Long-term outcome after neonatal intervention for congenital critical aortic stenosis.

BACKGROUND: This study explored long-term outcome and functional status of patients born with critical aortic stenosis (CAS) following neonatal surgical or catheter interventions. METHODS: A 40-year retrospective review of all consecutive patients within a large, single-center referral unit who required neonatal (<30 days) intervention for CAS. Additional detailed evaluation of surviving patients >7 years age was performed, with clinical assessment, objective cardiopulmonary exercise testing and state-of-the-art characterization of myocardial function (advanced echocardiography and cardiac MRI). RESULTS: Between 1970 and 2010, ninety-six neonates underwent CAS intervention (mean age 9 ± 7.5 days). Early death occurred in 19 (19.8%) and late death in 10 patients. Overall survival at 10 and 30 years was 70.1% and 68.5%, freedom from reintervention was 41.8% and 32.9% respectively. Among the 25 long-term survivors available for detailed assessment (median age 15.7 ± 6.4 years), 55% exhibited impaired peak oxygen uptake. Mean left ventricle (LV) ejection fraction was 65 ± 11.2%, with a mean LV end-diastolic volume z-score of 0.02 ± 1.4. Mean LV outflow tract Vmax was 2.3 ± 1.02 m/s. CAS patients had reduced LV longitudinal and increased radial strain (p = 0.003, p < 0.001 respectively). Five patients had severe LV diastolic dysfunction associated with endocardial fibroelastosis (EFE) (p = 0.0014). CONCLUSION: Despite high early mortality rate, long-term survival of patients with CAS is reasonable at the expense of high reintervention rate. With successful intervention, there remained long-term clinical and subclinical LV myocardial impairment, of which EFE was one marker. Long-term follow-up of all CAS patients is crucial, involving detailed myocardial functional assessment to help elucidate physiology and optimise management.

Uncharged mono- and bisoximes: In search of a zwitterion to countermeasure organophosphorus intoxication.

The current study imposes a new class of organophosphorus (OP)-inhibited cholinesterase reactivators by conceptualizing a family of asymmetric bisoximes with various reactivating scaffolds. Several novel nucleophilic warheads were investigated, putting forward 29 novel reactivating options, by evaluating their nucleophilicity and ability to directly decompose OP compounds. Adopting the so-called zwitterionic strategy, 17 mono-oxime and nine bisoxime reactivators were discovered with major emphasis on the bifunctional-moiety approach. Compounds were compared with clinically used standards and other known experimentally highlighted reactivators. Our results clearly favor the concept of asymmetric bisoximes as leading reactivators in terms of efficacy and versatility. These top-ranked compounds were characterized in detail by reactivation kinetics parameters and evaluated for potential CNS availability. The highlighted molecules 55, 57, and 58 with various reactivating warheads, surpassed the reactivating potency of pralidoxime and several notable uncharged reactivators. The versatility of lead drug candidate 55 was also inspected on OP-inhibited butyrylcholinesterase, revealing a much higher rate compared to existing clinical antidotes.

Organisation of paediatric echocardiography laboratories and governance of echocardiography services and training in Europe: current status, disparities, and potential solutions. A survey from the Association for European Paediatric and Congenital Cardiology (AEPC) imaging working group.

BACKGROUND: There is limited data on the organisation of paediatric echocardiography laboratories in Europe. METHODS: A structured and approved questionnaire was circulated across all 95 Association for European Paediatric and Congenital Cardiology affiliated centres. The aims were to evaluate: (1) facilities in paediatric echocardiography laboratories across Europe, (2) accredited laboratories, (3) medical/paramedical staff employed, (4) time for echocardiographic studies and reporting, and (5) training, teaching, quality improvement, and research programs. RESULTS: Respondents from forty-three centres (45%) in 22 countries completed the survey. Thirty-six centres (84%) have a dedicated paediatric echocardiography laboratory, only five (12%) of which reported they were European Association of Cardiovascular Imaging accredited. The median number of echocardiography rooms was three (range 1-12), and echocardiography machines was four (range 1-12). Only half of all the centres have dedicated imaging physiologists and/or nursing staff, while the majority (79%) have specialist imaging cardiologist(s). The median (range) duration of time for a new examination was 45 (20-60) minutes, and for repeat examination was 20 (5-30) minutes. More than half of respondents (58%) have dedicated time for reporting. An organised training program was present in most centres (78%), 44% undertake quality assurance, and 79% perform research. Guidelines for performing echocardiography were available in 32 centres (74%). CONCLUSION: Facilities, staffing levels, study times, standards in teaching/training, and quality assurance vary widely across paediatric echocardiography laboratories in Europe. Greater support and investment to facilitate improvements in staffing levels, equipment, and governance would potentially improve European paediatric echocardiography laboratories.

