{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,4]],"date-time":"2026-05-04T10:09:29Z","timestamp":1777889369200,"version":"3.51.4"},"reference-count":51,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2022,1,7]],"date-time":"2022-01-07T00:00:00Z","timestamp":1641513600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: Mitral stenosis with extensive mitral annular calcification (MAC) remains surgically challenging in respect to clinical outcome. Prolonged surgery time with imminent ventricular rupture and systolic anterior motion can be considered as a complex of causal factors. The aim of our alternative hybrid approach was to reduce the risk of annual rupture and paravalvular leaks and to avoid obstruction of the outflow tract. A review of the current literature was also carried out. Materials and Methods: Six female patients (mean age 76 \u00b1 9 years) with severe mitral valve stenosis and severely calcified annulus underwent an open implantation of an Edwards Sapien 3 prosthesis on cardiopulmonary bypass. Our hybrid approach involved resection of the anterior mitral leaflet, placement of anchor sutures and the deployment of a balloon expanded prosthesis under visual control. Concomitant procedures were carried out in three patients. Results: The mean duration of cross-clamping was 95 \u00b1 31 min and cardiopulmonary bypass was 137 \u00b1 60 min. The perioperative TEE showed in three patients an inconspicuous, heart valve-typical gradient on all implanted prostheses and a clinically irrelevant paravalvular leakage occurred in the anterior annulus. In the left ventricular outflow tract, mild to moderately elevated gradients were recorded. No adverse cerebrovascular events and pacemaker implantations were observed. All but one patient survived to discharge. Survival at one year was 83.3%. Conclusions: This \u201coff label\u201d implantation of the Edwards Sapien 3 prosthesis may be considered as a suitable bail-out approach for patients at high-risk for mitral valve surgery or deemed inoperable due to extensive MAC.<\/jats:p>","DOI":"10.3390\/medicina58010093","type":"journal-article","created":{"date-parts":[[2022,1,9]],"date-time":"2022-01-09T20:21:56Z","timestamp":1641759716000},"page":"93","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Hybrid Surgery for Severe Mitral Valve Calcification: Limitations and Caveats for an Open Transcatheter Approach"],"prefix":"10.3390","volume":"58","author":[{"given":"Erik","family":"Bagaev","sequence":"first","affiliation":[{"name":"German Centre for Cardiovascular Research (DZHK), Department of Cardiac Surgery, Ludwig Maximilian University of Munich, Partner Site Munich Heart Alliance, 80539 Munich, Germany"},{"name":"Department of Cardiac Surgery, Klinikum N\u00fcrnberg, Paracelsus Medical University, 90471 Nuremberg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ahmad","family":"Ali","sequence":"additional","affiliation":[{"name":"German Centre for Cardiovascular Research (DZHK), Department of Cardiac Surgery, Ludwig Maximilian University of Munich, Partner Site Munich Heart Alliance, 80539 Munich, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9903-3237","authenticated-orcid":false,"given":"Shekhar","family":"Saha","sequence":"additional","affiliation":[{"name":"German Centre for Cardiovascular Research (DZHK), Department of Cardiac Surgery, Ludwig Maximilian University of Munich, Partner Site Munich Heart Alliance, 80539 Munich, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1796-4434","authenticated-orcid":false,"given":"Sebastian","family":"Sadoni","sequence":"additional","affiliation":[{"name":"German Centre for Cardiovascular Research (DZHK), Department of Cardiac Surgery, Ludwig Maximilian University of Munich, Partner Site Munich Heart Alliance, 80539 Munich, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9830-1941","authenticated-orcid":false,"given":"Martin","family":"Orban","sequence":"additional","affiliation":[{"name":"German Centre for Cardiovascular Research (DZHK), Department of Cardiology, Ludwig Maximilian University of Munich, Partner Site Munich Heart Alliance, 80539 Munich, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michael","family":"Naebauer","sequence":"additional","affiliation":[{"name":"German