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Objectives: Clinical significance of aortopulmonary collaterals (APCs) in patients with univentricular heart remains controversial. This study aimed to evaluate the incidence and associated factors for APCs and their influence during staged palliation., Methods: In total, 430 patients who underwent staged palliation by bidirectional Glenn shunt and total cavopulmonary connection between 2003 and 2019 were examined. APCs were determined by angiogram. Incidence and interventions for APCs were analysed., Results: The most frequent diagnosis was hypoplastic left heart syndrome in 146 (34%) patients. The median age at Glenn and Fontan was 4.9 months and 2.1 years, respectively. APCs were observed in 54 (13%) patients at Glenn and in 179 (42%) at Fontan. Closure of APCs was performed before Glenn in 12 (3%) patients, at Glenn in 13 (3%), after Glenn in 8 (2%), before Fontan in 44 (10%), at Fontan in 26 (6%) and after Fontan in 52 (12%). Hypoplastic left heart syndrome (P < 0.01) was highly associated with the development of APCs before Glenn. Lower Nakata-Index and younger age at Glenn shunt were associated with the development of APCs at Fontan procedure. The presence of APCs or intervention for APCs before total cavopulmonary connection did not influence intensive care unit stay or mortality after total cavopulmonary connection., Conclusions: APCs were most frequently observed before Fontan procedure. Hypoplastic left heart syndrome was highly associated with the development of APCs before Glenn shunt. Lower Nakata-Index and younger age at Glenn shunt were associated with APCs before Fontan procedure., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background: Covered stents perform similar to surgically implanted conduits, although the stents work inside of vessels. We present a computed tomography (CT)-based workflow for the implantation of covered stents as extravascular conduits., Methods: We selected three different use cases: 1. Connecting a left-sided partially anomalous drainage of a pulmonary vein to the left atrium. 2. Bypassing an outgrown Dacron conduit in aortic recoarctation. 3. Re-directing hepatic venous blood to the left lung in a Fontan patient with heterotaxy, connecting the innominate vein to the right pulmonary artery like a right-sided cavopulmonary connection. By postprocessing and analyzing CT scans for planning and by the use of long needles under biplane fluoroscopy for the realization of the procedure, we projected and performed the exit of a long needle out of a vessel, the re-entering of a target vessel, and the bridging of the extravascular distance by implantation of covered stents., Results: In all three cases, the covered stents were placed successfully, connecting vessels of 15-50 mm distance from each other with very good hemodynamic results. In one case, two stents were placed consecutively, overlapping each other to accomplish an exact fitting at the connection sites to the native vessels., (© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Exoscopic surgery promises alleviation of physical strain, improved intraoperative visualization and facilitation of the clinical workflow. In this prospective observational study, we investigate the clinical usability of a novel 3D4K-exoscope in routine neurosurgical interventions. Questionnaires on the use of the exoscope were carried out. Exemplary cases were additionally video-documented. All participating neurosurgeons (n = 10) received initial device training. Changing to a conventional microscope was possible at all times. A linear mixed model was used to analyse the impact of time on the switchover rate. For further analysis, we dichotomized the surgeons in a frequent (n = 1) and an infrequent (n = 9) user group. A one-sample Wilcoxon signed rank test was used to evaluate, if the number of surgeries differed between the two groups. Thirty-nine operations were included. No intraoperative complications occurred. In 69.2% of the procedures, the surgeon switched to the conventional microscope. While during the first half of the study the conversion rate was 90%, it decreased to 52.6% in the second half (p = 0.003). The number of interventions between the frequent and the infrequent user group differed significantly (p = 0.007). Main reasons for switching to ocular-based surgery were impaired hand-eye coordination and poor depth perception. The exoscope investigated in this study can be easily integrated in established neurosurgical workflows. Surgical ergonomics improved compared to standard microsurgical setups. Excellent image quality and precise control of the camera added to overall user satisfaction. For experienced surgeons, the incentive to switch from ocular-based to exoscopic surgery greatly varies., (© 2021. The Author(s).)

Background: Transcatheter pulmonary valve (TPV) replacement (TPVR) has become the standard therapy for postoperative pulmonary outflow tract dysfunction in patients with a prosthetic conduit/valve, but there is limited information about risk factors for death or reintervention after this procedure., Objectives: This study sought to evaluate mid- and long-term outcomes after TPVR in a large multicenter cohort., Methods: International registry focused on time-related outcomes after TPVR., Results: Investigators submitted data for 2,476 patients who underwent TPVR and were followed up for 8,475 patient-years. A total of 95 patients died after TPVR, most commonly from heart failure (n = 24). The cumulative incidence of death was 8.9% (95% CI: 6.9%-11.5%) 8 years after TPVR. On multivariable analysis, age at TPVR (HR: 1.04 per year; 95% CI: 1.03-1.06 per year; P < 0.001), a prosthetic valve in other positions (HR: 2.1; 95% CI: 1.2-3.7; P = 0.014), and an existing transvenous pacemaker/implantable cardioverter-defibrillator (HR: 2.1; 95% CI: 1.3-3.4; P = 0.004) were associated with death. A total of 258 patients underwent TPV reintervention. At 8 years, the cumulative incidence of any TPV reintervention was 25.1% (95% CI: 21.8%-28.5%) and of surgical TPV reintervention was 14.4% (95% CI: 11.9%-17.2%). Risk factors for surgical reintervention included age (0.95 per year [95% CI: 0.93-0.97 per year]; P < 0.001), prior endocarditis (2.5 [95% CI: 1.4-4.3]; P = 0.001), TPVR into a stented bioprosthetic valve (1.7 [95% CI: 1.2-2.5]; P = 0.007), and postimplant gradient (1.4 per 10 mm Hg [95% CI: 1.2-1.7 per 10 mm Hg]: P < 0.001)., Conclusions: These findings support the conclusion that survival and freedom from reintervention or surgery after TPVR are generally comparable to outcomes of surgical conduit/valve replacement across a wide age range., Competing Interests: Funding Support and Author Disclosures Dr McElhinney has served as a consultant for Medtronic. Dr Levi has served as a consultant for Edwards and Medtronic. Dr Goldstein has served as a consultant for Medtronic. Dr Shahanavaz has served as a consultant for Edwards and Medtronic. Dr Qureshi has served as a consultant for Edwards, Medtronic, W.L. Gore and Associates, and Abiomed Inc. Dr Cabalka has served as a consultant for Medtronic. Dr Torres has served as a proctor for Edwards. Dr Morray has served as a consultant for Medtronic. Dr Armstrong has served as a consultant for Edwards and Medtronic; and has received research grants from Edwards. Dr Aboulhosn has served as a consultant for Edwards and Medtronic; and has received research grants from Edwards. Dr Berger has served as a consultant for Medtronic. Dr Sondergaard has served as a consultant for and received research grants from Edwards and Medtronic. Dr Schranz has served as a consultant for Medtronic. Dr Jones has served as a consultant for and received research grants from Edwards and Medtronic. Dr Cheatham has served as a consultant for Medtronic and NuMED. Dr Schubert has served as a proctor for Abbott, Edwards, Gore, Lifetech, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: The aim of this study was to compare the structure-function relationship with microperimetry and Octopus perimetry in primary open-angle glaucoma (POAG) patients with central visual field (VF) defects., Methods: Forty eyes of 24 patients with POAG were enrolled. Circumpapillary retinal nerve fiber layer (cpRNFL) analysis measured by spectral-domain optical coherence tomography (SD-OCT) of the superotemporal, temporal, and inferotemporal optic-nerve head sectors were related to corresponding microperimetric and Octopus VF clusters using the G2 grid-pattern with dynamic strategy, respectively. The structure-function relationships of both devices were assessed via a segmented regression, as well as linear regression across overall SD-OCT cpRNFL values and outside normative (<1%) SD-OCT cpRNFL values., Results: Linear and segmented regression fits were similar with both devices. Across overall cpRNFL sectorial values, structure-function relations for the superotemporal, temporal, and inferotemporal sectors were R2 = 0.176 (p = <0.001), R2 = 0.008 (p = 0.069), and R2 = 0.294 (p = <0.001) for microperimetry and R2 = 0.189 (p = <0.001), R2 = 0.020 (p = 0.002), and R2 = 0.326 (p = <0.001) for Octopus perimetry. For corresponding values outside normative limits (<1%), the relationships were R2 = 0.113 (p = <0.001), R2 = 0.001 (p = 0.836), and R2 = 0.420 (p = <0.001) for microperimetry and R2 = 0.192 (p = <0.001), R2 = 0.002, (p = 0.336), and R2 = 0.366 (p = <0.001) for Octopus perimetry., Discussion/conclusion: Structure-function analysis was similar for both devices. Fundus-tracking should be further evaluated in a longitudinal setting in patients affected by glaucoma., (© 2022 The Author(s). Published by S. Karger AG, Basel.)

