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Percy ED, Faggion Vinholo T, Newell P, Singh S, Hirji S, Awtry J, Semco R, Chowdhury M, Reed AK, Asokan S, Malarczyk A, Okoh A, Harloff M, Yazdchi F, Kaneko T, Sabe AA. The Impact of Frailty on Outcomes of Proximal Aortic Aneurysm Surgery: A Nationwide Analysis. J Cardiovasc Dev Dis 2024; 11:32. [PMID: 38276658 PMCID: PMC10816774 DOI: 10.3390/jcdd11010032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
(1) Background: This study examines frailty's impact on proximal aortic surgery outcomes. (2) Methods: All patients with a thoracic aortic aneurysm who underwent aortic root, ascending aorta, or arch surgery from the 2016-2017 National Inpatient Sample were included. Frailty was defined by the Adjusted Clinical Groups Frailty Indicator. Outcomes of interest included in-hospital mortality and a composite of death, stroke, acute kidney injury (AKI), and major bleeding (MACE). (3) Results: Among 5745 patients, 405 (7.0%) met frailty criteria. Frail patients were older, with higher rates of chronic pulmonary disease, diabetes, and chronic kidney disease. There was no difference in in-hospital death (4.9% vs. 2.4%, p = 0.169); however, the frail group exhibited higher rates of stroke and AKI. Frail patients had a longer length of stay (17 vs. 8 days), and higher rates of non-home discharge (74.1% vs. 54.3%) than non-frail patients (both p < 0.001). Sensitivity analysis confirmed increased morbidity and mortality in frail individuals. After adjusting for patient comorbidities and hospital characteristics, frailty independently predicted MACE (OR 4.29 [1.88-9.78], p = 0.001), while age alone did not (OR 1.00 [0.99-1.02], p = 0.568). Urban teaching center status predicted a lower risk of MACE (OR 0.27 [0.08-0.94], p = 0.039). (4) Conclusions: Frailty is associated with increased morbidity in proximal aortic surgery and is a more significant predictor of mortality than age. Coordinated treatment in urban institutions may enhance outcomes for this high-risk group.
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Affiliation(s)
- Edward D. Percy
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Division of Cardiovascular Surgery, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA
| | - Thais Faggion Vinholo
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Division of Cardiovascular Surgery, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA
| | - Paige Newell
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Supreet Singh
- Department of Internal Medicine, Mount Sinai Hospital, New York, NY 10029, USA
| | - Sameer Hirji
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Jake Awtry
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Robert Semco
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Muntasir Chowdhury
- Department of Internal Medicine, Trinity Health System, Steubenville, OH 43952, USA
| | - Alexander K. Reed
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94304, USA
| | - Sainath Asokan
- Department of Pediatrics, St. Christopher’s Hospital for Children, Philadelphia, PA 19134, USA
| | - Alexandra Malarczyk
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Alexis Okoh
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Morgan Harloff
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Farhang Yazdchi
- Division of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Tsuyoshi Kaneko
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University in St Louis, St. Louis, MO 63110, USA
| | - Ashraf A. Sabe
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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Memis F, Thijssen CGE, Gökalp AL, Notenboom ML, Meccanici F, Mokhles MM, van Kimmenade RRJ, Veen KM, Geuzebroek GSC, Sjatskig J, ter Woorst FJ, Bekkers JA, Takkenberg JJM, Roos-Hesselink JW. Elective Ascending Aortic Aneurysm Surgery in the Elderly. J Clin Med 2023; 12:jcm12052015. [PMID: 36902802 PMCID: PMC10004422 DOI: 10.3390/jcm12052015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND No clear guidelines exist for performing preventive surgery for ascending aortic (AA) aneurysm in elderly patients. This study aims to provide insights by: (1) evaluating patient and procedural characteristics and (2) comparing early outcomes and long-term mortality after surgery between elderly and non-elderly patients. METHODS A multicenter retrospective observational cohort-study was performed. Data was collected on patients who underwent elective AA surgery in three institutions (2006-2017). Clinical presentation, outcomes, and mortality were compared between elderly (≥70 years) and non-elderly patients. RESULTS In total, 724 non-elderly and 231 elderly patients were operated upon. Elderly patients had larger aortic diameters (57.0 mm (IQR 53-63) vs. 53.0 mm (IQR 49-58), p < 0.001) and more cardiovascular risk factors at the time of surgery than non-elderly patients. Elderly females had significantly larger aortic diameters than elderly males (59.5 mm (55-65) vs. 56.0 mm (51-60), p < 0.001). Short-term mortality was comparable between elderly and non-elderly patients (3.0% vs. 1.5%, p = 0.16). Five-year survival was 93.9% in non-elderly patients and 81.4% in elderly patients (p < 0.001), which are both lower than that of the age-matched general Dutch population. CONCLUSION This study showed that in elderly patients, a higher threshold exists to undergo surgery, especially in elderly females. Despite these differences, short-term outcomes were comparable between 'relatively healthy' elderly and non-elderly patients.
