Cost of Pacing in Pediatric Patients With Postoperative Heart Block After Congenital Heart Surgery.

Importance: Surgical correction of congenital heart defects (CHDs) has improved the lifespan and quality of life of pediatric patients. The number of congenital heart surgeries (CHSs) in children has grown continuously since the 1960s. This growth has been accompanied by a rise in the incidence of postoperative heart block requiring permanent pacemaker (PPM) implantation. Objective: To assess the trends in permanent pacing after CHS and estimate the economic burden to patients and their families after PPM implantation. Design, Setting, and Participants: In this economic evaluation study, procedure- and diagnosis-specific codes within a single-institution database were used to identify patients with postoperative heart block after CHS between January 1, 1960, and December 31, 2018. Patients younger than 4 years with postoperative PPM implantation were selected, and up to 20-year follow-up data were used for cost analysis based on mean hospital event charges and length of stay (LOS) data. Data were analyzed from January 1, 2020, to November 30, 2022. Exposure: Implantation of PPM after CHS in pediatric patients. Main Outcomes and Measures: Annual trends in CHS and postoperative PPM implantations were assessed. Direct and indirect costs associated with managing conduction health for the 20 years after PPM implantation were estimated using Markov model simulation and patient follow-up data. Results: Of the 28 225 patients who underwent CHS, 968 (437 female [45.1%] and 531 male [54.9%]; 468 patients aged <4 years) received a PPM due to postoperative heart block. The rate of CHS and postoperative PPM implantations increased by 2.2% and 7.2% per year between 1960 and 2018, respectively. In pediatric patients younger than 4 years with PPM implantation, the mean (SD) 20-year estimated direct and indirect costs from Markov model simulations were $180 664 ($32 662) and $15 939 ($1916), respectively. Using follow-up data of selected patients with clinical courses involving 1 or more complication events, the mean (SD) direct and indirect costs were $472 774 ($212 095) and $36 429 ($16 706), respectively. Conclusions and Relevance: In this economic evaluation study, the cost of PPM implantation in pediatric patients was found to accumulate over the lifespan. This cost may represent not only a substantial financial burden but also a health care burden to patient families. Reducing the incidence of PPM implantation should be a focused goal of CHS.

Impact of phase lag on synchronization in frustrated Kuramoto model with higher-order interactions.

The study of first order transition (explosive synchronization) in an ensemble (network) of coupled oscillators has been the topic of paramount interest among the researchers for more than one decade. Several frameworks have been proposed to induce explosive synchronization in a network and it has been reported that phase frustration in a network usually suppresses first order transition in the presence of pairwise interactions among the oscillators. However, on the contrary, by considering networks of phase frustrated coupled oscillators in the presence of higher-order interactions (up to 2-simplexes) we show here, under certain conditions, phase frustration can promote explosive synchronization in a network. A low-dimensional model of the network in the thermodynamic limit is derived using the Ott-Antonsen ansatz to explain this surprising result. Analytical treatment of the low-dimensional model, including bifurcation analysis, explains the apparent counter intuitive result quite clearly.

Generalizing the Domain-Gene-Species Reconciliation Framework to Microbial Genes and Domains.

Protein domains play an important role in the function and evolution of many gene families. Previous studies have shown that domains are frequently lost or gained during gene family evolution. Yet, most computational approaches for studying gene family evolution do not account for domain-level evolution within genes. To address this limitation, a new three-level reconciliation framework, called the Domain-Gene-Species (DGS) reconciliation model, has been recently developed to simultaneously model the evolution of a domain family inside one or more gene families and the evolution of those gene families inside a species tree. However, the existing model applies only to multi-cellular eukaryotes where horizontal gene transfer is negligible. In this work, we generalize the existing DGS reconciliation model by allowing for the spread of genes and domains across species boundaries through horizontal transfer. We show that the problem of computing optimal generalized DGS reconciliations, though NP-hard, is approximable to within a constant factor, where the specific approximation ratio depends on the "event costs" used. We provide two different approximation algorithms for the problem and demonstrate the impact of the generalized framework using both simulated and real biological data. Our results show that our new algorithms result in highly accurate reconstructions of domain family evolution for microbes.

