1
|
Yang Y, Zhou Z, Ma R, Ren J, Wu X. Antimicrobial-coated sutures versus non-coated sutures in reducing surgical site infection: an updated systematic review and meta-analysis. J Hosp Infect 2024; 150:40-50. [PMID: 38823643 DOI: 10.1016/j.jhin.2024.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 03/13/2024] [Accepted: 04/01/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Antimicrobial-coated sutures are one of the strategies to avoid surgical site infection (SSI) caused by microbial colonization on the surface of surgical sutures. AIM To investigate the effectiveness of antimicrobial-coated sutures in reducing SSI and develop the latest systematic evaluation evidence for clinical SSI prevention and the use of antimicrobial-coated sutures. METHODS The databases of MEDLINE, Embase, CINAHL, Cochrane, African Index Medicus, and WHO Global Health were searched from October 10th, 1990 to March 3rd, 2023 with language restricted to English, Spanish, and French. Meta-analysis was used to evaluate the impact of antimicrobial-coated sutures on SSI and whether their effectiveness is influenced by the type of sutures or wounds. Subgroup analyses were conducted based on type of sutures and wounds. Finally, quality of the retrieved evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). FINDINGS Twenty-six randomized control trials (RCTs) and nine observational studies (OBSs) met the inclusion criteria. Antimicrobial sutures significantly reduced SSI risk (RCTs: odds ratio: 0.74; 95% confidence interval: 0.63-0.87; P = 0.0002; OBSs: OR: 0.61; 95% CI: 0.48-0.76; P < 0.0001). Only subgroup analysis of Polydioxanone Suture (PDS) Plus vs PDS, Vicryl Plus vs Vicryl and mixed wounds revealed consistent results in favour of antimicrobial-coated sutures. According to GRADE, the quality of RCT evidence is moderate, while that of OBS evidence is low. CONCLUSION Antimicrobial-coated sutures are effective in reducing the risk of postoperative SSI among a large number of surgical patients. However, the available evidence is of moderate/low quality and many studies had conflicts of interest.
Collapse
Affiliation(s)
- Y Yang
- School of Medicine, Southeast University, Nanjing, China; Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Z Zhou
- Research Institute of General Surgery, Jinling Hospital Nanjing Medical University, Nanjing, China
| | - R Ma
- School of Medicine, Southeast University, Nanjing, China; Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - J Ren
- School of Medicine, Southeast University, Nanjing, China; Research Institute of General Surgery, Jinling Hospital, Nanjing, China.
| | - X Wu
- School of Medicine, Southeast University, Nanjing, China; Research Institute of General Surgery, Jinling Hospital, Nanjing, China.
| |
Collapse
|
2
|
Crisafi C, Grant MC, Rea A, Morton-Bailey V, Gregory AJ, Arora RC, Chatterjee S, Lother SA, Cangut B, Engelman DT. Enhanced Recovery After Surgery Cardiac Society turnkey order set for surgical-site infection prevention: Proceedings from the American Association for Thoracic Surgery ERAS Conclave 2023. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00281-2. [PMID: 38574802 DOI: 10.1016/j.jtcvs.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/23/2024] [Accepted: 03/18/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVES Surgical-site infections (SSIs) after cardiac surgery increase morbidity and mortality, consume health care resources, impair recovery, and diminish patients' quality of life. Numerous guidelines and expert consensus documents have been published to address the prevention and management of SSIs. Our objective is to integrate these documents into an order set that will facilitate the adoption and implementation of evidence-based best practices for preventing and managing SSIs after cardiac surgery. METHODS Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set for SSI reduction. Orders derived from consistent class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the turnkey order set in bold type. Selected orders that were inconsistent class I or IIA, class IIB or otherwise supported by published evidence, were also included in italicized type. RESULTS Preventative care begins with the preoperative identification of both modifiable and nonmodifiable SSI risks by health care providers. Assessment tools can be used to assist in identifying patients at a high risk of SSI. Preoperative recommendations include screening for and treating Staphylococcus aureus nasal carriage. Intraoperatively, tailored prophylactic intravenous antibiotics and maintaining blood glucose levels below 180 mg/dL are essential elements. Postoperative care includes maintaining normothermia, glucose control and patient engagement. CONCLUSIONS Despite the well-documented advantages of a multidisciplinary care pathway for SSI in cardiac surgery, there are inconsistencies in its adoption and implementation. This article provides an order set that incorporates recommendations from existing guidelines to prevent SSI in the cardiac surgical population.
