1
|
Zhang Z, Chi J, Duensing I, Qureshi H, Cui Q. Risks Following Total Knee Arthroplasty in Patients Who Have Antiphospholipid Syndrome. J Arthroplasty 2024; 39:1500-1504. [PMID: 38056723 DOI: 10.1016/j.arth.2023.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 11/22/2023] [Accepted: 11/29/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is recognized as a thrombophilic autoimmune condition characterized by a tendency to develop venous thromboembolism. Total knee arthroplasty (TKA) is a prevalent procedure in patients who have advanced knee arthritis. Notably, TKA is unequivocally considered a thrombotic risk factor. However, outcomes of APS patients after TKA are still poorly documented in literature. The purpose of this study was to evaluate APS as a potential risk factor for complications after TKA. METHODS Using the PearlDiver Mariner database from 2010 to 2022, APS patients undergoing primary TKA were identified and compared to 10:1 matched control based on age, sex, and relevant comorbidities. A total of 7,478 patients undergoing primary TKA were analyzed, of which 683 had APS. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications including revision up to 2 years. Ninety-day emergency department visit and inpatient readmission were also documented. RESULTS Within 90 days after TKA, patients who have APS exhibited higher rates of cerebrovascular accident (adjusted odds ratio 2.04, 95% confidence interval 1.12 to 3.57; P = .014) and deep vein thrombosis (adjusted odds ratio 2.87, 95% confidence interval 1.99 to 4.06; P < .001) as compared to matched controls. No difference in surgical or nonthrombotic medical complications was observed between 2 cohorts. CONCLUSIONS There were significantly higher rates of stroke and deep vein thrombosis in APS patients. Our study did not find statistical differences in other surgical complications or readmissions between the 2 groups. Orthopaedic surgeons should consider appropriate prophylaxis of thrombosis in this patient population undergoing TKA perioperatively.
Collapse
Affiliation(s)
- Zhichang Zhang
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia; Department of Orthopaedic Surgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui, Henan, China
| | - Jialun Chi
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Ian Duensing
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Huzaifah Qureshi
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Quanjun Cui
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| |
Collapse
|
2
|
Yoshino R, Nakatsubo M, Ujiie N, Yuzawa S, Ishida K, Kitada M. Granulocyte colony-stimulating factor-producing lung cancer complicated with antiphospholipid antibody syndrome: a case report. J Surg Case Rep 2024; 2024:rjae361. [PMID: 38817796 PMCID: PMC11138120 DOI: 10.1093/jscr/rjae361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 05/13/2024] [Indexed: 06/01/2024] Open
Abstract
No reports on granulocyte colony-stimulating factor-producing lung cancer associated with antiphospholipid antibody syndrome. A 73-year-old man was referred to our department to undergo surgery for lung cancer in the right upper lobe. His examination results suggested that his condition was caused by an elevated white blood cell count and an increased inflammatory response due to granulocyte colony-stimulating factor production. The presence of antiphospholipid antibody syndrome was suspected, and the decrease in coagulation factors was considered to be inhibited by the lupus anticoagulant. Perioperatively, the patient was treated with heparin and steroids, and a thoracoscopically assisted right upper lobectomy was performed. Postoperatively, histopathological examination revealed pleomorphic carcinoma, and the patient tested negative for anticardiolipin IgG antibodies. In lung cancer patients with elevated white blood cell counts, fever, and an inflammatory response, granulocyte colony-stimulating factor-producing lung cancer is an important differential diagnosis. Additionally, when coagulation abnormalities are observed preoperatively, a thorough examination is necessary to prepare for perioperative management.
