anti-arrhythmic drug therapy, pacing, and cardioversion. Catheter ablation plays a key role in control of arrhythmia. Risks and benefits must be carefully weighed. Among the important considerations are the clinical burden of arrhythmia, ventricular function, hemodynamic stability in tachycardia, suspected arrhythmia mechanisms, risks associated with anaesthesia, venous access, approaches to reaching the pulmonary venous atrium, and accompanying comorbidities. Careful review of surgical notes, electrocardiographic tracings, and advanced imaging is paramount, with particular attention to anatomic abnormalities such as venous obstructions and displaced conduction systems. Despite numerous challenges, ablation of atrial arrhythmias is effective in improving clinical status. Nevertheless, onset of new arrhythmias is common during long-term follow-up. Advanced technologies, such as high-density mapping catheters and remote magnetic guided ablation, carry the potential to further improve outcomes. Fontan patients with atrial arrhythmias should be referred to centres with dedicated expertise in congenital heart disease including catheter ablation, anaesthesia support, and advanced imaging.

Impact of obesity on post-operative arrhythmias after congenital heart surgery in children and young adults.

BACKGROUND: Obesity increases the risk of post-operative arrhythmias in adults undergoing cardiac surgery, but little is known regarding the impact of obesity on post-operative arrhythmias after CHD surgery. METHODS: Patients undergoing CHD surgery from 2007 to 2019 were prospectively enrolled in the parent study. Telemetry was assessed daily, with documentation of all arrhythmias. Patients aged 2-20 years were categorised by body mass index percentile for age and sex (underweight <5, normal 5-85, overweight 85-95, and obese >95). Patients aged >20 years were categorised using absolute body mass index. We investigated the impact of body mass index category on arrhythmias using univariate and multivariate analysis. RESULTS: There were 1250 operative cases: 12% underweight, 65% normal weight, 12% overweight, and 11% obese. Post-operative arrhythmias were observed in 38%. Body mass index was significantly higher in those with arrhythmias (18.8 versus 17.8, p = 0.003). There was a linear relationship between body mass index category and incidence of arrhythmias: underweight 33%, normal 38%, overweight 42%, and obese 45% (p = 0.017 for trend). In multivariate analysis, body mass index category was independently associated with post-operative arrhythmias (p = 0.021), with odds ratio 1.64 in obese patients as compared to normal-weight patients (p = 0.036). In addition, aortic cross-clamp time (OR 1.007, p = 0.002) and maximal vasoactive-inotropic score in the first 48 hours (OR 1.03, p = 0.04) were associated with post-operative arrhythmias. CONCLUSION: Body mass index is independently associated with incidence of post-operative arrhythmias in children after CHD surgery.

Epicardial atrial pacing after the extracardiac Fontan operation: Feasibility of an entirely transvenous approach.

This series describes an innovative technique for pacing in patients with sinus node dysfunction after extracardiac Fontan surgery. This transpulmonary approach to the left atrial epi-myocardium has been successfully applied to three patients at two centers and resulted in excellent acute and midterm pacing characteristics without known complications. The principal advantage of this procedure in comparison to prior iterations is the absence of pacing material within the pulmonary venous atrium, so that future systemic thromboembolism risk is minimized. The transpulmonary approach for permanent atrial pacing offers a novel solution to the unique challenges for patients after extracardiac Fontan operation.