Right disc thrombosis of the new Gore Cardioform ASD Occluder.

BACKGROUND: The GCA is a well performing device in terms of efficacy despite complex anatomies (aortic rim <5 mm and ASD diameter >17 mm) with a good safety profile. AIMS: To evaluate atrial septal defect (ASD) features impacting on right disc device thrombosis in patients who underwent Gore Cardioform ASD Occluder (GCA) implantation. METHODS: A total of 44 consecutive patients undergoing percutaneous ASD with GCA device from January 2020 to September 2022 at our tertiary care Center were evaluated. The minimum follow-up was 6 months. RESULTS: The patients were stratified in two groups according to a cut-off value of ASD diameter equal to 20 mm at sizing balloon, derived from ROC analysis (AUC = 0.894; p = 0.024). Baseline characteristics were comparable between groups in terms of age, sex, weight, height, and interatrial septum dimensions. Patients with ASD > 20 mm (n = 9) had a higher ASD/device dimension ratio, both at echocardiography (p = 0.009) and at sizing balloon (p = 0.001), longer fluoroscopic time (p = 0.022), and higher incidence of device thrombosis (0.006). Right disc thrombosis was observed in three patients of the ASD > 20 mm group, always in the inferior portion of the right disc. On univariate analysis, ASD diameter at sizing balloon (OR 1.360; p = 0.036) was the only positive predictor of device thrombosis. CONCLUSIONS: Right disc thrombosis of the GCA device may be under-recognized at follow-up, hence deserving clinical attention, especially in those patients with larger ASD diameters.

Regression of Cardiac Rhabdomyomas Producing a Severe Aortic Stenosis: Case Report and Discussion of the Literature.

We describe a case of a voluminous rhabdomyoma (R) detected by fetal echocardiography at 32 weeks' gestation (w.g.) obstructing the left ventricular inflow and aortic outflow tract, with a moderate aortic gradient at birth, not needing immediate surgery. At follow-up, the mass progressively regressed, leaving the aortic valve partly damaged, with a gradient that increased to a maximum of 100 mmHg at 9 years. The girl was then operated on successfully by a plasty of the aortic valve. The literature regarding R is discussed.

High preseason temperature variability drives convergence of xylem phenology in the Northern Hemisphere conifers.

Wood growth is key to understanding the feedback of forest ecosystems to the ongoing climate warming. An increase in spatial synchrony (i.e., coincident changes in distant populations) of spring phenology is one of the most prominent climate responses of forest trees. However, whether temperature variability contributes to an increase in the spatial synchrony of spring phenology and its underlying mechanisms remains largely unknown. Here, we analyzed an extensive dataset of xylem phenology observations of 20 conifer species from 75 sites over the Northern Hemisphere. Along the gradient of increase in temperature variability in the 75 sites, we observed a convergence in the onset of cell enlargement roughly toward the 5th of June, with a convergence in the onset of cell wall thickening toward the summer solstice. The increase in rainfall since the 5th of June is favorable for cell division and expansion, and as the most hours of sunlight are received around the summer solstice, it allows the optimization of carbon assimilation for cell wall thickening. Hence, the convergences can be considered as the result of matching xylem phenological activities to favorable conditions in regions with high temperature variability. Yet, forest trees relying on such consistent seasonal cues for xylem growth could constrain their ability to respond to climate warming, with consequences for the potential growing season length and, ultimately, forest productivity and survival in the future.

Unusual Aneurysm of a Cervical Aortic Arch: Surgical Repair Improves Fluid Dynamics.

The cervical aortic arch is a rare congenital vascular abnormality related to the anomalous development of the aortic arch. We present the case of a 6-year-old patient with a large aneurysmal cervical aortic arch who underwent surgical correction and arch reconstruction. Surgical repair was indicated based on the risk of progressive dilation and rupture, aiming to restore correct geometry and hemodynamics. We evaluated preoperative and postoperative hemodynamics using computational fluid dynamics simulations, and we also identified, within the repaired region, an area that remains affected by greater turbulent flow, requiring follow-up surveillance.

Minimally Invasive Surgery for Simple Congenital Heart Defects: Preserving Aesthetics without Jeopardizing Patient Safety.