Collapse
Affiliation(s)
- Ryusei Yoshino
- Department of Thoracic Surgery and Breast Surgery, Asahikawa Medical University Hospital, 2-1-1-1 Midorigaoka Higashi, Asahikawa, Hokkaido 078-8510, Japan
| | - Masaki Nakatsubo
- Department of Thoracic Surgery and Breast Surgery, Asahikawa Medical University Hospital, 2-1-1-1 Midorigaoka Higashi, Asahikawa, Hokkaido 078-8510, Japan
| | - Nanami Ujiie
- Department of Thoracic Surgery and Breast Surgery, Asahikawa Medical University Hospital, 2-1-1-1 Midorigaoka Higashi, Asahikawa, Hokkaido 078-8510, Japan
| | - Sayaka Yuzawa
- Department of Diagnostic Pathology, Asahikawa Medical University Hospital, 2-1-1-1 Midorigaoka Higashi, Asahikawa, Hokkaido 078-8510, Japan
| | - Kensuke Ishida
- Department of Respiratory Medicine, Nayoro City General Hospital, 1, West 7, South 8, Nayoro, Hokkaido 096-8511, Japan
| | - Masahiro Kitada
- Department of Thoracic Surgery and Breast Surgery, Asahikawa Medical University Hospital, 2-1-1-1 Midorigaoka Higashi, Asahikawa, Hokkaido 078-8510, Japan
| |
Collapse
|
3
|
Catastrophic Antiphospholipid Syndrome after Orthotopic Liver Transplant. Case Rep Transplant 2022; 2022:6209300. [PMID: 35573422 PMCID: PMC9098363 DOI: 10.1155/2022/6209300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 04/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background. Catastrophic antiphospholipid syndrome (CAPS) is an autoimmune thrombogenic disorder of small and large vessels caused by autoantibodies against phospholipids and phospholipid-binding proteins. This severe form of antiphospholipid syndrome (APS) presents clinically with simultaneous life-threatening multiorgan thrombosis and the presence of two or more persistent antiphospholipid antibodies (APL) confirmed on testing 12 weeks apart. Case Presentation. We describe a case report of a 66-year-old woman with detected antinuclear antibodies (ANA) pretransplant diagnosed with CAPS following orthotopic liver transplant. The patient had acute respiratory failure; Doppler ultrasound and CT angiogram confirmed thrombosis in the hepatic artery, subsequent occlusion of the jump graft, and a splenic infarct. Hypercoagulability workup showed elevated levels of anticardiolipin IgG and beta-2-glycoprotein IgG/IgM and positive lupus anticoagulant, treated with steroids and anticoagulation. The patient was discharged after one month and was transitioned from heparin to life-long warfarin. Conclusion. Our patient provided a standard presentation of CAPS with abnormal pretransplant levels of antinuclear antibodies (ANA). Although there have been studies investigating the relationship between anticardiolipin antibodies and lupus anticoagulants and APS, the relationship between pretransplant positive ANA or antimitochondrial antibodies (AMA) and CAPS has yet to be explored. Further studies will be needed to determine the significance of these antibodies. We recommend preoperative APL testing for patients with positive ANA and AMA at preliver transplant presentation.
Collapse
|
4
|
Zisa D, Goodman SM. Perioperative Management of Rheumatic Disease and Therapies. Rheum Dis Clin North Am 2022; 48:455-466. [PMID: 35400371 DOI: 10.1016/j.rdc.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Patients with rheumatic disease, including those with systemic lupus erythematous, rheumatoid arthritis, and spondyloarthritis, use total hip and knee arthroplasties at high rates. They represent a particularly vulnerable population in the perioperative setting because of their diseases and the immunosuppressant therapies used to treat them. Careful planning among internists, medical specialists, and the surgical team must therefore occur preoperatively to minimize risks in the postoperative period, particularly infection. Management of immunosuppressant medications, such as conventional synthetic disease-modifying antirheumatic drugs and targeted therapies including biologics, is one avenue by which this infectious risk can be mitigated.
Collapse
Affiliation(s)
- Diane Zisa
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Susan M Goodman
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA.
| |
Collapse
|
5
|
Anesthetic Management Using Epidural Analgesia for Emergency Laparoscopic Cholecystectomy in a Patient with Lupus Anticoagulant Positivity and Prolonged Activated Partial Thromboplastin Time. Case Rep Anesthesiol 2022; 2022:6310630. [PMID: 35087690 PMCID: PMC8789475 DOI: 10.1155/2022/6310630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/07/2022] [Indexed: 11/17/2022] Open
Abstract
Lupus anticoagulant (LA), an antiphospholipid antibody, prolongs in vitro activated partial thromboplastin time (APTT) despite the presence of a hypercoagulable state in vivo. Irrespective of whether they receive antithrombotic therapy, meticulous anesthetic management is imperative in patients with LA positivity to prevent thrombotic complication. Additionally, emergency surgery in such patients can be challenging, as the time to devise perioperative strategies is limited. Here, we described the case of a patient with LA positivity and prolonged APTT who underwent emergency laparoscopic cholecystectomy with successful anesthetic management using epidural analgesia. An 83-year-old woman presented with acute cholecystitis and underwent emergency laparoscopic cholecystectomy. Preoperative blood test results revealed a prolonged APTT of 83 s, prothrombin time/international normalized ratio of 1.14, and normal platelet count. The patient had experienced a marked prolongation of APTT ten years previously, which was attributed to LA positivity, and she had previously undergone surgery for rectal cancer under general and epidural anesthesia. The patient did not receive antithrombotic therapy, and she demonstrated neither liver dysfunction nor a bleeding tendency. We prioritized optimal analgesia to enable early mobilization; therefore, an epidural catheter was placed in preparation for transition to open abdominal surgery. The operation was completed under laparoscopy, and good pain control was achieved postoperatively with continuous epidural analgesia, facilitating early ambulation. The epidural catheter was removed on the second postoperative day, and the patient did not develop any signs of thromboembolism or neurologic complications during her hospital stay. Anesthetic management for emergency laparoscopic cholecystectomy was successfully performed using epidural analgesia in a patient with LA positivity and prolonged APTT. Careful evaluation of laboratory data, treatment history, and clinical symptoms is of critical importance in such patients.