Preparation, characterization, and performance evaluation of composite films of polyvinyl alcohol/ cellulose nanofiber extracted from Imperata cylindrica.

In recent years, production of cellulose nanofiber (CNF) from waste materials has achieved great interest owing to their renewable nature, biodegradability, high mechanical properties, economic value, and low density. Because Polyvinyl alcohol (PVA) is a synthetic biopolymer with good water solubility and biocompatibility, the composite material formed of CNF and PVA, is a sustainable way of monetizing to address environmental and economic issues. In this work pure PVA, PVA/CNF0.5, PVA/CNF1.0, PVA/CNF1.5, and PVA/CNF2.0 nanocomposite films were produced using the solvent casting approach with the addition of 0, 0.5, 1.0, 1.5, and 2.0 wt% of CNF concentrations respectively. The strongest water absorption behaviour was found as 25.82% for pure PVA membrane, followed by PVA/CNF0.5 (20.71%), PVA/CNF1.0 (10.26%), PVA/CNF1.5 (9.63%), and PVA/CNF2.0 (4.35%). The water contact angle of 53.1°, 47.8°, 43.4°, 37.7°, and 32.3° was formed between water droplet and the solid-liquid interface of pure PVA, PVA/CNF0.5, PVA/CNF1.0, PVA/CNF1.5, PVA/CNF2.0 composite films respectively. The SEM image clearly shows that a network structure like a tree form at the PVA/CNF0.5 composite film, where the sizes and number of pores are apparent. XRD analysis suggested that unique peaks found at 2θ = 17.5°, 28.1°, 33.4°, and 38° for nanocomposites indicating new crystal plane generated upon cross-linking in presence of malic acid. The maximum loss rate temperature (Td,max) for PVA/CNF0.5, PVA/CNF1.0, PVA/CNF1.5 was determined by TG analysis to be around 273.4 °C. FTIR studies suggested that PVA/CNF0.5 composite film showed the highest peak at 1428 cm-1 as compared to other PVA/CNF composite films representing the presence of higher crystalline band in the composite film matrix. PVA/CNF0.5 composite film was found to have a surface porosity and mean pore size of 27.35% and 0.19 µm respectively, classifying it in the MF membrane category. The maximum tensile strength (TS) of 5.27 MPa was found for PVA/CNF0.5, followed by PVA/CNF1.0, PVA/CNF1.5, pure PVA, and PVA/CNF2.0. The maximum young's modulus (111 MPa) was found for PVA/CNF1.0, followed by PVA/CNF0.5, PVA/CNF2.0, PVA/CNF1.5, and pure PVA, which could be attributed to the cyclization of the molecular structures by cross-linking. PVA/CNF0.5 exhibits greater elongation at break (21.7) than the other polymers, indicating a material's ability to undergo significant deformation before failure. Performance evaluation of the PVA/CNF0.5 composite film showed that 46.3% and 92.8% yield were found in the retentate for 200 mg/L of BSA, and 5 × 107 CFU/mL respectively. However, more than 90% E. coli was retained by PVA/CNF0.5 composite film, therefore absolute rating of this membrane is 0.22 µm. The size of this composite film may be therefore considered in the range of MF.

A novel ex vivo tracheobronchomalacia model for airway stent testing and in vivo model refinement.