Minimally invasive surgeries for pediatric patients have been proposed for decades, with different approaches in mind. Minimal right axillary thoracotomy (MRAT), proposed two decades ago, allows the preservation of patients' safety alongside faster aesthetic and functional recovery. The MRAT did not become widely adopted due to the prejudice that to follow a minimally invasive approach, safety and efficacy must be compromised. With this study, we aim to compare MRAT to the standard median sternotomy approach with a focus on safety and clinical outcomes. Between January 2017 and April 2021, 216 patients diagnosed with ASD, pAVSD, or PAPVD underwent surgical repair with different approaches in the same period. MRAT was used for 78 patients, and median sternotomy was used for 138 patients. In this last group, standard median sternotomy (SMS) was used for 116 patients, while a minimal skin incision (SMS mini) was used for 22 patients. There were no major complications overall nor in each specific approach. MRAT enabled the successful repair of simple heart defects, providing similar post-operative and cardiological recovery. MRAT does not compromise patients' safety and does not prolong the duration of surgery once the learning curve is overcome, which is generally after 15-20 consecutive operations.

Efficacy of Polyhexamethylene Biguanide in Reducing Post-Operative Infections: A Systematic Review and Meta-Analysis.

Background: Post-operative infections are a substantial cause of morbidity and mortality worldwide. Polyhexamethylene biguanide (PHMB) is an antimicrobial agent that has been used in various surgical settings to prevent infections. However, the literature on its efficacy in reducing post-operative infections remains unclear. Materials and Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy of PHMB in reducing post-operative infections. The risk of bias and methodologic quality of the included studies were also assessed. Results: The systematic review included nine RCTs, and eight were included in the meta-analysis that showed that the use of PHMB was associated with a reduction in the rate of post-operative infections. The overall effect size was statistically significant, with moderate heterogeneity across the included studies (log Peto's odds ratio [OR], -0.890; 95% confidence interval [CI], -1.411 to -0.369; I2 = 41.89%). However, the diversity in the application of PHMB and the potential influence of other factors, such as adherence to infection prevention protocols and organizational-level variables, underscore the need for further primary studies. Conclusions: Polyhexamethylene biguanide appears to be a promising intervention for reducing post-operative infections. However, more high-quality, well-designed RCTs are needed to confirm these findings and to explore the most effective ways to use PHMB within specific infection prevention bundles. Future research should also aim to control for potential confounding factors to provide a more comprehensive understanding of the efficacy of PHMB in reducing post-operative infections.

Cervical aortic arch in the pediatric population: a meta-analysis of individual patient's data.

Background: This is the first meta-analysis to analyze all reports of published pediatric cases of cervical aortic arch (CAA) by highlighting the clinical characteristics and treatment outcomes using the reported individual data of the patients. The aim of the study is to investigate the clinical features and surgical outcomes of such a rare disease in the pediatric population. Methods: A comprehensive search was conducted in various academic databases, including PubMed, ScienceDirect, SciELO, DOAJ, and Cochrane Library, until June 2022 for case reports describing the presence of cervical aortic arch in the pediatric age. Case reports and series were included if the following criteria were met: (1) description of the cervical aortic arch; (2) patient of pediatric age; and (3) published in the English language. All other types of publications that lacked patient-specific information were excluded from the analysis. This systematic review was conducted in accordance with the PRISMA guidelines. The primary outcome measure of the analysis was early and late mortality. Results: The literature search identified 2,272 potentially eligible articles, 72 of which met our inclusion criteria with 96 patients including the author's institutional case. At a median of 365 (90-730) days, the overall cohort registered a 7.3% (7/96) mortality rate. In the subset of patients who underwent surgery, the mortality rate was also 7.3% (4/55), and the mortality rate following surgery to treat only CAA was 2.4% (1/42). Dyspnea was identified as an independent determinant of mortality by employing the univariable Firth bias-reduced logistic regression method. Conclusion: Cervical aortic arch is a rare congenital heart disease that poses treatment challenges due to the high anatomical variability, diverse clinical presentations, and the presence of other concomitant diseases. The surgical treatment appears to be a safe and effective approach for resolving the symptoms, although it needs to be tailored individually for each patient. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=346826, Identifier: CRD42022346826.

