FRINK Linked Data Fragments server

Matches in SemOpenAlex for { <https://semopenalex.org/work/W3118942359> ?p ?o ?g. }

• W3118942359 endingPage "986" @default.
• W3118942359 startingPage "982" @default.
• W3118942359 abstract "Conduction disturbances remain a common complication following transcatheter aortic valve replacement (TAVR). Despite improvements in device technology and operator experience, the rate of permanent pacemaker (PPM) insertion has not changed significantly over time. Due to a dearth of research into management and treatment of these issues, there is great heterogeneity in practice, leading to significant variability in PPM rates, length of stay, and outcomes throughout the United States. The American College of Cardiology (ACC) sought to address the gaps of care and knowledge in areas in which evidence is new or evolving. Their recently published Expert Consensus Decision Pathway document reviewed the body of data currently available regarding conduction disturbances following TAVR. This article seeks to summarize key points of this document, with a particular focus on issues relevant to cardiac anesthesiologists, who are responsible for the care of TAVR patients before, during, and after their procedure. Although TAVR has emerged as a safe and effective treatment for aortic stenosis, conduction disturbances remain a frequently encountered complication.1Rodés-Cabau J Ellenbogen KA Krahn AD et al.Management of conduction disturbances associated with transcatheter aortic valve replacement: JACC Scientific Expert Panel.J Am Coll Cardiol. 2019; 74: 1086-1106Crossref PubMed Scopus (106) Google Scholar These can manifest as benign changes, such as PR interval prolongation or left bundle-branch block (LBBB), but also as high-degree atrioventricular (AV) block requiring PPM placement.2Auffret V Puri R Urena M et al.Conduction disturbances after transcatheter aortic valve replacement: Current status and future perspectives.Circulation. 2017; 136: 1049-1069Crossref PubMed Scopus (222) Google Scholar Conduction disturbances can occur during the procedure, but also may present days after hospital discharge. There are a lack of randomized controlled trials evaluating the optimal management of conduction disturbances following TAVR and no consensus regarding how to prepare for these potentially life-threatening complications before they occur. The ACC sought to provide guidance regarding management of conduction disturbances in the manuscript by Lilly et al. entitled “2020 ACC Expert Consensus Decision Pathway (ECDP) on Management of Conduction Disturbances in Patients Undergoing Transcatheter Aortic Valve Replacement.”3Lilly SM Deshmukh AJ Epstein AE et al.2020 ACC Expert Consensus Decision Pathway on Management of Conduction Disturbances in Patients Undergoing Transcatheter Aortic Valve Replacement: A report of the American College of Cardiology Solution Set Oversight Committee.J Am Coll Cardiol. 2020; 76: 2391-2411Crossref PubMed Scopus (20) Google Scholar This document was written by a committee of ACC members with representation from the fields of interventional cardiology, electrophysiology, and nursing. The target audience included clinicians from a diversity of specialties. It was intended to “inform and complement good clinical judgment” based on available data in a rapidly evolving field. The present article serves as a review of the ECDP, with a focus on issues pertaining to cardiac anesthesiologists. Where necessary, supplemental information is provided when the ECDP lacks appropriate discussion relevant to the anesthesiologist. Anesthesiologists participate in most TAVR cases.4Konigstein M Ben-Shoshan J Zahler D et al.Outcome of patients undergoing TAVR with and without the attendance of an anesthesiologist.Int J Cardiol. 2017; 241: 124-127Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Cardiac anesthesiologists are involved in the preprocedural workup of patients as part of the heart team approach to TAVR, as recommended by the ACC.5Nishimura RA Otto CM Bonow RO et al.2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Circulation. 