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Affiliation(s)
- Feyza Memis
- Department of Cardiology, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
| | - Carlijn G. E. Thijssen
- Department of Cardiology, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
- Department of Cardiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Arjen L. Gökalp
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Maximiliaan L. Notenboom
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Frederike Meccanici
- Department of Cardiology, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
| | - Mohammad Mostafa Mokhles
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Department of Cardiothoracic Surgery, Utrecht University Medical Center, 3584 CX Utrecht, The Netherlands
| | | | - Kevin M. Veen
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Guillaume S. C. Geuzebroek
- Department of Cardiothoracic Surgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Jelena Sjatskig
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Department of Cardiothoracic Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | | | - Jos A. Bekkers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Johanna J. M. Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Jolien W. Roos-Hesselink
- Department of Cardiology, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
- Correspondence: ; Tel.: +31-10-70-32-432
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Hemli JM, Pupovac SS, Gleason TG, Sundt TM, Desai ND, Pacini D, Ouzounian M, Appoo JJ, Montgomery DG, Eagle KA, Ota T, Di Eusanio M, Estrera AL, Coselli JS, Patel HJ, Trimarchi S, Brinster DR. Management of acute type A aortic dissection in the elderly: an analysis from IRAD. Eur J Cardiothorac Surg 2022; 61:838-846. [PMID: 34977934 DOI: 10.1093/ejcts/ezab546] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/05/2021] [Accepted: 11/20/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We sought to examine management and outcomes of (Stanford) type A aortic dissection (TAAAD) in patients aged >70 years. METHODS All patients with TAAAD enrolled in the International Registry of Acute Aortic Dissection database (1996-2018) were studied (n = 5553). Patients were stratified by age and therapeutic strategy. Outcomes for octogenarians were compared with those for septuagenarians. Variables associated with in-hospital mortality were identified by multivariable logistic regression. RESULTS In-hospital mortality for all patients (all ages) was 19.7% (1167 deaths), 16.1% after surgical intervention vs 52.1% for medical management (P < 0.001). Of the study population, 1281 patients (21.6%) were aged 71-80 years and 475 (8.0%) were >80 years. Fewer octogenarians underwent surgery versus septuagenarians (68.1% vs 85.9%, P < 0.001). Overall mortality was higher for octogenarians versus septuagenarians (32.0% vs 25.6%, P = 0.008); however, surgical mortality was similar (25.1% vs 21.7%, P = 0.205). Postoperative complications were comparable between surgically managed cohorts, although reoperation for bleeding was more common in septuagenarians (8.1% vs 3.2%, P = 0.033). Kaplan-Meier 5-year survival was significantly superior after surgical repair in all age groups, including septuagenarians (57.0% vs 13.7%, P < 0.001) and octogenarians (35.5% vs 22.6%, P < 0.001). CONCLUSIONS When compared with septuagenarians, a smaller percentage of octogenarians undergo surgical repair for TAAAD, even though postoperative outcomes are similar. Age alone should not preclude consideration for surgery in appropriately selected patients with TAAAD.