Collapse
|
6
|
Abstract
Patients with rheumatic disease, including those with systemic lupus erythematous, rheumatoid arthritis, and spondyloarthritis, use total hip and knee arthroplasties at high rates. They represent a particularly vulnerable population in the perioperative setting because of their diseases and the immunosuppressant therapies used to treat them. Careful planning among internists, medical specialists, and the surgical team must therefore occur preoperatively to minimize risks in the postoperative period, particularly infection. Management of immunosuppressant medications, such as conventional synthetic disease-modifying antirheumatic drugs and targeted therapies including biologics, is one avenue by which this infectious risk can be mitigated.
Collapse
Affiliation(s)
- Diane Zisa
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Susan M Goodman
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021, USA.
| |
Collapse
|
7
|
Muthu S, Chellamuthu G, Gopalsamy TP, Kandasamy V. Secondary Erosive Arthritis in a Young Lady - A Rare Manifestation of Primary Antiphospholipid Antibody Syndrome. J Orthop Case Rep 2021; 11:15-18. [PMID: 34141662 PMCID: PMC8180329 DOI: 10.13107/jocr.2021.v11.i02.2006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Arthritis in primary antiphospholipid antibody syndrome (PAPS) is a rare manifestation that is much more common in secondary antiphospholipid antibody syndrome (APS), particularly those associated with systemic lupus erythematosis (SLE), and has been reported to be non-erosive responding to conservative management. In this background, we describe a case of secondary erosive arthritis of knee (SEAK) in a female patient with PAPS. CASE REPORT Thirty-seven-year-old working women presented with chronic right knee pain for the past 2 years which was increasing in severity and interfering with her activities of daily living for the past 3 months. The patient was a known case of PAPS with a history of one early and one late abortion. On radiological examination, Grade IV secondary osteoarthritis knee was made out. The patient underwent total knee replacement. At 2 years follow-up, the patient had a good functional outcome. To the best of our knowledge, this is the first report of secondary osteoarthritis in PAPS requiring arthroplasty. Perioperative management is crucial in PAPS to prevent thromboembolic complications. Multimodality approach with strict patient compliance is a key to achieve good functional recovery. CONCLUSION SEAK can be a rare presentation of PAPS. Secondary causes like SLE or rheumatoid arthritis must be ruled out before a diagnosis of PAPS is made. Perioperative management in APS is critical and challenging. Multidisciplinary team approach involving internal medicine, anesthesiology, orthopedics, and rehabilitative departments is essential.
Collapse
Affiliation(s)
- Sathish Muthu
- Orthopaedic Research Group, Coimbatore, Tamil Nadu, India,
- Research Scholar, School of Engineering & Technology, Sharda University, Greater Noida, New Delhi, India
- Department of Orthopaedics, Government Dindigul Medical College and Hospital, Dindigul, Tamil Nadu, India
- Address of Correspondence: Dr. Sathish Muthu, Orthopaedic Research Group, Coimbatore, Tamil Nadu, India. E-mail:
| | | | | | - Velmurugan Kandasamy
- Department of Orthopaedics, Apollo Speciality Hospitals, Chennai, Tamil Nadu, India
| |
Collapse
|
8
|
Cunha E, Guzela V, Balbi GGM, Sobrado C, Andrade D. Anorectal diseases in patients with Antiphospholipid syndrome: a cross-sectional study. Adv Rheumatol 2020; 60:51. [PMID: 33028422 DOI: 10.1186/s42358-020-00153-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/25/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemorrhoid disease (HD) is one of the most common gastrointestinal complaints worldwide, affecting 4.4% of the general population in the United States. Since antiphospholipid syndrome (APS) may lead to intra-abdominal thrombosis, one may expect that this condition can impact the risk for HD development. Additionally, as APS patients are more prone to thrombosis and treatment with anticoagulants may increase risk of bleeding, one may also infer that rates of HD complications may be higher in this scenario. Nevertheless, no data in these regards have been published until now. The objective of the present study is to evaluate frequency of HD and describe its complications rates in antiphospholipid syndrome APS patients. METHODS We consecutively invited patients who fulfilled APS criteria to undergo proctological examination. After examination, patients were divided in two groups, based on the presence of HD, and compared regarding different clinical manifestations and antiphospholipid profile. We performed the analysis of the data, using chi-square and Mann Whitney U when applicable and considering a significance level of 0.05. Multivariate regression analysis included age and variables with p < 0.10 in the bivariate analysis. RESULTS Forty-one APS patients agreed to undergo proctological examination. All were female and overall median age was 43 (36-49). Seventeen (41.4%) patients were diagnosed with HD, with the following frequency distribution: 7 internal (41.2%), 4 external (23.5%) and 5 mixed hemorrhoids (29.4%). Of the internal hemorrhoids, 5 patients were classified as grade I (71.4%), 1 grade II (14.3%), and 1 grade IV (14.3%). Prior gestation (p = 0.067) and constipation (p = 0.067) correlated with a higher frequency of HD. In multivariate analysis, constipation remained as an important risk factor (OR 3.92,CI95% 1.03-14.2,p = 0.037). Five out of 17 patients (29.4%) reported anal bleeding, but it did not correlate with warfarin dose (p = 0.949). Surgical treatment was indicated for 10 patients (58.8%). Other anorectal findings were anal fissure, plicoma, condyloma and one chlamydial retitis. CONCLUSION We found an unexpected high frequency of hemorrhoids in APS patients, with a great proportion requiring surgical treatment.
