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Aerts L, Sardari Nia P. Mastering the learning curve of endoscopic mitral valve surgery. Front Cardiovasc Med 2023; 10:1162330. [PMID: 37424908 PMCID: PMC10325683 DOI: 10.3389/fcvm.2023.1162330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/05/2023] [Indexed: 07/11/2023] Open
Abstract
Endoscopic mitral valve surgery is a challenging procedure. Surgical volume is mandatory to achieve sufficient proficiency and superior results. To this date the learning curve has proven to be challenging. Offering high-fidelity simulation based training for both residents as experienced surgeons can help in establishing and enlarging surgical competences in shorter time without intraoperative trial and error.
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Zientara A, Hussein N, Bond C, Jacob KA, Naruka V, Doerr F, Nägele F, Pölzl L, Eid M, Jarral O, Cerqueira R, Haunschild J, Sádaba JR, Gollmann-Tepeköylü C. Basic principles of cardiothoracic surgery training: a position paper by the European Association for Cardiothoracic Surgery Residents Committee. Interact Cardiovasc Thorac Surg 2022; 35:6677230. [PMID: 36018268 PMCID: PMC9479886 DOI: 10.1093/icvts/ivac213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 07/14/2022] [Accepted: 08/25/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Alicja Zientara
- Department of Cardiac Surgery, Royal Brompton and Harefield Hospital , England, UK
| | - Nabil Hussein
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham , England, UK
| | - Chris Bond
- Department of Cardiac Surgery, Queen Elizabeth University Hospital , Birmingham, UK
- Michigan Society of Thoracic and Cardiovascular Surgery Quality Collaborative , Ann Arbor, MI, USA
| | - Kirolos A Jacob
- Department of Cardiothoracic Surgery, University Medical Center , Utrecht, Netherlands
| | - Vinci Naruka
- Department of Cardiothoracic Surgery, Barts Health NHS Trust, St Bartholomew’s hospital , London, UK
| | - Fabian Doerr
- Department of Cardiothoracic Surgery, University Hospital of Cologne , Cologne, Germany
| | - Felix Nägele
- Department of Cardiac Surgery, Medical University of Innsbruck , Innsbruck, Austria
| | - Leo Pölzl
- Department of Cardiac Surgery, Medical University of Innsbruck , Innsbruck, Austria
| | - Maroua Eid
- Department of Cardiac Surgery, University of Angers , Angers, France
| | - Omar Jarral
- Division of Cardiovascular and Thoracic Surgery, Duke University , Durham, NC, USA
| | - Rui Cerqueira
- Cardiothoracic Surgery Department, Centro Hospitalar Universitário São João , Porto, Portugal
| | - Josephina Haunschild
- University Department for Cardiac Surgery, Leipzig Heart Center, University of Leipzig , Leipzig, Germany
| | - J Rafael Sádaba
- Department of Cardiac Surgery, Hospital Universitario de Navarra , Pamplona, Spain
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Cerqueira RJ, Heuts S, Gollmann-Tepeköylü C, Syrjälä SO, Keijzers M, Zientara A, Jarral OA, Jacob KA, Haunschild J, Ariyaratnam P, Durko AP, Muller P, Myers PO, Sadaba JR, Lehtinen ML. Challenges and satisfaction in Cardiothoracic Surgery Residency Programmes: insights from a Europe-wide survey. Interact Cardiovasc Thorac Surg 2021; 32:167-173. [PMID: 33236099 DOI: 10.1093/icvts/ivaa248] [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: 06/04/2020] [Revised: 09/03/2020] [Accepted: 09/27/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The increasing complexity of surgical patients and working time constraints represent challenges for training. In this study, the European Association for Cardio-Thoracic Surgery Residents' Committee aimed to evaluate satisfaction with current training programmes across Europe. METHODS We conducted an online survey between October 2018 and April 2019, completed by a total of 219 participants from 24 countries. RESULTS The average respondent was in the fourth or fifth year of training, mostly on a cardiac surgery pathway. Most trainees follow a 5-6-year programme, with a compulsory final certification exam, but no regular skills evaluation. Only a minority are expected to take the examination by the European Board of Cardiothoracic Surgery. Participants work on average 61.0 ± 13.1 h per week, including 27.1 ± 20.2 on-call. In total, only 19.7% confirmed the implementation of the European Working Time Directive, with 42.0% being unaware that European regulations existed. Having designated time for research was reported by 13.0%, despite 47.0% having a postgraduate degree. On average, respondents rated their satisfaction 7.9 out of 10, although 56.2% of participants were not satisfied with their training opportunities. We found an association between trainee satisfaction and regular skills evaluation, first operator experience and protected research time. CONCLUSIONS On average, residents are satisfied with their training, despite significant disparities in the quality and structure of cardiothoracic surgery training across Europe. Areas for potential improvement include increasing structured feedback, research time integration and better working hours compliance. The development of European guidelines on training standards may support this.