Sustainable ionic liquids-based molecular platforms for designing acetylcholinesterase reactivators.

We report a green chemistry approach for preparation of oxime-functionalized ILs as AChE reactivators: amide/ester linked IL, l-alanine, and l-phenylalanine derived salts bearing pyridinium aldoxime moiety. The reactivation capacities of the novel oximes were evaluated towards AChE inhibited by typical toxic organophosphates, sarin (GB), VX, and paraoxon (PON). The studied compounds are mostly non-toxic up to the highest concentrations screened (2 mM) towards Gram-negative and Gram-positive bacteria cell lines and both filamentous fungi and yeasts in the in vitro screening experiments as well as towards the eukaryotic cell (CHO-K1 cell line). Introduction of the oxime moiety in initially biodegradable structure decreases its ability to biodegradation. The compound 3d was shown to reveal remarkable activity against the AChE inhibited by VX, exceeding conventional reactivators 2-PAM and obidoxime. The regularities on antidotal activity, cell viability, plasma stability, biodegradability as well as molecular docking study of the newly synthesized oximes will be used for further improvement of their structures.

Clinical Efficacy of Hyaluronic Acid with Iodine in Hard-to-Heal Wounds.

Hard-to-heal wounds do not heal spontaneously and need long-term care provided by specialists. That burdens the patients as well as the healthcare systems. Such wounds arise from several pathologies, which result in venous leg ulcers (VLU), diabetic foot ulcers (DFU), pressure ulcers (PU), or ulcers originating from post-surgical wounds (pSW). Given the complex nature of hard-to-heal wounds, novel treatments are sought to enable wound healing. We tested the clinical efficacy and applicability of fluid comprising hyaluronic acid and iodine complex (HA-I) in the treatment of hard-to-heal wounds. Patients (n = 56) with VLU, DFU, PU, or pSW hospitalised in multiple wound-care centres in the Czech Republic were treated with HA-I. Wound size, classically visible signs of infection, exudation, pain, and wound bed appearance were monitored for 12 weeks. The highest healing rate was in DFU (71.4%), followed by pSW (62.5%), VLU (55.6%), and PU (44.4%). Classical visible signs of infection were resolved within 8 weeks in all types of wounds. Wound bed appearance improved most noticeably in pSW and then in VLU. Exudation was lowered most significantly in DFU and pSW. The highest decrease in pain was in pSW and DFU. The treatment with HA-I successfully led to either complete closure or significant improvement in the wound's healing. Therefore, the complex of hyaluronic acid and iodine is suitable for the treatment of hard-to-heal wounds of various aetiologies.

Pregnancy Termination and Postnatal Major Congenital Heart Defect Prevalence After Introduction of Prenatal Cardiac Screening.

