Journal of cardiothoracic and vascular anesthesia最新文献

{"title":"Activated Clotting Time Measured by Hemochron Signature Elite in Adult Cardiac Surgery: Implications for Clinical Practice.","authors":"Filippo Maria Russo, Andrea Artoni, Mauro Cotza, Giacomo Veronese, Stefano Cenci, Mariantonia Villano, Nora Di Tomasso, Giovanna Pedrazzini, Maria Abbattista, Cristina Novembrino, Martina Anguissola, Rosanna Cardani, Flora Peyvandi, Marco Ranucci, Giacomo Grasselli","doi":"10.1053/j.jvca.2025.05.031","DOIUrl":"https://doi.org/10.1053/j.jvca.2025.05.031","url":null,"abstract":"<p><strong>Objectives: </strong>To assess concordance between Hemochron Response (ACTr) and the three-activator device Hemochron Signature Elite (ACTe) in adult cardiac surgery patients. To evaluate the correlation between ACTe and anti-Xa values.</p><p><strong>Design: </strong>Multicenter, prospective observational study.</p><p><strong>Setting: </strong>University hospitals.</p><p><strong>Participants: </strong>Thirty-five elective adult cardiac surgery patients.</p><p><strong>Interventions: </strong>Patients received 300 IU/kg of unfractionated heparin (UFH) before cardiopulmonary bypass (CPB), as recommended by guidelines. ACTe was the reference device, with ACTe target ≥ 450 seconds required to establish adequate anticoagulation during CPB. Otherwise, an additional 100 IU/kg UFH was administered, up to a maximum cumulative dose of 500 IU/kg. Blood samples for ACTe and ACTr and samples for anti-Xa activity were collected simultaneously at baseline and after each UFH administration. The analyses included Pearson correlation, linear regression, and the Bland-Altman test.</p><p><strong>Measurements and main results: </strong>Thirty-five patients were enrolled (71% male, median age 68 years). After 300 IU/kg UFH, 13 (37%) patients required a second heparin dose due to ACTe less than 450 seconds despite ACTr ≥ 450 seconds and 5 (14%) due to ACT less than 450 seconds with both devices. Following the second UFH administration, 10/18 (55%) patients still did not reach the target ACTe despite an ACTr ≥ 450 seconds, requiring a third UFH administration. ACTe and ACTr showed no correlation (r = 0.157, p = 0.369). Linear regression analysis demonstrated limited agreement (R² = 0.025). Bland-Altman analysis indicated a mean bias of -20.7% (95% CI -75.28% to +35.5%), with ACTe underestimating ACTr. The predicted ACTe, corresponding to an ACTr threshold of 450 seconds, was 357 seconds. Anti-Xa levels always exceeded 4 IU/mL, confirming adequate anticoagulation in all cases and were positively correlated to ACTe (r = 0.587, p < 0.001). Predicted ACTe interval corresponding to anti-Xa levels of 4 IU/mL was 263 to 515 seconds.</p><p><strong>Conclusions: </strong>ACTe and ACTr showed no correlation. Switching devices without adjusting ACT thresholds leads to unnecessary UFH redosing, despite adequate anticoagulation as measured by anti-Xa levels.</p>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-05-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144484385","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Right Ventricular Function and Echocardiographic Pressure-Volume Loops: Overview and Perioperative Clinical Implications.","authors":"Usman Ahmed, Feroze Mahmood, Alina Nicoara, Vahid Kiarad","doi":"10.1053/j.jvca.2025.05.019","DOIUrl":"https://doi.org/10.1053/j.jvca.2025.05.019","url":null,"abstract":"<p><p>Right ventricular (RV) mechanics have critical roles in cardiovascular physiology, yet their assessment remains challenging owing to the right ventricle's complex geometry and unique interaction with the pulmonary vascular system. This review explores RV structural, functional, and physiologic considerations, emphasizing their interplay with pulmonary hypertension (PH), heart failure, and perioperative outcomes. Traditional pressure- and volume-centric methods of RV evaluation, including echocardiography and right heart catheterization, often fail to provide comprehensive, load-independent measures of RV function. The integration of these measures for pressure-volume (PV) loop analysis has emerged as a valuable tool, offering insights into RV contractility, compliance, and ventriculoarterial coupling. This review highlights advances in intraoperative and noninvasive PV loop methodologies, including echocardiography-derived techniques and integration with catheter-based pressure measurements. These approaches enable detailed assessment of RV function, enhancing prognostic capabilities in such conditions as PH, heart failure with preserved ejection fraction, and postsurgical interventions like left ventricular assist device implantation and valve replacement. Despite the potential of RV PV loop analysis, its clinical adoption has been limited by technical complexities, cost, and the need for specialized expertise. This underscores the importance of standardizing PV loop acquisition techniques and validating surrogate markers, such as tricuspid annular plane systolic excursion/pulmonary artery systolic pressure ratio, to improve accessibility and utility. By providing a comprehensive overview of current and emerging methods for RV assessment, this review aims to foster a deeper understanding of RV mechanics, driving innovation in diagnostic, therapeutic, and prognostic strategies for cardiac surgeries.