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Gulkarov I, Salemi A, Pawlikowski A, Khaki R, Esham M, Lackey A, Paul S, Stein LH. Outcomes and Direct Cost of Isolated Nonemergent CABG in Patients With Low Ejection Fraction. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:557-564. [PMID: 37968874 DOI: 10.1177/15569845231207335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
OBJECTIVE Preoperative left ventricular ejection fraction (LVEF) is one of the main predictors of outcomes in cardiac surgery. We present current era outcomes and associated direct cost in nonemergent isolated coronary artery bypass surgery (CABG) patients with LVEF <20% over the past 6 years and compare it with higher EF subgroups. METHODS Six-year data from 2016 to 2022 at hospitals sharing Society of Thoracic Surgeons and financial data with Biome Analytics were analyzed based on 3 EF subgroups (EF ≤20%, EF 21% to 35%, and EF >35%). Outcomes and costs were assessed. RESULTS Overall 30-day mortality of 12,649 patients was 1.9%. The EF ≤20% (n = 248), EF 21% to 35% (n = 1,408), and EF >35 (n = 10,993) cohorts had mortality of 6.9%, 3.7%, and 1.6%, respectively. The EF ≤20% subgroup had higher use of cardiopulmonary bypass, blood products, and mechanical support. In addition, the EF ≤20% subgroup had higher complication rates in almost all measured categories. Also, the EF ≤20% cohort had significantly higher length of stay, intensive care unit (ICU) hours, ICU and hospital readmissions, and lowest discharge to home rate. The strongest factors associated with mortality were postoperative cardiac arrest, renal failure requiring dialysis, extracorporeal membrane oxygenation, sepsis, prolonged ventilation, and gastrointestinal event. The overall median direct cost of care was $37,387.79 ($27,605.18, $51,720.96), with a median direct cost of care in the EF ≤20%, EF 21% to 35%, and EF >35% subgroups of $52,500.17 ($34,103.52, $80,806.79), $44,108.32 ($31,597.58, $63,788.03), and $36,521.80 ($27,168.91, $50,019.31), respectively. CONCLUSIONS In nonemergent isolated CABG surgery, low EF continues to have higher surgical risks and higher direct cost of care despite advances in cardiovascular care.
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Affiliation(s)
- Iosif Gulkarov
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
- Department of Cardiothoracic Surgery, New York Presbyterian Queens, Flushing, NY, USA
| | - Arash Salemi
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
- Department of Cardiothoracic Surgery, RWJ Barnabas Health, Newark Beth Israel Medical Center, West Orange, NJ, USA
| | | | | | | | - Adam Lackey
- Department of Surgery, RWJ Barnabas Health, Jersey City Medical Center, NJ, USA
| | - Subroto Paul
- Department of Cardiovascular and Thoracic surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Louis H Stein
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
- Department of Cardiothoracic Surgery, RWJ Barnabas Health, Newark Beth Israel Medical Center, West Orange, NJ, USA
- Department of Surgery, RWJ Barnabas Health, Jersey City Medical Center, NJ, USA
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Bakaeen FG, Gaudino M, Whitman G, Doenst T, Ruel M, Taggart DP, Stulak JM, Benedetto U, Anyanwu A, Chikwe J, Bozkurt B, Puskas JD, Silvestry SC, Velazquez E, Slaughter MS, McCarthy PM, Soltesz EG, Moon MR. 2021: The American Association for Thoracic Surgery Expert Consensus Document: Coronary artery bypass grafting in patients with ischemic cardiomyopathy and heart failure. J Thorac Cardiovasc Surg 2021; 162:829-850.e1. [PMID: 34272070 DOI: 10.1016/j.jtcvs.2021.04.052] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 04/20/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Coronary Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Md
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University Jena, University Hospital, Jena, Germany
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David P Taggart
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - John M Stulak
- Division of Cardiothoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn
| | - Umberto Benedetto
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Anelechi Anyanwu
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute at Cedars-Sinai, Los Angeles, Calif
| | - Biykem Bozkurt
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Tex
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside Hospital, New York, NY
| | | | - Eric Velazquez
- Department of Cardiovascular Medicine, Heart and Vascular Center, Yale New Haven Health, New Haven, Conn
| | - Mark S Slaughter
- Department Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Ky
| | - Patrick M McCarthy
- Bluhm Cardiovascular Institute and Division of Cardiac Surgery in the Department of Surgery, Northwestern University, Chicago, Ill
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Coronary Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
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Di Tommaso L, Giordano R, Di Tommaso E, Iannelli G. Female gender and left ventricular dysfunction in myocardial surgical revascularization: the strange couple. J Thorac Dis 2018; 10:S2160-S2164. [PMID: 30123549 DOI: 10.21037/jtd.2018.06.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Luigi Di Tommaso
- Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy
| | - Raffaele Giordano
- Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy
| | - Ettorino Di Tommaso
- Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy
| | - Gabriele Iannelli
- Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy
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Becher T, Baumann S, Eder F, Perschka S, Loßnitzer D, Fastner C, Behnes M, Doesch C, Borggrefe M, Akin I. Comparison of peri and post-procedural complications in patients undergoing revascularisation of coronary artery multivessel disease by coronary artery bypass grafting or protected percutaneous coronary intervention with the Impella 2.5 device. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 8:360-368. [PMID: 28660768 DOI: 10.1177/2048872617717687] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND While coronary artery bypass grafting remains the standard treatment of complex multivessel coronary artery disease, the advent of peripheral ventricular assist devices has enhanced the safety of percutaneous coronary intervention. We therefore evaluated the safety in terms of inhospital outcome comparing protected high-risk percutaneous coronary intervention with the Impella 2.5 device and coronary artery bypass grafting in patients with complex multivessel coronary artery disease. METHODS This retrospective study included patients with complex multivessel coronary artery disease (SYNTAX score >22) undergoing either coronary artery bypass grafting before the implementation of a protected percutaneous coronary intervention programme with a peripheral ventricular assist device or protected percutaneous coronary intervention with the Impella 2.5 device following the start of the programme. The primary endpoint consisted of inhospital major adverse cardiac and cerebrovascular events. The combined secondary endpoint included peri and post-procedural adverse events. RESULTS A total of 54 patients (mean age 70.1±9.9 years, 92.6% men) were enrolled in the study with a mean SYNTAX score of 34.5±9.8. Twenty-six (48.1%) patients underwent protected percutaneous coronary intervention while 28 (51.9%) patients received coronary artery bypass grafting. The major adverse cardiac and cerebrovascular event rate was numerically higher in the coronary artery bypass grafting group (17.9 vs. 7.7%; P=0.43) but was not statistically significant. The combined secondary endpoint was not different between the groups; however, patients undergoing coronary artery bypass grafting experienced significantly more peri-procedural adverse events (28.6 vs. 3.8%; P<0.05). CONCLUSION Patients with complex multivessel coronary artery disease undergoing protected percutaneous coronary intervention with the Impella 2.5 device experience similar intrahospital major adverse cardiac and cerebrovascular event rates when compared to coronary artery bypass grafting. Protected percutaneous coronary intervention represents a safe alternative to coronary artery bypass grafting in terms of inhospital adverse events.
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Affiliation(s)
- Tobias Becher
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany.,2 DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
| | - Stefan Baumann
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany.,2 DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
| | - Frederik Eder
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany
| | - Simon Perschka
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany
| | - Dirk Loßnitzer
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany.,2 DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
| | - Christian Fastner
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany.,2 DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
| | - Michael Behnes
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany.,2 DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
| | - Christina Doesch
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany.,2 DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
| | - Martin Borggrefe
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany.,2 DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
| | - Ibrahim Akin
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany.,2 DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
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Development of an open-heart intraoperative risk scoring model for predicting a prolonged intensive care unit stay. BIOMED RESEARCH INTERNATIONAL 2014; 2014:158051. [PMID: 24818129 PMCID: PMC4004196 DOI: 10.1155/2014/158051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 03/07/2014] [Accepted: 03/21/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Based on a pilot study with 34 patients, applying the modified sequential organ failure assessment (SOFA) score intraoperatively could predict a prolonged ICU stay, albeit with only 4 risk factors. Our objective was to develop a practicable intraoperative model for predicting prolonged ICU stay which included more relevant risk factors. METHODS An extensive literature review identified 6 other intraoperative risk factors affecting prolonged ICU stay. Another 168 patients were then recruited for whom all 10 risk factors were extracted and analyzed by logistic regression to form the new prognostic model. RESULTS The multivariate logistic regression analysis retained only 6 significant risk factors in the model: age ≥ 60 years, PaO2/FiO2 ratio ≤ 200 mmHg, platelet count ≤ 120,000/mm(3), requirement for inotrope/vasopressor ≥ 2 drugs, serum potassium ≤ 3.2 mEq/L, and atrial fibrillation grading ≥ 2. This model was then simplified into the Open-Heart Intraoperative Risk (OHIR) score, comprising the same 6 risk factors for a total score of 7-a score of ≥ 3 indicating a likely prolonged ICU stay (AUC for ROC of 0.746). CONCLUSIONS We developed a new, easy to calculate OHIR scoring system for predicting prolonged ICU stay as early as 3 hours after CPB. It comprises 6 risk factors, 5 of which can be manipulated intraoperatively.