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Affiliation(s)
- Jonathan M Hemli
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Stevan S Pupovac
- Department of Cardiovascular & Thoracic Surgery, North Shore University Hospital/Northwell Health, Manhasset, NY, USA
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland, Baltimore, MD, USA
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Nimesh D Desai
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Davide Pacini
- Department of Cardiac Surgery, University Hospital S. Orsola, Bologna, Italy
| | - Maral Ouzounian
- Division of Cardiac Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Jehangir J Appoo
- Division of Cardiac Surgery, University of Calgary, Calgary, AB, Canada
| | - Daniel G Montgomery
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Kim A Eagle
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Takeyoshi Ota
- Center for Aortic Disease, University of Chicago Medical Center, Chicago, IL, USA
| | - Marco Di Eusanio
- Lancisi Cardiovascular Center, Politechnic University of Marche, Ancona, Italy
| | - Anthony L Estrera
- Department of Cardiothoracic & Vascular Surgery, McGovern Medical School, UTHealth, Memorial Hermann Heart & Vascular Institute, Houston, TX, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Texas Heart Institute, Houston, TX, USA
| | - Himanshu J Patel
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Santi Trimarchi
- Department of Scienze Cliniche e di Comunita, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Derek R Brinster
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
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Kalra K, Chen EP. Commentary: Aortic arch surgery-Acting your age. J Thorac Cardiovasc Surg 2020; 162:768-769. [PMID: 32417054 DOI: 10.1016/j.jtcvs.2020.02.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Kanika Kalra
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga.
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Hernandez-Vaquero D, Silva J, Escalera A, Álvarez-Cabo R, Morales C, Díaz R, Avanzas P, Moris C, Pascual I. Life Expectancy after Surgery for Ascending Aortic Aneurysm. J Clin Med 2020; 9:jcm9030615. [PMID: 32106425 PMCID: PMC7141111 DOI: 10.3390/jcm9030615] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/17/2020] [Accepted: 02/21/2020] [Indexed: 01/16/2023] Open
Abstract
Introduction: The life expectancy of patients who undergo ascending aortic replacement is unknown. The life expectancy of a population depends on a collection of environmental and socio-economic factors of the territory where they reside. Our aim was to compare the life expectancy of patients undergoing surgery for ascending aortic aneurysm with that of the general population matching by age, sex, and territory. In addition, we aimed to know the late complications, causes of death and risk factors. Methods: All patients who underwent elective replacement of an ascending aortic aneurysm at our institution between 2000 and 2019 were included. The long-term survival of the sample was compared with that of the general population using data of the National Institute of Statistics. Results: For patients who survived the postoperative period, observed cumulative survival at three, five and eight years was 94.07% (95% CI 91.87%-95.70%), 89.96% (95% CI 86.92%-92.33%) and 82.72% (95% CI 77.68%-86.71%). Cumulative survival of the general population at three, five and eight years was 93.22%, 88.30%, and 80.27%. Cancer and cardiac failure were the main causes of death. Conclusions: Long-term survival of patients undergoing elective surgery for ascending aortic aneurysm who survive the postoperative period completely recover their life expectancy.
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Affiliation(s)
- Daniel Hernandez-Vaquero
- Cardiac Surgery Department, Central University Hospital of Asturias, 33011 Oviedo, Spain; (J.S.); (A.E.); (C.M.); (R.D.)
- Instituto de Investigación Sanitaria del Principado de Asturias, 33011 Oviedo, Spain; (P.A.); (C.M.); (I.P.)
- Correspondence: ; Tel.: +0034-985108000
| | - Jacobo Silva
- Cardiac Surgery Department, Central University Hospital of Asturias, 33011 Oviedo, Spain; (J.S.); (A.E.); (C.M.); (R.D.)
- Department of Surgery, University of Oviedo, 33011 Oviedo, Spain
| | - Alain Escalera
- Cardiac Surgery Department, Central University Hospital of Asturias, 33011 Oviedo, Spain; (J.S.); (A.E.); (C.M.); (R.D.)
| | - Rubén Álvarez-Cabo
- Cardiac Surgery Department, Central University Hospital of Asturias, 33011 Oviedo, Spain; (J.S.); (A.E.); (C.M.); (R.D.)
| | - Carlos Morales
- Cardiac Surgery Department, Central University Hospital of Asturias, 33011 Oviedo, Spain; (J.S.); (A.E.); (C.M.); (R.D.)
| | - Rocío Díaz
- Cardiac Surgery Department, Central University Hospital of Asturias, 33011 Oviedo, Spain; (J.S.); (A.E.); (C.M.); (R.D.)
- Instituto de Investigación Sanitaria del Principado de Asturias, 33011 Oviedo, Spain; (P.A.); (C.M.); (I.P.)
| | - Pablo Avanzas
- Instituto de Investigación Sanitaria del Principado de Asturias, 33011 Oviedo, Spain; (P.A.); (C.M.); (I.P.)