Shifts of Leaf Litter-Induced Plant-Soil Feedback from Negative to Positive Driven by Ectomycorrhizal Symbiosis between Quercus ilex and Pisolithus arrhizus.

Ectomycorrhizas (ECM) are a common symbiotic association between fungi and various plant species in forest ecosystems, affecting community assemblages at the landscape level. ECMs benefit host plants by increasing the surface area for nutrient uptake, defending against pathogens, and decomposing organic matter in the soil. ECM-symbiotic seedlings are also known to perform better in conspecific soils than other species unable to carry the symbiosis, in a process referred to as plant-soil feedback (PSF). In this study, we tested the effects of different leaf litter amendments on ECM and non-ECM seedlings of Quercus ilex inoculated with Pisolithus arrhizus and how they altered the litter-induced PSF. Our experiment showed that the ECM symbiont induced a shift from negative PSF to positive PSF in Q. ilex seedlings by analysing plant and root growth parameters. However, non-ECM seedlings performed better than ECM seedlings in a no-litter condition, indicating an autotoxic effect when litter is present without ECM symbionts. Conversely, ECM seedlings with litter performed better at different decomposition stages, suggesting a possible role of the symbiosis of P. arrhizus and Q. ilex in recycling autotoxic compounds released from conspecific litter, transforming them into nutrients that are transferred to the plant host.

Topoclimate effect on treeline elevation depends on the regional framework: A contrast between Southern Alps (New Zealand) and Apennines (Italy) forests.

Deciphering the spatial patterns of alpine treelines is critical for understanding the ecosystem processes involved in the persistence of tree species and their altitudinal limit. Treelines are thought to be controlled by temperature, and other environmental variables but they have rarely been investigated in regions with different land-use change legacies. Here, we systematically investigated treeline elevation in the Apennines (Italy) and Southern Alps (New Zealand) with contrasting human history but similar biogeographic trajectories, intending to identify distinct drivers that affect their current elevation and highlight their respective peculiarities. Over 3622 km of Apennines, treeline elevation was assessed in 302 mountain peaks and in 294 peaks along 4504 km of Southern Alps. The major difference between the Southern Alps and Apennines treeline limit is associated with their mountain aspects. In the Southern Alps, the scarcely anthropized Nothofagus treeline elevation was higher on the warmer equator-facing slopes than on the pole-facing ones. Contrary to what would be expected based on temperature limitation, the elevation of Fagus sylvatica treelines in the Apennines was higher on colder, pole-facing slopes than on human-shaped equator-facing, warmer mountainsides. Pervasive positive correlations were found between treeline elevation and temperature in the Southern Alps but not in the Apennines. While the position of the Fagus and Nothofagus treelines converge on similar isotherms of annual average temperature, a striking isothermal difference between the temperatures of the hottest month on which the two taxonomic groups grow exists. We conclude that actual treeline elevation reflects the ecological processes driven by a combination of local-scale topoclimatic conditions, and human disturbance legacy. Predicting dynamic processes affecting current and future alpine treeline position requires further insight into the modulating influences that are currently understood at a regional scale.

A critical thermal transition driving spring phenology of Northern Hemisphere conifers.

Despite growing interest in predicting plant phenological shifts, advanced spring phenology by global climate change remains debated. Evidence documenting either small or large advancement of spring phenology to rising temperature over the spatio-temporal scales implies a potential existence of a thermal threshold in the responses of forests to global warming. We collected a unique data set of xylem cell-wall-thickening onset dates in 20 coniferous species covering a broad mean annual temperature (MAT) gradient (-3.05 to 22.9°C) across the Northern Hemisphere (latitudes 23°-66° N). Along the MAT gradient, we identified a threshold temperature (using segmented regression) of 4.9 ± 1.1°C, above which the response of xylem phenology to rising temperatures significantly decline. This threshold separates the Northern Hemisphere conifers into cold and warm thermal niches, with MAT and spring forcing being the primary drivers for the onset dates (estimated by linear and Bayesian mixed-effect models), respectively. The identified thermal threshold should be integrated into the Earth-System-Models for a better understanding of spring phenology in response to global warming and an improved prediction of global climate-carbon feedbacks.

