Surgical Vacuum-Assisted Closure Therapy for Mediastinitis Following HeartMate 3 BiVAD Implantation: A Case Report

Surgical Vacuum-Assisted Closure Therapy for Mediastinitis Following HeartMate 3 BiVAD Implantation: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Surgical Vacuum-Assisted Closure Therapy for Mediastinitis Following HeartMate 3 BiVAD Implantation: A Case Report Stanislav Georgiev, Krasimir Petkov, Philip Abedinov, Rumen Iliev, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7982713/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Mediastinitis following cardiac surgery in patients supported with mechanical circulatory support devices remains a serious and potentially fatal complication. Management of deep sternal wound infection in patients with a biventricular assist device (BiVAD) is surgically challenging due to the risk of device contamination and the complexity of wound reconstruction. Case presentation: A 57-year-old male with end-stage non-ischaemic cardiomyopathy underwent implantation of a HeartMate 3 BiVAD as destination therapy. Four weeks after discharge, he developed Escherichia coli mediastinitis with purulent sternal drainage and positive blood cultures. Computed tomography revealed a localised mediastinal abscess without driveline or pump involvement. The patient underwent repeated surgical debridement and prolonged vacuum- assisted closure (VAC) therapy combined with targeted antibiotic treatment. Device removal was avoided, and complete wound healing was achieved. During rehabilitation, he experienced recurrent orthostatic collapse on standing. Dynamic transoesophageal echocardiography demonstrated transient left-ventricular cavity collapse and inflow obstruction, consistent with preload insufficiency rather than device malfunction. Conclusions: This case illustrates that surgical vacuum-assisted closure (VAC) therapy can be an effective component of conservative management for mediastinitis after BiVAD implantation. A multidisciplinary approach integrating surgical, infectious, and haemodynamic assessment can allow infection resolution while preserving device function. BiVAD mediastinitis vacuum-assisted closure HeartMate 3 cardiac surgery LVAD orthostatic collapse Introduction Mediastinitis is a rare but severe postoperative complication after cardiac surgery. In patients supported by mechanical circulatory support (MCS) systems such as biventricular assist devices (BiVAD), infection control is complicated by the presence of prosthetic material and limited reconstructive options. Vacuum-assisted closure (VAC) therapy has emerged as an adjunct in managing deep sternal wound infections, promoting granulation, controlling bacterial load, and preserving device function. However, evidence on its use in patients with HeartMate 3 BiVAD support remains limited. We present a rare case of Escherichia coli mediastinitis following BiVAD implantation, successfully treated with repeated surgical debridement and prolonged VAC therapy without device explantation. Case Presentation Laboratory tests showed leukocytosis (WBC 33 × 10⁹/L), CRP 218 mg/L, procalcitonin 2.75 ng/mL, and INR 4.5. Both wound and blood cultures grew Escherichia coli . Contrast-enhanced computed tomography revealed a localised anterior mediastinal abscess without evidence of driveline or pump involvement. Transthoracic echocardiography confirmed normal BiVAD function without thrombus or pericardial effusion. Broad-spectrum antibiotic therapy with meropenem, teicoplanin, and colistin was initiated and subsequently de-escalated to teicoplanin and oral trimethoprim-sulfamethoxazole based on sensitivity results. The patient underwent repeated surgical debridement and application of vacuum-assisted closure (VAC) with negative-pressure settings of 75–100 mmHg. Over two weeks, progressive wound granulation was achieved, inflammatory markers normalised, and no device contamination was detected. VAC therapy was continued for six weeks until complete wound closure was achieved without flap reconstruction. During rehabilitation, the patient experienced recurrent orthostatic collapse within 30 seconds of standing. Dynamic transoesophageal echocardiography revealed normal ventricular geometry in the supine position but transient left-ventricular cavity collapse and inflow obstruction in the upright position, consistent with preload insufficiency rather than pump malfunction. After optimisation of volume status and gradual mobilisation, the episodes resolved. Discussion Deep sternal wound infection after mechanical circulatory support implantation represents a serious therapeutic dilemma. Device removal is typically considered in extensive infections involving the driveline or pump housing; however, this carries high surgical risk and may not be feasible in destination therapy patients. Our case demonstrates that VAC therapy can be a valuable surgical tool in achieving infection control while preserving BiVAD function. Negative- pressure wound therapy enhances perfusion, decreases bacterial load, and facilitates secondary healing without the need for extensive reconstruction. Several studies have reported successful use of VAC in LVAD-associated infections, but data on BiVAD patients remain