Importance: Prenatal cardiac screening of the first and second trimesters has had a major impact on postnatal prevalence of congenital heart defects (CHDs), rates of termination of pregnancy (TOP), and outcomes among children born alive with CHDs. Objective: To examine the prenatal and postnatal incidence of major CHDs (ie, necessitating intervention within the first year of life), detection rate trends, rates of TOP, and the association of cardiac screening with postnatal outcomes. Design, Settings, and Participants: In this cross-sectional study, 3827 fetuses with antenatally diagnosed major CHDs in the Czech Republic (population 10.7 million) between 1991 and 2021 were prospectively evaluated with known outcomes and associated comorbidities. Prenatal and postnatal prevalence of CHD in an unselected population was assessed by comparison with a retrospective analysis of all children born alive with major CHDs in the same period (5454 children), using national data registry. Data analysis was conducted from January 1991 to December 2021. Main Outcomes and Measures: Prenatal detection and postnatal prevalence of major CHDs and rate of TOPs in a setting with a centralized health care system over 31 years. Results: A total of 3 300 068 children were born alive during the study period. Major CHD was diagnosed in 3827 fetuses, of whom 1646 (43.0%) were born, 2069 (54.1%) resulted in TOP, and 112 (2.9%) died prenatally. The prenatal detection rate increased from 6.2% in 1991 to 82.8% in 2021 (P < .001). Termination of pregnancy decreased from 70% in 1991 to 43% (P < .001) in 2021. Of 627 fetuses diagnosed in the first trimester (introduced in 2007), 460 were terminated (73.3%). Since 2007, of 2066 fetuses diagnosed in the second trimester, 880 (42.6%) were terminated, resulting in an odds ratio of 3.6 (95% CI, 2.8-4.6; P < .001) for TOP in the first trimester compared with the second trimester. Postnatal prevalence of major CHDs declined from 0.21% to 0.14% (P < .001). The total incidence (combining prenatal detection of terminated fetuses with postnatal prevalence) of major CHD remained at 0.23% during the study period. Conclusions and Relevance: In this cross-sectional study, the total incidence of major CHD did not change significantly during the 31-year study period. The prenatal detection of major CHD approached 83% in the current era. Postnatal prevalence of major CHD decreased significantly due to early TOPs and intrauterine deaths. The introduction of first trimester screening resulted in a higher termination rate in the first trimester but did not revert the overall decreasing trend of termination for CHDs in general.

2,6-Disubstituted 7-(naphthalen-2-ylmethyl)-7H-purines as a new class of potent antitubercular agents inhibiting DprE1.

Phenotypic screening of an in-house library of small molecule purine derivatives against Mycobacterium tuberculosis (Mtb) led to the identification of 2-morpholino-7-(naphthalen-2-ylmethyl)-1,7-dihydro-6H-purin-6-one 10 as a potent antimycobacterial agent with MIC99 of 4 µM. Thorough structure-activity relationship studies revealed the importance of 7-(naphthalen-2-ylmethyl) substitution for antimycobacterial activity, yet opened the possibility of structural modifications at positions 2 and 6 of the purine core. As the result, optimized analogues with 6-amino or ethylamino substitution 56 and 64, respectively, were developed. These compounds showed strong in vitro antimycobacterial activity with MIC of 1 µM against Mtb H37Rv and against several clinically isolated drug-resistant strains, had limited toxicity to mammalian cell lines, medium clearance with respect to phase I metabolic deactivation (27 and 16.8 µL/min/mg), sufficient aqueous solubility (>90 µM) and high plasma stability. Interestingly, investigated purines, including compounds 56 and 64, lacked activity against a panel of Gram-negative and Gram-positive bacterial strains, indicating a specific mycobacterial molecular target. To investigate the mechanism of action, Mtb mutants resistant to hit compound 10 were isolated and their genomes were sequenced. Mutations were found in dprE1 (Rv3790), which encodes decaprenylphosphoryl-ß-d-ribose oxidase DprE1, enzyme essential for the biosynthesis of arabinose, a vital component of the mycobacterial cell wall. Inhibition of DprE1 by 2,6-disubstituted 7-(naphthalen-2-ylmethyl)-7H-purines was proved using radiolabelling experiments in Mtb H37Rv in vitro. Finally, structure-binding relationships between selected purines and DprE1 using molecular modeling studies in tandem with molecular dynamic simulations revealed the key structural features for effective drug-target interaction.

Prognostic Value of Transthoracic Echocardiography in Children With Pulmonary Arterial Hypertension.