Purpose: To analyze the difference in anterior chamber depth (ACD) after uneventful cataract surgery between 2 hydrophobic acrylic 1-piece intraocular lenses (IOLs) with different material properties., Setting: Hanusch Hospital, Vienna, Austria., Design: Single-center, bilateral randomized paired-eye controlled study., Methods: Patients scheduled for bilateral cataract surgery were randomized to receive the Clareon IOL in 1 eye and the AcrySof IQ IOL (both Alcon Laboratories, Inc.) in the contralateral eye. Preoperatively, a slitlamp examination, optical biometry (IOLMaster 700, Carl Zeiss Meditec AG), refraction, and visual acuity measurements were performed. ACD was assessed 1 hour and 1 week postoperatively and with additional measurement of uncorrected (UDVA) and corrected distance visual acuity (CDVA) 6 months postoperatively., Results: 80 eyes of 40 patients were analyzed in this study. ACD at the 6-month follow-up was 3.94 ± 0.30 mm for the Clareon IOL and 3.91 ± 0.32 mm for the AcrySof IQ IOL (P = .08). Statistically significant differences in the ACD shift between both IOLs were detected between 1 week and 6 months (P = .04) and 1 hour and 6 months (P = .04). There were no statistically significant differences between both IOLs in UDVA (P = .78), CDVA (P = .59), and spherical equivalent (SE, P = .39) at the 6-month visit. The mean absolute error between the measured and the aimed SE was not significant (P = .97)., Conclusions: There was no clinically relevant difference in ACD between the Clareon IOL and the AcrySof IQ IOL in patients after uneventful cataract surgery. Both IOLs yielded good refraction and visual acuity outcomes., (Copyright © 2021 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Background Right atrial (RA) dilatation and impaired right ventricular (RV) filling are common in patients with RV outflow tract dysfunction. We aimed to study potential correlations between atrial function with clinically relevant hemodynamic parameters and to assess the predictive impact of atrial performance on the recovery of exercise capacity and RV pump function after percutaneous pulmonary valve implantation (PPVI). Methods and Results Altogether, 105 patients with right ventricular outflow tract dysfunction (median age at PPVI, 19.2 years; range, 6.2-53.4 years) who underwent cardiac magnetic resonance imaging before and 6 months after PPVI were included. RA and left atrial maximal and minimal volumes as well as atrial passive and active emptying function were assessed from axial cine slices. RA emptying function was inversely related to invasive RV end-diastolic pressure, and RA passive emptying correlated significantly with peak oxygen uptake. After PPVI, a significant decrease in RA minimum volume was observed, whereas RA passive emptying function improved, and RA active emptying function decreased significantly. Patients with predominant right ventricular outflow tract stenosis showed more favorable changes in RA active and left atrial passive emptying than those with primary volume overload. None of the RA and left atrial emptying parameters was predictive for recovery of peak oxygen uptake or RV ejection fraction. Conclusions In patients with right ventricular outflow tract dysfunction, impaired RA emptying assessed by cardiac magnetic resonance imaging was associated with increased RV filling pressures and lower exercise capacity. PPVI leads to a reduction in RA size and improved passive RA emptying function. However, RA function was not associated with improved exercise performance and RV pump function.

Ocular aberrometry is an essential technique in vision science and ophthalmology. We demonstrate how a phase-sensitive single mode fiber-based swept source optical coherence tomography (SS-OCT) setup can be employed for quantitative ocular aberrometry with digital adaptive optics (DAO). The system records the volumetric point spread function at the retina in a de-scanning geometry using a guide star pencil beam. Succeeding test-retest repeatability assessment with defocus and astigmatism analysis on a model eye within ± 3 D dynamic range, the feasibility of technique is demonstrated in-vivo at a B-scan rate of >1 kHz in comparison with a commercially available aberrometer., Competing Interests: Authors Stefan Georgiev, Abhishek Kumar, Oliver Findl, Nino Hirnschall, Michael Niederleithner, Milana Kendrisic, Wolfgang Drexler and Rainer A. Leitgeb are represented below as SG, AK, OF, NH, MN, MK, WD and RAL. SG, MN, MK, WD and RAL declare no conflict of interest. AK: Wavesense Engineering GmbH (E, P). OF: Scientific advisor to Alcon, Carl Zeiss Meditec AG, Croma, Johnson & Johnson, Merck. NH: Scientific advisor to Hoya Surgical and Carl Zeiss Meditec AG, (© 2021 Optical Society of America under the terms of the OSA Open Access Publishing Agreement.)