Collapse
Affiliation(s)
- Cheryl Crisafi
- Heart & Vascular Program Baystate Health, University of Massachusetts Chan Medical, School-Baystate, Springfield, Mass.
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, Md
| | - Amanda Rea
- Division of Cardiac Surgery, University of Maryland St Joseph Medical Center, Towson, Md
| | | | - Alexander J Gregory
- Department of Anesthesiology, Cumming School of Medicine & Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Rakesh C Arora
- Division of Cardiac Surgery, Department of Surgery, Harrington Heart and Vascular, Institute, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | | | - Sylvain A Lother
- Sections of Infectious Diseases and Critical Care Rady Faculty of Health Sciences, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Busra Cangut
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Daniel T Engelman
- Heart & Vascular Program Baystate Health, University of Massachusetts Chan Medical, School-Baystate, Springfield, Mass
| |
Collapse
|
3
|
Bouza E, de Alarcón A, Fariñas MC, Gálvez J, Goenaga MÁ, Gutiérrez-Díez F, Hortal J, Lasso J, Mestres CA, Miró JM, Navas E, Nieto M, Parra A, Pérez de la Sota E, Rodríguez-Abella H, Rodríguez-Créixems M, Rodríguez-Roda J, Sánchez Espín G, Sousa D, Velasco García de Sierra C, Muñoz P, Kestler M. Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections ( SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery ( SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases ( CIBERES). J Clin Med 2021; 10:5566. [PMID: 34884268 PMCID: PMC8658224 DOI: 10.3390/jcm10235566] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 01/04/2023] Open
Abstract
This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.
Collapse
Affiliation(s)
- Emilio Bouza
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | | | | | - Juan Gálvez
- Virgen Macarena University Hospital, 41009 Seville, Spain;
| | | | - Francisco Gutiérrez-Díez
- Cardiovascular Surgery Department, Marques de Valdecilla University Hospital, 39008 Santander, Cantabria, Spain;
| | - Javier Hortal
- Anesthesia and Intensive Care Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - José Lasso
- Plastic Surgery Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - Carlos A. Mestres
- Department of Cardiac Surgery, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - José M. Miró
- Infectious Diseases Services, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain;
| | - Enrique Navas
- Infectious Diseases Department, Ramón y Cajal University Hospital, 28034 Madrid, Spain;
| | - Mercedes Nieto
- Cardiovascular Unit, Intensive Care Department, San Carlos Clinical Hospital, 28040 Madrid, Spain;
| | - Antonio Parra
- Department of Radiology, Marquez de Valdecilla University Hospital, 39008 Santander, Cantabria, Spain;
| | | | - Hugo Rodríguez-Abella
- Cardiac Surgery Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - Marta Rodríguez-Créixems
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | | | - Gemma Sánchez Espín
- Heart Clinical Management Unit, Virgen de la Victoria University Hospital, 29006 Malaga, Spain;
| | - Dolores Sousa
- Infectious Diseases Department, A Coruña Hospital Complex, 15006 A Coruña, Spain;
| | | | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | - Martha Kestler
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| |
Collapse
|
4
|
Khan R, Yee AL, Gilbert JA, Haider A, Jamal SB, Muhammad F. Triclosan-containing sutures: safety and resistance issues need to be addressed prior to generalized use. APPLIED NANOSCIENCE 2021. [DOI: 10.1007/s13204-021-01979-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
|
5
|
Shrestha P, Zhang Y, Chen WJ, Wong TY. Triclosan: antimicrobial mechanisms, antibiotics interactions, clinical applications, and human health. JOURNAL OF ENVIRONMENTAL SCIENCE AND HEALTH. PART C, TOXICOLOGY AND CARCINOGENESIS 2020; 38:245-268. [PMID: 32955413 DOI: 10.1080/26896583.2020.1809286] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The large-scale applications of Triclosan in industrial and household products have created many health and environmental concerns. Despite the fears of its drug-resistance and other issues, Triclosan is still an effective drug against many infectious organisms. Knowing the cross-interactions of Triclosan with different antibiotics, bacteria, and humans can provide much-needed information for the risk assessment of this drug. We review the current understanding of the antimicrobial mechanisms of Triclosan, how microbes become resistant to Triclosan, and the synergistic and antagonistic effects of Triclosan with different antibiotics. Current literature on the clinical applications of Triclosan and its effect on fetus/child development are also summarized.