- Department of Cardiology, Central University Hospital of Asturias, 33011 Oviedo, Spain
- Department of Medicine, University of Oviedo, 33011 Oviedo, Spain
| | - Cesar Moris
- Instituto de Investigación Sanitaria del Principado de Asturias, 33011 Oviedo, Spain; (P.A.); (C.M.); (I.P.)
- Department of Cardiology, Central University Hospital of Asturias, 33011 Oviedo, Spain
- Department of Medicine, University of Oviedo, 33011 Oviedo, Spain
| | - Isaac Pascual
- Instituto de Investigación Sanitaria del Principado de Asturias, 33011 Oviedo, Spain; (P.A.); (C.M.); (I.P.)
- Department of Cardiology, Central University Hospital of Asturias, 33011 Oviedo, Spain
- Department of Medicine, University of Oviedo, 33011 Oviedo, Spain
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Chung J, Stevens LM, Chu MWA, Dagenais F, Peterson MD, Boodhwani M, Bozinovski J, El-Hamamsy I, Yamashita MH, Atoui R, Bittira B, Payne D, Ouzounian M. The impact of age on patients undergoing aortic arch surgery: Evidence from a multicenter national registry. J Thorac Cardiovasc Surg 2020; 162:759-766.e1. [PMID: 32178917 DOI: 10.1016/j.jtcvs.2020.02.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 02/03/2020] [Accepted: 02/04/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Elderly patients are typically offered aortic surgery at similar diameter thresholds as younger patients, despite limited data quantifying their operative risk. We aim to report the incremental risk experienced by elderly patients undergoing aortic arch surgery. METHODS In total, 2520 patients underwent aortic arch surgery between 2002 and 2018 in 10 centers. Patients were divided into 3 groups: <65 years (n = 1325), 65 to 74 years (n = 737), and ≥75 years (n = 458). Outcomes of interest were in-hospital mortality, stroke, and the modified Society of Thoracic Surgeons composite for mortality or major morbidity (STS-COMP). Multivariable modeling was performed to determine the association of age with these outcomes. RESULTS As age increased, there was an increasing rate of comorbidities, including diabetes (P < .001), renal failure (P < .001), and previous stroke (P = .01). Rates of acute aortic syndrome (P = .50) and total arch repair were similar (P = .59) between groups. Older patients had greater mortality (<65: 6.1% vs 65-74: 9.0% vs ≥75: 14%, P < .001), stroke (6.3% vs 7.7% vs 11%, P = .01) and STS-COMP (25% vs 32% vs 38%, P < .001). After multivariable risk-adjustment, a step-wise increase in complications was observed in the older age groups relative to the youngest in terms of in-hospital mortality (65-74: odds ratio [OR] 1.57, P = .04; ≥75: OR, 2.94, P = .001) and STS-COMP (65-74: OR, 1.57, P < .001; ≥75: OR, 1.96, P < .001). CONCLUSIONS Older patients experienced elevated rates of mortality and morbidity following aortic arch surgery. These results support a more measured approach when evaluating elderly patients. Further research is needed on age-dependent natural history of thoracic aneurysms and size thresholds for intervention.
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Affiliation(s)
- Jennifer Chung
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Michael W A Chu
- Division of Cardiac Surgery, Western University, London, Ontario, Canada
| | - Francois Dagenais
- Division of Cardiac Surgery, Laval University, Quebec City, Quebec, Canada
| | - Mark D Peterson
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - John Bozinovski
- Division of Cardiac Surgery, University of British Columbia, Victoria, British Columbia, Canada
| | - Ismail El-Hamamsy
- Division of Cardiac Surgery, University of Montreal, Montreal, Ontario, Canada
| | - Michael H Yamashita
- Division of Cardiac Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rony Atoui
- Division of Cardiac Surgery, Health Sciences North, Sudbury, Ontario, Canada
| | - Bindu Bittira
- Division of Cardiac Surgery, Health Sciences North, Sudbury, Ontario, Canada
| | - Darrin Payne
- Division of Cardiac Surgery, Queen's University, Kingston, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada.
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7
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Blanding WM, Balsam LB. Proximal aortic surgery in the elderly: Is age just a number? J Thorac Cardiovasc Surg 2018; 157:64-65. [PMID: 29958660 DOI: 10.1016/j.jtcvs.2018.05.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Walker M Blanding
- College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Leora B Balsam
- Division of Cardiac Surgery, UMass Memorial Medical Center, Worcester, Mass.
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