Background Transthoracic echocardiography is part of the regular follow-up protocol at most pediatric pulmonary arterial hypertension (PAH) centers. We aimed to develop a comprehensive and simple echocardiographic risk stratification for children with PAH. Methods and Results We included 63 children with PAH and a biventricular cardiac anatomy without relevant shunt lesions (60% female patients; mean age, 9.0 years; 42 idiopathic PAH and 21 associated PAH) undergoing a standardized transthoracic echocardiographic assessment. The prognostic value of echocardiographic parameters was assessed using Cox proportional hazards survival analysis and recursive partitioning for classification tree methods. Over a median follow-up period of 4.0 years, 17 patients died and 4 underwent lung transplantation. Various echocardiographic parameters were associated with the combined endpoint of death and transplantation on univariate analysis. On further analysis, right atrial area (z score) and left ventricular diastolic eccentricity index (LVEId) emerged as robust and independent predictors of transplant-free survival. Considering mortality alone as an end point, a combination of right atrial area, left ventricular diastolic eccentricity index, and tricuspid annular plane systolic excursion were identified as independent predictors of outcome. Based on these parameters, we propose simple risk scores that can be applied at the bedside without computer assistance. CONCLUSIONS Echocardiographic parameters predict prognosis in children with pulmonary hypertension. A combination of widely available parameters including right atrial area, left ventricular eccentricity index, and tricuspid annular plane systolic excursion emerged as risk stratifiers that await external validation but may assist clinicians determining the prognosis of children with PAH.

Evaluation of Chemical Elements, Lipid Profiles, Nutritional Indices and Health Risk Assessment of European Eel (Anguilla anguilla L.).

The concentrations of ten elements (K, Na, Ca, Mg, Zn, Fe, Hg, Cu, Mn, and Cd) and fatty acids were analyzed in muscles of the European eel (Anguilla anguilla Linnaeus, 1758). The eels were caught in freshwater lakes connected with the Sawica River (north-eastern Poland). On this basis, it was determined whether the consumption of the fish is beneficial and safe for the health of the consumer. The results showed that the metal concentrations followed this order: K > Na > Ca > Mg > Zn > Fe > Hg > Cu > Mn > Cd. The fatty acids gave rise to the following sequence: MUFAs > SFAs > n-3 PUFAs > n-6 PUFAs. The target hazard quotient (THQ) value was below 1.0. The hazard quotient for the benefit-risk ratio HQEFA (0.39) also was below one, indicating that the intake of the recommended dose of EPA + DHA (250 mg/day) and the intake of mercury (0.415 mg/kg) for a person weighing 70 kg does not pose an obvious risk for human health. The lipid quality indices were OFA: 24.69, DFA: 74.36, AI: 0.55, and TI: 0.41. Based on the above statements, the consumption of eel meat is safe from a health point of view. However, the levels of toxic metals in the muscles of eels and their environment should continue to be monitored, as eels occupy a high position in the food chain.

Total Mercury and Fatty Acids in Selected Fish Species on the Polish Market: A Risk to Human Health.

The muscles of lake trout (Salvelinus namaycush Walbaum, 1792), crucian carp (Carassius carassius Linnaeus, 1758), flounder (Platichthys flesus Linnaeus, 1758), gilthead seabream (Sparus aurata Linnaeus, 1758), mackerel (Scomber scombrus Linnaeus, 1758) and tench (Tinca tinca Linnaeus, 1758) were examined. The total mercury (THg) was processed using the Milestone DMA-80 and the fatty acids were analyzed using the 7890A Agilent Technologies chromatograph. The THg content in analyzed fish ranged from 0.024 (lake trout) to 0.092 mg/kg wet weight (gilthead seabream). The muscles of fish examined had lower amounts of SFAs, and n-3 and n-6 PUFAs than MUFAs. The ratio of n-3/n-6 was higher in muscles of mackerel than other fish (p < 0.05). Due to the fact that both the THQ and HI are below 1, the tested fish are safe for the consumer from a nutritional point of view. Similarly, fatty acid indices indicate the safe consumption of selected fish species, and the daily consumption of the recommended dose of EPA + DHA (250 mg/day) and the concentration of mercury in fish calculations showed a hazard quotient for the benefit−risk ratio HQEFA below 1, suggesting that the intake of EPA + DHA poses no evident risk to human health. The ratio was calculated for a person weighing 60 kg. Therefore, it is important to monitor the fish, not only bought in the store, but also caught in various aquatic environments.