Collapse
Affiliation(s)
- Prabin Shrestha
- Biological Sciences Department, University of Memphis, Memphis, Tennessee, USA
| | | | - Wen-Jen Chen
- Biological Sciences Department, University of Memphis, Memphis, Tennessee, USA
| | - Tit-Yee Wong
- Biological Sciences Department, University of Memphis, Memphis, Tennessee, USA
| |
Collapse
|
6
|
Freitas Júnior RD, Becker TS, Rahal RMS, Paulinelli RR, Soares LR. Incisões cirúrgicas mamárias tratadas com 2-octilcianoacrilato versus sutura intradérmica com fio de nylon: ensaio clínico randomizado. Rev Col Bras Cir 2019; 46:e20192286. [DOI: 10.1590/0100-6991e-20192286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 08/10/2019] [Indexed: 12/25/2022] Open
Abstract
RESUMO Objetivo: avaliar o perfil de segurança e os resultados estéticos do 2-octilcianoacrilato versus sutura intradérmica com fio de nylon em cirurgias mamárias. Métodos: ensaio clínico randomizado, aberto, que avaliou a ocorrência de complicações, como deiscência, hematoma, infecção e reações alérgicas após o uso do 2-octilcianoacrilato ou do fio de nylon. Também foi analisado o tamanho das incisões, o tempo de fechamento da pele e o tempo cirúrgico total. O resultado estético foi avaliado após 40 e 180 dias da cirurgia, por meio da largura média da ferida operatória e por avaliação subjetiva conceitual (ótimo, bom, razoável ou ruim). Resultados: foram incluídas 79 pacientes, sendo 37 no grupo 2-octilcianoacrilato e 42 no grupo de sutura com fio de nylon. O estudo foi interrompido antes do término do recrutamento dos pacientes pela ocorrência de maior número de deiscências no grupo do adesivo (OR: 11,42; IC95%: 1,36-96,02; p=0,007). Em relação às demais complicações analisadas, ao tempo cirúrgico e ao resultado estético no pós-operatório, não se observaram diferenças significativas entre os grupos. A média do tamanho da ferida operatória foi maior no grupo do adesivo em relação ao grupo da sutura, mas não houve correlação entre o tamanho da ferida e o maior número de deiscências. Conclusão: o 2-octilcianoacrilato apresentou maior risco de deiscência em relação à sutura intradérmica, com resultados estéticos equivalentes.
Collapse
|
7
|
Vos RJ, Van Putte BP, Kloppenburg GTL. Prevention of deep sternal wound infection in cardiac surgery: a literature review. J Hosp Infect 2018; 100:411-420. [PMID: 29885873 DOI: 10.1016/j.jhin.2018.05.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 05/31/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Deep sternal wound infection (DSWI) is a dreaded complication of cardiac surgery with considerable consequences in terms of mortality, morbidity and treatment costs. In addition to standard surgical site infection prevention guidelines, multiple specific measures in the prevention of DSWI have been developed and evaluated in the past decades. This review focuses on these specific measures to prevent DSWI. METHODS An extensive literature search was performed to assess interventions in the prevention of DSWI. Articles describing results of a randomized controlled trial were categorized by type of intervention. Results were yielded and, if possible, pooled. RESULTS From a total of 743 articles found, 48 randomized controlled trials were selected. Studies were divided into 12 categories, containing pre-, peri- and postoperative preventive measures. Specific measures shown to be effective were: antibiotic prophylaxis with a first-generation cephalosporin for at least 24 h, application of local gentamicin before chest closure, sternal closure with figure-of-eight steel wires, and postoperative chest support using a corset or vest. CONCLUSION This study identified several measures that prevent DSWI after cardiac surgery that are not frequently applied in current practice. It is recommended that the guidelines on prevention of surgical site infection in cardiac surgery should be updated.