Aim: To compare the repeatability of 2 swept-source optical coherence tomography (SS-OCT) biometers, IOLMaster 700 (biometer A, Carl Zeiss Meditec AG) and ANTERION (biometer B, Heidelberg Engineering GmbH) and 1 optical low-coherence reflectometry (OLCR) device (biometer C, LENSTAR, LS900; Haag-Streit AG)., Setting: Department of Ophthalmology, Hanusch Hospital, Vienna Institute for Research in Ocular Surgery-Karl Landsteiner Institute, Vienna, Austria., Design: Prospective study that included patients scheduled for cataract surgery., Method: Three consecutive measurements were performed with 2 SS-OCT devices and 1 OLCR device. The repeatability of the following biometry variables was compared: keratometry, central corneal thickness, anterior chamber depth (ACD), lens thickness (LT), and axial eye length (AL). To assess the repeatability of each parameter, the within-subject SD (Sw) and coefficient of variation (CoV) were calculated., Result: Fifty eyes of 50 patients were included. The CoV values were below 0.5 for all variables, except for ACD and LT for biometer C. The Sw values for mean keratometry were 0.018 for biometer A, 0.083 for biometer B, and 0.137 for biometer C. For the ACD, the Sw values were 0.039 and 0.004 for biometer A and biometer B, respectively, and 0.134 for biometer C. For the AL, the values were 0.006 for biometer A, 0.008 for biometer B, and 0.012 for biometer C., Conclusions: All biometry devices included in the analysis presented a high repeatability. The SS-OCT devices showed a higher repeatability performance compared with the OLCR device., (Copyright © 2021 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Background: Endocarditis has emerged as one of the most impactful adverse events after transcatheter pulmonary valve replacement (TPVR), but there is limited information about risk factors for and outcomes of this complication., Objectives: The purpose of this study was to evaluate risk factors for and outcomes of endocarditis in a large multicenter cohort., Methods: The authors established an international registry focused on characterizing endocarditis after TPVR, including the incidence, risk factors, characteristics, and outcomes., Results: Investigators submitted data for 2,476 patients who underwent TPVR between July 2005 and March 2020 and were followed for 8,475 patient-years. In total, 182 patients were diagnosed with endocarditis a median of 2.7 years after TPVR, for a cumulative incidence of 9.5% (95% CI: 7.9%-11.1%) at 5 years and 16.9% (95% CI: 14.2%-19.8%) at 8 years (accounting for competing risks: death, heart transplant, and explant) and an annualized incidence of 2.2 per 100 patient-years. Staphylococcus aureus and Viridans group Streptococcus species together accounted for 56% of cases. Multivariable analysis confirmed that younger age, a previous history of endocarditis, and a higher residual gradient were risk factors for endocarditis, but transcatheter pulmonary valve type was not. Overall, right ventricular outflow tract (RVOT) reintervention was less often to treat endocarditis than for other reasons, but valve explant was more often caused by endocarditis. Endocarditis was severe in 44% of patients, and 12 patients (6.6%) died, nearly all of whom were infected with Staphylococcus aureus., Conclusions: The incidence of endocarditis in this multicenter registry was constant over time and consistent with prior smaller studies. The findings of this study, along with ongoing efforts to understand and mitigate risk, will be critical to improve the lifetime management of patients with heart disease involving the RVOT. Although endocarditis can be a serious adverse outcome, TPVR remains an important tool in the management of RVOT dysfunction., Competing Interests: Funding Support and Author Disclosures Drs McElhinney, Morray, Goldstein, Cabalka, Berger, and Schranz have served as consultants for Medtronic. Drs Aboulhosn and Levi have served as consultants for Edwards and Medtronic; and has received research grants from Edwards. Dr Qureshi has served as a consultant for Edwards, Medtronic, W.L. Gore and Associates, and Abiomed Inc. Dr Torres has served as a proctor for Edwards. Dr Shahanavaz has served as a consultant for Edwards and Medtronic. Dr Armstrong has served as a consultant for Edwards and Medtronic; and has received research grants from Edwards. Dr Sondergaard has served as a consultant for Edwards and Medtronic; and has received research grants from Edwards and Medtronic. Dr Jones has served as a consultant for Edwards and Medtronic; and has received research grants from Edwards and Medtronic. Dr Cheatham has served as a consultant for Medtronic and NuMED. Dr Schubert has served as a proctor for Abbott, Edwards, Gore, Lifetech, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the repeatability of aphakic intraoperative wavefront aberrometry and compare it with preoperative and postoperative aberrometry., Setting: Department of Ophthalmology, Hanusch Hospital, Vienna, Austria., Design: Prospective case series., Methods: Patients scheduled for cataract surgery were each measured 3 consecutive times using Hartmann-Shack wavefront sensing (HS-WFS) preoperatively, intraoperatively in aphakia, and 2 months postoperatively after intraocular lens implantation by a single examiner. Intraclass correlation coefficients (ICCs) of spherical equivalent (SE) values were evaluated for each timepoint. Intrasubject standard deviation (Sw) as repeatability (Sr) with corresponding repeatability limit () and mean SE differences with corresponding limits of agreement (LoA) were calculated for comparison., Results: A high consistency of repeated measurements was found with ICCs above 0.9 for each of the 3 timepoints. Intraobserver repeatability (Sr) and repeatability limit (r) of intraoperative aberrometry SE measurements (30 eyes of 30 patients) were 0.34 diopters (D) and 0.95 D, respectively. The LoA for intraoperative aphakic SE across 3 consecutive measurements were -0.71 to +0.85 D. For comparison, Sr and r for phakic preoperative measurements in the cataractous state (30 eyes of 30 patients) and postoperative measurements in the pseudophakic state (24 eyes of 24 patients) were 0.33 D and 0.93 D and 0.23 D and 0.64 D, respectively. Similarly, the LoA for preoperative and postoperative SE measurements were -0.66 to +0.60 D and -0.27 to +0.45 D, respectively., Conclusions: HS-WFS test-retest reliability was high for all 3 timepoints, but the intraoperative setting resulted in a lower repeatability and broadened the agreement range., (Copyright © 2021 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Objectives: Moyamoya vasculopathy (MMV) is a rare stenoocclusive cerebrovascular disease associated with increased risk of ischemic and hemorrhagic stroke, which can be treated using surgical revascularization techniques. Despite well-established neurosurgical procedures performed in experienced centers, bypass failure associated with neurological symptoms can occur. The current study therefore aims at characterizing the cases of bypass failure and repeat revascularization at a single center. Methods: A single-center retrospective analysis of all patients treated with revascularization surgery for MMV between January 2007 and December 2019 was performed. Angiographic data, cerebral blood flow analysis [H 2 O PET or single-photon emission CT (SPECT)], MRI, and clinical/operative data including follow-up assessments were reviewed. Results: We identified 308 MMV patients with 405 surgically treated hemispheres. Of the 405 hemispheres treated, 15 patients (3.7%) underwent repeat revascularization (median age 38, time to repeat revascularization in 60% of patients was within 1 year of first surgery). The most common cause of repeat revascularization was a symptomatic bypass occlusion (80%). New ischemic lesions were found in 13% of patients prior to repeat revascularization. Persistence of reduced or progressive worsening of cerebrovascular reserve capacity (CVRC) compared with preoperative status was observed in 85% of repeat revascularization cases. Intermediate-flow bypass using a radial artery graft was most commonly used for repeat revascularization (60%) followed by re-superficial temporal artery to middle cerebral artery (re-STA-MCA) bypass (26%). High-flow bypass using a saphenous vein graft and using an occipital artery to MCA bypass was each used once. Following repeat revascularization, no new ischemic events were recorded. Conclusion: Overall, repeat revascularization is needed only in a small percentage of the cases in MMV. A rescue surgery should be considered in those with neurological symptoms and decreased CVRC. Intermediate-flow bypass using a radial artery graft is a reliable technique for patients requiring repeat revascularization. Based on our institutional experience, we propose an algorithm for guiding the decision process in cases of bypass failure., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Lucia, Acker, Schlinkmann, Georgiev and Vajkoczy.)

Frank's sign is a diagonal crease of the ear lobe, supposedly related to cardiac pathology, and has strongly been associated with coronary artery atherosclerosis. A total of 45 consecutive adult patients referred for autopsy in a one-and-a-half-year period were extensively studied. Samples from both the ear lobes were obtained for histopathology, as well as cardiac samples from all four cardiac compartments. When compared patients with Frank's sign and those without it had no statistical difference in age (p = 0.0575). There was however a statistically significant increased cardiac weight (p = 0.0005), left ventricular wall thickness (p = 0.0002), and right ventricular wall thickness (p = 0.0043). Histopathology obtained from the ear lobes revealed myoelastofibrosis in an arterial vessel, located at the base of the crease, diffuse fibrosis, and Wallerian-like degeneration, with eosinophilic inclusions in the peripheral nerves. These changes suggest a time-related progression of the crease-associated changes. Our data suggest a significant correlation between the morphological changes of the myocardium and the presence of the ear lobe creases, with arterial myoelastofibrosis, Wallerian-like degeneration in peripheral nerves and deep tissue fibrosis found in the base of the crease.