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Affiliation(s)
- Rui J Cerqueira
- Cardiovascular Research and Development Unit, University of Porto and Department of Cardiothoracic Surgery, University Hospital Center of São João, Porto, Portugal
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | | | - Simo O Syrjälä
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Marlies Keijzers
- Department of Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Alicja Zientara
- Department of Cardiothoracic Surgery, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK
| | - Omar A Jarral
- Department of Cardiothoracic Surgery, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Kirolos A Jacob
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | | | | | - Andras P Durko
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Patrick Muller
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Patrick O Myers
- Department of Cardiac Surgery, CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | | | - Miia L Lehtinen
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
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Sihoe ADL. Developing training for uniportal video-assisted thoracic surgery: a commentary. Eur J Cardiothorac Surg 2020; 58:i1-i5. [PMID: 32529233 DOI: 10.1093/ejcts/ezaa140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/14/2020] [Accepted: 03/24/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Today, thoracic surgeons have many possible pathways to advance their training in video-assisted thoracic surgery (VATS). For uniportal VATS (uVATS) in particular, what are the training options available and does regulating training matter? METHODS The relevant literature pertaining to uVATS training is reviewed. RESULTS Current options for surgeons looking to train in uVATS range from videos on the internet, through 'experts' demonstrating live surgery, to symposia and hands-on wet labs being held in all regions of the world. All have merits, and the aspiring VATS surgeon can choose from a range of preceptorship and proctorship modules to suit his/her own training needs. However, issues in the formalizing training in uVATS remains unresolved. Is there an ideal pathway through uVATS training? At what point can a trainee be considered to have 'graduated' to become an expert in uVATS? Who indeed trains the trainer, and certifies the competence of a training centre? CONCLUSIONS Although a plethora of training options exist, formulation of a robust training curriculum can further bolster the status of uVATS as a sustainable surgical approach that can be delivered with consistent quality.
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Affiliation(s)
- Alan D L Sihoe
- Gleneagles Hong Kong Hospital, Hong Kong SAR, China.,International Medical Centre, Hong Kong SAR, China
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Park SJ, Kim DJ, Kim JB, Park KH, Lee JW. Cardiothoracic surgery training in South Korea: Challenges and new hopes. J Thorac Cardiovasc Surg 2020; 159:205-214.e1. [PMID: 31255338 DOI: 10.1016/j.jtcvs.2019.03.074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 03/14/2019] [Accepted: 03/18/2019] [Indexed: 11/17/2022]
Abstract
In this era when multiple challenges are surrounding the cardiothoracic surgery specialty, including an increase in procedural complexity and institutionalization of public reporting, it is rather paradoxical to have an unprecedentedly unfavorable condition for quality education while the level of proficiency and competency to be achieved during the course of training became more demanding. Cardiothoracic surgery in South Korea is also facing several challenges across multiple levels that includes a persistent low filling rate of residency positions, severe therapeutic deviation toward percutaneous transcatheter intervention in coronary artery disease, a social climate reluctant to cardiovascular surgery and consequent underestimation of surgical volume, and skewed health insurance reimbursement system. Meanwhile, some hopeful signs have been observed in our specialty because of ongoing efforts of our leaderships of the Society, including recent financial initiative and several educational platforms such as boot camp. We introduce our system internationally to share our experience for the purpose of promoting further discussions and encouraging persistent efforts toward education.