Assessment of Streptococcus mutans biofilm formation on calcium phosphate ceramics: The role of crystalline composition and microstructure.

Streptococcus mutans is one of the bacteria that initiates the colonization of the pellicle at the tooth surface. It forms a plaque, together with other bacteria, which gradually dissolves the pellicle and leaves the tooth surface unprotected against the acidic oral environment. Calcium phosphate ceramics are excellent synthetic materials for the study of biofilm formation in dentistry because they are comparable to teeth in chemical composition and structure. Calcium phosphates can be processed to achieve a variety of crystalline compounds with biologically relevant ionic substitutions and structures that allow study of the effect of the surface chemistry and the topography independently. In this article, we describe the preparation and characterization of three types of calcium phosphate-based materials as a suitable surface for the formation of the S. mutans biofilm: beta-tricalcium phosphate (ß-TCP); sintered hydroxyapatite (SHA); and calcium-deficient hydroxyapatite (CDHA). The densest biofilms were formed on the surfaces of SHA and CDHA, with no significant differences due to the stoichiometry or microstructure. In contrast, ß-TCP showed a lower susceptibility to S. mutans biofilm formation, suggesting that the crystalline structure is the controlling parameter. Subsequently, SHA was selected to develop a dental biofilm model that allowed study of S. mutans biofilm susceptibility to chlorhexidine and ethanol.

Assessment of Fish Quality Based on the Content of Heavy Metals.

The aim of this study was to estimate the fish quality in terms of the Cu, Fe, Mn and Zn contents. The research material was the muscle tissue of the fish crucian carp (Carassius carassius Linnaeus, 1758), flounder (Platichthys flesus Linnaeus, 1758), Gilthead seabream (Sparus aurata Linnaeus, 1758), mackerel (Scomber scombrus Linnaeus, 1758), Blue grenadier (Macruronus novaezelandiae Hector, 1871), rainbow trout (Oncorhynchus mykiss Walbaum, 1792), tench (Tinca tinca Linnaeus, 1758), tilapia (Oreochromis niloticus Linnaeus, 1758), Walleye pollock (Gadus chalcogrammus Pallas, 1814) and perch (Perca fluviatilis Linnaeus, 1758.). Heavy metals were determined with the atomic absorption spectrometry method (AAS). Significantly high concentrations of zinc (19.52 mg/kg wet weight), copper (0.77 mg/kg) and iron (6.95 mg/kg) were found in the muscles of crucian carp (p < 0.05) compared to the other fish studied, whereas Walleye pollock had a higher content of manganese (0.266 mg/kg) (p < 0.05). All studied fish species do not pose a threat to humans from these four metals. This was indicated by quality indexes (THQ and HI) whose values were below one. The values of these metals also did not exceed the maximum allowable concentrations established by the FAO (1983), but monitoring both the aquatic environment and the fish living there is necessary, for example, for the time-changing abiotic and biotic factors that can cause an increase in metals in the organs of fish.

Controlled Transdermal Iontophoresis of Insulin from Water-Soluble Polypyrrole Nanoparticles: An In Vitro Study.