Background: In our study, we sought to analyse the mid-term results after interventional aortic coarctation (CoA) stenting with sequential dilation of the stent., Methods: The data of all 218 patients, who are above the age of 6 years and underwent CoA-stent implantation in our hospital, were retrospectively analysed on the rate of re-interventions, complications and arterial hypertension at a follow-up time of 31 months. To avoid any aortic complications, stents were deployed primarily not in full size and a second cardiac catheterisation for further dilatation was scheduled within 6-12 months after the stent implantation., Results: The median peak invasive systolic pressure gradient declined significantly from 26.2 mmHg to 2.7 mmHg after stenting. There was one procedure related death due to an aortic rupture after stent implantation. There were in total 33 (15.1%) procedure-related complications including femoral artery complications, stent fracture and stent dislocation (in 9, 9 and 7 patients, respectively). In 85 patients a re-dilatation and in 25 patients a second stent-implantation was necessary at the first re-intervention. The systolic blood pressure declined significantly from 144 mmHg to 131 mmHg after stenting. The number of patients being normotensive changed from 18% before stenting to 78.5% after stenting with adjusted antihypertensive medication., Conclusion: Aortic stenting is an effective means for CoA treatment. With sequential dilation of the stent, a very low rate of life-threatening procedural complications and mortality can be achieved. CoA stenting with proper antihypertensive medications results in better control of blood pressure., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: The folded valve is a manual shortening of the Melody device, which has been validated as a valuable therapeutic option for the management of dysfunctional right ventricular outflow tracts needing a short valved stent. In this article, we aimed to evaluate, in a multicenter cohort, the mid-term outcomes of patients in whom a percutaneous pulmonary valve implantation was performed using the folded valve technique., Methods: A 2012 to 2018 retrospective multicenter study was performed in 7 European institutions. All patients who benefit from percutaneous pulmonary valve implantation with a folded Melody valve were included., Results: A total of 49 patients (median age, 19 years [range 4–56], 63% male) were included. The primary percutaneous pulmonary valve implantation indication was right ventricular outflow tract stenosis (n=19; 39%), patched native right ventricular outflow tracts were the most common substrate (n=15; 31%). The folded technique was mostly used in short right ventricular outflow tracts (n=28; 57%). Procedural success was 100%. After a median follow-up of 28 months (range, 4–80), folded Melody valve function was comparable to the immediate postimplantation period (mean transvalvular peak velocity=2.6±0.6 versus 2.4±0.6 m/s, P>0.1; only 2 patients had mild pulmonary regurgitation). Incidence rate of valve-related reinterventions was 2.1% per person per year (95% CI, 0.1%–3.9%). The probability of survival without valve-related reinterventions at 36 months was 90% (95% CI, 76%–100%)., Conclusions: The folded Melody valve is a safe technique with favorable mid-term outcomes up to 6.5 years after implantation, comparable with the usual Melody valve implantation procedure. Complications and reinterventions rates were low, making this technique relevant in selected patients.

A novel non-iterative digital adaptive optics technique is presented in which the wavefront error is calculated using the phase difference between the pupil field and its digital copies translated by a pixel along the horizontal and vertical direction in the pupil plane. This method provides slope data per pixel, thus can generate > 50k local slope data samples for a circular pupil of diameter 256 pixels with high accuracy and dynamic range. It offers more than 12x faster computational speed in comparison to the sub-aperture based digital adaptive optics method. Furthermore, it is independent of any system parameters, the light distribution in the pupil plane, or the intensity of the image. The technique is useful in applications such as interferometric or digital holography based microscopy, metrology, and as digital wavefront sensor in adaptive optics, where focusing of light in the sample is involved that creates a guide star or where the sample itself exhibits guide star-like structures. This technique is implemented in a point scanning swept-source OCT at 1060 nm, and a large wavefront error with a peak to valley of 20 radians and root mean square error of 0.71 waves is detected and corrected in case of a micro-beads phantom sample. Also, human photoreceptor images are recovered from aberrated retinal OCT volumes acquired at eccentricities of 2 and 2.5 degrees from the fovea in vivo ., Competing Interests: Authors Abhishek Kumar, Stefan Georgiev, Matthias Salas, and Rainer A. Leitgeb are represented below as AK, SG, MS, and RAL. AK: Wavesense Engineering GmbH (E, P). SG, MS and RAL declare no conflict of interest., (Published by The Optical Society under the terms of the Creative Commons Attribution 4.0 License. Further distribution of this work must maintain attribution to the author(s) and the published article’s title, journal citation, and DOI.)

This analysis of ocular manifestations of the COVID-19 that can occur both in the acute and the post-COVID period focuses on pathological changes associated with hypercoagulation: thrombosis of the central retinal vein, occlusion of the central retinal artery, and decreased peripapillary perfusion. Potential changes in corneal nerve fibers (CNF) associated with coronavirus infection remain poorly understood. Meanwhile, previous studies have shown the possibility of using CNF as biomarkers of polyneuropathy (PNP)., Purpose: To study clinical and diagnostic features of post-COVID PNP., Material and Methods: We examined 9 female patients aged 32 to 51 years who had suffered an infection caused by SARS-CoV-2 of varying severity. The patients were divided into two groups: the first consisted of 6 patients with clinical manifestations of PNP in the form of neuropathic pain, the second - 3 patients without clinical manifestations. Patients of group 1 underwent comprehensive examination including neurological examination, confocal microscopy of the cornea ( in vivo CM), electroneuromyography (ENMG) of the nerves of the upper and lower extremities, quantitative sensory testing in the zone of painful sensations, while patients of group 2 only underwent in vivo CM., Results: All patients of the first group, within 5-40 days after the onset of infection caused by SARS-CoV-2, exhibited symptoms of damage to various parts of the nervous system (peripheral nerves, thoracic spinal roots, trigeminal nerve). The main - and in most cases the only - symptom of the disease was neuropathic pain syndrome. In Guillain-Barré syndrome, for the first time using in vivo CM, the following changes were revealed: enlargement of in Langerhans cells, shortening of CNF and their processes, presence of neuromas., Conclusion: The standard neurological examination of patients with post-COVID neuropathy should be supplemented with special diagnostic methods for assessment of structural and functional state of the peripheral nerves. The in vivo CM method is capable of non-invasive assessment of changes in thin CNF and, with accumulation of empirical data, can be included in the algorithm for diagnosing post-COVID PNP.

Introduction: Central and paracentral retinal function is often compromised in various retinal diseases. In these conditions, microperimetry is an important tool for assessing retinal sensitivity values. As retinal diseases are prevalent among the elderly, cataract often coexists. This study investigates the effect of cataract surgery on retinal sensitivity in patients with cataract without retinal disease., Material and Methods: A total of 30 patients already scheduled for cataract surgery were enrolled and microperimetry and visual acuity evaluation was performed before and after cataract extraction. The patients were allocated to 1 of 3 study groups in accordance with the main cataract subtype: nuclear, cortical, or posterior subcapsular (PSC) cataract., Results: Visual acuity increased significantly after cataract surgery (from 0.34 to 0.00 logMar, p < 0.001, paired t test). Similarly, median retinal sensitivity increased significantly from 23 dB (IQR 21-25 dB) to 27 dB (IQR 25.75-28 dB) (p < 0.001, Wilcoxon test). The increase of retinal sensitivity after cataract surgery was highest in the PSC cataract group., Conclusion: This study showed an increase in retinal sensitivity values after cataract removal, especially in the PSC group. Therefore, coexisting cataract should be considered when interpreting microperimetry results., (© 2020 S. Karger AG, Basel.)

Introduction: Vitrectomy with peeling of epiretinal membrane (ERM) and internal limiting membrane offers the chance for improvement of metamorphopsia and visual acuity. Microscope integrated intraoperative optical coherence tomography (iOCT) enables real-time imaging of retinal alterations during peeling, such as intraoperative transient retinal thickening owing to tractional forces during peeling. The aim of our study was to measure the amounts of transient retinal thickening due to tractional forces during membrane peeling, as documented with iOCT, and to analyze possible effects on postoperative retinal function., Methods: This prospective, monocenter study included patients scheduled for pars plana vitrectomy with membrane peeling due to an idiopathic ERM. During peeling, an iOCT device (ReScan700, Carl Zeiss Meditec AG) with continuous OCT-assistance during the peeling procedure, and video documentation of the peeling procedure, was used for the assessment of intraoperative transient retinal thickening owing to tractional forces during peeling. Directly before and 3 months after surgery, macular-OCT scans and microperimetry were performed., Results: Twenty-five eyes of 25 patients were included in the study. Microperimetry could be performed in all patients, while iOCT documentation could be analyzed in 22 patients. Transient retinal thickening owing to tractional forces during peeling could be observed in 14 patients (64%), with a median thickening to 143% of the normal (preoperative) retinal thickness at that location (IQR 132-163). Six patients (24%) developed new deep microscotomata as seen in microperimetry 3 months after surgery, among them were 2 patients who also had transient retinal thickening during peeling., Conclusion: New deep microscotomata developed only in a minority of patients with transient retinal thickening owing to tractional forces during peeling., (© 2020 S. Karger AG, Basel.)