OBJECTIVES: We sought to develop an ex vivo trachea model capable of producing mild, moderate, and severe tracheobronchomalacia for optimizing airway stent design. We also aimed to determine the amount of cartilage resection required for achieving different tracheobronchomalacia grades that can be used in animal models. METHODS: We developed an ex vivo trachea test system that enabled video-based measurement of internal cross-sectional area as intratracheal pressure was cyclically varied for peak negative pressures of 20 to 80 cm H2O. Fresh ovine tracheas were induced with tracheobronchomalacia by single mid-anterior incision (n = 4), mid-anterior circumferential cartilage resection of 25% (n = 4), and 50% per cartilage ring (n = 4) along an approximately 3-cm length. Intact tracheas (n = 4) were used as control. All experimental tracheas were mounted and experimentally evaluated. In addition, helical stents of 2 different pitches (6 mm and 12 mm) and wire diameters (0.52 mm and 0.6 mm) were tested in tracheas with 25% (n = 3) and 50% (n = 3) circumferentially resected cartilage rings. The percentage collapse in tracheal cross-sectional area was calculated from the recorded video contours for each experiment. RESULTS: Ex vivo tracheas compromised by single incision and 25% and 50% circumferential cartilage resection produce tracheal collapse corresponding to clinical grades of mild, moderate, and severe tracheobronchomalacia, respectively. A single anterior cartilage incision produces saber-sheath type tracheobronchomalacia, whereas 25% and 50% circumferential cartilage resection produce circumferential tracheobronchomalacia. Stent testing enabled the selection of stent design parameters such that airway collapse associated with moderate and severe tracheobronchomalacia could be reduced to conform to, but not exceed, that of intact tracheas (12-mm pitch, 0.6-mm wire diameter). CONCLUSIONS: The ex vivo trachea model is a robust platform that enables systematic study and treatment of different grades and morphologies of airway collapse and tracheobronchomalacia. It is a novel tool for optimization of stent design before advancing to in vivo animal models.

Identification of Novel Protein Targets of Prodigiosin for Breast Cancer Using Inverse Virtual Screening Methods.

Prodigiosin (PG) is chemically formulated as 4-methoxy-5-[(5-methyl-4-pentyl-2H-pyrrol-2ylidene)methyl]-2,2'-bi-1H-pyrrole and it is an apoptotic agent. Only a few protein targets for PG have been identified so far for regulating various diseases; nevertheless, finding more PG targets is crucial for novel drug discovery research. A bioinformatics method was applied in this work to find additional potential PG targets. Initially, a text mining analysis was conducted to determine the relationship between PG and a variety of metabolic processes. One hundred sixteen proteins from the KEGG pathway were selected for the docking study. Inverse virtual screening was performed by Discovery Studio software 4.1 using CHARMm-based docking tool. Twelve proteins are screened out of 116 because their CDOCKER interaction energy is larger than - 40.22 kcal/mol. The best docking score with PG was reported to be - 44.25 kcal/mol, - 44.99 kcal/mol, and - 40.91 kcal/mol for three novel proteins, such as human epidermal growth factor-2 (HER-2), mitogen-activated protein kinase (MEK), and S6 kinase protein (S6K) respectively. The interactions in the S6K/PG complex are predominantly hydrophobic; however, hydrogen bond interactions can be identified in the MEK/PG and HER-2/PG complexes. The root-mean-square deviation (RMSD) and key interaction score system (KISS) were further used to validate the docking approach. The docking approach employed in this work has a low RMSD value (2.44 Å) and a high KISS score (0.5), indicating that it is significant.

DaTeR: error-correcting phylogenetic chronograms using relative time constraints.

MOTIVATION: A chronogram is a dated phylogenetic tree whose branch lengths have been scaled to represent time. Such chronograms are computed based on available date estimates (e.g. from dated fossils), which provide absolute time constraints for one or more nodes of an input undated phylogeny, coupled with an appropriate underlying model for evolutionary rates variation along the branches of the phylogeny. However, traditional methods for phylogenetic dating cannot take into account relative time constraints, such as those provided by inferred horizontal transfer events. In many cases, chronograms computed using only absolute time constraints are inconsistent with known relative time constraints. RESULTS: In this work, we introduce a new approach, Dating Trees using Relative constraints (DaTeR), for phylogenetic dating that can take into account both absolute and relative time constraints. The key idea is to use existing Bayesian approaches for phylogenetic dating to sample posterior chronograms satisfying desired absolute time constraints, minimally adjust or 'error-correct' these sampled chronograms to satisfy all given relative time constraints, and aggregate across all error-corrected chronograms. DaTeR uses a constrained optimization framework for the error-correction step, finding minimal deviations from previously assigned dates or branch lengths. We applied DaTeR to a biological dataset of 170 Cyanobacterial taxa and a reliable set of 24 transfer-based relative constraints, under six different molecular dating models. Our extensive analysis of this dataset demonstrates that DaTeR is both highly effective and scalable and that its application can significantly improve estimated chronograms. AVAILABILITY AND IMPLEMENTATION: Freely available from https://compbio.engr.uconn.edu/software/dater/. SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.