Collapse
Affiliation(s)
- R J Vos
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands; Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, The Netherlands.
| | - B P Van Putte
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands; Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - G T L Kloppenburg
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| |
Collapse
|
8
|
Konstantelias AA, Andriakopoulou CSI, Mourgela S. Triclosan-coated sutures for the prevention of surgical-site infections: a meta-analysis. Acta Chir Belg 2017; 117:137-148. [PMID: 28399780 DOI: 10.1080/00015458.2017.1287396] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The scope of this article is to perform a meta-analysis of the studies that compare the use of triclosan-coated sutures (TCS) to uncoated sutures in prevention of surgical-site infections (SSIs). METHODS A systematic search of randomized and non-randomized studies was carried out on Pubmed and Scopus databases until July 2016. RESULTS The meta-analysis of 30 studies (19 randomized, 11 non-randomized; 15,385 procedures) gave evidence that TCS were associated with a lower risk of SSIs (risk ratio [RR] = 0.68; 95% confidence interval [CI] 0.57-0.81). Triclosan-coated sutures were associated with lower risk for SSIs in high-quality randomized studies (Jadad score 4 or 5). A lower risk for the development of SSIs based on wound classification was observed in clean, clean-contaminated, and contaminated but not for dirty procedures. No benefit was observed in specific types of surgery: colorectal, cardiac, lower limb vascular or breast surgery. Only a trend was found for lower risk for wound dehiscence, whereas no difference was observed for all-cause mortality. CONCLUSIONS Further randomized studies are needed to confirm the role of TCS in specific surgical procedures and whether or not they are related with lower risk for mortality.
Collapse
Affiliation(s)
| | | | - Sofia Mourgela
- Department of Neurosurgery, Agios Savvas Cancer Hospital, Athens, Greece
| |
Collapse
|
9
|
Leaper DJ, Edmiston CE, Holy CE. Meta-analysis of the potential economic impact following introduction of absorbable antimicrobial sutures. Br J Surg 2017; 104:e134-e144. [PMID: 28093728 DOI: 10.1002/bjs.10443] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 11/03/2016] [Accepted: 11/03/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Despite several randomized trials, systematic reviews and meta-analyses that have demonstrated the effectiveness of antimicrobial (triclosan-coated or -impregnated) sutures (TCS), the clinical and economic impact of using these sutures compared with conventional non-antimicrobial-coated absorbable sutures (NCS) remains poorly documented. METHODS An independent systematic review and meta-analysis of all published evidence from January 2005 to September 2016 comparing TCS with NCS was conducted. Surgical-site infection (SSI) was the primary outcome. The results of the meta-analysis were used in a decision-tree deterministic and stochastic cost model, using the National Health Service (NHS England)-based cost of inpatient admissions for infections and differential costs of TCS versus NCS. RESULTS Thirty-four studies were included in the final assessment from an initial 163 identified citations; 20 of 34 studies were randomized, and 17 of 34 reported blinding of physicians and assessors. Using a random-effects model, the odds ratio for SSI in the TCS compared with NCS control groups was statistically significant (odds ratio 0·61, 95 per cent c.i. 0·52 to 0·73; P < 0·001). There was significant heterogeneity (I2 = 49 per cent). Using random-effects event estimates of SSI for TCS and NCS for each individual wound type, the mean savings per surgical procedure from using antimicrobial sutures were significant: £91·25 (90 per cent c.i. 49·62 to 142·76) (€105·09 (57·15 to 164·41); exchange rate 15 November 2016) across all wound types. CONCLUSION The reviewed literature suggested that antimicrobial sutures may result in significant savings across various surgical wound types.
Collapse
Affiliation(s)
- D J Leaper
- Faculty of Medical Sciences, University of Newcastle upon Tyne, Newcastle upon Tyne, and Department of Clinical Sciences, Institute of Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield, UK
| | - C E Edmiston
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - C E Holy
- Johnson & Johnson Epidemiology and Health Informatics - Medical Devices, New Brunswick, New Jersey, USA
| |
Collapse
|
10
|
Triclosan-containing sutures versus ordinary sutures for reducing surgical site infections in children: a double-blind, randomised controlled trial. THE LANCET. INFECTIOUS DISEASES 2017; 17:50-57. [DOI: 10.1016/s1473-3099(16)30373-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 07/19/2016] [Accepted: 07/26/2016] [Indexed: 01/27/2023]
|
11
|
Gudbjartsson T, Jeppsson A, Sjögren J, Steingrimsson S, Geirsson A, Friberg O, Dunning J. Sternal wound infections following open heart surgery – a review. SCAND CARDIOVASC J 2016; 50:341-348. [DOI: 10.1080/14017431.2016.1180427] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Sjögren
- Department of Cardiothoracic Surgery, Skane University Hospital, Lund, Sweden
| | - Steinn Steingrimsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Arnar Geirsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Orjan Friberg
- Department of Cardiothoracic Surgery, Orebro University Hospital, Orebro, Sweden
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| |
Collapse
|