Purpose: To evaluate overall patient satisfaction, spectacle independence, binocular visual acuity, rotational stability, prevalence of optical phenomena, and decentration and tilt after bilateral toric extended depth-of-focus intraocular lens (EDOF IOL) implantation targeted for micromonovision., Setting: Department of Ophthalmology, Hanusch Hospital, Vienna, Austria., Design: Prospective case series., Methods: The study included 52 eyes of 26 patients with regular corneal astigmatism from 0.75 to 2.60 diopters (D) that were implanted bilaterally with a toric EDOF IOL targeted for micromonovision. Postoperative visual acuity, astigmatism reduction, rotation, tilt, decentration, spectacle independence, patient satisfaction, and photic phenomena were assessed., Results: For the 52 eyes studied, binocular means expressed in logarithm of the minimum angle resolution for postoperative corrected distance, uncorrected distance, uncorrected intermediate, and uncorrected near visual acuities were -0.10 (±0.12), -0.01 (±0.13), 0.01 (±0.14), and 0.13 (±0.14), respectively. Mean refractive astigmatism reduction was 1.31 ± 0.67 D resulting in a mean refractive cylinder of 0.47 ± 0.46 D at the 3-month visit. Mean postoperative rotation was 3.5 ± 3.5 degrees, at the 3-month time point. Most prevalent dysphotopsia were halos, starburst, and glare affecting 6 (23%), 6 (23%), and 5 (19%) of 26 patients, respectively; 20 (77%) of 26 patients reported spectacle independence, with 19 (95%), 19 (95%), and 14 (70%) of 20 patients questioned being satisfied with distance, intermediate, and near vision, respectively., Conclusions: Toric EDOF IOL implantation targeted for micromonovision resulted in reliable reduction of preoperative astigmatism with a high degree of postoperative rotational predictability and centration, enabling functional distance, intermediate, and near vision, which manifested itself in high patient satisfaction.

Background: Catheterization in small children should be performed with the lowest diameter introducer sheaths to prevent permanent vessel damage. The objective of this study is to evaluate the clinical safety and efficacy of the Glidesheath Slender in small children., Methods and Results: We present a group of 52 patients (male: n = 36) with median age 118.5 days (min. 3; max. 1302), median weight: 5.3 kg (min. 1.4; max. 14.0), median height: 60.5 cm (min. 39; max. 102), and median body surface area 0.28 m2 (min. 0.12; max. 0.63) in whom percutaneous catheter interventions (n = 55) were performed via a Glidesheath Slender. In 49 children, the intervention was performed from femoral access (artery n = 35; vein n = 14) in 2 from the axillary arterial access and in 1 from the jugular venous access. In all patients, the vessel access was obtained under ultrasound guidance. After the catheterization, the pulse on the peripheral arteries (posterior tibial artery or radial artery) was palpable in all patients, and no signs for vessel dysfunction were present., Conclusion: The Glidesheath Slender effectively reduces the outer sheath diameter for various types of interventions in small children by one French, reducing the risk of vessel complications (stenosis, occlusion). Interventions via Glidesheath Slender in small patients are safe and feasible and extend the transcatheter possibilities in small children with congenital heart diseases.

Background: Percutaneous pulmonary valve implantation (PPVI) has become an important treatment of right ventricular outflow tract dysfunction. Studies directly comparing the long-term outcome of PPVI with the Melody valve to surgical pulmonary valve replacement (SPVR) are lacking., Methods: All patients treated with PPVI with the Melody valve and SPVR between January 2006 and December 2018 in our center were enrolled into a database and investigated with a standard follow-up protocol. The current study compares the outcomes in means of survival, reinterventions, infectious endocarditis, and performance of the valves., Results: The study included 452 patients, of whom 241 were treated with PPVI with the Melody valve and 211 patients with SPVR with different types of valves. Median follow-up time was 5.4 years (3 months to 12.5 years), and the total observation was 2449 patient-years. Estimated survival after 10 years was 94% in the Melody group and 92% in the SPVR group ( P =0.47). There was no difference in the estimated survival free of surgery on the implanted valve at 10 years (Melody, 87%, versus SPVR, 87%; P =0.54) or in the survival with the originally implanted pulmonary valve (Melody group, 80%; SPVR group, 73%; P =0.46) between both groups. The annualized incidence of infective endocarditis was 1.6% in the Melody group and 0.5% in the SPVR group, and the estimated survival free of endocarditis did not differ significantly between groups (Melody group, 82%; SPVR group, 86%; P =0.082). Survival free of valve replacement because of infective endocarditis was comparable between both groups (Melody, 88%; SPVR, 88%; P =0.35)., Conclusions: PPVI with the Melody valve and SPVR provides similar survival, freedom of reinterventions, and infective endocarditis with or without the need of replacement of the pulmonary valve. Being less invasive, PPVI should be considered a method for treatment for patients with dysfunctional right ventricular outflow tracts.

Context: The relevance of hyponatremia has been acknowledged by guidelines from the United States (2013) and Europe (2014). However, treatment recommendations differ due to limited evidence., Objective: In hyponatremia following pituitary surgery-caused by the syndrome of inappropriate antidiuretic hormone (SIADH) secretion-we compared fluid restriction with the pharmacological increase of water excretion by blocking the vasopressin 2 receptors with tolvaptan at a low and a moderate dose., Design: Prospective observational study., Setting: Neurosurgical Department of a University hospital with more than 200 surgical pituitary procedures per year., Patients: Patients undergoing pituitary surgery and developing serum sodium below 136 mmol/L. The diagnosis of SIADH was established by euvolemia (daily measurement of body weight and fluid balance), inappropriately concentrated urine (specific gravity), and exclusion of adrenocorticotropic and thyroid-stimulating hormone deficiency., Intervention: Patients were treated with fluid restriction (n = 40) or tolvaptan at 3.75 (n = 38) or 7.5 mg (n = 48)., Main Outcome Measures: Treatment efficacy was assessed by the duration of hyponatremia, sodium nadir, and length of hospitalization. Safety was established by a sodium increment below 10 mmol/L per day and exclusion of side effects., Results: Treatment with 7.5 mg of tolvaptan resulted in a significant attenuation of hyponatremia and in a significant overcorrection of serum sodium in 30% of patients. The duration of hospitalization did not differ between treatment groups., Conclusions: Tolvaptan at a moderate dose is more effective than fluid restriction in the treatment of SIADH. Overcorrection of serum sodium may be a side effect of tolvaptan even at low doses., (© Endocrine Society 2020.)