Antibacterial Effects of ZnO Nanodisks: Shape Effect of the Nanostructure on the Lethality in Escherichia coli.

The role of the shape of the nanostructure on the antibacterial effects of ZnO nanodisks has been investigated by detailed mass spectrometry-based proteomics along with other spectroscopic and microscopic studies on E. coli. The primary interaction study of the E. coli cells in the presence of ZnO nanodisks showed rigorous cell surface damage disrupting the cell wall/membrane components detected by microscopic and ATR-FTIR studies. Protein profiling of whole-cell extracts in the presence and absence of ZnO nanodisks identified several proteins that are upregulated and downregulated under the stress of the nanodisks. This suggests that the bacterial response to the primary stress leads to a secondary impact of ZnO nanodisk toxicity via regulation of the expression of specific proteins. Results showed that the ZnO nanodisks lead to the over-expression of peptidyl-dipeptidase Dcp, Transketolase-1, etc., which are important to maintaining the osmotic balance in the cell. The abrupt change in osmotic pressure leads to mechanical injury to the membrane, and nutritional starvation conditions, which is revealed from the expression of the key proteins involved in membrane-protein assembly, maintaining membrane integrity, cell division processes, etc. Thus, indicating a deleterious effect of ZnO nanodisk on the protective layer of E. coli. ZnO nanodisks seem to primarily affect the protective membrane layer, inducing cell death via the development of osmotic shock conditions, as one of the possible reasons for cell death. These results unravel a unique behavior of the disk-shaped ZnO nanostructure in executing lethality in E. coli, which has not been reported for other known shapes or morphologies of ZnO nanoforms.

The eco-friendly treatment of rubber industry effluent by using adsorbent derived from Moringa oleifera bark and Pseudomonas sp, cultured from effluent.

Rubber processing generates a large volume of wastewater containing rubber latex residues and chemicals. Remediation of the wastewater needs a cost-effective and environment-friendly treatment method. For this study, Moringa oleifera stem bark and Pseudomonas sp. bacteria were used for adsorption and microbial treatment of the effluent. The adsorbent surface was mostly amorphous with crystallinity index 37.9% and the BET surface area was 6.622 m2/g. FTIR analysis indicated involvement of O-H stretching, ketone α, ß-unsaturated, C-H stretching, carboxylic acid and derivatives O-C stretching functional groups in the adsorption process. The assessment of the above two agents was based on their reduction capabilities of the toxic parameters, such as total suspended and dissolved solids, total solids, biological and chemical oxygen demand, sulphate, ammonium, dissolved oxygen, phosphate, pH, electrical conductivity, turbidity, and oxidation reduction potential from the wastewater. A comparative study of the present work revealed that both the agents were effective in reduction of most of the above parameters below the safe discharge limits. However, the adsorption using Moringa oleifera stem bark was better compared to the biodegradation by Pseudomonas sp. bacteria. The main challenges that typically accompany biodegradation include microbe handling and a lower removal percentage than adsorption.

Downstream Process Development for Extraction of Prodigiosin: Statistical Optimization, Kinetics, and Biochemical Characterization.

Prodigiosin is natural red colourant derived from Serratia marcescens. However, the high cost of prodigiosin restricts its use in food and pharmaceutical industries, which can be addressed with the design of a suitable extraction procedure. Therefore, the present study aims to use Taguchi methodology to optimize various process parameters during ultrasound-assisted extraction (UAE) to get a higher prodigiosin extraction yield. The most significant contribution comes from the solid-to-liquid ratio (36.66%), followed by sonication of duty cycle (34.82%), medium pH (15.7%), and acoustic intensity (12.82%). The Taguchi technique predicts the highest optimal yield using the solid-liquid ratio (0.3 g/mL), duty cycle sonication (75%), acoustic intensity (12.5 w/cm2), and medium pH (3) as parameters. When the extraction conditions were optimized, the yield of prodigiosin increased by 4166.89 mg/L. In the future, the above extraction conditions determined using Taguchi approach will be applied for large-scale extraction of prodigiosin. Finally, a second-order kinetic model is used to suit the batch extraction investigation and the second-order rate constant (k) has a value of 4 × 10-5 L/mg/min. In the future, the rate constant, which is reported for the first time, will be used to create a batch extractor for commercial extraction of prodigiosin. Prodigiosin has also been shown to have substantial antioxidant and scavenging properties, which increase in a dose-dependent way with prodigiosin concentration. Because of its antioxidant and scavenging properties, prodigiosin can be used as food additives or pharmaceutical ingredients in industries.

