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Mitral valve replacement in infants is challenging and there are limited alternative valves available. Since the Boston group published their first report on alternative valves for mitral valve replacement in infants, there has been a growth in the literature on the topic, mostly based on the use of a stented bovine jugular vein graft (Melody® valve). The challenges of the Melody valve are firstly in its length of 28 mm unexpanded, which has the potential to cause left ventricular outflow tract obstruction, and secondly, the valve needs mechanical dilatation, which is laborious. A modified No-React® Injectable Biopulmonic™ Prosthesis (Bio Integral Surgical, Inc., Mississauga, ON, Canada) which is shorter (19 mm) and simpler in that it is self-expanding was implanted in a 14-month-old child to replace her mitral valve. The operation was successful and the short-term function of the prosthesis is good.

Background: Every year, around 15 million children, in developing countries, die or develop life-long disabilities because of congenital cardiac diseases. In this report we measure the effect of a pediatric cardiac surgery humanitarian project on the health of the individual and on the potential influence this has on the countries economy and its growing health services.Methods: We collected and analyzed data from the Italian NGO, Mission Bambini's database, including all congenital cardiac missions undertaken in Cambodia between 2012 and 2019. DALY's (Disability Adjusted Life Years) saved by the humanitarian mission were estimated and used to reflect on the impact this had on the populations economy. Progression in the local medical teams skills emulated the advancements made in the health sector of the region.Results: Between 2012 and 2019, 128 patients underwent a congenital cardiac operation at Angkor Hospital for Children at Siem Reap, Cambodia. The median age was 6 years. The majority of the pathologies included VSD, TOF, ASD. The mean Aristotle's Complexity Score was 6. Post-operative mortality was 0.8% (1/128). The cost-effectiveness analysis identified 5.360 DALY's saved by surgery. The competency of the local team was progressive with them being able to handle more complex cases on subsequent missions.Conclusion: In developing Countries, performing congenital cardiac surgery cases can be carried out successfully with improvement in both the economy and the health system of the country by increasing the years and the quality of life of the working population and developing the expertise of the regional team.

Simulations offer the potential of improving product and development process quality. However, a lack of overview of existing simulation methods and of documentation may make it difficult to apply them efficiently along the entire development process. To tackle this problem, a knowledge-based framework was developed to enhance simulation knowledge management, give an overview over all possible simulations, and provide means to standardize simulation processes for experts. This paper presents the first industrial evaluation of the framework concept by two workshops. The results exhibit a wide interest in the knowledge-based framework in industry and demonstrate aspects for further industrial application. Critical points particularly include an intuitive user interface and the integration into the specific IT environment of a company, which will be the next steps for evaluating the system in industrial conditions.

OBJECTIVESRepair of Tetralogy of Fallot (TOF) has currently excellent results with either transventricular or transatrial approach. However, it is unclear as to which has better late outcomes and what role of residual pulmonary valve (PV) regurgitation in the long term is. We report on late clinical outcomes after repair in a large series of patients with TOF, focusing on the type of surgical technique.METHODSThis analysis is a retrospective multicentre study on patients undergoing TOF repair in infancy. The exclusion criteria of the study were TOF with pulmonary atresia or absent PV.RESULTSWe selected 720 patients who had undergone TOF repair (median age 5.7 months, interquartile range 3.7–11.7). Preoperative cyanotic spells occurred in 18%. A transatrial repair was performed in 433 (60.1%) patients. The PV was preserved in 249 (35%) patients, while the right ventricular outflow tract was reconstructed with a transannular patch (60.4%) or a conduit (4.6%) in the rest of the patients. At a median follow-up of 4 years (range 1–21, 86% complete), 10 (1.6%) patients died, while 39 (6.3%) patients required surgical reoperation and 72 (11.7%) patients required an interventional procedure. The propensity match analysis showed that the incidence of postoperative complications and adverse events at follow-up were significantly increased in patients undergoing transventricular approach repair with transannular patch (P = 0.006) and PV preservation was a significant protective factor against postoperative complications (P = 0.009, odds ratio 0.5) and late adverse events (P = 0.022).CONCLUSIONSSurgical repair of TOF in infancy is a safe procedure, with good late clinical outcomes. However, transatrial approach and PV preservation at repair are associated with lower early and late morbidity.