The iontophoresis delivery of insulin (INS) remains a serious challenge due to the low permeability of the drug through the skin. This work aims to investigate the potential of water-soluble polypyrrole nanoparticles (WS-PPyNPs) as a drug donor matrix for controlled transdermal iontophoresis of INS. WS-PPyNPs have been prepared via a simple chemical polymerization in the presence of sodium dodecyl sulfate (SDS) as both dopant and the stabilizing agent. The synthesis of the soluble polymer was characterized using field emission scanning electron microscopy (FESEM), dynamic light scattering (DLS), fluorescence spectroscopy, and Fourier transform infrared (FT-IR) spectroscopy. The loading mechanism of INS onto the WS-PPyNPs is based on the fact that the drug molecules can be replaced with doped dodecyl sulfate. A two-compartment Franz-type diffusion cell was employed to study the effect of current density, formulation pH, INS concentration, and sodium chloride concentration on anodal iontophoresis (AIP) and cathodal iontophoresis (CIP) of INS across the rat skin. Both AIP and CIP delivery of INS using WS-PPyNPs were significantly increased compared to passive delivery. Furthermore, while the AIP experiment (60 min at 0.13 mA cm-2) show low cumulative drug permeation for INS (about 20.48 µg cm-2); the CIP stimulation exhibited a cumulative drug permeation of 68.29 µg cm-2. This improvement is due to the separation of positively charged WS-PPyNPs and negatively charged INS that has occurred in the presence of cathodal stimulation. The obtained results confirm the potential applicability of WS-PPyNPs as an effective approach in the development of controlled transdermal iontophoresis of INS.

Sandwich Structures Reflecting Thermal Radiation Produced by the Human Body.

Far infrared (FIR) textiles are a new category of functional textiles that have presumptive health and well-being functionality and are closely related to human thermo-physiological comfort. FIR exerts strong rotational and vibrational effects at the molecular level, with the potential to be biologically beneficial. In general, after absorbing either sunlight or heat from the human body, FIR textiles are designed to transform the energy into FIR radiation with a wavelength of 4-14 µm and pass it back to the human body. FIR textiles can meet increased demand for light, warm, comfortable, and healthy clothing. The main aim of this research is to describe the procedure for creating the FIR reflective textile layer as part of multilayer textile structures that have enhanced thermal protection. To develop the active FIR reflecting surface, the deposition of copper nanolayer on lightweight polyester nonwoven structure Milife, which has beneficial properties of low fiber diameters, good shape stability and comfort, was used. This FIR reflective layer was used as an active component of sandwiches composed of the outer layer, insulation layer, active layer, and inner layer. The suitable types of individual layers were based on their morphology, air permeability, spectral characteristics in the infra-red region, and thermal properties. Reflectivity, transmittance, and emissivity were evaluated from IR measurements. Human skin thermal behavior and the prediction of radiation from the human body dependent on ambient conditions and metabolic rate are also mentioned. The FIR reflective textile layer created, as part of multilayer textile structures, was observed to have enhanced thermal protection.

Genotoxicity of physical silver nanoparticles, produced by the HVAD method, for Chinchilla lanigera genome.

Each year, growing demand for silver nanoparticles (AgNP) contributes to the search for alternative methods of their production. Stable AgNP with antibacterial properties, low toxicity to the environment and living organisms are especially valued. In the study presented here, an attempt was made to assess the toxicity of two AgNP solutions produced using the HVAD method to the Chinchilla lanigera genome. The AgNO3 solution was the indicator and reference for the harmfulness of AgNP. The study was carried out in vitro on bone marrow cells isolated from Chinchilla lanigera bones. The genotoxicity was assessed by comet assay, following the treatment of cells with three silver solutions: unstable and sodium citrate-stabilized silver nanoparticles, as well as silver nitrate at three concentrations (5, 10 and 20 µg/L), after 3, 6 and 24 h. Based on the percentage of the DNA content in the comet tail and the tail moment, an increase in cell DNA integrity disruption was demonstrated in all tested variants: of solution, exposure time and concentration, compared to the control sample. A statistically significant correlation was determined between the level of induced DNA breaks and the concentration of the active solutions and the duration of their activity. A solution of silver nanoparticles stabilized with sodium citrate was shown to have the most harmful effect on bone marrow cells. Silver nitrate demonstrated a level of toxicity similar to these particles. Further studies are necessary to directly compare the genotoxic properties of AgNP produced using the HVAD method and the chemical method under the same conditions.

Synthesis and Decontamination Effect on Chemical and Biological Agents of Benzoxonium-Like Salts.