limited. This case expands that experience, showing effective eradication of E. coli mediastinitis through prolonged conservative management. The episode of orthostatic collapse emphasises the importance of dynamic echocardiographic assessment during rehabilitation. In MCS patients, sudden posture changes can transiently reduce venous return, leading to inflow insufficiency and haemodynamic instability even in the absence of pump malfunction. Bedside transoesophageal echocardiography in the upright position provided crucial insight and guided management. Conclusion VAC therapy can be an effective and safe component of conservative surgical management for mediastinitis in patients supported with BiVAD systems. Multidisciplinary collaboration and individualised wound control can enable infection resolution without device removal. Dynamic echocardiography should be considered in the evaluation of postural intolerance or unexplained collapse during rehabilitation. Declarations Ethical Approval and Consent Written informed consent for publication of clinical details and imaging was obtained from the patient. Conflicts of Interest The authors declare no conflicts of interest. Acknowledgements / AI Disclosure AI-assisted language editing was used under author supervision. The authors reviewed and verified all content for accuracy and integrity. Funding No specific funding was received for this work. Author Contribution SG designed the concept of the case report, performed the surgical VAC procedure, and drafted the manuscript.KP and PA participated in the pre- operative management and postoperative care of the patient. RI assisted with perioperative monitoring and data collection.YМ was part of the surgical team that performed the initial BiVAD implantation procedure. VT contributed to infectious disease management and antibiotic therapy.DP was the head of the surgical team responsible for the initial BiVAD implantation and provided overall supervision, critical revision of the manuscript, and final approval for submission.All authors read and approved the final version of the manuscript. References Loop FD, Lytle BW, Cosgrove DM, et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg. 1990;49(2):179–86. Schaffer JM, Allen JG, Weiss ES, et al. Infectious complications after left ventricular assist device implantation. J Heart Lung Transpl. 2011;30(2):164–74. Asch S, Deuse T, Feller E, et al. Vacuum-assisted closure for the treatment of LVAD- related infections. Eur J Cardiothorac Surg. 2010;37(4):880–5. Petrou A, et al. Mediastinitis following ventricular assist device implantation: management and outcome. Interact Cardiovasc Thorac Surg. 2019;29(1):71–7. Tang DG, et al. Vacuum-assisted closure in sternal wound management after cardiac surgery. Ann Thorac Surg. 2000;70(4):1082–6. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7982713","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":580010055,"identity":"79148880-0146-4103-a343-7d524c03d14f","order_by":0,"name":"Stanislav Georgiev","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYLCCBAYLBgb5gw0HEiqAPGbmBvzK2cBaJBgYJJgbDzw4A9LCSIQWBrAW9uaDD9tAHAJa5Oc3P3vw4I+EvMHtxoYDifNqo/nbgVp+VGzDqcXgGJu5QWKbhOGGO0C/JG47njvjMGMDY8+Z27i1sDGYSSQ2SDDObEgEaTmW2wDUwszYhluLfBv7N4mEPxL2EC1zjuXOJ6SF4RiPmUQCm0RivwRIS0NN7gZCWgyO5ZRJAP2S3M8DipdjB3I3ArUcxOcX+ebj2yR//LGxbWNvf/zxR01d7rzzhw8++FGBx2Fo4DCYPEC0eiCoI0XxKBgFo2AUjBAAAMkeYuYnSaRtAAAAAElFTkSuQmCC","orcid":"","institution":"University Hospital St. Ekaterina – Department of Cardiac Surgery, Medical University- Sofiа","correspondingAuthor":true,"prefix":"","firstName":"Stanislav","middleName":"","lastName":"Georgiev","suffix":""},{"id":580010056,"identity":"5b0fb320-3abe-4795-aa75-f4aee5d90ac2","order_by":1,"name":"Krasimir Petkov","email":"","orcid":"","institution":"University Hospital St. Ekaterina – Department of Cardiac Surgery, Medical University- Sofiа","correspondingAuthor":false,"prefix":"","firstName":"Krasimir","middleName":"","lastName":"Petkov","suffix":""},{"id":580010057,"identity":"e26738c9-6949-4903-bf0e-c53dbeb1a7a2","order_by":2,"name":"Philip Abedinov","email":"","orcid":"","institution":"University Hospital St. Ekaterina – Department of Cardiac Surgery, Medical University- Sofiа","correspondingAuthor":false,"prefix":"","firstName":"Philip","middleName":"","lastName":"Abedinov","suffix":""},{"id":580010058,"identity":"52ec1676-2224-4ec1-ae96-11c4055651f7","order_by":3,"name":"Rumen Iliev","email":"","orcid":"","institution":"University Hospital St. Ekaterina – Department of Cardiac Surgery, Medical University- Sofiа","correspondingAuthor":false,"prefix":"","firstName":"Rumen","middleName":"","lastName":"Iliev","suffix":""},{"id":580010061,"identity":"c8a359b5-b7bb-4ea4-a6fd-9319b2276cf9","order_by":4,"name":"Yordan Makedonski","email":"","orcid":"","institution":"University Hospital St. Ekaterina – Department of Cardiac Surgery, Medical University- Sofiа","correspondingAuthor":false,"prefix":"","firstName":"Yordan","middleName":"","lastName":"Makedonski","suffix":""},{"id":580010062,"identity":"6fabf886-11f9-48b2-9f7d-ba3df3fc68b8","order_by":5,"name":"Vera Tabakova","email":"","orcid":"","institution":"University Hospital St. Ekaterina – Department of Cardiac Surgery, Medical