Collapse
Affiliation(s)
- E Cunha
- Undergraduate student, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - V Guzela
- Discipline of Colorectal Surgery, Hospital das Clínicas/Faculdade de Medicina (HC-FMUSP), University of São Paulo, São Paulo, SP, Brazil
| | - G G M Balbi
- Discipline of Rheumatology, Hospital das Clínicas/Faculdade de Medicina (HC-FMUSP), University of São Paulo, Av. Dr. Arnaldo 455, Third Floor, Room 3109, São Paulo, 01246903, Brazil.,Discipline of Rheumatology, Hospital Universitário, Federal University of Juiz de Fora, Juiz de Fora, MG, Brazil
| | - C Sobrado
- Discipline of Colorectal Surgery, Hospital das Clínicas/Faculdade de Medicina (HC-FMUSP), University of São Paulo, São Paulo, SP, Brazil
| | - D Andrade
- Discipline of Rheumatology, Hospital das Clínicas/Faculdade de Medicina (HC-FMUSP), University of São Paulo, Av. Dr. Arnaldo 455, Third Floor, Room 3109, São Paulo, 01246903, Brazil.
| |
Collapse
|
9
|
Kim JW, Kim TW, Ryu KH, Park SG, Jeong CY, Park DH. Anaesthetic considerations for patients with antiphospholipid syndrome undergoing non-cardiac surgery. J Int Med Res 2020; 48:300060519896889. [PMID: 31937174 PMCID: PMC7113712 DOI: 10.1177/0300060519896889] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 12/02/2019] [Indexed: 12/30/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an acquired thrombotic autoimmune disorder that is clinically characterized by the development of thrombosis and obstetric morbidities in patients with antiphospholipid antibodies. Due to hypercoagulability, the focus of management is anticoagulation for the prevention of thrombosis and its recurrence. When such patients undergo surgery, however, the underlying risk of thrombosis increases as a result of anticoagulant withdrawal, immobilization, and/or intimal injury. Conversely, there is also an increased risk of bleeding due to thrombocytopaenia, possible disseminated intravascular coagulation, or progression to catastrophic APS, as a result of excessive anticoagulation, surgery, and infection. Measures for appropriate perioperative anticoagulation are discussed in this review, as well as anaesthetic considerations for preventing perioperative complications in patients with APS undergoing non-cardiac surgery.
Collapse
Affiliation(s)
- Jae Won Kim
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Tae Woo Kim
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Keon Hee Ryu
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Sun Gyoo Park
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Chang Young Jeong
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Dong Ho Park
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| |
Collapse
|
10
|
Arias EJ, Bruck B, Vellimana AK, Eby C, Reynolds MR, Blinder MA, Zipfel GJ. Plasmapheresis for Management of Antiphospholipid Syndrome in the Neurosurgical Patient. Oper Neurosurg (Hagerstown) 2019; 16:E124-E129. [PMID: 29800263 DOI: 10.1093/ons/opy135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/26/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Antiphospholipid syndrome (APS) is an autoimmune disorder associated with a hypercoagulable state and increased risk of intraoperative and postoperative thrombosis. Few neurosurgical studies have examined the management of these patients, though the standard of care in most other disciplines involves the use of anticoagulation therapy. However, this is associated with risks such as hemorrhage, thrombosis due to warfarin withdrawal, and is not compatible with operative intervention. CLINICAL PRESENTATION We report the cases of 2 antiphospholipid positive patients who were on anticoagulant therapy and underwent surgical bypasses and received perioperative management with plasmapheresis. The first was a 44-yr-old woman who presented with worsening vision, recurring headaches, and a known left internal carotid artery aneurysm that was unsuccessfully treated twice via extracranial to intracranial (ECIC) bypass at another institution. Preoperative tests at our institution revealed elevated beta 2 glycoprotein 1 IgA autoantibodies. The second case was a 24-yr-old woman with previously diagnosed APS, who presented for surgical evaluation of moyamoya disease after sustaining recurrent left hemispheric strokes. Both cases were managed with perioperative plasmapheresis to avoid the need for anticoagulation during the perioperative period, and both underwent successful ECIC bypass procedures without perioperative ischemic or hemorrhagic complications. CONCLUSION Management of neurosurgical patients with APS can be a precarious proposition. We describe the successful use of plasmapheresis and antiplatelet therapy to better manage patients undergoing neurosurgical procedures, specifically ECIC bypass, and feel this approach can be considered in future cases.
