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Outcomes of surgical repair of anomalous origin of the left coronary artery from the pulmonary artery in infants and children. Cardiol Young 2022; 32:36-41. [PMID: 33906700 DOI: 10.1017/s104795112100161x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Anomalous origin of the left coronary artery from the pulmonary artery is associated with high mortality if not timely surgery. We reviewed our experience with anomalous origin of the left coronary artery from the pulmonary artery to assess the preoperative variables predictive of outcome and post-operative recovery of left ventricular function. METHODS A retrospective review was conducted and collected data from patients who underwent anomalous origin of the left coronary artery from the pulmonary artery repair at our institute from April 2005 to December 2019. Left ventricular function was assessed by ejection fraction and the left ventricular end-diastolic dimension index. The outcomes of reimplantation repair were analysed. RESULTS A total of 30 consecutive patients underwent anomalous origin of the left coronary artery from the pulmonary artery repair, with a median age of 14.7 months (range, 1.5-59.6 months), including 14 females (46.67%). Surgery was performed with direct coronary reimplantation in 12 patients (40%) and the coronary lengthening technique in 18 (60%). Twelve patients had concomitant mitral annuloplasty. There were two in-hospital deaths (6.67%), no patients required mechanical support, and no late deaths occurred. Follow-up echocardiograms demonstrated significant improvement between the post-operative time point and the last follow-up in ejection fraction (49.43%±19.92% vs 60.21%±8.27%, p < 0.01) and in moderate or more severe mitral regurgitation (19/30 vs 5/28, p < 0.01). The left ventricular end-diastolic dimension index decreased from 101.91 ± 23.07 to 65.06 ± 12.82 (p < 0.01). CONCLUSIONS Surgical repair of anomalous origin of the left coronary artery from the pulmonary artery has good mid-term results with low mortality and reintervention rates. The coronary lengthening technique has good operability and leads to excellent cardiac recovery. The decision to concomitantly correct mitral regurgitation should be flexible and be based on the pathological changes of the mitral valve and the degree of mitral regurgitation.
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Cashen K, Kwiatkowski DM, Riley CM, Buckley J, Sassalos P, Gowda KN, Iliopoulos I, Bakar A, Chiwane S, Badheka A, Moser EAS, Mastropietro CW. Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery: A Retrospective Multicenter Study. Pediatr Crit Care Med 2021; 22:e626-e635. [PMID: 34432672 DOI: 10.1097/pcc.0000000000002820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We aimed to describe characteristics and operative outcomes from a multicenter cohort of infants who underwent repair of anomalous left coronary artery from the pulmonary artery. We also aimed to identify factors associated with major adverse cardiovascular events following anomalous left coronary artery from the pulmonary artery repair. DESIGN Retrospective chart review. SETTING Twenty-one tertiary-care referral centers. PATIENTS Infants less than 365 days old who underwent anomalous left coronary artery from the pulmonary artery repair. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Major adverse cardiovascular events were defined as the occurrence of postoperative extracorporeal membrane oxygenation, cardiopulmonary resuscitation, left ventricular assist device, heart transplantation, or operative mortality. Factors independently associated with major adverse cardiovascular events were identified using multivariable logistic regression analysis. We reviewed 177 infants (< 365 d old) who underwent anomalous left coronary artery from the pulmonary artery repair between January 2009 and March 2018. Major adverse cardiovascular events occurred in 36 patients (20%). Twenty-nine patients (16%) received extracorporeal membrane oxygenation, 14 (8%) received cardiopulmonary resuscitation, four (2%) underwent left ventricular assist device placement, two (1%) underwent heart transplantation, and six (3.4%) suffered operative mortality. In multivariable analysis, preoperative inotropic support (odds ratio, 3.5; 95% CI, 1.4-8.5), cardiopulmonary bypass duration greater than 150 minutes (odds ratio, 6.9 min; 95% CI, 2.9-16.7 min), and preoperative creatinine greater than 0.3 mg/dL (odds ratio, 2.4 mg/dL; 95% CI, 1.1-5.6 mg/dL) were independently associated with major adverse cardiovascular events. In patients with preoperative left ventricular end-diastolic diameter measurements available (n = 116), left ventricular end-diastolic diameter z score greater than 6 was also independently associated with major adverse cardiovascular events (odds ratio, 7.6; 95% CI, 2.0-28.6). CONCLUSIONS In this contemporary multicenter analysis, one in five children who underwent surgical repair of anomalous left coronary artery from the pulmonary artery experienced major adverse cardiovascular events. Preoperative characteristics such as inotropic support, creatinine, and left ventricular end-diastolic diameter z score should be considered when planning for potential postoperative complications.