University- Sofiа","correspondingAuthor":false,"prefix":"","firstName":"Vera","middleName":"","lastName":"Tabakova","suffix":""},{"id":580010064,"identity":"db0e23e2-72a2-4be1-a2e5-52c955e94f61","order_by":6,"name":"Dimitar Petkov","email":"","orcid":"","institution":"University Hospital St. Ekaterina – Department of Cardiac Surgery, Medical University- Sofiа","correspondingAuthor":false,"prefix":"","firstName":"Dimitar","middleName":"","lastName":"Petkov","suffix":""}],"badges":[],"createdAt":"2025-10-29 18:53:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7982713/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7982713/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102973655,"identity":"6b2e728e-cb12-4fe1-b111-be5b112e2a32","added_by":"auto","created_at":"2026-02-19 06:56:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":304041,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7982713/v1/1018cb4a-25d4-45eb-8b71-7ad3d3089e95.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical Vacuum-Assisted Closure Therapy for Mediastinitis Following HeartMate 3 BiVAD Implantation: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMediastinitis is a rare but severe postoperative complication after cardiac surgery. In patients supported by mechanical circulatory support (MCS) systems such as biventricular assist devices (BiVAD), infection control is complicated by the presence of prosthetic material and limited reconstructive options. Vacuum-assisted closure (VAC) therapy has emerged as an adjunct in managing deep sternal wound infections, promoting granulation, controlling bacterial load, and preserving device function. However, evidence on its use in patients with HeartMate 3 BiVAD support remains limited. We present a rare case of \u003cem\u003eEscherichia coli\u003c/em\u003e mediastinitis following BiVAD implantation, successfully treated with repeated surgical debridement and prolonged VAC therapy without device explantation.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003e \u003c/p\u003e \u003cp\u003eLaboratory tests showed leukocytosis (WBC 33 \u0026times; 10⁹/L), CRP 218 mg/L, procalcitonin 2.75 ng/mL, and INR 4.5. Both wound and blood cultures grew \u003cem\u003eEscherichia coli\u003c/em\u003e. Contrast-enhanced computed tomography revealed a localised anterior mediastinal abscess without evidence of driveline or pump involvement. Transthoracic echocardiography confirmed normal BiVAD function without thrombus or pericardial effusion.\u003c/p\u003e \u003cp\u003eBroad-spectrum antibiotic therapy with meropenem, teicoplanin, and colistin was initiated and subsequently de-escalated to teicoplanin and oral trimethoprim-sulfamethoxazole based on sensitivity results. The patient underwent repeated surgical debridement and application of vacuum-assisted closure (VAC) with negative-pressure settings of 75\u0026ndash;100 mmHg. Over two weeks, progressive wound granulation was achieved, inflammatory markers normalised, and no device contamination was detected. VAC therapy was continued for six weeks until complete wound closure was achieved without flap reconstruction.\u003c/p\u003e \u003cp\u003eDuring rehabilitation, the patient experienced recurrent orthostatic collapse within 30 seconds of standing. Dynamic transoesophageal echocardiography revealed normal ventricular geometry in the supine position but transient left-ventricular cavity collapse and inflow obstruction in the upright position, consistent with preload insufficiency rather than pump malfunction. After optimisation of volume status and gradual mobilisation, the episodes resolved.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDeep sternal wound infection after mechanical circulatory support implantation represents a serious therapeutic dilemma. Device removal is typically considered in extensive infections involving the driveline or pump housing; however, this carries high surgical risk and may not be feasible in destination therapy patients. Our case demonstrates that VAC therapy can be a valuable surgical tool in achieving infection control while preserving BiVAD function. Negative- pressure wound therapy enhances perfusion, decreases bacterial load, and facilitates secondary healing without the need for extensive reconstruction. Several studies have reported successful use of VAC in LVAD-associated infections, but data on BiVAD patients remain limited. This case expands that experience, showing effective eradication of \u003cem\u003eE. coli\u003c/em\u003e mediastinitis through prolonged conservative management.\u003c/p\u003e \u003cp\u003eThe episode of orthostatic collapse emphasises the importance of dynamic echocardiographic assessment during rehabilitation. In MCS patients, sudden posture changes can transiently reduce venous return, leading to inflow insufficiency and haemodynamic instability even in the absence\u003c/p\u003e \u003cp\u003e of pump malfunction. Bedside transoesophageal echocardiography in the upright position provided crucial insight and guided management.