Systematic Mapping of Conduction Tissue Regions During Congenital Heart Surgery.

PURPOSE: Damage to the cardiac conduction system is a major risk of congenital cardiac surgery. Localization of the conduction system is commonly based on anatomic landmarks, which are variable in congenital heart diseases. We introduce a novel technique for identification of conduction tissue regions based on real-time fiberoptic confocal microscopy. DESCRIPTION: We developed a fiberoptic confocal microscopy-based technique to document conduction tissue regions and deployed it in pediatric patients undergoing repair of common congenital heart defects. The technique applies clockface schematics for intraoperative documentation of the location of conduction tissue regions. EVALUATION: We created clockface schematics for 11 patients with ventricular septal defects, 6 with tetralogy of Fallot, and 10 with atrioventricular canal defects. The approach revealed substantial variability in the location of the conduction system in hearts with congenital defects. The clockface schematics were used to create plans for subsequent surgical repair. CONCLUSIONS: The clockface schematic provides a reliable fiducial system to document and communicate variability of conduction tissue regions in the heart and applies this information for decision-making during congenital cardiac surgery.

An eco-friendly removal of Cd(II) utilizing banana pseudo-fibre and Moringa bark as indigenous green adsorbent and modelling of adsorption by artificial neural network.

Heavy metal-contaminated water can be effectively treated using adsorbents made from abundantly available biomass. The present investigation was carried out to adsorb Cd(II) from synthetic solution by banana pseudo-stem (BP) and Moringa oleifera stem bark (MB). Adsorption efficiencies of both adsorbents were studied in the batch reactor by conducting experiments to determine the consequences of changes of pH, adsorbent dosages, initial Cd(II) concentrations, incubation time, and temperature. The process parameters were tuned to attain the highest possible removal percentage. The characterization of the adsorbents was performed by utilizing Fourier-transform infrared spectroscopy (FTIR), field emission scanning electron microscopy (FESEM), and energy-dispersive X-ray (EDX) for the fresh and metal-loaded adsorbents. Atomic absorption spectroscopy (AAS) was employed to calculate the amount of Cd(II) in an aqueous solution. The experimental data were entirely consistent with the pseudo-second-order model for BP and MB. The findings of the study illustrated the better adsorption efficiency of BP-derived adsorbent (≈ 99%) at optimum conditions over the MB (≈ 97%), and the corresponding adsorption capacities were 11.98 and 7.04 mg/g, respectively. The 4 (four) well-known isotherm models were attempted both in linear and non-linear forms. BP (R2 =0.995) and MB (R2 =0.994) were found to be best described by the Freundlich isotherm, which was selected based on the highest R2 value. In thermodynamic studies, ΔH and ΔS were calculated for both the adsorbents. Cd(II) adsorption on BP and MB was endothermic, as evidenced by the positive ΔH. Finally, the prediction of the removal percentage was made by the artificial neural network (ANN) modelling. The present work developed regionally derived waste materials which are helpful for small-scale industrial units for their waste management in an economical and sustainable way.

Toward cardiac tissue characterization using machine learning and light-scattering spectroscopy.