Collapse
Affiliation(s)
- Eric J Arias
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Brent Bruck
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ananth K Vellimana
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Charles Eby
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew R Reynolds
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Morey A Blinder
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri.,Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| |
Collapse
|
11
|
Chen RX, Zhou YZ, Li PC, Yang HX, Fei YY, Hu XM, Wu W, Zhao LD, Chen H, Zhang X. The efficacy and safety of antithrombotic therapy in patients with positive antiphospholipid antibodies receiving invasive procedures: experience from a single tertiary center. Clin Rheumatol 2019; 38:1897-1904. [PMID: 30847686 DOI: 10.1007/s10067-019-04483-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/14/2019] [Accepted: 02/17/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate the efficacy and safety of antithrombotic prophylaxis and to explore potential risk factors for thrombotic/bleeding events in patients with positive antiphospholipid (aPL) antibodies receiving invasive procedures. METHOD All aPL-positive patients who underwent invasive procedures in Peking Union Medical College Hospital, from January 2002 to April 2018, were retrospectively enrolled. Demographic features, clinical features, antiphospholipid antibody profiles, types of invasive procedures, and antithrombotic management, as well as complications and outcomes, were systematically reviewed and recorded. RESULTS A total of 111 aPL-positive patients with 130 invasive procedures were enrolled. One hundred nine (83.8%) cases were on regular antithrombotic therapy which started at least 1 month prior to the invasive procedures, with 58 (44.6%) receiving anticoagulation therapy, 27 (20.8%) receiving antiplatelet therapy, and 24 (18.5%) receiving both. During the periprocedural period, the median time free of antithrombotic therapy was 2.5 days (interquartile range 1.5-6.0 days). Two (1.5%) periprocedural thrombotic events and 18 (13.8%) bleeding events were identified. Large open/laparoscopic surgeries of the thorax and abdomen were associated with a higher risk of bleeding (OR 3.46, 95% CI 1.24-9.67, p = 0.014). All bleeding events were manageable and not life-threatening. CONCLUSIONS Aggressive antithrombotic therapy was associated with fewer thrombotic events in aPL-positive patients receiving invasive procedures, but might contribute to an increased bleeding rate, especially in large open surgeries. This study justifies more caution in prophylactic antithrombotic therapy in periprocedural aPL-positive patients.
Collapse
Affiliation(s)
- Ru-Xuan Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China
| | - Yang-Zhong Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China
| | - Peng-Chong Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China
| | - Hua-Xia Yang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China
| | - Yun-Yun Fei
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China
| | - Xiao-Min Hu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China
| | - Wei Wu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li-Dan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China.
| | - Hua Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China.
| | - Xuan Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China.
| |
Collapse
|
12
|
The Efficacy of Therapeutic Plasma Exchange in Antiphospholipid Antibody-positive Patients With Spontaneous Intracerebral Hemorrhage and High D-dimer Levels. Neurologist 2018; 23:7-11. [PMID: 29266037 DOI: 10.1097/nrl.0000000000000159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We investigated the efficacy of plasma exchange (PE) in antiphospholipid antibody (aPL)-positive patients with a spontaneous intracerebral hemorrhage (ICH) and high D-dimer levels. MATERIALS AND METHODS From May 2013 to May 2016, we evaluated 32 patients who were below the age of 50 and presented with spontaneous ICH. Five patients were positive for aPL antibody and 3 had a higher level of D-dimer. These 3 patients underwent 5 sessions of PE using fresh frozen plasma as replacement fluid. We analyzed the days postadmission until PE-start, the days of intensive care unit (ICU) hospitalization, D-dimer series, Glasgow Coma Scale (GCS) scores, and modified Rankin scale (mRS) scores. D-dimer levels and GCS scores were recorded at both pre-PE and post-PE stages. The mRS scores were recorded at pre-PE stage and 3 months post-PE. RESULTS The mean postadmission period until PE-start was 8.33 days. The mean ICU hospitalization was 17.33 days. The D-dimer level pre-PE ranged from 2.34 to 5.44 mg/L fibrinogen equivalent unit (FEU). The D-dimer level post-PE ranged from 1.05 to 3.30 mg/L FEU. The amount of decline of the D-dimer level between pre-PE and post-PE ranged from 0.65 to 2.14 mg/L FEU. The GCS score pre-PE was between 7 and 8. The highest post-PE GCS score was 14. The improved GCS scores post-PE ranged from 3 to 6. The improved mRS scores of 3 months post-PE ranged from 3 to 4. CONCLUSIONS The concurrent presence of positive aPL and a higher D-dimer level may worsen the neurological outcome of patients with a spontaneous ICH. Aggressive PE is effective for the treatment of such patients, decreasing the extent of the ICU hospitalization.