</p>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-05-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144248009","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Protective Effect of Remote Ischemic Preconditioning on Acute Kidney Injury Following Pediatric Cardiac Surgery: A Systematic Review and Meta-Analysis.","authors":"Peiwen Cheng, Guozhen Wang, Yong An","doi":"10.1053/j.jvca.2025.05.022","DOIUrl":"https://doi.org/10.1053/j.jvca.2025.05.022","url":null,"abstract":"<p><p>Cardiac surgery in children is a major risk factor for acute kidney injury (AKI) because of the high risk of AKI due to the combination of hemodynamic instability, ischemia-reperfusion injury, and inflammation. However, the protective role of remote ischemic preconditioning (RIPC) in this setting is unclear. This systematic review and meta-analysis was conducted to assess whether RIPC reduces the incidence of AKI in pediatric cardiac surgery patients. PubMed, EMBASE, and the Cochrane Library were systematically searched for randomized controlled trials (RCTs) of RIPC in pediatric cardiac surgery. The primary outcome indicator was the incidence of postoperative AKI, and secondary outcome indicators included serum creatinine (sCr) level, tumor necrosis factor (TNF)-α level, and intensive care unit (ICU) length of stay (LOS). Six RCTs with a total of 1,098 patients were included in the analysis. RIPC significantly reduced the incidence of AKI (odds ratio, 0.38; 95% confidence interval, 0.25-0.60; p < 0.00001; I² = 38%). There was no significant effect on postoperative sCr, TNF-α levels and ICU LOS (p > 0.05 for all; I² >80%). Sensitivity analyses showed a large impact of some studies on the results. The data indicate that RIPC significantly reduced the incidence of AKI after pediatric cardiac surgery, showing its potential renoprotective effect. Although the effect on other postoperative indicators was not significant, high heterogeneity limits the certainty of the conclusions. Future studies should focus on multicenter, large-scale trials with detailed subgroup analyses to explore the mechanism of action and effects of RIPC in different patient populations.</p>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-05-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144325838","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Deep Parasternal Intercostal Plane Blocks and Their Role in a Cardiac Fast-Track Program.","authors":"Amir Zabida, Karen Foley, Cristopher Araya Gonzalez, Santiago Chaverra, Margarita Otalora Esteban, Kirubanand Senniappan, Paola Vidal Díaz, Juan Camilo Segura-Salguero, Bilal Ansari, Michael Kahn, Vivek Rao, George Djaiani","doi":"10.1053/j.jvca.2025.05.018","DOIUrl":"https://doi.org/10.1053/j.jvca.2025.05.018","url":null,"abstract":"<p><strong>Objectives: </strong>To determine if deep parasternal intercostal plane (DPIP) blocks are associated with reduced opioid consumption and a subsequent reduction in postoperative delirium after cardiac surgery.</p><p><strong>Design: </strong>A retrospective observational study.</p><p><strong>Setting: </strong>A single-center tertiary care hospital.</p><p><strong>Participants: </strong>Three hundred and eight adult patients who underwent cardiac surgery with median sternotomy between March 2021 and February 2023.</p><p><strong>Interventions: </strong>DPIP blocks are performed after chest closure in the operating room under sterile conditions and with real-time ultrasound guidance. The control group did not receive DPIP blocks.</p><p><strong>Measurements and main results: </strong>Median [range] postoperative hydromorphone consumption at 12 hours was 0.8 [0-2.6] mg vs. 1.2 [0-2.6] mg, p = 0.0004, and at 24 hours was 0.4 [0-3.2] mg versus 0.6 [0-3.4] mg, p = 0.007 in the DPIP and control groups, respectively. Predictors of reduced hydromorphone requirements included the presence of DPIP blocks, use of a dexmedetomidine infusion, and absence of composite comorbidities. Postoperative delirium was present in 17 (11%) and 23 (14.9%) patients in the DPIP block and control groups respectively (odds ratio 0.76; 95% confidence interval 0.38-1.53, p = 0.45). The median [IQR] time to extubation was 135 [65, 274] minutes versus 196.5 [74, 420] minutes in the DPIP and control groups, respectively, p = 0.04. There was no difference with respect to major morbidity and mortality between the two groups.</p><p><strong>Conclusions: </strong>DPIP blocks were associated with decreased perioperative opioid consumption, and earlier tracheal extubation after cardiac surgery. DPIP blocks may be incorporated within the fast-track cardiac anesthesia pathways; however, alternative strategies need to be further explored to reduce postoperative delirium after cardiac surgery.