2017; 135 (-e95): e1159Crossref PubMed Scopus (1223) Google Scholar They care for these patients during the procedure in the operating room or catheterization laboratory and after the procedure in recovery rooms and intensive care units. In these roles, the anesthesiologist may be called upon to anticipate, diagnose, and manage conduction disturbances (Fig 1). A better understanding of why these complications occur following TAVR enables the optimization of care for each individual. This includes advanced preparation of patients at high risk for conduction disturbances and allows for a more liberal approach to low-risk patients, which may result in a less- invasive procedure and an earlier discharge.6Wood DA Lauck SB Cairns JA et al.The Vancouver 3M (Multidisciplinary, Multimodality, but Minimalist) clinical pathway facilitates safe next-day discharge home at low-, medium-, and high-volume transfemoral transcatheter aortic valve replacement centers: The 3M TAVR study.JACC Cardiovasc Interv. 2019; 12: 459-469Crossref PubMed Scopus (95) Google Scholar Conduction disturbances following TAVR are common. The incidence of new-onset LBBB has been reported in as many as 65% of patients.7Baan Jr., J Yong ZY Koch KT et al.Factors associated with cardiac conduction disorders and permanent pacemaker implantation after percutaneous aortic valve implantation with the CoreValve prosthesis.Am Heart J. 2010; 159: 497-503Crossref PubMed Scopus (142) Google Scholar High-degree AV block, defined as third-degree AV heart block or second-degree type II (Mobitz II) heart block, occurs in 15% of cases and is an established indication for PPM.8Kusumoto FM Schoenfeld MH Barrett C et al.2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.J Am Coll Cardiol. 2019; 74: e51-e156Crossref PubMed Scopus (119) Google Scholar Although factors such as valve design and deployment techniques have been shown to affect the rate of conduction disturbances, they cannot be explained by these reasons alone. The rate of PPM insertion has not decreased since commercial approval in 2012 despite improvements in device technology and operator experience.9Auffret V Lefevre T Van Belle E et al.Temporal trends in transcatheter aortic valve replacement in France: FRANCE 2 to FRANCE TAVI.J Am College Cardiol. 2017; 70: 42-55Crossref PubMed Scopus (191) Google Scholar This suggests that some fixed percentage of TAVR patients may have high-risk anatomic features for which proceduralists cannot compensate, but also that there is a lack of understanding of all factors involved. Although the exact mechanisms of conduction disturbances after TAVR are not understood fully, the anatomy of the cardiac conduction system plays an important role.10Ghadimi K Patel PA Gutsche JT et al.Perioperative conduction disturbances after transcatheter aortic valve replacement.J Cardiothoracic Vasc Anesth. 2013; 27: 1414-1420Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar The bundle of His connects the AV node to the Purkinje fibers via the left and right bundle branches. This important component of the conduction pathway runs within the membranous portion of the interventricular septum between the right and noncoronary cusps of the aortic valve and exits at its most inferior portion. Thus, proper TAVR implantation into the left ventricular outflow tract (LVOT) can overlap this region of the membranous septum and may lead to anatomic compression resulting in transient or permanent interruption of conduction to the right and left bundle branches. Balloon aortic valvuloplasty also may cause conduction disturbances by the same mechanism.11Banerjee K Kandregula K Sankaramangalam K et al.Meta-analysis of the impact of avoiding balloon predilation in transcatheter aortic valve implantation.Am J Cardiol. 2018; 122: 477-482Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Damage to the conduction system may occur directly and immediately following implantation, but also may occur indirectly and delayed in a manner that is poorly understood.12Nuis RJ Van Mieghem NM Schultz CJ et al.Timing and potential mechanisms of new conduction abnormalities during the implantation of the Medtronic CoreValve System in patients with aortic stenosis.Eur Heart J. 2011; 32: 2067-2074Crossref PubMed Scopus (142) Google Scholar Other anatomic risk factors for conduction disturbances include the presence of LVOT calcium adjacent to the noncoronary cusp, a shorter membranous septum, a smaller LVOT, or a comparatively smaller ratio of the LVOT-to-prosthesis diameter.13Lader JM Barbhaiya CR Subnani K et al.Factors predicting persistence of AV nodal block in post-TAVR patients following permanent pacemaker implantation.Pacing Clin Electrophysiol. 