Objectives: This study aimed to compare pulmonary artery (PA) growth between patients who received a right ventricle-to-PA (RV-PA) shunt and those who received a modified Blalock-Taussig shunt (mBTS)., Methods: All consecutive patients with hypoplastic left heart syndrome who underwent the Norwood I procedure between 2001 and 2017 were included in the study. Pre-stage 2 angiograms were analysed to measure the size of the PA. The Nakata index was calculated to estimate PA growth. The ratio of the right PA to left PA cross-sectional area (RPA/LPA) was used to calculate the difference in growth between the 2 branches. Study end points were shunt failure, shunt-related mortality and growth of the PAs., Results: A total of 223 patients with hypoplastic left heart syndrome (RV-PA group = 137, mBTS group = 86) underwent the Norwood I procedure, and 186 patients (RV-PA n = 116, mBTS n = 70) achieved the stage 2 procedure. PA growth was better in patients with mBTS (Nakata index: RV-PA = 282, mBTS = 315 mm2/m2, P = 0.021). LPA growth was worse compared to RPA growth in both groups (RPA/LPA: RV-PA = 1.21, mBTS = 1.29, P = 1.0). Patients with RV-PA shunts experienced more frequent shunt stenosis compared to patients with mBTS (26 vs 2, P < 0.010). Freedom from shunt failure was 83.3 ± 3.2% and 94 ± 2% at 6 months in the RV-PA and mBTS groups, respectively (P = 0.003)., Conclusions: PA growth is significantly better in patients who received an mBTS. Moreover, patients with an RV-PA shunt more frequently experienced shunt failure due to shunt stenosis. However, survival after the NW procedure is not shunt dependent and growth of the LPA is less pronounced than RPA, regardless of the shunt type., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Purpose: Primary open-angle glaucoma (POAG) is a chronic progressive optic neuropathy, leading to degeneration of retinal ganglion cells and characteristic morphological changes at the optic disc. In advanced stages of the disease, functional tests, such as standard automated perimetry (SAP), are the main diagnostic tools to detect progression. Compared to SAP, microperimetry offers fundus imaging with motion tracking to ensure precise stimulation of certain locations of the retina. Aim of the study was to assess reproducibility of microperimetry compared to SAP in patients with POAG., Methods: This prospective monocenter study included patients suffering from POAG with visual field defects in the central 20° zone. After inclusion into the study, 3 consecutive study visits were scheduled within 1 month, assessing microperimetry and SAP at each visit., Results: From 19 patients recruited, data from 18 patients could be analyzed. No significant difference between study visits could be detected in mean retinal sensitivity in microperimetry and SAP (microperimetry p = 0.401; SAP p = 0.644; Friedman's 2-way analysis of variance). The intraclass-correlation coefficient was 0.981 (95% CI 0.978-0.984) for microperimetry and 0.948 (95% CI 0.941-0.955) for SAP. Absolute agreement between deep scotoma points was found in 81 test locations (79%) in microperimetry and in 35 test locations (20%) in SAP (p = 0.003, chi-square test)., Conclusions: Microperimetry and conventional perimetry showed high reproducibility, with slightly better performance of microperimetry. However, the reduced angle of visual field in microperimetry limits its application to central glaucomatous field damage., (© 2019 S. Karger AG, Basel.)

In this work, the partition coefficients K and diffusion lengths L D of radon in some polymers are experimentally determined for several temperatures in the range T = 5-31 °C. Some of the obtained values are compared to published data available for the given temperatures. It is shown that the temperature dependencies of the partition coefficients K ( T ) , the diffusion lengths L D ( T ) , and the permeabilities P ( T ) could be described analytically for the studied temperature range 5-31 °C. This allows estimation of these quantities in the given temperature range and quantitative description of the transport of radon in the studied polymers.

Background: Pre-stenting is a widely used technique for transcatheter pulmonary valve implantation (TPVI). For the Melody valve a pre-stent creates a reliable and solid landing zone. In contrast to the Melody valve, the Edwards Sapien valve consists of a strong balloon expandable stent designed for implantation in the aortic position. The usage of a Sapien valve in pulmonary position might therefore obviate the need of a pre-stent., Methods: This retrospective, single centre study reviewed the procedural outcomes of patients receiving the Sapien XT transcatheter valve in pulmonary position without prior implantation of a pre-stent. All consecutive patients with dysfunctional right ventricle to pulmonary artery (RV-PA) conduits or with dysfunctional pulmonary valve treated at the German Heart Centre in Munich were included in this study., Results: We report on successful implantation of a Sapien XT/3 without usage of a pre-stent., Conclusions: Abandonment of the pre-stent simplified the procedure and reduces the radiation burden for the patients., Competing Interests: Conflicts of Interest: P Ewert is proctor for Medtronic and Edwards. A Eicken is proctor for Medtronic. The other authors have no conflicts of interest to declare., (2019 Cardiovascular Diagnosis and Therapy. All rights reserved.)

Objectives: The aim of this study was to report long-term outcomes after percutaneous pulmonary valve implantation (PPVI)., Background: Excellent short- and mid-term results after PPVI for right ventricular outflow tract (RVOT) dysfunction have been reported. Data on long-term results after PPVI are scarce., Methods: All 226 patients treated with PPVI at a single institution were prospectively enrolled in a database and included in the study. Follow-up information regarding outcomes was collected. Risk-factor analysis for death and reinterventions was performed., Results: Follow-up data (up to 11 years) were available in 96% of the patients. At the end of the study period, 219 patients (92.8%) still lived with the initially implanted valve. Seven patients died, 2 of them from procedure-related complications. Seventeen patients (7.2%) needed valve replacement surgically (n = 11) or percutaneously (n = 6) for infectious endocarditis (n = 10) or valve degeneration (n = 7). In the remaining patients, the valves retained excellent function, and right ventricular dimensions and exercise capacity improved. A post-interventional RVOT gradient >15 mm Hg was a risk factor for death (hazard ratio: 7.57; 95% confidence interval: 1.26 to 45.38; p = 0.027) and for valve failure (hazard ratio: 3.76; 95% confidence interval: 1.43 to 9.93; p = 0.007). The best outcome was achieved with RVOT pre-stenting and a post-interventional gradient <15 mm Hg, resulting in an estimated event-free survival rate of 88% at 10 years., Conclusions: Patients after PPVI have excellent long-term outcomes. Right ventricular volumes, function, and exercise capacity improve significantly. A residual RVOT gradient <15 mm Hg was associated with the best outcome., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The application of the compact disk (CD) method for radon measurements at mines, caves and other workplaces needs testing under highly variable exposure conditions. We present the results from a blind comparison of CDs exposed in the Laboratory of Natural Radiation (Saelices el Chico, Spain). During the exposure the temperature varied from 6.5 to 24.9 °C (average 12.6 °C) and the 222 Rn activity concentrations varied from <10 Bq m -3 to 147 kBq m -3 . Good correspondence was observed between the integrated 222 Rn activity concentration determined by the reference instruments in the laboratory (122,500 ± 6100 kBq h m -3 ) and that assessed by analysis of the CDs at a depth 80 µm beneath the front surface (118,000 ± 12,000 kBq h m -3 ) and at a depth of 120 µm (106,000 ± 12,000 kBq h m -3 ). The theoretical modeling of the CD response under variable temperature and radon concentration suggested that the small bias is probably due to the time variation of the calibration factor because of the time variations of the temperature.

Objectives: The aim of this study was to investigate the impact of an early extubation strategy on the outcome following extracardiac total cavopulmonary connection., Methods: From 1999 through 2017, 458 patients underwent extracardiac total cavopulmonary connection; 257 (56%) patients were managed with an early extubation strategy adopted in 2009 (group A). Their outcome was compared with those of 201 (44%) patients treated before 2009 (group B). In group A, the outcome of unstable patients, defined as >75th percentile for volume administered and inotrope scores, was compared with those of stable patients., Results: Ventilation time (median: 4 h vs 16 h, P < 0.001), fluid volume administered during the first 24 h (mean: 110 ml/kg vs 164 ml/kg, P = 0.003), chest tube duration (median: 3 days vs 4 days, P = 0.028) and length of intensive care unit stay (median: 6 days vs 7 days, P = 0.001) were less in group A than in group B. The reintubation rate (7% vs 6%, P = 0.547) and early mortality (0.8% vs 1.5%, P = 0.465) were similar between groups. The 80 unstable group A patients received more inotropic support (P < 0.001) and fluid volume (P < 0.001) than stable patients, but the ventilation time (6 h vs 5 h, P = 0.220), the reintubation rate (10% vs 6%, P = 0.283) and the length of intensive care unit stay (7 days vs 6 days, P = 0.590) were similar. In unstable patients, mean arterial pressure before extubation was significantly lower than stable patients (P = 0.001). However, mean arterial pressure in unstable patients increased significantly (P < 0.001) soon after extubation, and became similar to the value in stable patients., Conclusions: Early extubation following extracardiac total cavopulmonary connection improves postoperative haemodynamics and recovery regardless of the initial haemodynamic status., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Concern has been raised that Sprotte needles predispose to spinal anes-thesia failure. Nevertheless, these needles are associated with a low incidence of postdural puncture headache. The impact of the paramedian approach to postdural puncture headache remains controversial. The objective of this prospective randomized study was to compare Sprotte, Quincke and Atraucan needles as well as the midline and the paramedian approach in terms of postdural puncture headache and spinal anesthesia failure in patients undergoing Caesarean section., Methods: 655 patients were randomized to 5 groups. A midline approach was used in four groups. The spinal needles were the 25G Sprotte, 27G Sprotte, 26G Atraucan and 25G Quincke. In the fifth group a 25G Quincke needle was used by the paramedian approach., Results: The incidence of postdural puncture headache was 0% in both 25G and 27G Sprotte groups, 2.5% in the 26G Atraucan group, and 7.2% and 2.7% in the 25G Quincke midline and paramedian approach respectively. A significant difference in terms of postdural puncture headache was found between 25G Sprotte and 25G Quincke needles (P = 0.004), while the failure rate was similar between these two needles. A significant difference in spinal anesthesia failure rate was observed between midline and paramedian approaches (P = 0.041)., Conclusions: Sprotte but not Atraucan needle design correlates with lower incidence of postdural puncture headache compared to Quincke design. Sprotte needles are not associated with a higher spinal anesthesia failure compared to Quincke needles. The incidence of postdural puncture headache by the paramedian approach is not significantly reduced whereas the spinal anesthesia failure rate is increased in comparison to the midline approach.

