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Barac YD, Witberg G, Assali A, Klempfner R, Krutzwald-Josefson E, Rubchevsky V, Abergel E, Kornowski R, Aravot D. The Clinical SYNTAX score predicts survival better than the SYNTAX score in coronary revascularization. J Thorac Cardiovasc Surg 2024; 167:164-173.e4. [PMID: 35331554 DOI: 10.1016/j.jtcvs.2022.02.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 01/30/2022] [Accepted: 02/08/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) trial showed that the SYNTAX score (SS) is a useful tool for customizing revascularization treatment for patients with multivessel coronary disease. In the past decade, the Clinical SS (CSS) has emerged as a comprehensive tool. This novel tool considers the SS as well as patient clinical parameters such as age, creatinine clearance, and ejection fraction, which were shown to be relevant for patient prognosis. Thus, in the current work we set out to compare the survival predictive values of the SS versus the CSS and their future application in real-world implementation of the revascularization guidelines. METHODS This study was a subanalysis of data collected in a prospective national registry in Israel that enrolled consecutive patients with left main and/or 2- to 3-vessel coronary artery disease involving the proximal or mid-left anterior descending artery; the MULTI-vessel Coronary Artery Disease (MULTICAD). The revascularization method was chosen by the physicians taking care of the patients at each hospital and the patients were followed for 5 years. Patients were categorized according to their SS, the CSS, and their revascularization method (primary coronary intervention [PCI] vs coronary artery bypass grafting [CABG]) and patient survival were compared. RESULTS A total of 585 patients were enrolled in the study and were followed for 5 years. The median CSS was 27, with 288 patients showing a CSS ≥27, with a mean CSS of 47.85 and a mean SS of 29.05. At 3 and 5 years post-treatment, the CSS ≥27 group had a lower survival probability, CSS ≥27 was associated with a lower survival probability among patients who underwent PCI compared with those who underwent CABG. More specifically, the high-CSS CABG group had a 5-year mortality rate of 16.8%, whereas the high-CSS PCI group had a 5-year mortality rate of 32.2%. In a comparison of SS with CSS for the 5-year mortality outcome prediction, CSS was superior to SS with a higher area under the curve. CONCLUSIONS This prospective registry of real-world revascularization strategies in patients with multivessel disease showed that CSS is a better predictive tool of postrevascularization survival than SS. Moreover, it showed that surgical revascularization in patients with CSS ≥27 is associated with better all-cause mortality outcome after CABG as compared with after PCI. This attests to the need for a score that considers clinical parameters in a real-world scenario.
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Affiliation(s)
- Yaron D Barac
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Rabin Medical Center, Petach-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Guy Witberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Division of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Abid Assali
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Division of Cardiology, Meir Medical Center, Cefar Sava, Israel
| | - Robert Klempfner
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Leviev Heart Center, Sheba Medical Center, Ramat-Gan, Israel
| | - Efrat Krutzwald-Josefson
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Rabin Medical Center, Petach-Tikva, Israel
| | - Victor Rubchevsky
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Rabin Medical Center, Petach-Tikva, Israel
| | - Eytan Abergel
- Division of Cardiology, Rambam Medical Center, Haifa, Israel
| | - Ran Kornowski
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Division of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Dan Aravot
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Rabin Medical Center, Petach-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Sulaiman S, Harik L, Merz CNB, Fremes SE, Masterson Creber R, Rong LQ, Alkhouli M, Gaudino M. Revascularization strategies for multivessel coronary artery disease based on sex and age. Eur J Cardiothorac Surg 2023; 64:ezad374. [PMID: 37947309 PMCID: PMC10641124 DOI: 10.1093/ejcts/ezad374] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/30/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES This study describes coronary revascularization strategies used by sex and age in the USA. METHODS A sex-stratified cohort study from the National Inpatient Sample from the Agency for Healthcare Research and Quality (USA) including patients admitted for coronary revascularization with primary or secondary diagnoses of chronic coronary syndrome or non-ST elevation myocardial infarction who underwent ≥3-vessel coronary artery bypass grafting or percutaneous coronary intervention from January 2019 to December 2020. The primary outcome was the use rate of coronary artery bypass grafting or multivessel percutaneous coronary intervention. Prespecified subgroups included age and non-ST elevation myocardial infarction. RESULTS Among 121 150 patients (21.7% women), there were no sex differences in age (women: 66.6 [66.5-66.7], men: 67.6 [67.5-67.7], standardized mean difference: 0.1) or non-ST elevation myocardial infarction incidence (women: 37.4%, men: 45.7%, standardized mean difference: 0.17). The majority of women (74.2%) and men (84.9%) underwent bypass grafting, which was unaffected by age, race or non-ST elevation myocardial infarction. Women were less likely to undergo bypass grafting than percutaneous intervention (adjusted odds ratio 0.49, 95% confidence interval 0.44-0.54; P < 0.001) and a disparity most pronounced in patients >80 years old (adjusted odds ratio 0.31, 95% confidence interval 0.22-0.45; P < 0.001). CONCLUSIONS Most patients with multivessel coronary artery disease needing revascularization undergo bypass grafting, irrespective of sex, age or clinical presentation. The sex disparity in the use of bypass grafting is mostly seen among patients >80 years old.