2019; 42: 1347-1354Crossref PubMed Scopus (5) Google Scholar, 14Hamdan A Guetta V Klempfner R et al.Inverse relationship between membranous septal length and the risk of atrioventricular block in patients undergoing transcatheter aortic valve implantation.JACC Cardiovasc Interv. 2015; 8: 1218-1228Crossref PubMed Scopus (95) Google Scholar, 15Latsios G Gerckens U Buellesfeld L et al.Device landing zone” calcification, assessed by MSCT, as a predictive factor for pacemaker implantation after TAVI.Catheterization Cardiovasc Interv. 2010; 76: 431-439Crossref PubMed Scopus (120) Google Scholar As the ECDP outlines, the management of conduction disturbances begins before device implantation with a proper workup to assess risks factors and formulate a suitable plan for pacing after the procedure should the need arise. In some instances, awareness of the presence of certain risk factors may allow for procedural modifications that can reduce the risk of PPM.16Scarsini R De Maria GL Joseph J et al.Impact of complications during transfemoral transcatheter aortic valve replacement: How can they be avoided and managed?.J Am Heart Assoc. 2019; 8e013801Crossref PubMed Scopus (26) Google Scholar These adjustments may include selecting a balloon-expandable valve, a high valve implant, or avoidance of pre- and post-aortic valvuloplasty.1Rodés-Cabau J Ellenbogen KA Krahn AD et al.Management of conduction disturbances associated with transcatheter aortic valve replacement: JACC Scientific Expert Panel.J Am Coll Cardiol. 2019; 74: 1086-1106Crossref PubMed Scopus (106) Google Scholar In other cases, awareness of patient risk factors only enables the anesthesiologist to predict more accurately the likelihood of high-degree AV block, facilitating appropriate preparedness. The incidence of baseline right bundle-branch block (RBBB) on a preoperative electrocardiogram (ECG) is reported to be approximately 10% and has been shown in multiple studies to predict strongly the need for PPM after TAVR.17Erkapic D De Rosa S Kelava A et al.Risk for permanent pacemaker after transcatheter aortic valve implantation: A comprehensive analysis of the literature.J Cardiovasc Electrophysiol. 2012; 23: 391-397Crossref PubMed Scopus (164) Google Scholar The ECDP does not describe any modifiable technique specific to RBBB that can decrease the incidence of developing high-degree AV block. In contrast, pre-existing LBBB has not been shown consistently to predict PPM implantation after TAVR, although data have been inconsistent.18Kiani S Kamioka N Black GB et al.Development of a risk score to predict new pacemaker implantation after transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2019; 12: 2133-2142Crossref PubMed Scopus (35) Google Scholar Because patients with LBBB are known to be older and with a lower left ventricular ejection fraction, the ECDP suggests that some reports of increased rate of PPM implantation associated with LBBB may be due to knowledge gaps and a perceived rather than actual risk of high-degree AV block. Prolonged QRS interval without RBBB is also not a risk factor for PPM after TAVR.18Kiani S Kamioka N Black GB et al.Development of a risk score to predict new pacemaker implantation after transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2019; 12: 2133-2142Crossref PubMed Scopus (35) Google Scholar Likewise, pre-existing first-degree AV block is not a known independent risk factor. However, it is important to note the baseline PR interval on ECG, because PR interval prolongation, defined as an increase of greater than 20 ms after TAVR, has been shown to predict independently delayed onset AV block, defined as high-degree AV block occurring two or more days after implant.19Mangieri A Lanzillo G Bertoldi L et al.Predictors of advanced conduction disturbances requiring a late (≥48 H) permanent pacemaker following transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2018; 11: 1519-1526Crossref PubMed Scopus (45) Google Scholar Although a single ECG is useful in the workup of TAVR before the procedure, it may be insufficient for detecting all conduction disturbances. Twenty-four-hour continuous rhythm monitoring is better at detecting transient episodes of AV block or severe bradycardia, which may predispose to conduction disturbances after TAVR. Anesthesiologists should be aware that symptomatic bradycardia and severe symptomatic aortic stenosis both have a common clinical presentation, which