Ross Operation in Pediatric Population: Impact of the Surgical Timing and the Native Pulmonary Diameter on the Outcome.

Aortic valve replacement early in life may be inevitable. Ross operation, until present day, remains the favorite surgical option in pediatrics with irreparable aortic valve disease. Nonetheless, the necessity for re-operation was always its principal limitation due to aortic valve failure or homograft degeneration. We present our 25 years of experience in the pediatric population. From August 1994 until June 2018, 157 children below 18 years underwent the Ross operation. This retrospective review aims at assessing the long-term outcomes, as well as the risk factors for re-operation after Ross procedure. Median age was 10.9 years, of which seven patients were infants, 79 children, and 71 adolescents. The median follow-up time was 14 years. Hospital mortality was 0.6%. Freedom from autograft re-operation for children was 96.7% and 94.1% at 10 and 20 years, respectively; whereas for adolescents, it was 92.6% and 74.9% at 10 and 20 years. For children, freedom from homograft re-operation was 92.5%, 83.5%, and 56.2% at 10, 15, and 20 years; while for adolescents, it was 96.8%, 91.8%, and 86.7% at 10, 15, and 20 years. Homograft size (p = 0.008) and childhood (p = 0.05) were risk factors for homograft re-operation. Pulmonary valve diameter > 24 mm (p = 0.044) and adolescence (p = 0.032) were risk factors for autograft re-operation. Our experience demonstrated excellent early and late survival. While children have preferential outcomes concerning autograft re-operation, those who received a smaller homograft had a higher right-sided re-intervention incidence than adolescents. Pulmonary diameter > 24 mm at surgery was an indicator of future autograft failure.

Clonality drives structural patterns and shapes the community assemblage of the Mediterranean Fagus sylvatica subalpine belt.

Past anthropogenic disturbances lowered the altitudinal distribution of the Mediterranean Fagus sylvatica forests below 2,000 m a.s.l. Accordingly, our current understanding of the southern distribution range of F. sylvatica forests is restricted to managed stands below this elevation, neglecting relic forests growing above. This study has shed light on the structure and species assemblage of an unmanaged relict subalpine F. sylvatica stand growing within the core of its southernmost glacial refugia and at its highest species range elevation limit (2,140 m a.s.l.) in southern Apennines (Italy). Here, tree biometric attributes and understory species abundances were assessed in eight permanent plots systematically positioned from 1,650 to 2,130 m a.s.l. In the subalpine belt, F. sylvatica had formed a dense clonal stem population that was layered downward on the steepest slopes. The density and spatial aggregation of the stems were increased, while their stature and crown size were decreased. Above 2,000 m, changes in tree growth patterns, from upright single-stemmed to procumbent multi-stemmed, and canopy layer architecture, with crowns packed and closer to the floor, were allowed for the persistence of understory herbaceous species of biogeographic interest. Clonal layering represents an adaptive regeneration strategy for the subalpine belt environmental constraints not previously recognized in managed Mediterranean F. sylvatica forests. The clonal structure and unique species assemblage of this relic forest highlight the value of its inclusion in the priority areas networks, representing a long-term management strategy of emblematic glacial and microclimatic refugia.

Primary Arterial Switch Operation for Late Presentation of Transposition of the Great Arteries With Intact Ventricular Septum.

Transposition of the great arteries (TGA) with intact ventricular septum (IVS) are subject to neonatal arterial switch operation (ASO) to avoid deconditioning of the left ventricle (LV). Often an early repair is not feasible in developing countries where late referral is frequent. We aim to explore ASO outcomes in late TGA-IVS and compare "unfavorable candidates" (LV myocardial mass <35gr/m2 unfavorable geometry. banana-like LV shape) with other late TGA-IVS. Single-center retrospective study on late TGA-IVS who underwent primary ASO between 2015 and 2018. We divide patients into 2 groups: unfavorable candidates and favorable candidates TGA. We report categorical variables as number and percentage and continuous variables as median with interquartile range. Differences were assessed with Chi-squared or Fisher exact tests, Wilcoxon sign-rank, and Wilcoxon-rank sum tests. 45 TGA-IVS were referred with a median age of 35 days. Pre-operative echocardiography identified banana-like LV shape in 66.7%; unfavorable LV geometry in 47.6% and LV mass <35gr/m2 in 51%. Only 1 death occurred related to myocardial ischemia. Five patients (11%) required ECMO for LV dysfunction, with unfavorable candidates having a higher but not significant use (18.7% vs 6.9%, P = 0.33). At discharge, echocardiography demonstrated significant LV mass improvement compared to pre-operative (58.6 vs 33.8 gr/m2, P < 0.0001) with no significant echocardiographic difference between unfavorable and favorable late-TGA. Primary ASO in late presenter TGA-IVS can be performed safely with low mortality having a low threshold to ECMO. Significantly unconditioned LV are amenable with primary ASO with good LV mass recovery.