Centre for Cardiovascular Research (DZHK), Department of Cardiology, Ludwig Maximilian University of Munich, Partner Site Munich Heart Alliance, 80539 Munich, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Julinda","family":"Mehilli","sequence":"additional","affiliation":[{"name":"German Centre for Cardiovascular Research (DZHK), Department of Cardiology, Ludwig Maximilian University of Munich, Partner Site Munich Heart Alliance, 80539 Munich, Germany"},{"name":"Medizinische Klinik I, Landshut-Achdorf Hospital, 84036 Landshut, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Steffen","family":"Massberg","sequence":"additional","affiliation":[{"name":"German Centre for Cardiovascular Research (DZHK), Department of Cardiology, Ludwig Maximilian University of Munich, Partner Site Munich Heart Alliance, 80539 Munich, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Andreas","family":"Oberbach","sequence":"additional","affiliation":[{"name":"German Centre for Cardiovascular Research (DZHK), Department of Cardiac Surgery, Ludwig Maximilian University of Munich, Partner Site Munich Heart Alliance, 80539 Munich, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christian","family":"Hagl","sequence":"additional","affiliation":[{"name":"German Centre for Cardiovascular Research (DZHK), Department of Cardiac Surgery, Ludwig Maximilian University of Munich, Partner Site Munich Heart Alliance, 80539 Munich, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2022,1,7]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e008513","DOI":"10.1161\/CIRCIMAGING.118.008513","article-title":"Disease Activity in Mitral Annular Calcification","volume":"12","author":"Massera","year":"2019","journal-title":"Circ. Cardiovasc. Imaging"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"555","DOI":"10.1016\/j.jtcvs.2018.05.099","article-title":"Current and evolving strategies in the management of severe mitral annular calcification","volume":"157","author":"Bedeir","year":"2018","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"777","DOI":"10.1016\/S0022-5223(03)00081-3","article-title":"Mitral valve surgery in patients with extensive calcification of the mitral annulus","volume":"126","author":"Feindel","year":"2003","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"590","DOI":"10.1016\/S0003-4975(10)64712-1","article-title":"Rupture of Left Ventricle Following Mitral Valve Replacement","volume":"46","author":"Karlson","year":"1988","journal-title":"Ann. Thorac. Surg."},{"key":"ref_5","first-page":"162","article-title":"Direct transatrial implantation of balloon-expandable valve for mitral stenosis with severe annular calcifications: Early experience and lessons learned\u2020","volume":"53","author":"Eleid","year":"2017","journal-title":"Eur. J. Cardio-Thorac. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"132","DOI":"10.1016\/j.jtcvs.2018.03.016","article-title":"Transatrial implantation of a transcatheter heart valve for severe mitral annular calcification","volume":"156","author":"Praz","year":"2018","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1361","DOI":"10.1016\/j.jcin.2016.04.022","article-title":"Transcatheter Mitral Valve Replacement in Native Mitral Valve Disease With Severe Mitral Annular Calcification: Results From the First Multicenter Global Registry","volume":"9","author":"Guerrero","year":"2016","journal-title":"JACC Cardiovasc. Interv."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1171","DOI":"10.1016\/j.athoracsur.2015.05.048","article-title":"Sapien XT Transcatheter Mitral Valve Replacement under Direct Vision in the Setting of Significant Mitral Annular Calcification","volume":"101","author":"Murashita","year":"2016","journal-title":"Ann. Thorac. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1097\/imi.0000000000000272","article-title":"Edwards Sapien Xt in Native Stenotic Mitral Valve, Open Technique on Cardiopulmonary Bypass: An Option, but Safe?","volume":"11","author":"Dahle","year":"2016","journal-title":"Innov. Technol. Tech. Cardiothorac. Vasc. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"441","DOI":"10.1093\/eurheartj\/ehy590","article-title":"Outcomes of transcatheter mitral valve replacement for degenerated bioprostheses, failed annuloplasty rings, and mitral annular calcification","volume":"40","author":"Yoon","year":"2018","journal-title":"Eur. Heart J."