may include syncopal events. In some patients, continuous rhythm monitoring may reveal that PPM implantation is indicated before TAVR, which could alter perioperative TAVR management. There is no consensus for when to perform 24-hour continuous ECG monitoring before TAVR. Computed tomography (CT) imaging is another standard component of the TAVR workup before the procedure. Primarily performed for valve sizing and the assessment of vascular caliber and tortuosity, more recently CT imaging has been used to determine the likelihood of developing conduction disturbances after TAVR. Identifiable risk factors include the presence of significant LVOT calcium near the noncoronary cusp and a comparatively small LVOT in relation to prosthesis size.13Lader JM Barbhaiya CR Subnani K et al.Factors predicting persistence of AV nodal block in post-TAVR patients following permanent pacemaker implantation.Pacing Clin Electrophysiol. 2019; 42: 1347-1354Crossref PubMed Scopus (5) Google Scholar,15Latsios G Gerckens U Buellesfeld L et al.Device landing zone” calcification, assessed by MSCT, as a predictive factor for pacemaker implantation after TAVI.Catheterization Cardiovasc Interv. 2010; 76: 431-439Crossref PubMed Scopus (120) Google Scholar A short membranous septum, as measured by CT, also has been shown to predict strongly the need for PPM after TAVR and may allow for an adjustment in implantation technique.14Hamdan A Guetta V Klempfner R et al.Inverse relationship between membranous septal length and the risk of atrioventricular block in patients undergoing transcatheter aortic valve implantation.JACC Cardiovasc Interv. 2015; 8: 1218-1228Crossref PubMed Scopus (95) Google Scholar Jilaihawi et al. prospectively studied the value of measuring this distance before implantation.20Jilaihawi H Zhao Z Du R et al.Minimizing permanent pacemaker following repositionable self-expanding transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2019; 12: 1796-1807Crossref PubMed Scopus (95) Google Scholar His team reported a reduction in PPM rate to 3% and new LBBB to 9% by attempting to implant the valve prosthesis at a depth less than the length of the membranous septum. The ECDP states that baseline conduction abnormalities should not alter the plan for general anesthesia or monitored anesthesia care, which instead should be selected based on what is suited best for the individual patient. Medications, including beta-blockers and calcium channel blockers, can be given safely without increasing the risk of conduction disturbances after TAVR, because their site of action is the AV node and not the bundle of His. The same likely is true for volatile anesthetics, dexmedetomidine, and propofol, all of which can cause bradycardia at the doses commonly used. As part of routine anesthesia care, the anesthesiologist is responsible for ensuring sufficient vascular access for resuscitation, which may involve obtaining central venous access. As such, there may be an overlap between line placement required by the anesthesiologist and what is necessary for the procedure itself. Communication of the care plan between anesthesiologist and proceduralist, therefore, is required. The ideal catheter used for central venous access in TAVR should have at least one large-bore side port to allow for fluid administration. The introducer portion of the catheter should feature a locking mechanism that proximally stabilizes the pacing wire electrode insertion depth. Based on the anticipated needs for intraoperative and postoperative pacing, a number of pacing strategies can be used as described by the ECDP. Regardless of the access site or service team that places the central venous line, the anesthesiologist should have access to the side port for purposes of resuscitation. All patients undergoing TAVR should have some form of temporary intraoperative pacing capability, regardless of the choice of valve used. Although it is true that only balloon-expandable valves explicitly require periods of rapid ventricular pacing for deployment, proceduralists using a self-expanding prosthesis for TAVR may use temporary pacing to stabilize the heart during deployment, or for pre- and post-deployment balloon aortic valvuloplasty.21Grube E Laborde JC Gerckens U et al.Percutaneous implantation of the CoreValve self-expanding valve prosthesis in high-risk patients with aortic valve disease: The Siegburg first-in-man study.Circulation. 