Purpose: Internal limiting membrane (ILM) flap transposition in surgical repair of macular holes represents a new technique offering good anatomical success rates with large macular holes. The aim of the study was to examine microperimetric outcomes 1 year after ILM flap transposition for surgical repair of macular holes., Methods: Patients with idi-opathic macular holes scheduled for 23-G pars plana vitrectomy with ILM peeling, ILM flap transposition, and SF6 tamponade were examined in a prospective case series. Distance corrected visual acuity (DCVA), optical coherence tomography, and microperimetry were measured before and 1 year after surgery., Results: In all eyes, closure of the macular hole could be achieved. While foveal sensitivity improved in 71%, perifoveal sensitivity improved in 86% of the cases. DCVA improved in 83% and was unchanged in 17% of the cases., Conclusions: Beside visual acuity, foveal and perifoveal macular sensitivity improved, underlining the functional success of surgery after ILM peeling with ILM flap transposition., (© 2018 S. Karger AG, Basel.)

This work presents the results from simultaneous measurements of 222Rn in soil-gas by compact discs (CDs) and diffusion chambers. The measurements were performed in three terrains with high, medium and low 222Rn-in-soil-gas concentrations. Good correlations between the CD measurements and the reference diffusion chamber measurements are observed. The results indicate that it is important to apply temperature correction in the CD measurements, in order to account for the actual temperature during the exposure of the CDs in the soil.

Background: Patients with congenital cardiovascular disease involving the right ventricular outflow tract and with prosthetic valves in the heart are at high risk for developing infective endocarditis (IE). Recently, there has been concern about relatively high rates of IE after percutaneous pulmonary valve implantation (PPVI). Although there are factors specific to percutaneous valves that could plausibly contribute to the risk of IE, including procedural steps prior to implantation such as crimping the valved stent or mechanical forces during dilation, little is known about actual risk factors for this complication., Methods and Results: The purpose of this study was to assess the incidence rate of IE after PPVI in a single centre long-term experience. The cumulative follow-up time comprised 883.4 patient years for 226 transcatheter valves implanted in the pulmonic position. The annualized incidence rate of IE for all patients receiving valved stents in the RVOT was 1.9%. Freedom from IE 8 years after PPVI was estimated at 87%. The probability for valve removal because of IE was estimated after 8 years at 7%., Conclusion: In our experience, the incidence rate of IE after PPVI is acceptable and comparable to surgically implanted biological valves. Despite some IE events, freedom from reoperation was high and there was good performance of the valve in long-term follow-up., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: This study aimed to develop a method for retrieval of the new meshed nitinol atrial septal defect occluders - Ceraflex and Occlutech., Background: The newly developed atrial septal defect occluders have potential benefits considering implantation, but concerns regarding their removal in case of embolisation have been raised., Methods: Over 21 years, 1449 patients underwent interventional atrial septal defect occlusion in our institution. We reviewed the cases of embolisation of the device, developed a strategy for device removal, and tested it on the benchside and in animal tests., Results: In 11 patients (0.8%), the intended atrial septal defect occlusion was complicated by an embolisation of the device. In contrast to the Amplatzer septal occluders, retrieval of Occlutech devices larger than 16 mm with snare techniques was impossible. In benchside tests, this was confirmed and a new method for removal of large meshed devices was developed. This involved the commercially available Maslanka® biopsy forceps. The feasibility of this technique in vivo was tested in a pig model. During animal tests, using the Maslanka biopsy forceps it was possible to interventionally retrieve embolised Ceraflex and Occlutech devices of different sizes - 10, 16, 30, and 40 mm - into a 12-F sheath., Conclusion: It was impossible to retrieve Occlutech and Ceraflex devices larger than 16 mm into a large sheath in vivo and during benchside tests. However, this was feasible on the bench and in vivo using the Maslanka biopsy forceps even with the largest available devices.

Background: To investigate the feasibility and mid-term results of percutaneous pulmonary valve implantation (PPVI) in patients with conduit free or "native" right ventricular outflow tracts (RVOT)., Methods and Results: We identified all 18 patients with conduit free or "native" right ventricular outflow tract, who were treated with percutaneous pulmonary valve implantation (PPVI) in our institution. They were divided into two groups - these in whom the central pulmonary artery was used as an anchoring point for the preparation of the landing zone (n=10) for PPVI and these, in whom a pulmonary artery branch was used for this purpose (n=8). PPVI was performed successfully in all patients with significant immediate RVOT gradient and pulmonary regurgitation grade reduction. Four patients had insignificant paravalvular regurgitation. In one patient the valve was explanted after 4months because of bacterial endocarditis. A follow-up of 19 (4-60) months showed sustained good function of the other implanted valves. The MRI indexed right ventricular end diastolic volume significantly decreased from 108(54-174) ml/m 2 before the procedure to 76(60-126) ml/m 2 six months after PPVI, p=0.01., Conclusions: PPVI is feasible with good mid-term results in selected patients with a "native" RVOT without a previously implanted conduit. Creating a stable landing zone with a diameter less than the largest available valve (currently 29mm) is crucial for the technical success of the procedure. Further studies and the development of new devices could widen the indications for this novel treatment., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: To evaluate the test-retest reproducibility of a novel microperimeter with fundus image tracking (MP3, Nidek Co, Japan) in healthy subjects and patients with macular disease., Methods: Ten healthy subjects and 20 patients suffering from range of macular diseases were included. After training measurements, two additional microperimetry measurements were scheduled. Test-retest reproducibility was assessed for mean retinal sensitivity, pointwise sensitivity, and deep scotoma size using the coefficient of repeatability and Bland-Altman diagrams. In addition, in a subgroup of patients microperimetry was compared with conventional perimetry., Results: Average differences in mean retinal sensitivity between the two study measurements were 0.26 ± 1.7 dB (median 0 dB; interquartile range [IQR] -1 to 1) for the healthy and 0.36 ± 2.5 dB (median 0 dB; IQR -1 to 2) for the macular patient group. Coefficients of repeatability for mean retinal sensitivity and pointwise retinal sensitivity were 1.2 and 3.3 dB for the healthy subjects and 1.6 and 5.0 dB for the macular disease patients, respectively. Absolute agreement in deep scotoma size between both study days was found in 79.9% of the test loci., Conclusion: The microperimeter MP3 shows an adequate test-retest reproducibility for mean retinal sensitivity, pointwise retinal sensitivity, and deep scotoma size in healthy subjects and patients suffering from macular disease. Furthermore, reproducibility of microperimetry is higher than conventional perimetry., Translational Relevance: Reproducibility is an important measure for each diagnostic device. Especially in a clinical setting high reproducibility set the basis to achieve reliable results using the specific device. Therefore, assessment of the reproducibility is of eminent importance to interpret the findings of future studies.