Collapse
|
13
|
Okano M, Nakayama K, Tamada N, Shinkura Y, Yanaka KI, Onishi H, Tanaka H, Shinke T, Tanaka H, Okita Y, Emoto N, Hirata KI. Reversible Parkinsonism and Multiple Cerebral Infarctions after Pulmonary Endarterectomy in a Patient with Antiphospholipid Syndrome. Intern Med 2018; 57:2019-2023. [PMID: 29321405 PMCID: PMC6096019 DOI: 10.2169/internalmedicine.9880-17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Antiphospholipid syndrome (APS) is a cause of chronic thromboembolic pulmonary hypertension (CTEPH) and it is associated with an increased risk of postoperative neurological complications. We experienced a case of reversible parkinsonism after pulmonary endarterectomy (PEA) and subsequent multiple cerebral infarctions under standard anticoagulation therapy in a patient with CTEPH associated with APS. Strict management using a combination of antiplatelet and anticoagulation therapy should be considered in patients with a high titer of triple antiphospholipid antibodies in the perioperative period. We should be aware of the high risk of postoperative neurologic manifestations in patients with APS.
Collapse
Affiliation(s)
- Mitsumasa Okano
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Kazuhiko Nakayama
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Naoki Tamada
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Yuto Shinkura
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Ken-Ichi Yanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hiroyuki Onishi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Toshiro Shinke
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hiroshi Tanaka
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Japan
| | - Yutaka Okita
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Japan
| | - Noriaki Emoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
- Department of Clinical Pharmacy, Kobe Pharmaceutical University, Japan
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| |
Collapse
|
14
|
Goodman SM, Bass AR. Perioperative medical management for patients with RA, SPA, and SLE undergoing total hip and total knee replacement: a narrative review. BMC Rheumatol 2018; 2:2. [PMID: 30886953 PMCID: PMC6390575 DOI: 10.1186/s41927-018-0008-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/03/2018] [Indexed: 12/12/2022] Open
Abstract
Total hip (THA) and total knee arthroplasty (TKA) are widely used, successful procedures for symptomatic end stage arthritis of the hips or knees, but patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and spondyloarthritis (SPA) including ankylosing spondylitis (AS) and psoriatic arthritis (PSA) are at higher risk for adverse events after surgery. Utilization rates of THA and TKA remain high for patients with RA, and rates of arthroplasty have increased for patients with SLE and SPA. However, complications such as infection are increased for patients with SLE, RA, and SPA, most of whom are receiving potent immunosuppressant medications and glucocorticoids at the time of surgery. Patients with SLE and AS are also at increased risk for perioperative cardiac and venous thromboembolism (VTE), while RA patients do not have an increase in perioperative cardiac or VTE risk, despite an overall increase in VTE and cardiac disease. This narrative review will discuss the areas of heightened risk for patients with RA, SLE, and SPA, and the perioperative management strategies currently used to minimize the risks.
Collapse
Affiliation(s)
- Susan M. Goodman
- Department of Medicine, Weill Cornell Medical School, Division of Rheumatology Hospital for Special Surgery, 535 E 70th St, New York City, NY 10021 USA
| | - Anne R. Bass
- Department of Medicine, Weill Cornell Medical School, Division of Rheumatology Hospital for Special Surgery, 535 E 70th St, New York City, NY 10021 USA
| |
Collapse
|
15
|
Funke A, Danowski A, de Andrade DCO, Rêgo J, Levy RA. A importância de reconhecer a síndrome antifosfolípide na medicina vascular. J Vasc Bras 2017; 16:140-149. [PMID: 29930638 PMCID: PMC5915862 DOI: 10.1590/1677-5449.011416] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A síndrome antifosfolipíde (SAF) é uma doença autoimune sistêmica caracterizada por trombose arterial ou venosa recorrente e/ou morbidade gestacional e pela presença dos anticorpos antifosfolipídeos, podendo apresentar outras manifestações vasculares, como microangiopatia, arteriopatia crônica e SAF catastrófica. Determinados testes laboratoriais para a síndrome (por exemplo, o anticoagulante lúpico) podem sofrer interferência do uso de medicações anticoagulantes, dificultando o diagnóstico. A fisiopatologia da SAF é complexa, sendo enumerados no texto diversos mecanismos patogênicos relacionados à coagulação, ao endotélio e às plaquetas. Por fim, discutimos o tratamento da SAF de acordo com a presença e o tipo de manifestações clínicas, o uso dos anticoagulantes orais diretos e o manejo perioperatório de pacientes com SAF.