2006; 114: 1616-1624Crossref PubMed Scopus (619) Google Scholar Beyond these intraoperative requirements, pacing may be required after the procedure in patients who develop high-degree AV block during the procedure, or those who are at high risk of delayed-onset AV block. Temporary pacing in patients undergoing TAVR is achieved most frequently with a transvenous pacing wire electrode placed into the right ventricle under fluoroscopy via the femoral vein or right internal jugular vein (RIJ). These sites offer the most direct access to the right heart. In some practices, the responsibility of obtaining central venous access and placement of the pacing wire electrode may fall to the anesthesiologist, while in other situations this may be performed by the proceduralist. The choice of access site is both patient- and team-specific. Femoral vein access can be performed by proceduralists efficiently with the same sterile prep and draping as the procedure itself. This approach is efficient and may carry less risk of mechanical complications compared to RIJ catheters, particularly in patients who are not under general anesthesia. For patients requiring temporary pacing into the postoperative phase, femoral venous pacing is not preferred in fast-track pathways.22Neuburger PJ Saric M Huang C et al.A practical approach to managing transcatheter aortic valve replacement with sedation.Semin Cardiothorac Vasc Anesth. 2016; 20: 147-157Crossref PubMed Scopus (10) Google Scholar Early ambulation and getting out of bed to a chair require flexion of the hip, which is contraindicated when femoral lines are in place. Pacing via RIJ access then is preferred and usually obtained by the cardiac anesthesiologist. In patients with unfavorable RIJ anatomy, the left subclavian vein is an alternative that allows for easier placement of the pacing wire electrode into the heart compared to the left internal jugular or right subclavian veins. This site usually does not impede access to the surface of the left chest required for intraprocedural transthoracic echocardiography. Temporary pacing also can be achieved by using the left ventricular wire that is placed across the aortic valve for the TAVR prosthesis.23Faurie B Souteyrand G Staat P et al.Left ventricular rapid pacing via the valve delivery guidewire in transcatheter aortic valve replacement.JACC. Cardiovasc Interv. 2019; 12: 2449-2459Crossref PubMed Scopus (20) Google Scholar Alligator clips are applied directly to this wire and grounded to the patient, then connected to an external pacing box. This method reduces the number of invasive lines and may increase procedural efficiency and decrease complications. Experience with this technique is limited, and the anesthesiologist should note the absence of central venous access for resuscitation, and that the left ventricular wire cannot remain in place into the phase of care after the procedure. In addition to complications related to central venous line placement, placement of the pacing wire electrode may be associated with myocardial perforation, pericardial tamponade, and unreliable capture of pacing, particularly with patient movement. There are a variety of pacing wire electrodes available commercially that can be broadly classified as either active or passive fixation. Active fixation electrodes incorporate some type of myocardial fixation mechanism, such as a prong or corkscrew at the distal tip. Although this may improve the stability and reliability of capture, it also may lead to myocardial injury and perforation. The ECDP states it is reasonable to use in patients expected to require pacing in the postoperative phase. Many pacing wire electrodes have a soft balloon tip mechanism to reduce the risk of myocardial perforation during placement. Management of postimplantation conduction disturbances ultimately is dictated by 12-lead ECG analysis, although evaluation begins with observing leads II and V in the procedure suite. In patients with a normal baseline ECG and no new conduction disturbances, the risk of developing high-degree AV block is low, and there is consensus that the temporary pacing wire electrode and central venous catheter can be removed.24Schoechlin S Jalil F Blum T et al.Need for pacemaker implantation in patients with normal QRS duration immediately after transcatheter aortic valve implantation.Europace. 