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2679","DOI":"10.1093\/eurheartj\/ehy271","article-title":"Clinical and haemodynamic outcomes of balloon-expandable transcatheter mitral valve implantation: A 7-year experience","volume":"39","author":"Urena","year":"2018","journal-title":"Eur. Heart J."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1841","DOI":"10.1016\/j.jacc.2018.02.054","article-title":"1-Year Outcomes of Transcatheter Mitral Valve Replacement in Patients With Severe Mitral Annular Calcification","volume":"71","author":"Guerrero","year":"2018","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1437","DOI":"10.1016\/j.jacc.2018.07.033","article-title":"Open Atrial Transcatheter Mitral Valve Replacement in Patients With Mitral Annular Calcification","volume":"72","author":"Russell","year":"2018","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1657","DOI":"10.1001\/jama.2015.3656","article-title":"Preferred Reporting Items for a Systematic Review and Meta-analysis of Individual Participant Data: The PRISMA-IPD statement","volume":"313","author":"Stewart","year":"2015","journal-title":"JAMA"},{"key":"ref_15","first-page":"727","article-title":"2021 ESC\/EACTS Guidelines for the management of valvular heart disease","volume":"60","author":"Vahanian","year":"2021","journal-title":"Eur. Heart J."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"378","DOI":"10.1093\/oxfordjournals.bja.a013444","article-title":"Central nervous system complications of cardiac surgery","volume":"84","author":"Arrowsmith","year":"2000","journal-title":"Br. J. Anaesth."},{"key":"ref_17","first-page":"46","article-title":"Mitral Valve Repair is Feasible Following Extensive Decalcification and Reconstruction of the Atrioventricular Groove","volume":"24","author":"Price","year":"2015","journal-title":"J. Heart Valve Dis."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1143","DOI":"10.1016\/j.athoracsur.2008.12.041","article-title":"Midterm Survival after Decalcification of the Mitral Annulus","volume":"87","author":"Papadopoulos","year":"2009","journal-title":"Ann. Thorac. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"834","DOI":"10.1093\/ndt\/gfn544","article-title":"Association of renal function with cardiac calcifications in older adults: The cardiovascular health study","volume":"24","author":"Asselbergs","year":"2008","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1492","DOI":"10.1161\/01.CIR.0000058168.26163.BC","article-title":"Mitral Annular Calcification Predicts Cardiovascular Morbidity and Mortality: The Framingham Heart Study","volume":"107","author":"Fox","year":"2003","journal-title":"Circulation"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"902","DOI":"10.1378\/chest.10-2963","article-title":"Mitral Annular Calcification Predicts Cardiovascular Morbidity and Mortality in Middle-aged Patients With Atrial Fibrillation: The Belgrade Atrial Fibrillation Study","volume":"140","author":"Potpara","year":"2011","journal-title":"Chest"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"389","DOI":"10.1016\/j.amjcard.2009.09.042","article-title":"Mitral Annular Calcium Causing Mitral Stenosis","volume":"105","author":"Pressman","year":"2010","journal-title":"Am. J. Cardiol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"2030","DOI":"10.1016\/j.athoracsur.2017.05.008","article-title":"Transapical Mitral Valve Implantation for Native Mitral Valve Stenosis Using a Balloon-Expandable Prosthesis","volume":"104","author":"Kiefer","year":"2017","journal-title":"Ann. Thorac. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"202","DOI":"10.4414\/cvm.2012.01677","article-title":"Worldwide first surgical implantation of a transcatheter valved stent in mitral position","volume":"15","author":"Carrel","year":"2012","journal-title":"Cardiovasc. Med."