Collapse
Affiliation(s)
- Andreas Funke
- Universidade Federal do Paraná - UFPR, Hospital de Clínicas, Curitiba, PR, Brasil
| | - Adriana Danowski
- Hospital Federal dos Servidores do Estado - HFSE, Rio de Janeiro, RJ, Brasil
| | | | - Jozelia Rêgo
- Universidade Federal de Goiás - UFG, Faculdade de Medicina, Goiânia, GO, Brasil
| | | |
Collapse
|
16
|
Atisha-Fregoso Y, Espejo-Poox E, Carrillo-Maravilla E, Pulido-Ramírez AL, Lugo Baruqui D, Hernández-Molina G, Cabral AR. Perioperative management of patients with antiphospholipid syndrome: a single-center experience. Rheumatol Int 2017; 37:1159-1164. [PMID: 28474094 DOI: 10.1007/s00296-017-3727-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 04/19/2017] [Indexed: 12/15/2022]
Abstract
The objective was to describe the management and risk factors for complications of antiphospholipid syndrome (APS) patients who underwent a surgical procedure in a single center. We reviewed medical records of all patients with primary or secondary APS who underwent an elective surgery during a 6-year period. Demographical data, management of anticoagulation and complications were recorded. We identified 43 patients, mean age 37.9 ± 8.9 years, who underwent a total of 48 elective surgeries. All patients had history of at least one thrombotic event and were under vitamin K antagonists. Before surgery, all patients received bridging therapy with intravenous infusion of heparin or low molecular weight heparin (LMWH). Among the LMWH group, 36 had a full anticoagulation regimen and nine prophylactic doses. In 62% of the surgeries, we identified an optimal management of periprocedural anticoagulation according to guidelines. Overall six patients had severe bleeding and three thrombotic complications (full anticoagulation regimen n = 2 and prophylactic dose group n = 1). Patients with optimal management of anticoagulation experienced less thrombotic and hemorrhagic complications (7 vs. 33%; OR 0.14, 95% CI 0.02-0.81; p = 0.040) and patients with INR ≤1.5 at surgery had fewer episodes of major bleeding (6 vs. 29%; OR 0.19, 95% CI 0.02-0.98; p = 0.050). All three thrombotic events occurred in patients with INR ≤1.5. Proper management of anticoagulation based on guidelines is associated with less complications in patients with APS. Notwithstanding the proper use of bridging therapy, some patients may develop thrombotic complications.
Collapse
Affiliation(s)
- Yemil Atisha-Fregoso
- Medicine Division, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Av. Vasco de Quiroga 15. Col. Belisario Domínguez, Sección XVI, Tlalpan, Mexico City, 14080, DF, Mexico
| | - Eric Espejo-Poox
- Medicine Division, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Av. Vasco de Quiroga 15. Col. Belisario Domínguez, Sección XVI, Tlalpan, Mexico City, 14080, DF, Mexico
| | - Eduardo Carrillo-Maravilla
- Medicine Division, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Av. Vasco de Quiroga 15. Col. Belisario Domínguez, Sección XVI, Tlalpan, Mexico City, 14080, DF, Mexico
| | - Alma Lilia Pulido-Ramírez
- Medicine Division, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Av. Vasco de Quiroga 15. Col. Belisario Domínguez, Sección XVI, Tlalpan, Mexico City, 14080, DF, Mexico
| | - Diego Lugo Baruqui
- Medicine Division, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Av. Vasco de Quiroga 15. Col. Belisario Domínguez, Sección XVI, Tlalpan, Mexico City, 14080, DF, Mexico
| | - Gabriela Hernández-Molina
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Av. Vasco de Quiroga 15. Col. Belisario Domínguez, Sección XVI, Tlalpan, 14080, México, D.F., Mexico
| | - Antonio R Cabral
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Av. Vasco de Quiroga 15. Col. Belisario Domínguez, Sección XVI, Tlalpan, 14080, México, D.F., Mexico. .,The Ottawa Hospital, University of Ottawa, 1967 Riverside Drive, Ottawa, ON, Canada.