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Affiliation(s)
- Katherine Cashen
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI
| | - David M Kwiatkowski
- Department of Pediatrics, Pediatric Heart Center Lucille Packard Children's Hospital, Palo Alto, CA
| | - Christine M Riley
- Department of Pediatrics, Children's National Health System, Washington, DC
| | - Jason Buckley
- Department of Pediatrics, Medical University of South Carolina Children's Hospital, Charleston, SC
| | - Peter Sassalos
- Department of Cardiac Surgery, University of Michigan, CS Mott Children's Hospital, Ann Arbor, MI
| | | | - Ilias Iliopoulos
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Adnan Bakar
- Department of Pediatrics, Zucker School of Medicine at Hofstra/Northwell, Cohen Children's Medical Center of New York, New Hyde Park, NY
| | - Saurabh Chiwane
- Department of Pediatrics, Cardinal Glennon Children's Hospital, St. Louis, MO
| | - Aditya Badheka
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA
| | - Elizabeth A S Moser
- Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Christopher W Mastropietro
- Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
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Adam EL, Generoso G, Bittencourt MS. Anomalous Coronary Arteries: When to Follow-up, Risk Stratify, and Plan Intervention. Curr Cardiol Rep 2021; 23:102. [PMID: 34196813 DOI: 10.1007/s11886-021-01535-x] [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] [Accepted: 05/17/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Coronary artery anomalies are a diverse group of entities, ranging from benign variations of normal anatomy to life-threatening conditions. There is, however, no universal consensus in their classification, risk stratification, and management. The aim of this review is to develop a straightforward clinical approach for the assessment and care of patients with anomalous coronary arteries. RECENT FINDINGS Autopsy series and population screening studies have recently provided useful clinical data on the prevalence and outcomes of coronary anomalies. Also, findings on coronary computed tomography angiography, magnetic resonance imaging, and invasive angiography, enriched with fractional flow reserve and intravascular ultrasound, have allowed identification of several high-risk features associated with specific coronary anomalies. Management of patients with anomalous coronary arteries requires an individualized approach based on clinical, physiological, and anatomic features. High-quality studies are paramount for further development of this fascinating field.
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Affiliation(s)
| | - Giuliano Generoso
- University Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Marcio Sommer Bittencourt
- University Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
- DASA, Sao Paulo, Brazil.
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Tan C, Holland M, Quinonez L. Repair of Anomalous Left Anterior Descending Coronary Artery Arising From the Pulmonary Artery Using a Dacron Interposition Bypass Graft. World J Pediatr Congenit Heart Surg 2021; 12:679-681. [PMID: 33956544 DOI: 10.1177/2150135120983803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
An anomalous left anterior descending artery arising from the pulmonary artery (ALADAPA) is exceedingly rare. We present an adult case of ALADAPA that was repaired using a Dacron interposition graft.
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Affiliation(s)
- Corinne Tan
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Margaret Holland
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Luis Quinonez
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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Triglia LT, Guariento A, Zanotto L, Zanotto L, Cattapan C, Hu R, Zhang H, Herbst C, Hörer J, Sarris G, Ebels T, Maruszewski B, Tobota Z, Blitzer D, Lorenzoni G, Bottigliengo D, Gregori D, Padalino M, Di Salvo G, Vida VL. Anomalous left coronary artery from pulmonary artery repair: Outcomes from the European Congenital Heart Surgeons Association Database. J Card Surg 2021; 36:1910-1916. [PMID: 33651393 DOI: 10.1111/jocs.15448] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/07/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We sought to determine the surgical outcomes of patients with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) enrolled in the European Congenital Heart Surgeons Association (ECHSA) database. MATERIALS AND METHODS From 1999 to 2019, 907 patients with ALCAPA underwent surgical repair and were included in the current study. The primary outcome was in-hospital mortality. Secondary outcomes included frequency and results of concomitant mitral valve surgery and postoperative mechanical circulatory support (MCS). RESULTS The overall in-hospital mortality was 6% (54/907) and was significantly higher in neonates (p = .01), patients with lower body surface area (BSA) (p = .01), and those requiring postoperative MCS (p = .001). Associated mitral valve surgery was performed in 144 patients (15.9%) and was associated with longer cardiopulmonary bypass (CPB) and aortic cross-clamp times (AOX) (p ≤ .0001) but was not significantly related to an increase in in-hospital mortality. Postoperative MCS was required in 66 patients (7.3%). These patients were younger (p ≤ .001), had a lower BSA (p ≤ .001), and required a longer CPB (p ≤ .001) and AOX time (p ≤ .001). CONCLUSIONS ALCAPA repair can be achieved successfully, and with low surgical risk. Concomitant mitral valve procedures can be performed without increasing operative mortality. The use of MCS remains a valuable option, especially in younger patients.