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eVAC therapy can be an effective and safe component of conservative surgical management for mediastinitis in patients supported with BiVAD systems. Multidisciplinary collaboration and individualised wound control can enable infection resolution without device removal. Dynamic echocardiography should be considered in the evaluation of postural intolerance or unexplained collapse during rehabilitation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthical Approval and Consent\u003c/h2\u003e \u003cp\u003eWritten informed consent for publication of clinical details and imaging was obtained from the patient.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConflicts of Interest\u003c/h2\u003e \u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eAcknowledgements / AI Disclosure\u003c/h2\u003e \u003cp\u003eAI-assisted language editing was used under author supervision. The authors reviewed and verified all content for accuracy and integrity.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo specific funding was received for this work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSG designed the concept of the case report, performed the surgical VAC procedure, and drafted the manuscript.KP and PA participated in the pre- operative management and postoperative care of the patient. RI assisted with perioperative monitoring and data collection.YМ was part of the surgical team that performed the initial BiVAD implantation procedure. VT contributed to infectious disease management and antibiotic therapy.DP was the head of the surgical team responsible for the initial BiVAD implantation and provided overall supervision, critical revision of the manuscript, and final approval for submission.All authors read and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLoop FD, Lytle BW, Cosgrove DM, et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg. 1990;49(2):179\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchaffer JM, Allen JG, Weiss ES, et al. Infectious complications after left ventricular assist device implantation. J Heart Lung Transpl. 2011;30(2):164\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsch S, Deuse T, Feller E, et al. Vacuum-assisted closure for the treatment of LVAD- related infections. Eur J Cardiothorac Surg. 2010;37(4):880\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePetrou A, et al. Mediastinitis following ventricular assist device implantation: management and outcome. Interact Cardiovasc Thorac Surg. 2019;29(1):71\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang DG, et al. Vacuum-assisted closure in sternal wound management after cardiac surgery. Ann Thorac Surg. 2000;70(4):1082\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"BiVAD, mediastinitis, vacuum-assisted closure, HeartMate 3, cardiac surgery, LVAD, orthostatic collapse","lastPublishedDoi":"10.21203/rs.3.rs-7982713/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7982713/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMediastinitis following cardiac surgery in patients supported with mechanical circulatory support devices remains a serious and potentially fatal complication. Management of deep sternal wound infection in patients with a biventricular assist device (BiVAD) is surgically challenging due to the risk of device contamination and the complexity of wound reconstruction.\u003c/p\u003e\n\u003cp\u003eCase presentation:\u003c/p\u003e\n\u003cp\u003eA 57-year-old male with end-stage non-ischaemic cardiomyopathy underwent implantation of a HeartMate 3 BiVAD as destination therapy. Four weeks after discharge, he developed \u003cem\u003eEscherichia coli \u003c/em\u003emediastinitis with purulent sternal drainage and positive blood cultures.\u003c/p\u003e\n\u003cp\u003eComputed tomography revealed a localised mediastinal abscess without driveline or pump involvement. The patient underwent repeated surgical debridement and prolonged vacuum- assisted closure (VAC) therapy combined with targeted antibiotic treatment. Device removal was avoided, and complete wound healing was achieved. During rehabilitation, he experienced recurrent orthostatic collapse on standing. Dynamic transoesophageal echocardiography demonstrated transient left-ventricular cavity collapse and inflow obstruction, consistent with preload insufficiency rather than device malfunction.\u003c/p\u003e\n\u003cp\u003eConclusions:\u003c/p\u003e\n\u003cp\u003eThis case illustrates that surgical vacuum-assisted closure (VAC) therapy can be an effective component of conservative management for mediastinitis after BiVAD implantation. A multidisciplinary approach integrating surgical, infectious, and haemodynamic assessment can allow infection resolution while preserving device function.\u003c/p\u003e","manuscriptTitle":"Surgical Vacuum-Assisted Closure Therapy for Mediastinitis Following HeartMate 3 BiVAD Implantation: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-27 20:24:51","doi":"10.21203/rs.3.rs-7982713/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7dbcecd7-4ce1-4b29-ab6a-4f2dc0d63377","owner":[],"postedDate":"January 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-19T06:54:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-27 20:24:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7982713","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7982713","identity":"rs-7982713","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}