Topography modulates near-ground microclimate in the Mediterranean Fagus sylvatica treeline.

Understanding processes controlling forest dynamics has become particularly important in the context of ongoing climate change, which is altering the ecological fitness and resilience of species worldwide. However, whether forest communities would be threatened by projected macroclimate change or unaffected due to the controlling effect of local site conditions is still a matter for debate. After all, forest canopy buffer climate extremes and promote microclimatic conditions, which matters for functional plant response, and act as refugia for understory species in a changing climate. Yet precisely how microclimatic conditions change in response to climate warming will depend on the extent to which vegetation structure and local topography shape air and soil temperature. In this study, we posited that forest microclimatic buffering is sensitive to local topographic conditions and canopy cover, and using meteorological stations equipped with data-loggers we measured this effect during 1 year across a climate gradient (considering aspect as a surrogate of local topography) in a Mediterranean beech treeline growing in contrasting aspects in southern Italy. During the growing season, the below-canopy near-ground temperatures were, on average, 2.4 and 1.0 °C cooler than open-field temperatures for south and north-west aspects, respectively. Overall, the temperature offset became more negative (that is, lower under-canopy temperatures at the treeline) as the open-field temperature increased, and more positive (that is, higher under-canopy temperatures at the treeline) as the open-field temperature decreased. The buffering effect was particularly evident for the treeline on the south-facing slope, where cooling of near-ground temperature was as high as 8.6 °C for the maximum temperature (in August the offset peaked at 10 °C) and as high as 2.5 °C for the average temperature. In addition, compared to the south-facing slope, the northern site exhibited less decoupling from free-air environment conditions and low variability in microclimate trends that closely track the free-air biophysical environment. Although such a decoupling effect cannot wholly isolate forest climatic conditions from macroclimate regional variability in the south-facing treeline, it has the potential to partly offset the regional macroclimatic warming experienced in the forest understory due to anthropogenic climate change.

Visual evoked potential abnormalities in dementia with Lewy bodies.

OBJECTIVES: Visuo-perceptual deficits and visual hallucinations (VHs) are common disturbances in patients with dementia with Lewy bodies (DLB) and those with Parkinson's disease (PD). In particular, delays in visual evoked potential (VEP), reversed by l-dopa administration, have previously been observed in PD patients. Impairment in metabolic functions of dopaminergic amacrine cells within the inner plexiform layer of the retina has been largely documented and has been posited as the underlying cause of visual and retinal alterations in PD. The aims of the present study were to investigate the presence of VEP abnormalities in DLB patients, as compared to a PD control group, and to assess the presence of significant correlations between neurophysiological measures and clinical symptoms (i.e., presence of visuospatial deficits and/or visual hallucinations). METHODS: Fifteen DLB patients and fifteen matched PD patients underwent pattern reversal before and after l-dopa administration, and a short neuropsychological assessment. RESULTS: In DLB patients, we observed delay of the P100 latency to foveal stimuli in both eyes compared to normative values. Compared to PD, DLB patients showed higher values of the P100 latency for foveal stimulation from the right eye prior to l-dopa administration (p = 0.018). No correlations between VEP alterations, visuo-spatial deficit and visual hallucinations were found. DISCUSSION: Our findings demonstrated a longer P100 delay in DLB than in PD patients, especially along the right visual pathway. In contrast to previous studies, which focused on a dopaminergic pre-geniculate impairment of visual pathways, our evidence suggests that other mechanisms, possibly relying on thalamic involvement, which is known to be dysfunctional in DLB, can interfere with VEP abnormalities.