SIGNIFICANCE: The non-destructive characterization of cardiac tissue composition provides essential information for both planning and evaluating the effectiveness of surgical interventions such as ablative procedures. Although several methods of tissue characterization, such as optical coherence tomography and fiber-optic confocal microscopy, show promise, many barriers exist that reduce effectiveness or prevent adoption, such as time delays in analysis, prohibitive costs, and limited scope of application. Developing a rapid, low-cost non-destructive means of characterizing cardiac tissue could improve planning, implementation, and evaluation of cardiac surgical procedures. AIM: To determine whether a new light-scattering spectroscopy (LSS) system that analyzes spectra via neural networks is capable of predicting the nuclear densities (NDs) of ventricular tissues. APPROACH: We developed an LSS system with a fiber-optics probe and applied it for measurements on cardiac tissues from an ovine model. We quantified the ND in the cardiac tissues using fluorescent labeling, confocal microscopy, and image processing. Spectra acquired from the same cardiac tissues were analyzed with spectral clustering and convolutional neural networks (CNNs) to assess the feasibility of characterizing the ND of tissue via LSS. RESULTS: Spectral clustering revealed distinct groups of spectra correlated to ranges of ND. CNNs classified three groups of spectra with low, medium, or high ND with an accuracy of 95.00 ± 11.77 % (mean and standard deviation). Our analyses revealed the sensitivity of the classification accuracy to wavelength range and subsampling of spectra. CONCLUSIONS: LSS and machine learning are capable of assessing ND in cardiac tissues. We suggest that the approach is useful for the diagnosis of cardiac diseases associated with changes of ND, such as hypertrophy and fibrosis.

In Vivo Molding of Airway Stents.

Like ready-to-wear clothing, medical devices come in a fixed set of sizes. While this may accommodate a large fraction of the patient population, others must either experience suboptimal results due to poor sizing or must do without the device. Although techniques have been proposed to fabricate patient-specific devices in advance of a procedure, this process is expensive and time consuming. An alternative solution that provides every patient with a tailored fit is to create devices that can be customized to the patient's anatomy as they are delivered. This paper reports an in vivo molding process in which a soft flexible photocurable stent is delivered into the trachea or bronchi over a UV-transparent balloon. The balloon is expanded such that the stent conforms to the varying cross-sectional shape of the airways. UV light is then delivered through the balloon curing the stent into its expanded conformal shape. The potential of this method is demonstrated using phantom, ex vivo and in vivo experiments. This approach can produce stents providing equivalent airway support to those made from standard materials while providing a customized fit.

Unveiling the urease like intrinsic catalytic activities of two dinuclear nickel complexes towards the in situ syntheses of aminocyanopyridines.

Designing metal complexes as functional models for metalloenzymes remains one of the main targets in synthetic bioinorganic chemistry. Furthermore, the utilization of the product(s) derived from the catalytic reaction for subsequent organic transformation that occurs in biological systems is an even more difficult challenge for biochemists. Urease, the most efficient enzyme known, catalyzes the hydrolysis of urea and it contains an essential dinuclear NiII cluster in the active site. Inspired by the catalytic properties of urease, two dinickel(ii) complexes viz. Ni2L12(OAc)2(H2O) (1) and Ni2L22(OAc)2(H2O) (2) [HL1 = 2,4-dimethyl-6-{[(2'-dimethyl aminoethyl)methylamino]methyl}-phenol and HL2 = 2,4-dichloro-6-{[(2'-dimethyl aminoethyl)methylamino]methyl}-phenol] have been synthesized and characterized in this report. Both the complexes have shown the urease kind of activity with the liberation of ammonia from urea in aqueous solution. The plausible mechanistic pathway and kinetics of the reactions have been studied. Besides, the liberated ammonia has been utilized in the one-pot synthesis of biologically active products like 2-amino-3-cyanopyridines and their derivatives in aqueous medium with excellent yields.

Toward detection of conduction tissue during cardiac surgery: Light at the end of the tunnel?