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Jarral OA, Athanasiou T. Off-pump surgery: is it beneficial in patients with left ventricular dysfunction? Expert Rev Cardiovasc Ther 2014; 12:155-60. [PMID: 24386937 DOI: 10.1586/14779072.2014.877343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
On-pump coronary artery bypass surgery remains the gold standard for complex multivessel disease. Off-pump revascularization has matured as a technique over the last twenty years, but is used in less than 20% of cases worldwide. The poor uptake has been attributed to the significant learning curve in learning the procedure and conflicting evidence reports, together with concerns over mortality related conversion, graft patency and completeness of revascularization. Given these concerns, patient selection continues to be paramount and the subgroups that benefit most are hotly debated. Patients with left ventricular dysfunction constitute a high-risk subgroup which is enlarging in size. There is some evidence to suggest that avoidance of cardiopulmonary bypass in this group may lead to superior results in terms of early mortality, non-cardiac complications and organ dysfunction. Even with the theoretical risk of incomplete revascularization, the technique may be an attractive option in managing high-risk patients.
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Affiliation(s)
- Omar A Jarral
- Department of Surgery and Cancer, Imperial College London, London, UK
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Weiner M, Reich D, Lin H, Krol M, Fischer G. Influence of increased left ventricular myocardial mass on early and late mortality after cardiac surgery. Br J Anaesth 2013; 110:41-6. [DOI: 10.1093/bja/aes299] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Surgical treatment for heart failure. Int Anesthesiol Clin 2012; 50:43-54. [PMID: 22735719 DOI: 10.1097/aia.0b013e31825d93d0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Small GR, Yam Y, Chen L, Ahmed O, Al-Mallah M, Berman DS, Cheng VY, Chinnaiyan K, Raff G, Villines TC, Achenbach S, Budoff MJ, Cademartiri F, Callister TQ, Chang HJ, Delago A, Dunning A, Hadamitzky M, Hausleiter J, Kaufmann P, Lin F, Maffei E, Min JK, Shaw LJ, Chow BJ. Prognostic Assessment of Coronary Artery Bypass Patients With 64-Slice Computed Tomography Angiography. J Am Coll Cardiol 2011; 58:2389-95. [DOI: 10.1016/j.jacc.2011.08.047] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 07/13/2011] [Accepted: 08/09/2011] [Indexed: 11/27/2022]
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Vicente R, Pajares A, Vicente JL, Aparicio R, Loro JM, Moreno I, Soria A, López A, Porta J, de la Fuente C, Herrera P, Tur A, Osseyran F, Guillén A, Martí F, Llagunes J, Mateo E, Aguar F, Peña JJ, Marqués JI, Ripoll A, Reina C, Ferrandis P, Muedra V, Llopis E, Cantó M, García C. [Mortality following cardiac surgery in the National Health Service Hospitals of the Community of Valencia in 2007: a descriptive analysis]. ACTA ACUST UNITED AC 2010; 57:79-85. [PMID: 20336998 DOI: 10.1016/s0034-9356(10)70168-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To analyze clinical records of cardiac surgery patients in an attempt to identify factors associated with mortality in the postoperative critical care units of the public health service hospitals in the Community of Valencia, Spain, in 2007. METHODS Retrospective study of cases from January 1, 2007 to December 31, 2007. The charts of all patients who underwent cardiac surgery with or without extracorporeal circulation were reviewed. A data collection protocol was followed to obtain information on age, sex, body mass index (BMI), presurgical risk factors, type of surgery, duration of extracorporeal circulation, duration of ischemia, cause of death, and length of stay in the postoperative critical care unit. RESULTS The study population consisted of 2113 patients at 5 public hospitals; 124 patients (70 men, 54 women) died. The mean (SD) age was 70 (9.43) years (range, 36-91 years). The mean BMI was 28.19 kg/m2 (maximum, 42 kg/m2). The mean Euroscore was 21.92 (maximum, 94.29). Hypertension was present as a preoperative risk factor in most patients (74.2%); dyslipidemia was present in 51.6%, diabetes mellitus in 38.7%, stroke in 73%, and renal failure in 2.4%. It was noteworthy was that the group who underwent coronary revascularization had the highest mortality rate (nearly 35% of the 124 patients). The next highest mortality rate (19.4%) was in patients who had combined procedures (valve repair or substitution plus coronary revascularization). Mortality was 18.5% in the group undergoing aortic valve surgery and 11.3% in those undergoing mitral valve surgery. The mean duration of extracorporeal circulation was 148.63 minutes. The mean duration of myocardial ischemia was 94.91 minutes. The most frequent cause of death was cardiogenic shock (54.8%). This was followed by distributive shock (29.8%) and hemorrhagic shock (8.9%). The mean length of stay in the postoperative critical care unit was 13.6 days. Overall mortality was 5.87%. CONCLUSIONS The highest mortality rate among cardiac surgery patients in postoperative critical care units in hospitals in the Community of Valencia in 2007 was in patients who underwent coronary revascularization. The most prevalent preoperative risk factor was hypertension. Cardiogenic shock and distributive shock were the most frequent causes of death in these patients. A system for classifying risk is needed in order to predict mortality in critical care units and improve perioperative care.