2019; 21: 1851-1856Crossref PubMed Scopus (5) Google Scholar Many TAVR programs will do this based on intraoperative ECG findings alone. Patients with baseline first-degree AV block and/or LBBB who do not experience PR or QRS interval prolongation are also at low risk for complete heart block.25Bagur R Rodés-Cabau J Gurvitch R et al.Need for permanent pacemaker as a complication of transcatheter aortic valve implantation and surgical aortic valve replacement in elderly patients with severe aortic stenosis and similar baseline electrocardiographic findings.JACC Cardiovasc Interv. 2012; 5: 540-551Crossref PubMed Scopus (114) Google Scholar These patients still should be admitted to a telemetry unit for monitoring overnight and there should be a contingency plan if conduction disturbances occur, which may include transcutaneous pacing.26Toggweiler S Stortecky S Holy E et al.The electrocardiogram after transcatheter aortic valve replacement determines the risk for post-procedural high-degree AV block and the need for telemetry monitoring.JACC Cardiovas Interv. 2016; 9: 1269-1276Crossref PubMed Scopus (79) Google Scholar Placement of transvenous pacing wire electrodes without fluoroscopy can be challenging, particularly in emergent conditions. In patients with RBBB who develop transient or persistent high-degree AV block after valve implantation, the need is likely for PPM. Even in such clear cases, the ECDP states it is preferable to exit the procedure suite and have the patient recover in a monitored setting, rather than perform PPM implantation as part of the same anesthetic. Separating the two procedures allows for informed consent and permits the arrangement of appropriate equipment and personnel. In many cases, same-day PPM placement and next-day discharge still can be achieved. In patients without RBBB who develop transient high-degree AV block, monitoring for 24 hours is warranted. With resolution, patients may be candidates for discharge without further workup, as there are no specific guidelines for when to use further electrophysiologic studies for decision-making. Patients who do not fit the above criteria as either high or low risk for PPM represent the most challenging cohort to manage. In these situations, it can be difficult to determine the appropriate level of monitoring and intervention, particularly with enhanced focus on reducing cost and hospital length of stay. Studies have revealed that delayed-onset AV block should be a concern, but also that as many as 68% of patients who received a PPM after TAVR were found to not require RV pacing at 30 days.27Sharma E Chu AF. Predictors of right ventricular pacing and pacemaker dependence in transcatheter aortic valve replacement patients.J Interv Card Electrophysiol. 2018; 51: 77-86Crossref PubMed Scopus (11) Google Scholar Based on available data, the ECDP recommends at least 48-hour inpatient telemetry monitoring and continuation of temporary pacing capability for all patients who develop a new LBBB or an increase in PR or QRS interval of greater than 10%. If conduction disturbances do not worsen, discharge with an ambulatory event monitoring device for 14 days may be considered. This device should have the ability to detect delayed-onset AV block and notify emergency medical services. Anesthesiologists care for TAVR patients in every perioperative phase of care. They should be familiar with the pathophysiology, diagnosis, and management of TAVR-related conduction disturbances, which remains frequent complications despite numerous technical and operational advances. To date there is not a standardized approach to management, and, therefore, it remains difficult to evaluate appropriately the safety and efficacy of strategies in large multicenter studies. Differences in management account for significant variations in clinical outcomes and costs. The ECDP serves as an important document that summarizes available data to allow for a more evidence-based approach to the management of conduction disturbances." @default.
• W3118942359 created "2021-01-18" @default.
• W3118942359 creator A5021466253 @default.
• W3118942359 creator A5086913757 @default.
• W3118942359 creator A5088088610 @default.
• W3118942359 date "2021-04-01" @default.
• W3118942359 modified "2023-10-18" @default.
• W3118942359 title "Anesthetic Management of Conduction Disturbances Following Transcatheter Aortic Valve Replacement: A Review of the 2020 ACC Expert Consensus Decision Pathway" @default.