Postoperative conduction block requiring lifetime pacemaker placement continues to be a considerable source of morbidity for patients undergoing repair of congenital heart defects. Damage to the cardiac conduction system (CCS) during surgical procedures is thought to be a major cause of conduction block. Intraoperative identification and avoidance of the CCS is thus a key strategy to improve surgical outcomes. A number of approaches have been developed to avoid conduction tissue damage and mitigate morbidity. Here we review the historical and contemporary approaches for identification of conduction tissue during cardiac surgery. The established approach for intraoperative identification is based on anatomic landmarks established in extensive histologic studies of normal and diseased heart. We focus on landmarks to identify the sinus and atrioventricular nodes during cardiac surgery. We also review technologies explored for intraoperative tissue identification, including electrical impedance measurements and electrocardiography. We describe new optical approaches, in particular, and optical spectroscopy and fiberoptic confocal microscopy (FCM) for identification of CCS regions and working myocardium during surgery. As a template for translation of future technology developments, we describe research and regulatory pathways to translate FCM for cardiac surgery. We suggest that along with more robust approaches to surgeon training, including awareness of fundamental anatomic studies, optical approaches such as FCM show promise in aiding surgeons with repairs of heart defects. In particular, for complex defects, these approaches can complement landmark-based identification of conduction tissue and thus help to avoid injury to the CCS due to surgical procedures.

Localization of the sinoatrial and atrioventricular nodal region in neonatal and juvenile ovine hearts.

Localization of the components of the cardiac conduction system (CCS) is essential for many therapeutic procedures in cardiac surgery and interventional cardiology. While histological studies provided fundamental insights into CCS localization, this information is incomplete and difficult to translate to aid in intraprocedural localization. To advance our understanding of CCS localization, we set out to establish a framework for quantifying nodal region morphology. Using this framework, we quantitatively analyzed the sinoatrial node (SAN) and atrioventricular node (AVN) in ovine with postmenstrual age ranging from 4.4 to 58.3 months. In particular, we studied the SAN and AVN in relation to the epicardial and endocardial surfaces, respectively. Using anatomical landmarks, we excised the nodes and adjacent tissues, sectioned those at a thickness of 4 µm at 100 µm intervals, and applied Masson's trichrome stain to the sections. These sections were then imaged, segmented to identify nodal tissue, and analyzed to quantify nodal depth and superficial tissue composition. The minimal SAN depth ranged between 20 and 926 µm. AVN minimal depth ranged between 59 and 1192 µm in the AVN extension region, 49 and 980 µm for the compact node, and 148 and 888 µm for the transition to His Bundle region. Using a logarithmic regression model, we found that minimal depth increased logarithmically with age for the AVN (R2 = 0.818, P = 0.002). Also, the myocardial overlay of the AVN was heterogeneous within different regions and decreased with increasing age. Age associated alterations of SAN minimal depth were insignificant. Our study presents examples of characteristic tissue patterns superficial to the AVN and within the SAN. We suggest that the presented framework provides quantitative information for CCS localization. Our studies indicate that procedural methods and localization approaches in regions near the AVN should account for the age of patients in cardiac surgery and interventional cardiology.

Preclinical evaluation of a pediatric airway stent for tracheobronchomalacia.

OBJECTIVES: We sought to demonstrate in an animal model that helical stents made from a nickel titanium alloy called nitinol (NiTi) and designed for malacic airways could be delivered and removed without significant trauma while minimally impeding mucus clearance during the period of implantation. METHODS: Stents were delivered and removed from the tracheas of healthy 20 kg swine (n = 5) using tools designed to minimize trauma. In 4-week experiments, the stents were implanted on day 0, removed after 3 weeks, and swine were put to death after 4 weeks. Weekly bronchoscopies, radiographs, and mucus clearance examinations were performed in vivo. Hematoxylin and eosin staining and scanning electron microscopy imaging were used to evaluate foreign body response, tracheal tissue reaction, and damage and to measure unciliated regions. RESULTS: In all in vivo experiments, the stent was implanted and removed atraumatically. Mucus clearance was maintained throughout the experiment period. Hematoxylin and eosin-stained slides showed that foreign body response and tracheal tissue damage were localized to the stented subsections. Tracheal tissue reaction and damage was further restricted to the epithelium and submucosal layers. Scanning electron microscopy imaging revealed that the cilia were absent only over the contact area between the trachea and the wire forming the helical stent. CONCLUSIONS: Helical nitinol stents designed to provide radial support for malacic airways were well tolerated in a porcine model, providing for mucus clearance while also enabling atraumatic removal.