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Affiliation(s)
- R Vicente
- Sección de Anestesiología y Cuidados Críticos de Cirugía Cardiaca en la Comunidad Valenciana.
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Ahmadi SH, Karimi A, Movahedi N, Shirzad M, Marzban M, Tazik M, Aramin H, Dowlatshahi S, Fathollahi MS. Is severely left ventricular dysfunction a predictor of early outcomes in patients with coronary artery bypass graft? HEART ASIA 2010; 2:62-6. [PMID: 27325945 DOI: 10.1136/ha.2009.001008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/27/2009] [Indexed: 11/04/2022]
Abstract
BACKGROUND Traditionally, the Coronary artery bypass grafting (CABG) surgery outcomes of patients with low ejection fraction (EF) have been worse compared to patients with moderate to good left ventricular function. During the past decade, despite improvements in surgical techniques, the trend in the outcomes of these patients remained unclear. AIM We sought to determine the effect of left ventricular dysfunction on early mortality and morbidity and to specify predictors of early mortality of isolated CABG in a large group of patients EF≤35%. METHOD We retrospectively analyzed data of 14 819 consecutive patients undergoing isolated CABG from February 2002 to March 2008 at Tehran Heart Center. Patients were divided into two groups based on their LVEF (EF≤35% and EF>35%). Differences in case-mix between patients with EF≤35% and those without were controlled by constructing a propensity score. RESULTS Mean age of our patients was 58.7±9.5 years. EF≤35% was present in 1342 (9.1%) of patients. In-hospital mortality was significantly increased univariate in EF≤35%, while this association diminished after confounders were adjusted for by using the propensity score (p=0.242). Following adjustment it was demonstrated that renal failure, cardiac arrest, heart block, infectious complication, total ventilation time, and total ICU hours were more frequent in patients with EF≤35%. CONCLUSION We demonstrated EF≤35% was not predictor of in-hospital mortality in patients underwent CABG. Careful preoperative patient selection remains essential in patients with EF≤35% undergoing CABG.
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Affiliation(s)
- Seyed Hossein Ahmadi
- Cardiovascular Surgery Department, Tehran Heart Center, Medical Sciences, University of Tehran, Iran
| | - Abbasali Karimi
- Cardiovascular Surgery Department, Tehran Heart Center, Medical Sciences, University of Tehran, Iran
| | - Namvar Movahedi
- Cardiovascular Surgery Department, Tehran Heart Center, Medical Sciences, University of Tehran, Iran
| | - Mahmood Shirzad
- Cardiovascular Surgery Department, Tehran Heart Center, Medical Sciences, University of Tehran, Iran
| | - Mehrab Marzban
- Cardiovascular Surgery Department, Tehran Heart Center, Medical Sciences, University of Tehran, Iran
| | - Mokhtar Tazik
- Clinical Research Department, Tehran Heart Center, Medical Sciences, University of Tehran, Iran
| | - Hermineh Aramin
- Clinical Research Department, Tehran Heart Center, Medical Sciences, University of Tehran, Iran
| | - Samaneh Dowlatshahi
- Clinical Research Department, Tehran Heart Center, Medical Sciences, University of Tehran, Iran
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