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Affiliation(s)
- Sung Jun Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dong Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea; Education Council of the Korean Society of Thoracic and Cardiovascular Surgery, Seoul, South Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea; Education Council of the Korean Society of Thoracic and Cardiovascular Surgery, Seoul, South Korea
| | - Kay-Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea; Education Council of the Korean Society of Thoracic and Cardiovascular Surgery, Seoul, South Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Szczechowicz MP, Easo J, Zhigalov K, Mashhour A, Mkalaluh S, Weymann A. Training of Residents in Cardiac Surgery-Does It Have Impact on the Outcome? Thorac Cardiovasc Surg 2019; 69:13-18. [PMID: 31770776 DOI: 10.1055/s-0039-3400263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES In many centers, training in cardiac surgery is considered to increase perioperative risk. This study aims to test whether a resident working as the main operator is a genuine risk factor. METHODS We analyzed patients who underwent elective isolated aortic valve replacement, elective isolated coronary artery bypass grafting, or both, in our institution, from 2008 to 2016. Redo- and off-pump surgery, ejection fraction < 30%, and other concomitant procedures were the exclusion criteria. After this selection, we included 3,077 patients in our study. Within this group, 357 (11.6%) had been operated by residents and 2,720 (88.4%) by senior surgeons. We performed propensity score matching using the nearest neighbor method with a ratio of 1:2, considering the most important preoperative conditions. In this way, the 357 patients operated by residents were matched with the 714 patients who were operated by senior surgeons. The standardized mean differences were highly reduced after matching, so both groups had similar risk profiles. We compared surgical data, postoperative adverse events, and the 30-day mortality between the two groups. RESULTS The times of surgery, cardiopulmonary bypass, and cross-clamp were longer if residents operated (p < 0.001). There were no differences regarding postoperative adverse events, time of mechanical ventilation, and the intensive care unit length of stay. The 30-day mortality rates of the two groups were very similar (p = 0.75, power = 0.8). CONCLUSION Training in cardiac surgery is safe, and carefully selected patients can be operated by residents without increased risk of perioperative mortality and complications.
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Affiliation(s)
- Marcin Piotr Szczechowicz
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg, Groningen, Oldenburg, Germany
| | - Jerry Easo
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg, Groningen, Oldenburg, Germany
| | - Konstantin Zhigalov
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg, Groningen, Oldenburg, Germany
| | - Ahmed Mashhour
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg, Groningen, Oldenburg, Germany
| | - Sabreen Mkalaluh
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg, Groningen, Oldenburg, Germany
| | - Alexander Weymann
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg, Groningen, Oldenburg, Germany
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Chan J, Oo S, Yeatman M. Is there a national variation in cardiothoracic trainees’ satisfaction? Evaluation of the United Kingdom General Medical Council national training surveys. J Card Surg 2019; 34:1069-1074. [DOI: 10.1111/jocs.14211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jeremy Chan
- Department of Cardiothoracic SurgeryMorriston Hospital Swansea UK
| | - Shwe Oo
- Department of Cardiothoracic SurgeryBristol Heart Institute Bristol UK
| | - Mark Yeatman
- Department of Cardiothoracic SurgeryBristol Heart Institute Bristol UK
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Greco E, Santamaria V, Pomar JL. A Pan-European training in cardio vascular or cardio thoracic surgery: Update and current challenges. CIRUGIA CARDIOVASCULAR 2019. [DOI: 10.1016/j.circv.2019.03.001] [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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Sihoe ADL, Gonzalez-Rivas D, Yang TY, Zhu Y, Jiang G. High-volume intensive training course: a new paradigm for video-assisted thoracoscopic surgery education. