Conduit Diameter Research Articles

PS02.010: ESTABLISHMENT OF THE UPPER GI INTERNATIONAL ROBOTIC ASSOCIATION (UGIRA)

Abstract Background Robot-assisted surgery is increasingly performed for both benign and malignant upper gastro-intestinal disease. However, no global consensus exists regarding exact techniques and implementation methods of robotic esophageal and gastric surgery. To facilitate the effective implementation and advancement of these procedures, evidence based guidelines should be generated. In this context, the ‘Upper GI International Robotic Association’ (UGIRA) was established in 2017. Until now, 20 experienced robotic surgeons from 10 different countries in Europe (The Netherlands, Germany, United Kingdom, Denmark), Asia (Japan, Hong Kong, North-Korea, Taiwan), North-America (United States of America), and South-America (Brazil) have confirmed to become a member of the UGIRA. By means of an oral presentation, we would like to announce the establishment of the UGIRA and to introduce its primary aims, which are: To set up a web-based registry for international data collection.An international registry is created to enable international collaboration on research. Data collection should especially focus on the robotic elements of upper gastro-intestinal surgery, such as trocar positions, anastomotic technique, conduit stapling technique, and conduit diameter in esophagectomy.To establish guidelines for robotic upper gastro-intestinal surgical procedures.The approach to robotic upper gastro-intestinal surgical procedures should be standardized by formulating step-by-step guidelines. These guidelines will encompass robotic surgery for both benign (i.e. hiatal hernia, fundoplication) and malignant disease (i.e. esophageal and gastric cancer), with the exception of bariatric procedures.To form effective training programs that involve proctoring by experienced surgeons.In order to safely implement robotic surgery, training pathways that involve proctoring should be followed. The UGIRA will serve as the core platform to establish these training pathways and to appoint proctors in all continents. Completion of the training pathway will result in UGIRA credentialing. Methods Not applicable. Results Not applicable. Conclusion The UGIRA was recently established to facilitate the effective implementation and advancement of robotic esophageal and gastric surgery worldwide. To this end, the primary aims include setting up a web-based international registry, establishing guidelines for robotic upper gastro-intestinal procedures, and forming effective training pathways that involve proctoring. Disclosure All authors have declared no conflicts of interest.

Plant height and hydraulic vulnerability to drought and cold.

Understanding how plants survive drought and cold is increasingly important as plants worldwide experience dieback with drought in moist places and grow taller with warming in cold ones. Crucial in plant climate adaptation are the diameters of water-transporting conduits. Sampling 537 species across climate zones dominated by angiosperms, we find that plant size is unambiguously the main driver of conduit diameter variation. And because taller plants have wider conduits, and wider conduits within species are more vulnerable to conduction-blocking embolisms, taller conspecifics should be more vulnerable than shorter ones, a prediction we confirm with a plantation experiment. As a result, maximum plant size should be short under drought and cold, which cause embolism, or increase if these pressures relax. That conduit diameter and embolism vulnerability are inseparably related to plant size helps explain why factors that interact with conduit diameter, such as drought or warming, are altering plant heights worldwide.

Intra-organismal variation in the structure of plant vascular transport tissues in poplar trees

Phloem and xylem conduit structure vary greatly throughout the body of Populus trichocarpa trees, particularly between roots and shoots. This has implications for understanding organ and whole plant vascular function. Woody plant vascular transport occurs predominantly within secondary xylem and phloem, which are both produced by the vascular cambium during secondary growth. We examined how vessel and sieve tube structure varied throughout the plant body of P. trichocarpa trees and whether xylem and phloem conduit structure was correlated across different positions within the plant. We excavated entire juvenile P. trichocarpa trees and measured vessel and sieve tube structural traits of current-year growth in 1 m increments along the main root:shoot axis. Trees were > 4 m tall and had roots that extended 4–5 m at their longest length. We found that both sieve tube and vessel diameters greatly varied throughout the plant body and with organ diameter. Roots had wider diameter conduits than shoots. Sieve tube diameter was strongly correlated with vessel diameter, which may be related to their common developmental origin. Other structural traits, such as pit membrane area and pit density for xylem, and sieve plate area and number of sieve areas per plate for phloem, also varied and were correlated with changes in conduit diameter. The median air-seeding pressure of vessels (Pm) and vessel length did not differ between roots and shoots. Understanding plant vascular function will likely require increased knowledge of whole plant structure and function, since plant performance may be limited by any point along the transport pathway. Considering intra-organismal variation may be a way to evaluate structure–function hypotheses while controlling for confounding sources of variation that may impact inter-specific comparisons.

Conduit Artery Diameter During Exercise Is Enhanced After Local, but Not Remote, Ischemic Preconditioning.

Introduction: The ability of ischemic preconditioning (IPC) to enhance exercise capacity may be mediated through altering exercise-induced blood flow and/or vascular function. This study investigated the hypothesis that (local) IPC enhances exercise-induced blood flow responses and prevents decreases in vascular function following exercise.Methods: Eighteen healthy, recreationally trained, male participants (mean ±SD: age 32 ± 8 years; BMI 24.2 ± 2.3; blood pressure 122 ± 10/72 ± 8 mmHg; resting HR 58 ± 9 beats min-1) received IPC (220 mmHg; 4 × 5-min bilateral arms), REMOTE IPC (220 mmHg; 4 × 5-min bilateral legs), or SHAM (20 mmHg; 4 × 5-min bilateral arms) in a counterbalanced order prior to 30-min of submaximal (25% maximal voluntary contraction) unilateral rhythmic handgrip exercise. Brachial artery diameter and blood flow were assessed every 5-min throughout the 30-min submaximal exercise using high resolution ultrasonography. Pre- and post-exercise vascular function was measured using flow-mediated dilation (FMD).Results: IPC resulted in enlarged brachial artery diameter during exercise [0.016 cm (0.003–0.03 cm), P = 0.015] compared to REMOTE IPC, but blood flow during exercise was similar between conditions (P > 0.05). Blood flow (l/min) increased throughout exercise (time: P < 0.005), but there was no main effect of condition (P = 0.29) or condition ∗ time interaction (P = 0.83). Post-exercise FMD was similar between conditions (P > 0.05).Conclusion: Our data show that local (but not remote) IPC, performed as a strategy prior to exercise, enhanced exercise-induced conduit artery diameter dilation, but these changes do not translate into increased blood flow during exercise nor impact post-exercise vascular function.

The accuracy of the thermal dissipation technique for estimating sap flow is affected by the radial distribution of conduit diameter and density

There are conflicting reports on the accuracy of the thermal dissipation probe (TDP, the Granier method) measurement using the original formula, which is widely used to estimate the transpiration of individual trees and forest stands. In this article, six woody species of three wood types were used to study a possible association between TDP measurement accuracy and wood anatomical characteristics, including the vessel diameter and density, as well as sapwood depth. We found that TDP technique with Granier’s original equation underestimated the sap flux density in six species to various degrees, dependent on conduit size and sap flux. Our calibration using two conifers with small diameters and a high density of tracheids was relatively consistent with Granier’s calibration; however, because there were larger diameters and lower densities of vessels in the two diffuse-porous species, the original calibration significantly underestimated sap flow. Two ring-porous species had the largest diameters and lowest densities of vessels. In particular, Robinia pseudoacacia possessed the shallowest sap wood depth, less than a probe length. Our calibration for the ring-porous species, especially R. pseudoacacia, deviated far from the original calibration, which mostly underestimated the sap flow. The degree of underestimation was well associated with sap wood depth and the radial diameter and density distribution of conduits. Our results demonstrated that a new calibration must be operated for each species together with the sapwood depth determination and more probes may be applied for one stem in the field to obtain the more accurate sap flux. In addition, we investigated the effects of different environmental temperature and perfusing fluid composition on the TDP-based sap flux measurement. We found that an environmental temperature reduction from 25 to 0 °C did not alter the values of the maximum temperature difference (ΔTm) between a heated probe and a reference probe when there was no sap flow, verifying that ΔTm measured at night can be used as a reference in daytime.

A numerical model in predicting the initial karst development in porous limestone

The numerical model proposed in this paper represents a new method in predicting initial karst spatial distribution of carbonate aquifers. Karstification Index, \( \varPhi_{\text{K}} \), is a measure of the possible largest amount of calcite that can be dissolved from a unit area of rock and transported by groundwater flow during a unit length of time. Mathematically, it is defined as \( \varPhi_{\text{K}} = q \cdot s \), where q is the flux of groundwater and s is the rock solubility; and Karstification Index, \( \varPhi_{\text{K}} \), is the function of flow, heat, and calcium concentration. The numerical model simulates the time- and space-dependent susceptibility to, and process of, karstification by iterative calculations between \( \varPhi_{\text{K}} \) and hydraulic conductivity. A sample calculation is presented on a hypothetical limestone plateau with steep escarpment, a spring, and a river on one side, a vertical no flow boundary on the other side, and a horizontal impermeable base. The rock has an equivalent porous-medium hydraulic conductivity of K = 5E−8 ms−1, which is characteristic to non-karstified limestone. Initially, the spring is located at the intersection of the water table and the escarpment’s face some distance above the river. The simulation result showed that the water table is lowered in 2325 years across the plateau, but the spring’s drop is stopped after 65 years. Karstification is most intensive along the water table due to the higher value of Karstification Index which resulted from the intensive flux of the water. The continual decline of the water table results in a laterally elongated and progressively expanding body of karstified rock and finally as a horizontal conduit at river level. The concentration of Ca2+ and conduit diameter decrease from the spring toward the impermeable vertical wall on the opposite side and downward to the base of the plateau. The results are consistent with general theories and empirical observations of karst and cave evolution.

Hydrogeological characterization of flow system in a karstic aquifer, Seymareh dam, Iran

In order to determine the characteristics of the flow system in a karstic aquifer, an extensive hydrogeological study includes dye tracing test was conducted. The aquifer suited left abutment of Seymareh Dam, in Ravandi Anticline and discharges by more than 50 springs in the southern flank. Flow system in the aquifer is mainly controlled by the reservoir of Seymareh Dam. Time variations of the spring discharge and water table in the observation wells were highly correlated with the reservoir water level. The average groundwater velocity ranges from 0.2 to more than 14 m/h based on the dye tracing test. The probable flow paths were differentiated in two groups including the flow paths in the northern and southern flanks of Ravandi Anticline. Types of groundwater flow in the proposed flow paths are determined as diffuse or conduit flow type considering groundwater velocity and shape of the breakthrough curves. An index is proposed for differentiation of diffuse and conduit flow system based on relationship of groundwater velocity and hydraulic gradient. Dominant geometry of the flow routs (e.g., conduit diameter and fracture aperture) is estimated for the groundwater flow paths toward the springs. Based on velocity variations and variance coefficient of the water table and discharge of springs on map view a major karst conduit was probably developed in the aquifer. This research emphasizes applying of an extensive hydrogeological study for characterization of flow system in the karst aquifer.

HYDRODYNAMICS AND HEAT AND MASS TRANSFER IN MUSHROOM-SHAPED HEADS OF THERMOCHEMICAL PLUMES

The model of a thermochemical mantle plume is described. The scheme of origination of the plume from the core-mantle boundary is presented. The basic ratios for determining the thermal power and the diameters of thermochemical plumes are given. After eruption of the melt from the plume conduit to the surface, melting occurs along the base of the crustal block above the plume roof, resulting in the formation of a mushroom-shaped head of the plume, which means that a large intrusive body (deep-rooted batholith) is formed. The relative thermal power of such plumes is 1.9<Ka<10. Based on the laboratory and theoretical modeling results, we present the thermal and hydrodynamic structure of the thermochemical plume with the mushroom-shaped head. The parameters of some plumes, that are responsible for formations of batholiths in North Asia, are estimated from the geological data, including the age intervals and the extent of magmatism. Relying on the model of the flat horizontal liquid layer, hydrodynamics and heat transfer of the mushroom-shaped plume head are considered. The variations in temperature and flow velocity in the melt of the plume head are assessed. The compositional changes in the melt of the plume head are determined by stages: (1) after settling of refractory minerals; (2) after settling of plagioclase in the melt resulting from the first stage. The tables show the calculation data, including the weight contents of oxides and the normative compositions for the melts at T melt =1410 °C and T melt =1380 °C. The thickness of the residual melt is estimated for the case of the Khentei plume. Its head’s thickness ( l ) is equal to the plume conduit diameter ( d ): l = d =29 km. The proposed model of the plume with the mushroom-shaped head was used to calculate the normative composition of the melt with a chemical composition similar to that of normal granites.

Geochemical and textural constraints on degassing processes in sub-Plinian eruptions: case-study of the Greenish Pumice eruption of Mount Somma-Vesuvius

Plinian eruptions are characterized by high intensity and an overall steady character, and result in a stable convective column. The main processes controlling the dynamics of such steady and stable plume systems have been extensively investigated. Conversely, sub-Plinian eruptions are unsteady, as recorded by the large variability of the products and deposits. Our knowledge of the processes creating this unsteadiness on various timescales remains limited, and still requires more observations as well as theoretical and experimental investigation. Here, we focus on the sub-Plinian eruption of the Greenish Pumice (GP, 19,265 ± 105 BP), Mt. Somma-Vesuvius (Italy). On the basis of coupled geochemical and textural analyses of samples from the well-established stratigraphy of the GP deposits, we investigate volatiles (H2O, CO2, F, Cl) to better constrain the unsteady sub-Plinian eruptive style. This allows us to carry out a detailed study of the degassing processes in relation to the eruption dynamics. We find that degassing by open-system processes generally dominates throughout the entire eruption, but alternates with episodes of closed-system degassing. The fluctuating degassing regimes, responsible for the variable magma ascent rate within the conduit, are also responsible for the eruptive column instability. Volatile behavior is well correlated with textural heterogeneities of the eruptive products. Both reflect higher conduit heterogeneity than for Plinian eruptions, where we find a higher horizontal gradient in magma ascent velocity due to a smaller conduit diameter.

Turbulent and Laminar Flow in Karst Conduits Under Unsteady Flow Conditions: Interpretation of Pumping Tests by Discrete Conduit‐Continuum Modeling

AbstractDue to the duality in terms of (1) the groundwater flow field and (2) the discharge conditions, flow patterns of karst aquifer systems are complex. Estimated aquifer parameters may differ by several orders of magnitude from local (borehole) to regional (catchment) scale because of the large contrast in hydraulic parameters between matrix and conduit, their heterogeneity and anisotropy. One approach to deal with the scale effect problem in the estimation of hydraulic parameters of karst aquifers is the application of large‐scale experiments such as long‐term high‐abstraction conduit pumping tests, stimulating measurable groundwater drawdown in both, the karst conduit system as well as the fractured matrix. The numerical discrete conduit‐continuum modeling approach MODFLOW‐2005 Conduit Flow Process Mode 1 (CFPM1) is employed to simulate laminar and nonlaminar conduit flow, induced by large‐scale experiments, in combination with Darcian matrix flow. Effects of large‐scale experiments were simulated for idealized settings. Subsequently, diagnostic plots and analyses of different fluxes are applied to interpret differences in the simulated conduit drawdown and general flow patterns. The main focus is set on the question to which extent different conduit flow regimes will affect the drawdown in conduit and matrix depending on the hydraulic properties of the conduit system, i.e., conduit diameter and relative roughness. In this context, CFPM1 is applied to investigate the importance of considering turbulent conditions for the simulation of karst conduit flow. This work quantifies the relative error that results from assuming laminar conduit flow for the interpretation of a synthetic large‐scale pumping test in karst.

Transcatheter Pulmonary Valve Replacement With the Melody Valve in Small Diameter Expandable Right Ventricular Outflow Tract Conduits

ObjectivesThis study sought to evaluate the safety, feasibility, and outcomes of transcatheter pulmonary valve replacement (TPVR) in conduits ≤16 mm in diameter. BackgroundThe Melody valve (Medtronic, Minneapolis, Minnesota) is approved for the treatment of dysfunctional right ventricular outflow tract (RVOT) conduits ≥16 mm in diameter at the time of implant. Limited data are available regarding the use of this device in smaller conduits. MethodsThe study retrospectively evaluated patients from 9 centers who underwent percutaneous TPVR into a conduit that was ≤16 mm in diameter at the time of implant, and reported procedural characteristics and outcomes. ResultsA total of 140 patients were included and 117 patients (78%; median age and weight 11 years of age and 35 kg, respectively) underwent successful TPVR. The median original conduit diameter was 15 (range: 9 to 16) mm, and the median narrowest conduit diameter was 11 (range: 4 to 23) mm. Conduits were enlarged to a median diameter of 19 mm (29% larger than the implanted diameter), with no difference between conduits. There was significant hemodynamic improvement post-implant, with a residual peak RVOT pressure gradient of 7 mm Hg (p < 0.001) and no significant pulmonary regurgitation. During a median follow-up of 2.0 years, freedom from RVOT reintervention was 97% and 89% at 2 and 4 years, respectively, and there were no deaths and 5 cases of endocarditis (incidence rate 2.0% per patient-year). ConclusionsIn this preliminary experience, TPVR with the Melody valve into expandable small diameter conduits was feasible and safe, with favorable early and long-term procedural and hemodynamic outcomes.

The effect of polyploidization on tree hydraulic functioning

Recent research has highlighted the importance of living tissue in wood. Polyploidization can impact amounts and arrangements of living cells in wood, potentially leading to increased drought tolerance. Tetraploid variants were created from the apple cultivar Malus ×domestica 'Gala' (Gala-4x), and their vulnerability to drought-induced cavitation and their hydraulic capacitance were compared to those of their diploid predecessors (Gala-2x). Assuming a positive correlation between polyploidy and drought tolerance, we hypothesized lower vulnerability and higher capacitance for the tetraploid. Vulnerability to drought-induced cavitation and the hydraulic capacitance were quantified through acoustic emission and continuous weighing of shoots during a bench-top dehydration experiment. To underpin the hydraulic trait results, anatomical variables such as vessel area, conduit diameter, cell wall reinforcement, and ray and vessel-associated parenchyma were measured. Vulnerability to drought-induced cavitation was intrinsically equal for both ploidy variants, but Gala-4x proved to be more vulnerable than Gala-2x during the early phase of desiccation as was indicated by its significantly lower air entry value. Higher change in water content of the leafy shoot, higher amount of parenchyma, and larger vessel area and size resulted in a significantly higher hydraulic capacitance and efficiency for Gala-4x compared to Gala-2x. Both ploidy variants were typified as highly sensitive to drought-induced cavitation, with no significant difference in their overall drought vulnerability. But, when water deficit is short and moderate, Gala-4x may delay a drought-induced decrease in performance by trading hydraulic safety for increased release of capacitively stored water from living tissue.

Responses of stem hydraulic traits in Salix psammophila and Caragana korshinskii to manipulated precipitation variation.

With a precipitation manipulation experiment (Control, +45% and -50%), the responses of stem hydraulic traits in two dominant shrubs (Salix psammophila and Caragana korshinskii) of water-wind erosion crisscross region of the Loess Plateau to projected precipitation variation were examined to elucidate their adaptability to future precipitation changes. Results showed that the specific hydraulic conductivity (Ks), leaf specific conductivity (Kl) and Huber value in S. psammophila increased significantly by irrigation but showed no responses to drought. The predawn and midday leaf water potential and water transport efficiency (Ks and Kl) in C. korshinskii decreased significantly by drought, and showed no responses to irrigation. The embolism resistance across different treatments did not differ in the two shrubs. The midday native embolisms across treatments in S. psammophila were almost the same. Drought increased midday native embolism in C. korshinskii. Irrigation increased conduit diameter and conduit area per stem sap area while drought increased the vessel density and decreased the hydraulic diameter in S. psammophila. Irrigation had no effect on xylem anatomy, whereas drought increased the vessel density and wood density in C. korshinskii. These results indicated that irrigation promoted stem hydraulic function in S. psammophila, and drought decreased stem hydraulic function in C. korshinskii. C. korshinskii may be less resistant to future dry climate than S. psammophila.

Maximal strength training-induced improvements in forearm work efficiency are associated with reduced blood flow.

Maximal strength training (MST) improves work efficiency. However, since blood flow is greatly dictated by muscle contractions in arms during exercise and vascular conductance is lower, it has been indicated that arms rely more upon adapting oxygen extraction than legs in response to the enhanced work efficiency. Thus, to investigate if metabolic and vascular responses are arm specific, we used Doppler-ultrasound and a catheter placed in the subclavian vein to measure blood flow and the arteriovenous oxygen difference during steady-state work in seven young men [24 ± 3 (SD) yr] following 6 wk of handgrip MST. As expected, MST improved maximal strength (49 ± 9 to 62 ± 10 kg) and the rate of force development (923 ± 224 to 1,086 ± 238 N/s), resulting in a reduced submaximal oxygen uptake (30 ± 9 to 24 ± 10 ml/min) and concomitantly increased work efficiency (9.3 ± 2.5 to 12.4 ± 3.9%) (all P < 0.05). In turn, the work efficiency improvement was associated with reduced blood flow (486 ± 102 to 395 ± 114 ml/min), mediated by a lower blood velocity (43 ± 8 to 32 ± 6 cm/s) (all P < 0.05). Conduit artery diameter and the arteriovenous oxygen difference remained unaltered. The maximal work test revealed an increased time to exhaustion (949 ± 239 to 1,102 ± 292 s) and maximal work rate (both P < 0.05) but no change in peak oxygen uptake. In conclusion, despite prior indications of metabolic and vascular limb-specific differences, these results reveal that improved work efficiency after small muscle mass strength training in the upper extremities is accompanied by a blood flow reduction and coheres with what has been documented for lower extremities. NEW & NOTEWORTHY Maximal strength training increases skeletal muscle work efficiency. Oxygen extraction has been indicated to be the adapting component with this increased work efficiency in arms. However, we document that decreased blood flow, achieved by blood velocity reduction, is the adapting mechanism responding to the improved aerobic metabolism in the forearm musculature.