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"745","DOI":"10.1093\/icvts\/ivt249","article-title":"Transcatheter valve used in a bailout technique during complicated open mitral valve surgery","volume":"17","author":"Astarci","year":"2013","journal-title":"Interact. Cardiovasc. Thorac. Surg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"2609","DOI":"10.1093\/eurheartj\/eht254","article-title":"Transcatheter mitral valve replacement using a balloon-expandable prosthesis in a patient with calcified native mitral valve stenosis","volume":"34","author":"Sinning","year":"2013","journal-title":"Eur. Heart J."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"749","DOI":"10.1093\/ejcts\/ezt364","article-title":"On-pump fibrillating heart mitral valve replacement with the SAPIEN XT transcatheter heart valve","volume":"45","author":"Ferrari","year":"2013","journal-title":"Eur. J. Cardio-Thorac. Surg."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1085","DOI":"10.1016\/j.athoracsur.2014.10.018","article-title":"Direct Access Implantation of a Melody Valve in Native Mitral Valve: A Hybrid Approach in the Presence of Extensive Mitral Annular Calcification","volume":"99","author":"Love","year":"2015","journal-title":"Ann. Thorac. Surg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"2119","DOI":"10.1093\/eurheartj\/ehv167","article-title":"First-in-man transapical mitral valve replacement using the Direct Flow Medical\u00ae aortic valve prosthesis","volume":"36","author":"Mellert","year":"2015","journal-title":"Eur. Heart J."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e003031","DOI":"10.1161\/CIRCINTERVENTIONS.115.003031","article-title":"(First Reported Case of Transcatheter Mitral Valve Implantation in Mitral Annular Calcification with a Fully Repositionable and Self-Expanding Valve","volume":"8","author":"Lim","year":"2015","journal-title":"Circ. Cardiovasc. Interv."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"e47","DOI":"10.1016\/j.jtcvs.2015.10.040","article-title":"Mitral valve replacement with a transcatheter valve in the setting of severe mitral annular calcification","volume":"151","author":"Lee","year":"2015","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_32","first-page":"382","article-title":"Surgical antegrade transcatheter mitral valve implantation for symptomatic mitral valve disease and heavily calcified annulus","volume":"51","author":"Langhammer","year":"2016","journal-title":"Eur. J. Cardio-Thorac. Surg."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1111\/jocs.12737","article-title":"Robotic Transcatheter Mitral Valve Replacement Using the Sapien XT in the Setting of Severe Mitral Annular Calcification","volume":"31","author":"Koeckert","year":"2016","journal-title":"J. Card. Surg."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"e433","DOI":"10.1016\/j.athoracsur.2016.03.097","article-title":"Implantation of Transcatheter Aortic Prosthesis in 3 Patients With Mitral Annular Calcification","volume":"102","author":"Baumgarten","year":"2016","journal-title":"Ann. Thorac. Surg."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"e303","DOI":"10.1016\/j.athoracsur.2017.05.014","article-title":"Transcatheter Valve Implantation in Mitral Annular Calcification During Open Surgery: Extended Collar Technique","volume":"104","author":"Bapat","year":"2017","journal-title":"Ann. Thorac. Surg."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"e57","DOI":"10.1016\/j.athoracsur.2016.06.105","article-title":"Mitral Valve Replacement With Sapien 3 Transcatheter Valve in Severe Mitral Annular Calcification","volume":"103","author":"Polomsky","year":"2017","journal-title":"Ann. Thorac. Surg."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"e57","DOI":"10.1016\/j.athoracsur.2018.02.066","article-title":"Hybrid Open Minimally Invasive Transcatheter Mitral Valve Replacement","volume":"106","author":"Marcus","year":"2018","journal-title":"Ann. Thorac. Surg."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"470","DOI":"10.1177\/0218492318783306","article-title":"Surgical antegrade transcatheter valve implantation and heavily calcified heart","volume":"26","author":"Lupon","year":"2018","journal-title":"Asian Cardiovasc. Thorac. Ann."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1111\/jocs.14004","article-title":"The role of surgical transcatheter valve implantation for the treatment of severe mitral annular calcification","volume":"34","author":"Jeganathan","year":"2019","journal-title":"J. Card. Surg."