ResumenEl trastorno de ansiedad generalizada (TAG) se caracteriza por una preocupación excesiva (anticipación aprensiva) e incontrolable que provoca niveles elevados de ansiedad y de malestar emocional. En los últimos años, el modelo metacognitivo (Wells, 1999) cuenta con fuerte apoyo empírico y estudia dicho trastorno focalizando su atención en el procesamiento cognitivo subyacente implicado. Se presenta a continuación el caso clínico de un varón de 33 años de edad con diagnóstico de F41.1, trastorno de ansiedad generalizada [300.02], según criterios DSM-V (APA, 2013). Basándonos en la terapia cognitivo conductual y haciendo especial hincapié en el modelo antes citado, se detalla el proceso de intervención terapéutica llevado a cabo así como los resultados de la evaluación pre y postratamiento que muestran la eficiencia y eficacia del mismo.AbstractGeneralized anxiety disorder (GAD) is characterized by excessive and irrepressible worry (apprehensive anticipation) that causes high anxiety levels and emotional distress. In the last few years, the metacognitive model (Wells, 1999) has had a strong empirical support and studied said disorder focusing its attention on the underlying cognitive processing involved. Next, the clinical case of a 33-year-old male with a diagnosis of F41.1, Generalized Anxiety Disorder [300.02], according to DSM-V criteria (APA, 2013), will be presented. Based on the cognitive behavioral therapy and with particular emphasis on the model cited above, the therapeutic intervention process conducted is detailed as well as the results of the pre- and post-treatment evaluation that show its efficiency and effectiveness.

Understanding what types of knowledge need to be managed is essential for researchers and practitioners in order to implement knowledge management within the engineering design process. However, obtaining a fast overview from literature of the types of knowledge to consider is not an easy task. In order to identify the types of knowledge in engineering design, we conducted a literature review searching for classifications of design knowledge. We analysed the types of knowledge from the literature and summarized them in a taxonomy to classify design knowledge. The taxonomy can be used as a theoretical base for researchers and practitioners dealing with knowledge management in engineering design, in order to support the understanding of the type of knowledge to consider for their purposes. It can be also used to classify the knowledge of a company in order to match it with the situations during the design process that each of the identified knowledge types can support.

Implantable cardioverter-defibrillator (ICD) is the gold standard therapy for the prevention of sudden cardiac death. Nevertheless, ICD placement in the paediatric population is still limited because of several technical difficulties. Several implantation techniques have been proposed but experience in infants with very low weight and less than 6 months is very limited. We herein describe a case of a minimally invasive ICD epicardial implantation in a 4-month-old infant weighing 5 kg. A diagnosis of arrhythmic cardiomyopathy with left ventricular non-compaction disease with ventricular tachycardia storms, QT prolongation and Wolff-Parkinson-White pattern was made. Antiarrhythmic drugs, radiofrequency ablation and sympathetic denervation were not effective. ICD implantation was successful allowing the infant to survive and bridging to heart transplantation.

Summary Surgical site infection after heart surgery increases morbidity and mortality. The method of presurgical hand disinfection could influence the infection risk. From February to April 2003, we compared the microbiological efficacy of hand-rubbing (R) and hand-scrubbing (S) procedures. The surgical team alternately used hand-scrubbing or hand-rubbing techniques every two weeks. Fingertip impressions were taken before and immediately after hand disinfection, every 2 h and at the end of the operation. Acceptability of hand rubbing was assessed by a questionnaire. Mean durations of surgical procedures were 259 ± 68 and 244 ± 69 min for groups S and R respectively ( P = 0.43). Bacterial counts immediately after hand disinfection were comparable with the two techniques, but significantly lower in group R at the end of surgery. No differences were observed between the percentages of negative samples taken after 2 h, 4 h and at the end of surgery between the two groups. Bacterial skin flora reduction immediately after hand disinfection, after 2 h and 4 h of operating time and at the end of surgery was better in group R, but the difference was not statistically significant. Before surgery, the hand-rubbing method with alcohol solution preceded by hand washing with mild neutral soap is as effective as hand scrubbing to reduce bacterial counts on hands. It decreased the bacterial counts both immediately after hand disinfection and at the end of long cardiothoracic surgical procedures. The acceptability of hand rubbing was excellent and it can be considered to be a valid alternative to the conventional hand-scrubbing protocol.

A methodology and a tool for Design for Adaptability (DfA), developed in a project comprising academic and industrial partners, are validated to assess if they accomplish the objectives of the project. The DfA methodology and tool, developed by the academic partners, are applied in diverse use-cases by the industrial partners. A questionnaire is developed to collate the opinions of the industrial personnel who use the methodology and tool. An analysis of these opinions shows that: (a) the methodology and tool have high genericness, usability, tailorability, scalability and cost-effectiveness, and (b) designs and products developed using the methodology and tool have reduced lifecycle cost, shortened cycle time, extended lifespan, increased value to stakeholders and reduced consumption of natural resources and energy in their manufacturing. Based on the opinions of the industrial personnel, the objectives of the project are accomplished. Merits and demerits of the validation approach are also discussed.