Evolution of the magma feeding system during a Plinian eruption: The case of Pomici di Avellino eruption of Somma–Vesuvius, Italy

The current paradigm for volcanic eruptions is that magma erupts from a deep magma reservoir through a volcanic conduit, typically modelled with fixed rigid geometries such as cylinders. This simplistic view of a volcanic eruption does not account for the complex dynamics that usually characterise a large explosive event. Numerical simulations of magma flow in a conduit combined with volcanological and geological data, allow for the first description of a physics-based model of the feeding system evolution during a sustained phase of an explosive eruption. The method was applied to the Plinian phase of the Pomici di Avellino eruption (PdA, 3945 ±10 cal yr BP) from Somma–Vesuvius (Italy). Information available from volcanology, petrology, and lithology studies was used as input data and as constraints for the model. In particular, Mass Discharge Rates (MDRs) assessed from volcanological methods were used as target values for numerical simulations. The model solutions, which are non-unique, were constrained using geological and volcanological data, such as volume estimates and types of lithic components in the fall deposits.Three stable geometric configurations of the feeding system (described assuming elliptical cross-section of variable dimensions) were assessed for the Eruptive Units 2 and 3 (EU2, EU3), which form the magmatic Plinian phase of PdA eruption. They describe the conduit system geometry at time of deposition of EU2 base, EU2 top, and EU3. A 7-km deep dyke (length 2a=200–400 m, width 2b=10–12 m), connecting the magma chamber to the surface, characterised the feeding system at the onset of the Plinian phase (EU2 base). The feeding system rapidly evolved into hybrid geometric configuration, with a deeper dyke (length 2a=600–800 m, width 2b=50 m) and a shallower cylindrical conduit (diameter D=50 m, dyke-to-cylinder transition depth ∼2100 m), during the eruption of the EU2 top. The deeper dyke reached the dimensions of 2a=2000 m and 2b=60 m at EU3 peak MDR, when the shallower cylinder had enlarged to a diameter of 60 m and a transition depth of 3000 m.The changes in feeding system geometry indicate a partitioning of the driving pressure of the eruption, which affected both magma movement to the surface and dyke growth. This implies that a significant portion of the magma injected from the magma chamber filled the enlarging dyke before it erupted to the surface. In this model, the lower dyke acted as a sort of magma “capacitor” in which the magma was stored briefly before accelerating to the cylindrical conduit and erupting. The capacitor effect of the lower dyke implies longer times of transit for the erupting magma, which also underwent several steps of decompression. On the other hand, the decompression of magma within the capacitor provided the driving pressure to maintain the flow into the upper cylindrical conduit, even as the base of the dyke started to close due to the drop in driving pressure from progressive emptying of the magma chamber.The shallower cylindrical conduit was shaped through the erosion of conduit wall rocks at and above the fragmentation level. Using the lithic volume and duration of EU3, the erosion rate of shallower cylindrical conduit was calculated at ∼5×103 m3/s. The outcomes of this work represent an important baseline for further petrologic and geophysical studies devoted to the comprehension of processes driving volcanic eruptions.