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Affiliation(s)
- Laura Torlai Triglia
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Alvise Guariento
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Lorenza Zanotto
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Lucia Zanotto
- Department of Statistical Sciences, University of Padua, Padua, Italy
| | - Claudia Cattapan
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Renjie Hu
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Claudia Herbst
- Department of Surgery, Division of Cardiac Surgery and Pediatric Heart Center, Medical University Vienna, Vienna, Austria
| | - Jurgen Hörer
- Division for Congenital and Pediatric Heart Surgery, University Hospital of Munich (LUM), Munich, Germany
| | - George Sarris
- Department of Pediatric and Congenital Cardiac Surgery, Athens Heart Surgery Institute, IASO Children's Hospital, Athens, Greece
| | - Tjark Ebels
- Departments of Congenital Cardiothoracic Surgery Thoraxcentrum, University Medical Center Groningen, Groningen, Netherlands
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
| | - Zdzislaw Tobota
- Department for Pediatric Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
| | - David Blitzer
- Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | | | | | - Dario Gregori
- Biostatistic Unit, University of Padua, Padua, Italy
| | - Massimo Padalino
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Giovanni Di Salvo
- Department of Children and Woman's Health, Pediatric Cardiology Unit, University of Padua, Padua, Italy
| | - Vladimiro L Vida
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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Chai PJ. Commentary: Another Look at Late-Presentation of Anomalous Left Coronary From the Pulmonary Artery - What Have We Learned? Semin Thorac Cardiovasc Surg 2020; 33:151-152. [PMID: 33171246 DOI: 10.1053/j.semtcvs.2020.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 10/30/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Paul J Chai
- Children's Healthcare of Atlanta, Emory University School of Medicine, Georgia.
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Kwiatkowski DM, Mastropietro CW, Cashen K, Chiwane S, Flores S, Iliopoulos I, Karki KB, Migally K, Radman MR, Riley CM, Sassalos P, Smerling J, Costello JM. Characteristics and Surgical Outcomes of Patients With Late Presentation of Anomalous Left Coronary Artery From the Pulmonary Artery: A Multicenter Study. Semin Thorac Cardiovasc Surg 2020; 33:141-150. [PMID: 32858217 DOI: 10.1053/j.semtcvs.2020.08.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 08/20/2020] [Indexed: 11/11/2022]
Abstract
We sought to describe the clinical course and outcomes of patients who are diagnosed with anomalous left coronary artery from the pulmonary artery (ALCAPA) after infancy. We conducted a retrospective evaluation of patients who underwent ALCAPA surgery between January 2009 to March 2018 at 21 US centers. Clinical presentation, inpatient management, and postoperative outcomes of patients repaired ≥1 year of age were described. To characterize this cohort, we compared these data to patients repaired before 1 year of age. Of 248 ALCAPA patients, 71 (29%) underwent repair ≥1 year of age. Among this subset, the median age at diagnosis was 8.3 years. Chronic arrhythmia occurred in 7%. Patients had good postoperative recovery of left ventricle (LV) dysfunction (90%) and LV dilation (75%), although a low incidence of recovery of mitral regurgitation (40%). Compared to infants, older patients were more likely to present with cardiac arrest (11% vs 1%) and less likely to have moderate or worse LV dysfunction or mitral regurgitation. Older patients had significantly less postoperative extracorporeal membrane oxygenation use, and shorter ICU and hospital stay. In the older cohort, operative mortality occurred in only 1 patient and no patient died after discharge (median follow-up 2.7 years). Survival of patients who presented with ALCAPA beyond infancy was excellent, although chronic mitral regurgitation and chronic arrhythmia were not uncommon. Patients who underwent ALCAPA repair ≥1 year of age were less likely to present with LV dysfunction but more likely to present with cardiac arrest than younger patients.