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Affiliation(s)
- Samian Sulaiman
- Division of Cardiology, West Virginia University, Morgantown, WV, USA
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN, USA
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - C Noel Bairey Merz
- Department of Cardiology, Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephen E Fremes
- Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | | | - Lisa Q Rong
- Department of Anesthesia, Weill Cornell Medicine, New York, NY, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
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3
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Gaudino M, Di Franco A, Cao D, Giustino G, Bairey Merz CN, Fremes SE, Kirtane AJ, Kunadian V, Lawton JS, Masterson Creber RM, Sandner S, Vogel B, Zwischenberger BA, Dangas GD, Mehran R. Sex-Related Outcomes of Medical, Percutaneous, and Surgical Interventions for Coronary Artery Disease: JACC Focus Seminar 3/7. J Am Coll Cardiol 2022; 79:1407-1425. [PMID: 35393023 DOI: 10.1016/j.jacc.2021.07.066] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/12/2021] [Indexed: 12/15/2022]
Abstract
Biological and sociocultural differences between men and women are complex and likely account for most of the variations in the epidemiology and treatment outcomes of coronary artery disease (CAD) between the 2 sexes. Worse outcomes in women have been described following both conservative and invasive treatments of CAD. For example, increased levels of residual platelet reactivity during treatment with antiplatelet drugs, higher rates of adverse cardiovascular outcomes following percutaneous coronary revascularization, and higher operative and long-term mortality after coronary bypass surgery have been reported in women compared with in men. Despite the growing recognition of sex-specific determinants of outcomes, representation of women in clinical studies remains low and sex-specific management strategies are generally not provided in guidelines. This review summarizes the current evidence on sex-related differences in patients with CAD, focusing on the differential outcomes following medical therapy, percutaneous coronary interventions, and coronary artery bypass surgery.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA.
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Stephen E Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ajay J Kirtane
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center and the Cardiovascular Research Foundation, New York, New York, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brittany A Zwischenberger
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Khaled S, Jaha N, Shalaby G. Clinical Characteristics and Short-Term Outcomes of Patients Presenting with Acute Myocardial Infarction having Multi-vessel disease - A Single Middle- eastern Tertiary-Care Center Experience. Indian Heart J 2022; 74:28-33. [PMID: 34864019 PMCID: PMC8891000 DOI: 10.1016/j.ihj.2021.11.184] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/03/2021] [Accepted: 11/30/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Patients with multi-vessel coronary artery disease (MVD) compared to single-vessel coronary artery disease (CAD) have more comorbidities and poor in-hospital outcomes. We aim to analyze MVD-AMI patients regarding clinical data and short-term outcomes. METHODS This is a retrospective analysis of the prospectively collected data registry, a single-center study reviewing the clinical details and hospital outcome measures of AMI patients referred to our center for early revascularization from 2016 to 2019. RESULT Out of 3041 patients presented with AMI, 491 (16%) had MVD on coronary angiogram. MVD-AMI patients were older, had a higher prevalence of DM, HTN, and prior history of ischemic heart disease compared to the non- MVD -AMI group (p < 0.001 for all). However, they presented more with non-anterior myocardial infarction, showed higher rates of post-myocardial infarction LV dysfunction, and mortality (p < 0.001). Older MVD-AMI patients showed higher rates of in-hospital morbidities and mortality compared to younger ones (p < 0.001). MVD- AMI women and Middle Eastern patients were older and showed a higher prevalence of cardiovascular risk factors compared to MVD-AMI men and South Asian patient population respectively. There were no significant differences recorded among the different subgroups of MVD-AMI patients regarding the hospital outcome measures. CONCLUSION Our study highlighted the clinical characters and poor outcomes of a high-risk group of MVD-AMI with different demographic backgrounds. Although age was a strong predictor for in-hospital poor outcomes, neither gender nor ethnicity affected the outcomes in them.