Background: Increased coagulation activity has been established in paroxysmal atrial fibrillation (PAF), but data on the anticoagulant system are scarce., Purpose: To examine the protein C anticoagulant pathway in the early hours of the disease., Materials and Methods: Fifty-one patients (26 men and 25 women; mean age 59.84 ± 1.60 years) and 52 controls (26 men and 26 women; mean age 59.50 ± 1.46 years) were selected for the study. Protein C antigen and its activity, total protein S, free protein S and its activity, soluble forms of endothelial protein C receptor (sEPCR), and thrombomodulin (sTM) were examined in the plasma., Results: The indicators were studied in patients between the 2nd and the 24th hour after the onset of arrhythmia. Levels of protein C were significantly elevated in patients compared to controls (111.40% ± 6.66% vs 94.83% ± 4.47%; P = .039). Protein C activity showed significant reduction in PAF (73.13% ± 5.80% vs 103.3% ± 3.80%; P < .001). Total protein S levels did not differ significantly (108.20% ± 4.07% vs 102.40% ± 3.65%; P = .30). Free protein S (76.81% ± 6.01% vs 122.10% ± 3.97%; P < .001) and its activity (71.39% ± 6.27% vs 119.50% ± 6.54%; P < .001) were reduced in patients. Higher levels of sEPCR (203.10 ± 10.33 vs 133.10 ± 7.37 ng/mL; P < .001) and sTM (6.50±0.40 vs 4.48±0.28 ng/mL; P < .001) were measured in PAF., Conclusion: Protein C activity is reduced still in the first hours (until the 24th hour) of PAF clinical manifestation, determining reduced activity of the anticoagulant pathway as a whole. The established low levels of free protein S and its activity as well as low sEPCR and sTM levels are a possible explanation of the changes in protein C activity.

We report a case of successful, life-saving implantation of a covered Cheatham Platinum stent, an all-in-one NuDEL catheter system, in an adult with aortic rupture after bare-metal stenting for re-coarctation of the aorta.

Objectives: We aimed to investigate whether early postoperative extubation following the Fontan operation is universally feasible and can be used as a management tool in unstable patients., Methods: All patients undergoing the Fontan operation in our centre between 2004 and 2013 (n=253) were analysed. Until 2008, patients were extubated according to standard criteria and comprised group 1. Group 2 included all patients presenting after 2009, when early extubation was always aimed regardless of the haemodynamic status. Patients who exceeded the 75th percentiles for volume requirements and inotrope scores for the respective group were defined as unstable. Comparisons of outcomes between groups and subgroups and analysis of the changes in haemodynamic and treatment parameters with extubation in unstable patients after 2009 were performed., Results: Compared with group 1, patients from group 2 were ventilated for shorter duration (p<0.001), had similar re-intubation rates (p=0.50), and needed less volume (p=0.01). In group 2, the unstable patients were not ventilated for longer durations (p=0.19), but had higher re-intubation rates (p=0.03) than the stable patients. Compared with the unstable patients from group 1, the unstable patients from group 2 were ventilated for shorter duration (p<0.001), had similar re-intubation rates (p=0.66), and needed less volume (p=0.006). There was a significant acute and sustained increase in mean arterial pressure with extubation and a parallel reduction in volume requirements and inotrope scores in the unstable patients from group 2., Conclusions: Timely extubation is universally applicable following the Fontan operation. Early postoperative extubation can be valuable for improving Fontan haemodynamics.

Objectives: This study sought to investigate the impact of tricuspid regurgitation (TR) on right ventricular function after percutaneous pulmonary valve implantation (PPVI)., Background: PPVI provides a less invasive alternative to surgery in patients with right ventricular-to-pulmonary artery (RV-PA) conduit dysfunction. Recovery of the right ventricle has been described after PPVI for patients with pulmonary stenosis and for those with pulmonary regurgitation. Additional TR enforces RV dysfunction by supplemental volume overload. Limited data are available on the potential of the right ventricle to recover in such a specific hemodynamic situation., Methods: In a matched cohort study, we compared patients who underwent PPVI with additional TR with those without TR., Results: The degree of TR improved in 83% of the patients. In our patients (n = 36) exercise capacity and right ventricular volume index improved similarly 6 months after PPVI in patients with and without important TR. None of them had significant TR in the long-term follow-up of median 78 months., Conclusions: PPVI improves not only RV-PA-conduit dysfunction, but also concomitant TR. In patients with a dysfunctional RV-PA conduit and TR, the decision whether to fix TR should be postponed after PPVI., (Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

There are no studies to date on the early changes in the hemostasis profile of patients with paroxysmal atrial fibrillation (PAF).Given the key role of the fibrinolytic system in maintaining blood fluidity, our aim was to examine its activity in patients with clinical manifestation of the disease <24 hours.We studied 51 nonanticoagulated patients with a first episode of the disease (26 men, 25 women; mean age 59.84 ± 1.60 years) and 52 controls (26 men, 26 women; mean age 59.50 ± 1.46 years) who matched the patients in terms of gender, age, comorbidities, and conducted treatment. Using enzyme-linked immunoassays and colorimetric assays we assessed the plasminogen activity, tissue plasminogen activator level (t-PA), plasminogen activator inhibitor 1 activity (PAI-1), α2-antiplasmin activity (α2-AP), D-dimer level, and vitronectin level. Blood samples were collected immediately after hospitalization.Patients were hospitalized between the second and twenty fourth hours (mean 8.14 ± 0.76 hours) after the onset of PAF. Compared to controls, plasminogen (159.40 ± 4.81 vs 100.2 ± 2.88%, P < 0.001) and t-PA levels (11.25 ± 0.35 vs 6.05 ± 0.31 ng/mL, P < 0.001) were significantly higher in the patient group. PAI-1 activity (7.33 ± 0.37 vs 15.15 ± 0.52 AU/mL, P < 0.001) and α2-AP (112.9 ± 2.80 vs 125.60 ± 3.74%, P < 0.05) as well as vitronectin plasma levels (134.7 ± 5.83 vs 287.3 ± 10.44 mcg/mL, P < 0.001) were lower in the PAF group. Conversely, the levels of D-dimer in patients were significantly higher (0.53 ± 0.07 vs 0.33 ± 0.02 ng/mL, P < 0.05).Early changes in the fibrinolytic system occur in PAF, suggesting their close relationship with the manifestation of the disease. There is high plasma fibrinolytic activity, during the very first 24 hours of the disease, which is most likely a pathophysiological response to the intensified procoagulation process., Competing Interests: The authors have no conflicts of interest to disclose.

Background: Data on coagulation changes in paroxysmal atrial fibrillation (PAF) are scarce. The aim of this study was to examine plasma antithrombin (AT) levels and activity as well as thrombin-antithrombin (TAT) complex levels in the early hours of the clinical manifestation of PAF., Methods: Fifty-one patients (26 men and 25 women; mean age 59.84 ± 1.60 years) were consecutively selected with PAF duration < 24 hours, and 52 controls (26 men and 26 women; mean age 59.50 ± 1.46 years) matched the patients in terms of gender, age and comorbidities. Plasma levels and activity of AT and levels of the covalent TAT complex were studied once in each study participant., Results: AT plasma levels in PAF patients were statistically significantly lower compared to controls (164.69 ± 10.51 vs. 276.21 ± 8.29 μg/mL, P < 0.001). Plasma activity of the anticoagulant was also significantly lower in PAF (71.33±4.87 vs. 110.72±3.09%, P < 0.001). TAT complex concentration in plasma was higher in the patient group (5.32 ± 0.23 vs. 3.20 ± 0.14 μg/L, P < 0.001)., Conclusion: We can say that PAF is associated with significantly reduced AT levels and activity and increased levels of TAT complex during the first 24 hours after its manifestation. These changes indicate a reduced activity of AT anticoagulant system, which is a probable prerequisite for the established enhanced coagulation (high TAT complex levels).