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Affiliation(s)
- David M Kwiatkowski
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, California.
| | - Christopher W Mastropietro
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Katherine Cashen
- Division of Critical Care, Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, Michigan
| | - Saurabh Chiwane
- Division of Pediatric Critical Care, Department of Pediatrics, Saint Louis University, Cardinal Glennon Children's Hospital, Saint Louis, Missouri
| | - Saul Flores
- Sections of Critical Care and Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Ilias Iliopoulos
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Karan B Karki
- Division of Critical Care, Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Karl Migally
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Monique R Radman
- Division of Critical Care, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Christine M Riley
- Division of Cardiac Critical Care, Children's National Health System, Washington, District of Columbia
| | - Peter Sassalos
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Jennifer Smerling
- Department of Pediatrics, Columbia University College of Physicians & Surgeons, Morgan Stanley Children's Hospital of New York, New York, New York
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
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Surgical outcomes for anomalous left coronary artery from the pulmonary artery: Influence of late presentation. J Thorac Cardiovasc Surg 2019; 159:1945-1952.e1. [PMID: 31767362 DOI: 10.1016/j.jtcvs.2019.09.179] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 09/09/2019] [Accepted: 09/13/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Although surgical outcomes for anomalous left coronary artery from the pulmonary artery (ALCAPA) are excellent in the modern era with the coronary reimplantantion technique, mortality remains high in Chinese population. This study was undertaken to review the surgical management for ALCAPA in our center and assess the midterm outcomes. METHODS This was a retrospective review of 105 patients who underwent surgical repair for ALCAPA from January 2008 to January 2018. RESULTS The diagnosis of ALCAPA was not made before referred to our hospital in 31 patients (30%). Median age at repair was 7.6 months (interquartile range, 4.3-25.4 months). Mean preoperative left ventricular ejection fraction was 47.3% ± 16.9%. Concomitant mitral intervention was performed in 52 patients (50%). Mechanical circulatory support was used in 15 patients (14%). Early mortality was 14%. Classification and regression tree analysis identified 3 risk groups for early mortality, among which patients with preoperative left ventricular ejection fraction ≤41.6% and age at repair >127 days were the most likely to suffer from mortality. Using nonlinear mixed-effect model to assess the time course for postoperative left ventricular ejection fraction, patients of this group also needed significantly longer time for recovery of left ventricular function after surgery (P < .0001). CONCLUSIONS Late referral of patients with ALCAPA is not uncommon in our center. Older age at repair in patients with preoperative left ventricular dysfunction is the main reason for higher early mortality, and is also associated with longer time to normalization of left ventricular function after surgery.
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Jacobs ML, Jacobs JP, Hill KD, O'Brien SM, Pasquali SK, Vener D, Kumar SR, Chiswell K, St Louis JD, Mayer JE, Habib RH, Shahian DM, Fernandez FG. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2019 Update on Research. Ann Thorac Surg 2019; 108:671-679. [PMID: 31336062 PMCID: PMC8104073 DOI: 10.1016/j.athoracsur.2019.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 07/14/2019] [Indexed: 11/17/2022]
Abstract
As the largest congenital and pediatric cardiac surgical clinical data registry in the world, The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD) serves as a platform for reporting of outcomes and for quality improvement. In addition, it is an important source of data for clinical research and for innovations related to quality measurement. Each year, several teams of investigators undertake analyses of data in the STS CHSD pertaining to the surgical management of specific diagnostic and procedural groups, or to specific processes of care, and their associations with patient characteristics and outcomes across centers participating in the STS CHSD. Additional ongoing projects involve the development of new or refined metrics for quality measurement and reporting of outcomes and center-level performance. The STS, through its Workforce for National Databases and the STS Research Center and Workforce on Research Development provides multiple pathways through which investigators may propose and perform outcomes research projects based on STS CHSD data. This report reviews research published within the past year.
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Affiliation(s)
- Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Jeffrey P Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Johns Hopkins All Children's Heart Institute, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida
| | - Kevin D Hill
- Department of Pediatrics and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Sara K Pasquali
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - David Vener
- Department of Anesthesia, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - S Ram Kumar
- Department of Surgery, Children's Hospital of Los Angeles, Keck University of Southern California School of Medicine, Los Angeles, California
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - James D St Louis
- Department of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert H Habib
- The Society of Thoracic Surgeons Research Center, Chicago, Illinois
| | - David M Shahian
- Department of Surgery, Division of Cardiac Surgery, and Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Felix G Fernandez
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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