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Affiliation(s)
- Sheeren Khaled
- Banha University, Banha, Egypt; King Abdullah Mediacl City, Makkah, Saudi Arabia.
| | - Najeeb Jaha
- King Abdullah Mediacl City, Makkah, Saudi Arabia.
| | - Ghada Shalaby
- King Abdullah Mediacl City, Makkah, Saudi Arabia; Zagazige University, Zagazige, Egypt.
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Qiao HY, Li JH, Schoepf UJ, Bayer RR, Tinnefeld FC, Di Jiang M, Yang F, Guo BJ, Zhou CS, Ge YQ, Lu MJ, Jiang JW, Lu GM, Zhang LJ. Prognostic implication of CT-FFR based functional SYNTAX score in patients with de novo three-vessel disease. Eur Heart J Cardiovasc Imaging 2020:jeaa256. [PMID: 33184644 DOI: 10.1093/ehjci/jeaa256] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 08/22/2020] [Indexed: 02/01/2023] Open
Abstract
AIMS This study was aimed at investigating whether a machine learning (ML)-based coronary computed tomographic angiography (CCTA) derived fractional flow reserve (CT-FFR) SYNTAX score (SS), 'Functional SYNTAX score' (FSSCTA), would predict clinical outcome in patients with three-vessel coronary artery disease (CAD). METHODS AND RESULTS The SS based on CCTA (SSCTA) and ICA (SSICA) were retrospectively collected in 227 consecutive patients with three-vessel CAD. FSSCTA was calculated by combining the anatomical data with functional data derived from a ML-based CT-FFR assessment. The ability of each score system to predict major adverse cardiac events (MACE) was compared. The difference between revascularization strategies directed by the anatomical SS and FSSCTA was also assessed. Two hundred and twenty-seven patients were divided into two groups according to the SSCTA cut-off value of 22. After determining FSSCTA for each patient, 22.9% of patients (52/227) were reclassified to a low-risk group (FSSCTA ≤ 22). In the low- vs. intermediate-to-high (>22) FSSCTA group, MACE occurred in 3.2% (4/125) vs. 34.3% (35/102), respectively (P < 0.001). The independent predictors of MACE were FSSCTA (OR = 1.21, P = 0.001) and diabetes (OR = 2.35, P = 0.048). FSSCTA demonstrated a better predictive accuracy for MACE compared with SSCTA (AUC: 0.81 vs. 0.75, P = 0.01) and SSICA (0.81 vs. 0.75, P < 0.001). After FSSCTA was revealed, 52 patients initially referred for CABG based on SSCTA would have been changed to PCI. CONCLUSION Recalculating SS by incorporating lesion-specific ischaemia as determined by ML-based CT-FFR is a better predictor of MACE in patients with three-vessel CAD. Additionally, the use of FSSCTA may alter selected revascularization strategies in these patients.