Percutaneous pulmonary valve implantation in small conduits: A multicenter experience

BackgroundGuidelines allow percutaneous pulmonary valve implantation (PPVI) in conduits above 16mm diameter. Balloon dilatation of a conduit to a diameter>110% of the original implant size is also not recommended. We analyzed patients undergoing PPVI in such conditions. Methods and resultsNine patients (May 2008–July 2016) from 8 institutions underwent PPVI in conduits <16mm diameter. Five patients with 16–18mm conduit diameter underwent PPVI after over-expansion of the conduit>110%. Mean age and weight of the 14 patients was 12.1 (7.7 to 16) years and 44.9 (19 to 83) kg.Median conduit diameter at PPVI was 12 (10 to 17) mm. Median systolic right ventricular pressure was 70 (40 to 94) mmHg. Procedure was successful in all cases. A confined conduit rupture occurred in 7 patients (50%) and was treated with covered stent in 6. One patient experienced dislocation of 2 pulmonary artery stents that were parked distally. The post-implantation median systolic right ventricular pressure was 36 (28 to 51) mmHg. A fistula between right-ventricle outflow and aorta was found in one patient, secondary to undiagnosed conduit rupture. This was closed surgically. After a median follow-up of 20.16 (6.95 to 103.61) months, all the patients are asymptomatic with no significant RVOT stenosis. ConclusionsPPVI is feasible in small conduits but rate of ruptures is high. Although such ruptures remain contained and can be managed with covered stents in our experience, careful selection of patients and high level of expertise are necessary. More studies are needed to better assess the risk of PPVI in this population.

Endothelial Shear Stress of the Saphenous Vein Composite Graft Based on the Internal Thoracic Artery

Endothelial shear stress (ESS) has been suggested as a factor affecting atherosclerosis and remodeling of native vessels and bypass conduits. We compared ESS levels of internal thoracic artery (ITA) and saphenous vein (SV) composite grafts intraoperatively and 1 year after coronary artery bypass grafting (CABG). Intraoperative ESS was calculated by measuring flow volumes and diameters of proximal and distal ITAs and SV conduits in 23 patients who received SV Y-composite grafts based on the in situ left ITA. Early (1.2 ± 0.5 days) and 1-year (12.9 ± 1.1 months) postoperative angiograms were performed in 23 and 15 patients, respectively. An intragraft Doppler-guidewire study for ESS measurement was performed in 6 patients during 1-year angiography. Intraoperative diameters of proximal and distal ITAs and SV conduits were 2.0 ± 0.2 mm, 1.8 ± 0.3 mm, and 3.2 ± 0.4 mm, respectively. ESS levels were significantly different between them (41.0 ± 21.0, 28.4 ± 25.2, and 4.3 ± 3.0 dyne/cm2, respectively). Proximal and distal ITA diameters increased significantly on early angiograms and remained unchanged, but SV diameter increased to 3.7 mm (95% confidence interval, 3.5 to 4.0 mm; p < 0.001) on the early angiogram and decreased to 2.9 mm (95% confidence interval, 2.7 to 3.2 mm; p < 0.001) at 1 year. Significant correlations were found between the initial ESS and proportional changes in conduit diameters during postoperative year 1. SV ESS increased in all 6 patients at 1 year, with no significant differences in ESS levels between the 3 conduits (29.9 ± 7.9, 28.8 ± 7.9, and 21.6 ± 16.3 dyne/cm2, respectively). Initial ESS appears to be associated with proportional changes in conduit diameters in the first year after CABG. ESS values of SV composite grafts were similar to left ITA conduits 1 year after CABG.

Acclimation of branch and leaf hydraulics in adult Fagus sylvatica and Picea abies in a forest through-fall exclusion experiment.

Decreasing water availability due to climate change poses the question of whether and to what extent tree species are able to hydraulically acclimate and how hydraulic traits of stems and leaves are coordinated under drought. In a through-fall exclusion experiment, hydraulic acclimation was analyzed in a mixed forest stand of Fagus sylvatica L. and Picea abies (L.) Karst. In drought-stressed (TE, through-fall exclusion over 2 years) and control (CO) trees, hydraulic vulnerability was studied in branches as well as in leaves (F. sylvatica) and end-twigs (P. abies, entirely formed during the drought period) sampled at the same height in sun-exposed portions of the tree crown. In addition, relevant xylem anatomical traits and leaf pressure-volume relations were analyzed. The TE trees reached pre-dawn water potentials down to -1.6 MPa. In both species, water potentials at 50% loss of xylem hydraulic conductivity were ~0.4 MPa more negative in TE than in CO branches. Foliage hydraulic vulnerability (expressed as water potential at 50% loss of leaf/end-twig hydraulic conductance) and water potential at turgor loss point were also, respectively, 0.4 and 0.5 MPa lower in TE trees. Minor differences were observed in conduit mean hydraulic diameter and cell wall reinforcement. Our findings indicate significant and fast hydraulic acclimation under relatively mild drought in both tree species. Acclimation was well coordinated between branches and foliage, which might be essential for survival and productivity of mature trees under future drought periods.