We report the case of an unusual variation of a Kommerell's diverticulum in a left aortic arch with an aberrant left subclavian artery, associated with dilatation of the distal aortic arch, surgically treated without the use of extracorporeal circulation.

The paper at hand builds up on the fundamentals developed within the field of Real Options Analysis (ROA) and presents the monetary assessment of two Architectures of a Carbon Fibre Placement System with different degrees of Adaptability. The analysis is based on the assessment of two decisive Key Parameters (KPs), that capture physical, functional, and other performance aspects that are of subjective value to one or several stakeholders. It pays tribute to the crucial influence of uncertainty both from the technological as well as from the market point of view by the use of Monte-Carlo Simulation and lays out the results as a Expexted Net Present Value (ENPV) distribution allowing for in depth interpretation including risk aspects.

The way of applying simulations in the product development process (PDP) presents a great potential for improvement. Nowadays relevant decisions regarding simulations in PDP are made by developers, who are not simulation experts. Furthermore, an early holistic strategic planning of the simulations in the different phases of PDP is not a common step in industry. The aforementioned shortcomings can be compensated with a systematic modeling and guided exploitation of the knowledge related to simulations. This paper presents an approach for the creation of a knowledge-based framework in this domain and the research plan, describing the necessary steps and ressources to conduct the work.

Throughout the end of March to beginning of May 2006, 212 owned cats and 608 owned dogs from a heavy endemic area for canine heartworm (HW) disease in northern Italy have been examined to assess HW infection prevalence. Both cats and dogs were clinically examined and blood samples were taken from each animal to be examined for HW antibody (Ab). Ab-positive cats were further examined for circulating microfilariae, HW antigens (Ag) and by echocardiography (ECHO) to assess the presence of adult worms. Dogs were clinically examined and blood samples taken from each animal were examined for circulating microfilariae and for HW Ag. Ten cats (4.7%) were found Ab positive. Of these, 6 cats were Ag positive (2.6%) and in 4 (1.8%) the worms were visualized by ECHO. HW prevalence in dogs was 36% (221/608). One hundred and seventy-six (29%) were both microfilaraemic and Ag positive, 40 (7%) had occult infections (no circulating microfilariae) and 7 (1%) were microfilaraemic but Ag negative. Upon owners’ consent, 132 cats (including cats Ab and/or Ag and ECHO positive) were prophylactically treated against HW disease with an imidacloprid/moxidectin spot-on combination (10% imidacloprid/1% moxidectin) monthly administered for 6 months. Cats were re-examined for HW infection in November, 1 month after the last drug administration, and in May–June 2007, 7–8 months after the last treatment. All 122 cats found HW negative before treatment, were found negative at the two examinations at the end of study. The 4 cats Ab positive, 2 cats Ab and Ag positive and 1 Ab, Ag and ECHO positive at the beginning of treatment were found negative. Throughout the treatment, transitory hypersalivation and generic signs of annoyance were reported by owners in 6 cats (4.5%). All signs regressed spontaneously.

International audience

The term "subannular" left ventricular aneurysm (LVA) implies that the aneurysm's origin is very close to the aorta. In the absence of an infective etiology, subannular LVAs are very rare among Caucasians. Only a few cases have been reported in the literature. We present the case of a patient with a subannular LVA who underwent surgery at our Institution.

Among cardiac tumors myxoma is the most common benign neoplasm. The aim of this study was to review our Institution's 15-year experience with intracardiac myxoma.From 1985 through 2001, 38 patients (22 males, 16 females, mean age 57.06 +/- 11.1, range 32-74 years) underwent surgical resection of a cardiac myxoma at our Institution. The tumor was located in the left atrium in 29 patients (76.3%), in the right atrium in 8 patients (21%), and in the right ventricle in 1 patient (2.6%). The duration of symptoms prior to surgery ranged from 2 to 30 days. None of the patients had a familial myxoma. The surgical approach comprised complete wide excision in all patients. The incidence of delayed death, thromboembolic complications, valve degeneration, recurrence and reoperation were reviewed and the Kaplan-Meier survival curve was elaborated.There were no perioperative deaths. Three patients (7.9%) developed postoperative neurological sequelae: transient ischemic attacks in 2 patients (5.2%) and a stroke with persistent neurological deficit in 1 patient (2.6%). One patient (2.6%) required pacemaker implantation for complete atrioventricular block. An inferior myocardial infarction occurred in 1 patient (2.6%). During the follow-up, complete in 89.4% of the patients (34 out of 38 patients, mean 96.8 +/- 68.4 months, range 1-218 months), there were 2 (5.8%) non-cardiac related deaths. All the patients underwent clinical examination and echocardiography at regular intervals (1 year): no neurological event was observed during the follow-up and 29 patients (90.6%) are in NYHA functional class I. At 15 years the event-free rate is 85.2%. At 15 years the actuarial survival for the whole group is 92%.At present, the diagnosis of myxoma is easy to make and two-dimensional echocardiography plays a major role in this field. Surgery is the gold standard treatment and the clinical long-term results are excellent.