| |
Collapse
|
17
|
Li CZ, Li CC, Hsieh CC, Lin MC, Hueng DY, Liu FC, Chen YH. Fatal antiphospholipid syndrome following endoscopic transnasal-transsphenoidal surgery for a pituitary tumor: A case report. Medicine (Baltimore) 2017; 96:e5774. [PMID: 28072724 PMCID: PMC5228684 DOI: 10.1097/md.0000000000005774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The fatal type of antiphospholipid syndrome is a rare but life-threating condition. It may be triggered by surgery or infection. Endoscopic transnasal-transsphenoidal surgery is a common procedure for pituitary tumor. We report a catastrophic case of a young woman died of fatal antiphospholipid syndrome following endoscopic transnasal-transsphenoidal surgery. METHODS AND RESULT A 31-year-old woman of a history of stroke received endoscopic transnasal-transsphenoidal surgery for a pituitary tumor. The whole procedure was smooth. However, the patient suffered from acute delirium on postoperative day 4. Then, her consciousness became comatose state rapidly with dilatation of pupils. Urgent magnetic resonance imaging of brain demonstrated multiple acute lacunar infarcts. The positive antiphosphoipid antibody and severe thrombocytopenia were also noted. Fatal antiphospholipid syndrome was diagnosed. Plasma exchange, corticosteroids, anticoagulant agent were prescribed. The hemodynamic condition was gradually stable. However, the consciousness was still in deep coma. The patient died of organ donation 2 months later. CONCLUSION If patients have a history of cerebral stroke in their early life, such as a young stroke, the APS and higher risk of developing fatal APS after major surgery should be considered. The optimal management of APS remains controversial. The best treatment strategies are only early diagnosis and aggressive therapies combing of anticoagulant, corticosteroid, and plasma exchange. The intravenous immunoglobulin is prescribed for patients with refractory APS.
Collapse
Affiliation(s)
- Chiao-Zhu Li
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei Department of Surgery, Kaohsiung Armed Forces General Hospital Department of Surgery, Zoying Branch, Kaoshiung Armed Forces General Hospital Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | | | | | | | | | | | | |
Collapse
|
18
|
Complement activation in antiphospholipid syndrome and its inhibition to prevent rethrombosis after arterial surgery. Blood 2016; 127:365-7. [DOI: 10.1182/blood-2015-09-672139] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
|
19
|
How I treat catastrophic thrombotic syndromes. Blood 2015; 126:1285-93. [DOI: 10.1182/blood-2014-09-551978] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 07/02/2015] [Indexed: 12/21/2022] Open
Abstract
Abstract
Catastrophic thrombotic syndromes are characterized by rapid onset of multiple thromboembolic occlusions affecting diverse vascular beds. Patients may have multiple events on presentation, or develop them rapidly over days to weeks. Several disorders can present with this extreme clinical phenotype, including catastrophic antiphospholipid syndrome (APS), atypical presentations of thrombotic thrombocytopenic purpura (TTP) or heparin-induced thrombocytopenia (HIT), and Trousseau syndrome, but some patients present with multiple thrombotic events in the absence of associated prothrombotic disorders. Diagnostic workup must rapidly determine which, if any, of these syndromes are present because therapeutic management is driven by the underlying disorder. With the exception of atypical presentations of TTP, which are treated with plasma exchange, anticoagulation is the most important therapeutic intervention in these patients. Effective anticoagulation may require laboratory confirmation with anti–factor Xa levels in patients treated with heparin, especially if the baseline (pretreatment) activated partial thromboplastin time is prolonged. Patients with catastrophic APS also benefit from immunosuppressive therapy and/or plasma exchange, whereas patients with HIT need an alternative anticoagulant to replace heparin. Progressive thrombotic events despite therapeutic anticoagulation may necessitate an alternative therapeutic strategy. If the thrombotic process can be controlled, these patients can recover, but indefinite anticoagulant therapy may be appropriate to prevent recurrent events.
Collapse
|
20
|
Abstract
Coagulopathy and bleeding in thoracic surgery may be compounded by the chronic use of anticoagulants and antiplatelet agents. Timely preoperative cessation and postoperative resumption of these antithrombotic drugs are critical in reducing the risks of perioperative major bleeding and thromboembolism. This article describes the various strategies for the optimal perioperative management of antithrombotics based on individual assessment of each patient and the most recent multisociety guidelines.
Collapse
Affiliation(s)
- Mathew Thomas
- Division of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32082, USA.
| | - K Robert Shen
- Division of General Thoracic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55205, USA
| |
Collapse
|
21
|
|
22
|
|