• W3118942359 cites W1150726894 @default.
• W3118942359 cites W1997721487 @default.
• W3118942359 cites W2016633191 @default.
• W3118942359 cites W2045498254 @default.
• W3118942359 cites W2055606289 @default.
• W3118942359 cites W2073233880 @default.
• W3118942359 cites W2121638461 @default.
• W3118942359 cites W2149820004 @default.
• W3118942359 cites W2338828923 @default.
• W3118942359 cites W2463213207 @default.
• W3118942359 cites W2587215794 @default.
• W3118942359 cites W2663280559 @default.
• W3118942359 cites W2754083347 @default.
• W3118942359 cites W2776473974 @default.
• W3118942359 cites W2802810203 @default.
• W3118942359 cites W2886715168 @default.
• W3118942359 cites W2900277959 @default.
• W3118942359 cites W2919976021 @default.
• W3118942359 cites W2969587132 @default.
• W3118942359 cites W2969722774 @default.
• W3118942359 cites W2970602664 @default.
• W3118942359 cites W2972620244 @default.
• W3118942359 cites W2975358661 @default.
• W3118942359 cites W2977460679 @default.
• W3118942359 cites W2986202787 @default.
• W3118942359 cites W3093603655 @default.
• W3118942359 cites W4239414585 @default.
• W3118942359 doi "https://doi.org/10.1053/j.jvca.2020.12.030" @default.
• W3118942359 hasPubMedId "https://pubmed.ncbi.nlm.nih.gov/33441272" @default.
• W3118942359 hasPublicationYear "2021" @default.
• W3118942359 type Work @default.
• W3118942359 sameAs 3118942359 @default.
• W3118942359 citedByCount "0" @default.
• W3118942359 crossrefType "journal-article" @default.
• W3118942359 hasAuthorship W3118942359A5021466253 @default.
• W3118942359 hasAuthorship W3118942359A5086913757 @default.
• W3118942359 hasAuthorship W3118942359A5088088610 @default.
• W3118942359 hasBestOaLocation W31189423591 @default.
• W3118942359 hasConcept C164705383 @default.
• W3118942359 hasConcept C177713679 @default.
• W3118942359 hasConcept C2780007028 @default.
• W3118942359 hasConcept C2780026749 @default.
• W3118942359 hasConcept C42219234 @default.
• W3118942359 hasConcept C71924100 @default.
• W3118942359 hasConceptScore W3118942359C164705383 @default.
• W3118942359 hasConceptScore W3118942359C177713679 @default.
• W3118942359 hasConceptScore W3118942359C2780007028 @default.
• W3118942359 hasConceptScore W3118942359C2780026749 @default.
• W3118942359 hasConceptScore W3118942359C42219234 @default.
• W3118942359 hasConceptScore W3118942359C71924100 @default.
• W3118942359 hasIssue "4" @default.
• W3118942359 hasLocation W31189423591 @default.
• W3118942359 hasOpenAccess W3118942359 @default.
• W3118942359 hasPrimaryLocation W31189423591 @default.
• W3118942359 hasRelatedWork W2546153974 @default.
• W3118942359 hasRelatedWork W2549135832 @default.
• W3118942359 hasRelatedWork W2596416638 @default.
• W3118942359 hasRelatedWork W2597019447 @default.
• W3118942359 hasRelatedWork W2763459175 @default.
• W3118942359 hasRelatedWork W2888691009 @default.
• W3118942359 hasRelatedWork W2922536977 @default.
• W3118942359 hasRelatedWork W2981749206 @default.
• W3118942359 hasRelatedWork W4252371801 @default.
• W3118942359 hasRelatedWork W4295539672 @default.
• W3118942359 hasVolume "35" @default.
• W3118942359 isParatext "false" @default.
• W3118942359 isRetracted "false" @default.
• W3118942359 magId "3118942359" @default.
• W3118942359 workType "article" @default.