To identify the major determinants of survival and nonsurvival for patients in need of intra-aortic balloon pump (IABP) support after cardiac surgery and to define the role of ventilator-associated pneumonia.Retrospective study.University and general hospital.A total of 105 consecutive patients undergoing cardiac surgery requiring IABP support and prolonged mechanical ventilation for24 hours.All patients were assigned into 1 of 2 groups: survival (n = 69) and nonsurvival (n = 36).Differences between the survival and nonsurvival groups were tested with the Student's t-test, chi-square test, and frequency analysis. The overall survival rate was 65.7%. Nonsurvivors (34.3%) had higher rates of acute myocardial infarction (27.7% v 4.3%; p0.002), Canadian Cardiovascular Society functional class III and IV (44.4% and 13.8%; p0.001), and depressed left ventricular ejection fraction (31.3 +/- 6.4% v 42.4 +/- 7.2%; p0.001). The nonsurvival group had longer duration of cardiopulmonary bypass (165 +/- 74.3 minutes v 135 +/- 36 minutes; p0.006) and aortic occlusion (81.8 +/- 9 minutes v 68.6 +/- 25.7 minutes; p0.004). In the nonsurvival group, 21 patients were not weaned from the IABP, and 15 patients were weaned from the IABP but died from renal failure (26.6%), multiorgan failure (13.3%), infection, and respiratory failure (66.6%). In the nonsurvival group, mechanical ventilation time was longer in patients weaned from the IABP.These data suggest that for patients not weaned from the IABP, the major determinants of death are low cardiac output (33.3%) and multiorgan failure (47.6%). Patients with a left ventricular ejection fraction of30% have a poorer outcome. In patients weaned from the IABP, ventilator-associated pneumonia (66.6%) was the major cause of death.

Bilateral internal thoracic artery (ITA) harvesting is significantly underused, whereas the radial artery is being used with increasing frequency. We have retrospectively analyzed perioperative and short-term outcomes of patients receiving a radial artery versus those receiving a right ITA as a second arterial graft.Between February 1999 and May 2000, 250 patients underwent coronary artery bypass grafting using the radial artery (156 patients) or the right ITA (94 patients) in combination with the left ITA and, when required, the saphenous vein.There was a higher prevalence of risk factors in the radial artery group. More coronary artery bypass graftings (p0.001) were performed with the radial artery. Operative mortality was not different (p = not significant). In the right ITA group there was more bleeding (p0.001) and a longer hospital stay (p0.001). Mean follow-up was 8.1 +/- 3.9 months. The probability of survival was similar (p = not significant).The radial artery can extend the benefits of multiple arterial grafting to those patients who are usually excluded from bilateral ITA harvesting because of multiple risk factors. Perioperative and short-term results are good.

Cases of pericardial cyst have been reported by many authors, but the incidence of epicardial cyst originating directly from the epicardium in the pericardial cavity is extremely rare. A case of successful resection of epicardial cyst fortuitously discovered and diagnosed during cardiac operation is presented.

A 70-year man, with chest pain history, was referred for thoracic aortic aneurysm diagnosed by CT scan. A CT scan (Fig. 1a) was repeated for stent-graft selection, completed by MR due to diagnosis doubt (Fig. 1b). Radiological findings were consistent with a peri-aortic tumor and revealed a groin mass, whose histology was nonHodgkin lymphoma. Chemotherapy was effective (Fig. 2). European Journal of Cardio-thoracic Surgery 25 (2004) 1126 www.elsevier.com/locate/ejcts

Partial left ventriculectomy (PLV) was recently introduced for end-stage dilated cardiomyopathy to improve ventricular function. Since November 1996 we have performed PLV in 14 patients; preoperatively 4 patients had idiopathic dilated cardiomyopathy and 10 had ischemic dilated cardiomyopathy. 57.1% of patients were in New York Heart Association functional Class IV. The mitral valve was replaced in 11 patients. Postoperative echocardiography showed a reduction of left end-diastolic diameter (55.4 +/- 5.4 mm) and an increase in forward ejection (cardiac index from 2.19 +/- 0.571 min/m2 to 2.67 +/- 0.931/min/m2). The 30-day mortality was 28.6% and 20-month survival was 57.2%. Only one patient was not in NYHA functional class due to postoperative progressive mitral incompetence. Prognostic factors should be identified to avoid early failure. However, even if the mortality rate for PLV high, this operation is a valid choice for the treatment of end-stage dilated cardiomyopathy.