</p>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-05-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144266321","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Temporal Trends and Severity of Postoperative Delirium in Cardiac Surgery: Insights from a Systematic Review and Meta-analysis.","authors":"Tahereh Shamsi, Siddhartha Reddy Janga, Nikitha Uma Baskaran, Valluvan Rangasamy, Rushil Vladimir Ramachandran, Mei Chen, Sruthi Ganesh, Victor Novack, Balachundhar Subramaniam","doi":"10.1053/j.jvca.2025.05.020","DOIUrl":"10.1053/j.jvca.2025.05.020","url":null,"abstract":"<p><p>Postoperative delirium (POD) is one of the most common neurocognitive complications following cardiac surgery, typically occurring within 72 hours and leading to serious consequences, including falls, prolonged hospitalization, and increased healthcare costs. Annually, over two million cardiac surgeries, including coronary artery bypass grafting, are performed worldwide. This study systematically reviews and meta-analyzes the incidence, duration, time to onset, and severity of delirium following cardiac surgery. No previous comprehensive analysis has addressed all these outcomes, particularly regarding temporal patterns and severity of POD. A systematic review was performed following PRISMA guidelines. The studies included adult patients who underwent cardiac surgery and were assessed for delirium using validated tools. Statistical analyses included random-effects meta-analysis for incidence rates and subgroup analyses. Twenty-seven studies involving 5,126 participants from 2009 to March 2024 were included. The overall incidence of POD was 25.1% (95% confidence interval [CI]: 21.8%-28.3%), with a mean duration of 2.378 days (95% CI: 2.086-2.671), and onset occurring at 1.706 days (95% CI: 1.198-2.214). Only three studies assessed the severity of delirium, reporting a maximum Confusion Assessment Method score of 9.308 (95% CI: 7.309-11.307) on a scale of 0 to 19. Subgroup analyses were conducted to examine heterogeneity but revealed no significant differences in outcomes. Therefore, a meta-regression analysis focusing on age, surgery duration, assessment length, study design, and assessment tools was performed. The incidence and burden of POD highlight the need for regular screening and effective management strategies.</p>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-05-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144333221","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Extracorporeal Membrane Oxygenation in the Awake or Extubated Patient.","authors":"Giuseppe Cuttone, Luigi La Via, Giovanni Misseri, Gennaro Martucci, Massimiliano Sorbello, Nicolò Patroniti, Federico Pappalardo","doi":"10.1053/j.jvca.2025.05.021","DOIUrl":"https://doi.org/10.1053/j.jvca.2025.05.021","url":null,"abstract":"<p><p>Extracorporeal membrane oxygenation (ECMO) traditionally has been used under deep sedation and mechanical ventilation. However, recent advancements have led to the development of awake ECMO strategies, allowing patients to remain conscious. This comprehensive review explores the evolving landscape of awake ECMO, from its historical context to current practices and future directions. We examine the rationale behind awake ECMO, including potential benefits such as preserved muscle strength, reduced sedation-related complications, and improved patient engagement in care. The review details key considerations in patient selection, emphasizing the importance of careful physiologic, psychological, and social assessment to identify suitable candidates for awake ECMO. Technical aspects of awake ECMO implementation are discussed, including cannulation strategies, circuit management, and the integration of extracorporeal support with spontaneous breathing. The unique challenges in managing awake ECMO patients are highlighted, addressing issues such as pain control, anxiety management, and early mobilization protocols. The review synthesizes current evidence on outcomes associated with awake ECMO, focusing in particular on its application as a bridge to lung transplantation and in acute respiratory failure. Although early data suggest promising results in selected populations, the need remains for more robust, large-scale studies to definitively establish the efficacy and safety of awake ECMO across various clinical scenarios. Emerging technologies and future directions in awake ECMO are explored, including the development of more compact and portable systems, advanced monitoring tools, and novel approaches to patient-ECMO interaction. Finally, the importance of specialized training programs and the potential for dedicated awake ECMO units within specialized centers are examined.