Photoperiod and temperature as dominant environmental drivers triggering secondary growth resumption in Northern Hemisphere conifers.

Wood formation consumes around 15% of the anthropogenic CO2 emissions per year and plays a critical role in long-term sequestration of carbon on Earth. However, the exogenous factors driving wood formation onset and the underlying cellular mechanisms are still poorly understood and quantified, and this hampers an effective assessment of terrestrial forest productivity and carbon budget under global warming. Here, we used an extensive collection of unique datasets of weekly xylem tissue formation (wood formation) from 21 coniferous species across the Northern Hemisphere (latitudes 23 to 67°N) to present a quantitative demonstration that the onset of wood formation in Northern Hemisphere conifers is primarily driven by photoperiod and mean annual temperature (MAT), and only secondarily by spring forcing, winter chilling, and moisture availability. Photoperiod interacts with MAT and plays the dominant role in regulating the onset of secondary meristem growth, contrary to its as-yet-unquantified role in affecting the springtime phenology of primary meristems. The unique relationships between exogenous factors and wood formation could help to predict how forest ecosystems respond and adapt to climate warming and could provide a better understanding of the feedback occurring between vegetation and climate that is mediated by phenology. Our study quantifies the role of major environmental drivers for incorporation into state-of-the-art Earth system models (ESMs), thereby providing an improved assessment of long-term and high-resolution observations of biogeochemical cycles across terrestrial biomes.

Lombardy regional urgent reorganization for congenital cardiac patients following the Covid-19 pandemic.

OBJECTIVE: By the end of February 2020, the COVID-19 pandemic infection had spread in Northern Italy, with thousands of patients infected. In Lombardy, the most affected area, the majority of public and private hospitals were dedicated to caring for COVID-19 patients and were organized following the 'Hub-and-Spoke' model for other medical specialties, like cardiac surgery and interventional procedures for congenital cardiac disease (CHD). Here, we report how the congenital cardiac care system was modified in Lombardy and the first results of this organization. METHODS: We describe a modified 'Hub-and-Spoke' model - that involves 59 birthplaces and three specialized Congenital Cardiac Centers -- and how the hub center organized his activity. We also reported the data of the consecutive cases hospitalized during this period. RESULTS: From 9 March to 15 April, we performed: a total of 21 cardiac surgeries, 4 diagnostic catheterizations, 3 CT scans, and 2 CMR. In three cases with prenatal diagnosis, the birth was scheduled. The spoke centers referred to our center six congenital cardiac cases. The postop ExtraCorporeal Membrane Oxygenation support was required in two cases; one case died. None of these patients nor their parents or accompanying person was found to be COVID-19-positive; 2 pediatric intensivists were found to be COVID-19-positive, and needed hospitalization without mechanical ventilation; 13 nurses had positive COVID swabs (4 with symptoms), and were managed and isolated at home. CONCLUSION: Our preliminary data suggest that the model adopted met the immediate needs with a good outcome without increased mortality, nor COVID-19 exposure for the patients who underwent procedures.

A Misdiagnosed Case of Double Outlet Right Atrium Associated With Hypoplastic Right Ventricle.

Double outlet right atrium (DORA) is a rare congenital heart disease in which the right atrium opens into both ventricles. The reduced leftward motion of the interventricular septum causes a malalignment between the atrial and the ventricular septum at the cardiac crux, which is the pathognomonic feature of this heart defect. We describe a case of significant exertional desaturation in an adult patient who was diagnosed with DORA, restrictive right ventricle, and anomalous tricuspid valve. Subsequently, the patient underwent one-and-a-half ventricular palliation.

Surgical Rescue After Failed Percutaneous Closure of an Aorto-Atrial Tunnel.

Congenital sinus of Valsalva aneurysm is a rare disorder, mostly involving the right and noncoronary sinuses, in which intracardiac rupture is more likely foreseen into the right chambers. Because of the unfavorable prognosis, which includes heart failure and sudden death, detection itself is an indication for treatment, which may be performed either surgically or percutaneously. We present a case of a four-year-old patient with aorto-right atrial tunnel, in which a transcatheter attempt of closure was performed, complicated by new onset of aortic valve regurgitation, requiring surgical intervention.