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Affiliation(s)
- Hong Yan Qiao
- Department of Medical Imaging, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu 210002, China
- Department of Medical Imaging, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu 214041, China
| | - Jian Hua Li
- Department of Cardiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - U Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC 29425, USA
| | - Richard R Bayer
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC 29425, USA
| | - Fiona C Tinnefeld
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC 29425, USA
| | - Meng Di Jiang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - Fei Yang
- Department of Medical Imaging, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu 214041, China
| | - Bang Jun Guo
- Department of Medical Imaging, Jinling Hospital, Medical School of Southern Medical University, Nanjing, Jiangsu 210002, China
| | - Chang Sheng Zhou
- Department of Medical Imaging, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu 210002, China
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - Ying Qian Ge
- CT Scientific Marketing, Siemens Healthcare, Shanghai, China
| | - Meng Jie Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - Jian Wei Jiang
- Department of Medical Imaging, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu 214041, China
| | - Guang Ming Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - Long Jiang Zhang
- Department of Medical Imaging, Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu 210002, China
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
- Department of Medical Imaging, Jinling Hospital, Medical School of Southern Medical University, Nanjing, Jiangsu 210002, China
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Chambergo-Michilot D, Runzer-Colmenares FM, Zamora Á, Santa-Cruz F, Zamora M. Body mass index and coronary revascularization in women with coronary artery disease: insight into obesity paradox. REVISTA COLOMBIANA DE CARDIOLOGÍA 2020. [DOI: 10.1016/j.rccar.2019.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Kogan A, Ram E, Levin S, Fisman EZ, Tenenbaum A, Raanani E, Sternik L. Impact of type 2 diabetes mellitus on short- and long-term mortality after coronary artery bypass surgery. Cardiovasc Diabetol 2018; 17:151. [PMID: 30497472 PMCID: PMC6264047 DOI: 10.1186/s12933-018-0796-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 11/26/2018] [Indexed: 12/21/2022] Open
Abstract
Background Type 2 diabetes mellitus (DM) is a frequent co-morbidity among patients undergoing coronary artery bypass grafting (CABG) surgery. The aim of this study was to evaluate the impact of DM on the early- and long-term outcomes of patients who underwent isolated CABG. Methods We performed an observational cohort study in a large tertiary medical center over a period of 11 years. All data from patients who had undergone isolated CABG surgery between 2004 and 2014 were obtained from our departmental database. The study population included 2766 patients who were divided into two groups: Group I (1553 non-diabetic patients), and Group II (1213 patients suffering from type 2 DM). Group II patients were then divided into two subgroups: subgroup IIA (981 patients treated with oral antihyperglycemic medications) and subgroup IIB (232 insulin-treated patients with or without additional oral antihyperglycemic drugs). In-hospital, 1-, 3-, 5- and 10-year mortality outcome variables were evaluated. Mean follow-up was 97 ± 41 months. Results In-hospital mortality was similar between Group I and Group II patients (1.87% vs. 2.31%, p = 0.422) and between the subgroups IIA and IIB (2.14% vs. 3.02%, p = 0.464). Long-term mortality (1, 3, 5 and 10 years) was higher in Group II (DM type 2) compared with Group I (non-diabetic patients) (5.3% vs. 3.6%, p = 0.038; 9.3% vs. 5.6%, p < 0.001; 15.3% vs. 9.3%, p < 0.001 and 47.3% vs. 29.6% p < 0.001). Kaplan–Meier analysis demonstrated that all-cause mortality was higher in Group II compared with Group I (p < 0.001) and in subgroup IIB compared with subgroup IIA (p = 0.001). Multivariable analysis showed that DM increased the mortality hazard by twofold, and among diabetic patients, insulin treatment increased the mortality hazard by twofold. Conclusions Diabetic and non-diabetic patients have similar in-hospital mortality rates. Survival rates of diabetic patients start to deteriorate 3 year after surgery. Type 2 DM is an independent predictor for long-term mortality after isolated CABG surgery. Mortality is even higher when the diabetes treatment strategy included insulin. Electronic supplementary material The online version of this article (10.1186/s12933-018-0796-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexander Kogan
- Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler School of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel. .,Cardiac Surgery Intensive Care Unit, Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. .,Tel Aviv University, Tel Aviv, Israel.
| | - Eilon Ram
- Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler School of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel.,Tel Aviv University, Tel Aviv, Israel
| | - Shany Levin
- Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler School of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel
| | | | | | - Ehud Raanani
- Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler School of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel.,Tel Aviv University, Tel Aviv, Israel
| | - Leonid Sternik
- Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler School of Medicine, Tel Aviv University, 52621, Tel Aviv, Israel.,Tel Aviv University, Tel Aviv, Israel
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