Benzoxonium chloride belongs to the group of quaternary ammonium salts, which have been widely used for decades as disinfectants because of their high efficacy, low toxicity, and thermal stability. In this study, we have prepared the C10-C18 set of benzoxonium-like salts to evaluate the effect of their chemical and biological decontamination capabilities. In particular, biocidal activity against a panel of bacterial strains including Staphylococcus aureus in biofilm form was screened. In addition, the most promising compounds were successfully tested against Francisella tularensis as a representative of potential biological warfare agents. From a point of view of chemical warfare protection, the efficiency of BOC-like compounds to degrade the organophosphate simulant fenitrothion was examined. Notwithstanding that no single compound with universal effectiveness was identified, a mixture of only two compounds from this group would be able to satisfactorily cover the proposed decontamination spectrum. In addition, the compounds were evaluated for their cytotoxicity as a basic safety parameter for potential use in practice. In summary, the dual effect on chemical and biological agents of benzoxonium-like salts offer attractive potential as active components of decontamination mixtures in the case of a terrorist threat or chemical or biological accidents.

Importance of Acute Anterior Angulation in Double Aortic Arch Needing Attention at Primary Surgery.

BACKGROUND: Vascular rings are rare congenital abnormalities of the aortic arch. There are many embryological variants including a double aortic arch. In symptomatic children, division of ring and release of airway structures may be sufficient. Persistence of symptoms can be related to an anterior angle formed between the two arches. The aim of this study is to evaluate the clinical efficacy in improving symptoms and on changing this angle at the primary surgery. METHODS: All children who had surgery for double aortic arch between 2005 and 2020, were studied. Relevant factors were analyzed for persistent symptoms including anatomical substrates and surgical details. RESULTS: A total of 87 out of 224 children had surgery for a double aortic arch. At presentation, airway symptoms (n = 74/87) were more common than esophageal symptoms (n = 27/87). Early onset symptoms within 1 year were seen in 49 children. In addition to division of one arch, surgical steps also included realigning the anterior left arch, thereby eliminating the acute angle in 36 children (after 2014). After surgery, symptom relief within 12 months following surgery was seen in 64% of children (56 out of 87) but in 27 out of 36 children (75%) with additional surgical modification, as against 29 out of 51 (57%) in those with division of the arch. Symptoms persisted beyond 1 year needing reintervention in eight children. CONCLUSION: Anterior arch angulation plays an important role in double aortic arch by causing a "nutcracker" phenomenon. Repair in double aortic arch should consider this aspect and include modification of surgical steps by realigning the corresponding aortic arch branches and an anterior pexy in selected cases.

Enhanced 3D visualization for planning biventricular repair of double outlet right ventricle: a pilot study on the advantages of virtual reality.

Aims: We aim to determine any additional benefit of virtual reality (VR) experience if compared to conventional cross-sectional imaging and standard three-dimensional (3D) modelling when deciding on surgical strategy in patients with complex double outlet right ventricle (DORV). Methods and results: We retrospectively selected 10 consecutive patients with DORV and complex interventricular communications, who underwent biventricular repair. An arterial switch operation (ASO) was part of the repair in three of those. Computed tomography (CT) or cardiac magnetic resonance imaging images were used to reconstruct patient-specific 3D anatomies, which were then presented using different visualization modalities: 3D pdf, 3D printed models, and VR models. Two experienced paediatric cardiac surgeons, blinded to repair performed, reviewed each case evaluating the suitability of repair following assessment of each visualization modalities. In addition, they had to identify those who had ASO as part of the procedure. Answers of the two surgeons were compared to the actual operations performed. There was no mortality during the follow-up (mean = 2.5 years). Two patients required reoperations. After review of CT/cardiac magnetic resonance images, the evaluators identified the surgical strategy in accordance with the actual surgical plan in 75% of the cases. When using 3D pdf this reached only 70%. Accordance improved to 85% after revision of 3D printed models and to 95% after VR. Use of 3D printed models and VR facilitated the identification of patients who required ASO. Conclusion: Virtual reality can enhance understanding of suitability for biventricular repair in patients with complex DORV if compared to cross-sectional images and other 3D modelling techniques.