Small-sized conduits in the right ventricular outflow tract in young children: bicuspidalized homografts are a good alternative to standard conduits.

Downsizing a homograft (HG) through bicuspidalization has been used for more than 2 decades to overcome the shortage of small-sized conduits for reconstruction of the right ventricular outflow tract (RVOT) in young children. Our goal was to investigate the durability of bicuspidalized HGs compared with other small HGs. A retrospective analysis of 93 conduits ≤20 mm, implanted over 23 years, was performed. The end-points were survival, structural valve degeneration and conduit replacement. The conduits comprised 40 pulmonary HGs, 12 aortic HGs, 17 bicuspidalized HGs and 24 xenografts. The median age, mean conduit diameter and z-value at implantation were 1.4 (interquartile range 0.3-3) years, 16.5 ± 2.7 mm and 2.8 ± 1.3, respectively. Valve position was heterotopic in 59 patients and orthotopic in 34 patients. At a mean follow-up period of 7.6 ± 5.9 years, the hospital survival rate was 89%. Freedom from explant at 5 and 10 years was 83 ± 5% and 52 ± 6%, respectively. Freedom from structural valve degeneration was 79 ± 5% at 5 years and 47 ± 6% at 10 years [68 ± 8% for pulmonary HG, 42 ± 16% for bicuspidalized HG, 31 ± 15% for aortic HG and 20 ± 9% for xenografts (log rank P < 0.001)]. Multivariable analysis indicated an increased risk for structural valve degeneration with smaller conduit size (hazard ratio 0.79, 95% confidence interval 0.67-0.94; P < 0.008), extra-anatomic position (hazard ratio 2.71, 95% confidence interval 1.33-5.50; P = 0.006) and the use of xenografts compared with non-downsized pulmonary HGs (hazard ratio 4.90, 95% confidence interval 2.23-10.76; P < 0.001). Appropriately sized pulmonary HGs remain the most durable option for a right ventricular outflow tract conduit in young children. However, when a small pulmonary HG is unavailable, bicuspidalization offers a valid alternative, preferable to xenograft conduits, at mid-term follow-up.

Superior Lower Extremity Vein Graft Bypass Patency among Married Patients with Peripheral Artery Disease

Outcome disparities associated with lower extremity bypass (LEB) for peripheral artery disease (PAD) have been identified but are poorly understood. Marital status may affect outcomes through factors related to health risk behaviors, adherence, and access to care but has not been characterized as a predictor of surgical outcomes and is often omitted from administrative data sets. We evaluated associations between marital status and vein graft patency following LEB using multivariable models adjusting for established risk factors. Consecutive patients undergoing autogenous LEB for PAD were identified and analyzed. Survival analysis and Cox proportional hazards models were used to evaluate patency stratified by marital status (married versus single, divorced, or widow[er]) adjusting for demographic, comorbidity, and anatomic factors in multivariable models. Seventy-three participants who underwent 79 autogenous vein LEB had complete data and were analyzed. Forty-three patients (58.9%) were married, and 30 (41.1%) were unmarried. Compared with unmarried patients, married patients were older at the time of their bypass procedure (67.3±10.8years vs. 62.2±10.6years; P=0.05). Married patients also had a lower prevalence of female gender (11.6% vs. 33.3%; P=0.02). Diabetes, hypertension, hyperlipidemia, and smoking were common among both married and unmarried patients. Minimum great saphenous vein conduit diameters were larger in married versus unmarried patients (2.82±0.57mm vs. 2.52±0.65mm; P=0.04). Twenty-four-month primary patency was 66% for married versus 38% for unmarried patients. In a multivariable proportional hazards model adjusting for proximal and distal graft inflow/outflow, medications, gender, age, race, smoking, diabetes, and minimum vein graft diameter, married status was associated with superior primary patency (hazard ratio [HR] = 0.33; 95% confidence limits [0.11, 0.99]; P=0.05); other predictive covariates included preoperative antiplatelet therapy (HR=0.27; 95% confidence limits [0.10,0.74]; P=0.01) and diabetes (HR = 2.56; 95% confidence limits [0.93-7.04]; P=0.07). Marital status is associated with vein graft patency following LEB. Further investigation into the mechanistic explanation for improved patency among married patients may provide insight into social or behavioral factors influencing other disparities associated with LEB outcomes.