</p>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-05-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144275039","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Unanticipated Abdominal Compartment Syndrome in an Infant Undergoing Atrioventricular Septal Defect Repair.","authors":"Ettienne Coetzee, Jacques Scherman, Nadia du Plessis, Justiaan Swanevelder","doi":"10.1053/j.jvca.2025.05.016","DOIUrl":"https://doi.org/10.1053/j.jvca.2025.05.016","url":null,"abstract":"","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-05-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144302173","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Moderate Aortic Stenosis: Can We Predict Who Will Benefit from Intervention?","authors":"J Brad Meers, Matthew M Townsley","doi":"10.1053/j.jvca.2025.05.017","DOIUrl":"https://doi.org/10.1053/j.jvca.2025.05.017","url":null,"abstract":"","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-05-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144225529","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Highlights from the American College of Cardiology and American Heart Association 2024 Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery.","authors":"Perin Kothari, Matthew W Vanneman, Christine Choi, Rachel Diehl, Vikram Fielding-Singh","doi":"10.1053/j.jvca.2025.05.014","DOIUrl":"https://doi.org/10.1053/j.jvca.2025.05.014","url":null,"abstract":"<p><p>Increasing noncardiac surgery volumes globally combined with the growing prevalence of cardiovascular risk factors continues to pose a challenge for anesthesiologists caring for patients in the perioperative period. Forty-five percent of all patients >45 years old have multiple cardiovascular risk factors, with cardiovascular complications reported in three percent of surgical admissions. In 2024, the American College of Cardiology and the American Heart Association, in collaboration with several subspecialty societies, updated the 2014 guidelines on the management of cardiovascular diseases in the perioperative period for patients undergoing noncardiac surgery. Some of the topics covered include perioperative risk calculators, guidelines for diagnostic testing, perioperative considerations for cardiovascular comorbidities, management of medical therapies, and anesthetic/intraoperative management strategies. Since the guidelines are broad and detailed, this article highlights essential recommendations that are especially relevant to the busy perioperative physician.</p>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-05-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144248007","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Unifying Weaning Success Criteria to Bridge the Extracorporeal Membrane Oxygenation Gap: Variations in Determinants Based on Definitions of Successful Weaning.","authors":"Hibiki Serizawa, Ginga Suzuki, Saria Nishioka, Toshimitsu Kobori, Yuka Masuyama, Saki Yamamoto, Yoshimi Nakamichi, Mitsuru Honda, Yosuke Sasaki","doi":"10.1053/j.jvca.2025.05.015","DOIUrl":"https://doi.org/10.1053/j.jvca.2025.05.015","url":null,"abstract":"<p><strong>Objective: </strong>To investigate the factors contributing to the \"ECMO gap,\" the discrepancy between successful weaning from venoarterial extracorporeal membrane oxygenation (VA-ECMO) and survival to hospital discharge, using different definitions of successful weaning.</p><p><strong>Design: </strong>Single-center retrospective observational study.</p><p><strong>Setting: </strong>A tertiary academic medical center intensive care unit.</p><p><strong>Participants: </strong>Patients aged ≥18 years who underwent VA-ECMO between January 2018 and June 2023. Patients who died while on ECMO were excluded. Successful weaning from ECMO was defined using two criteria: survival for 48 hours (Definition 1) and independence from mechanical circulatory support (MCS) within 30 days (Definition 2).</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>Multivariate logistic regression analysis was performed to identify factors associated with the ECMO gap for each definition, with Bayesian logistic regression conducted as a sensitivity analysis. Of the 130 ECMO patients, 110 were included in the analysis. Acute myocardial infarction and sepsis-induced cardiogenic shock (SICS) were associated with the ECMO gap under Definition 1. Under Definition 2, age (p = 0.04) was significantly associated with the ECMO gap,\" while SICS showed a trend toward significance (p = 0.06). Bayesian analysis supported the association between age (odds ratio [95% confidence interval]: 0.08 [0.01-0.16]) and the ECMO gap. SICS showed a possible association (odds ratio [95% confidence interval]: 3.15 [0.26-6.33]); however, the wide credible interval suggests caution in interpretation.</p><p><strong>Conclusions: </strong>The factors associated with the ECMO gap vary depending on the definition of successful weaning from ECMO. Specifically, advanced age and sepsis (eg, SICS) may hinder long-term recovery and contribute to the ECMO gap. Standardizing the definition of successful ECMO weaning is essential to improving patient outcomes and refining treatment strategies.</p>","PeriodicalId":15176,"journal":{"name":"Journal of cardiothoracic and vascular anesthesia","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-05-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144225530","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}