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1016\/j.jccase.2020.06.017","article-title":"Open-heart transseptal transcatheter mitral valve implantation with mitral annular calcification","volume":"22","author":"Morita","year":"2020","journal-title":"J. Cardiol. Cases"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1186\/s13019-020-1083-8","article-title":"Surgical mitral valve replacement using direct implantation of Sapien 3 valve in a patients with severe mitral annular calcification without adjunctive techniques, a case report","volume":"15","author":"Albacker","year":"2020","journal-title":"J. Cardiothorac. Surg."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"2388","DOI":"10.1016\/j.jcin.2020.07.007","article-title":"Contemporary Transcatheter Mitral Valve Replacement for Mitral Annular Calcification or Ring","volume":"13","author":"Tiwana","year":"2020","journal-title":"JACC Cardiovasc. Interv."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"293","DOI":"10.1016\/j.jcin.2012.09.019","article-title":"Transcatheter Aortic Valve Replacement with the SAPIEN 3: A new balloon-expandable transcatheter heart valve","volume":"6","author":"Binder","year":"2013","journal-title":"JACC Cardiovasc. Interv."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1878","DOI":"10.1093\/eurheartj\/ehv333","article-title":"Clinical trial design principles and endpoint definitions for transcatheter mitral valve repair and replacement: Part 2: Endpoint definitions: A consensus document from the Mitral Valve Academic Research Consortium","volume":"36","author":"Stone","year":"2015","journal-title":"Eur. Heart J."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"508","DOI":"10.1111\/jocs.13767","article-title":"Transcatheter mitral valve implantation for degenerated mitral bioprostheses or failed surgical annuloplasty rings: A systematic review and meta-analysis","volume":"33","author":"Hu","year":"2018","journal-title":"J. Card. Surg."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1417","DOI":"10.1161\/CIRCULATIONAHA.106.631549","article-title":"Impact of Prosthesis-Patient Mismatch on Survival After Mitral Valve Replacement","volume":"115","author":"Magne","year":"2007","journal-title":"Circulation"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1016\/S0735-1097(16)30402-8","article-title":"Effective orifice area reference values with the different sizes of the sapien 3 balloon-expanding transcatheter aortic valve","volume":"67","author":"Oberweis","year":"2016","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"840","DOI":"10.1002\/ccd.28496","article-title":"Balloon assisted translocation of the mitral anterior leaflet to prevent left ventricular outflow obstruction (BATMAN): A novel technique for patients undergoing transcatheter mitral valve replacement","volume":"95","author":"Helmy","year":"2019","journal-title":"Catheter. Cardiovasc. Interv."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"849","DOI":"10.1002\/ccd.28791","article-title":"BATMAN\u2014Savior or vigilante?","volume":"95","author":"Khan","year":"2020","journal-title":"Catheter. Cardiovasc. Interv."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"1149","DOI":"10.1093\/ejcts\/ezab217","article-title":"Cardiac surgery following transcatheter aortic valve replacement","volume":"60","author":"Saha","year":"2021","journal-title":"Eur. J. Cardio-Thorac. Surg."},{"key":"ref_51","doi-asserted-by":"crossref","unstructured":"De Palo, M., Scicchitano, P., Malvindi, P.G., and Paparella, D. (2021). Endocarditis in Patients with Aortic Valve Prosthesis: Comparison between Surgical and Transcatheter Prosthesis. Antibiotics, 10.","DOI":"10.3390\/antibiotics10010050"}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/58\/1\/93\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,13]],"date-time":"2025-10-13T14:13:03Z","timestamp":1760364783000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/58\/1\/93"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,1,7]]},"references-count":51,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2022,1]]}},"alternative-id":["medicina58010093"],"URL":"https:\/\/doi.org\/10.3390\/medicina58010093","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,1,7]]}}}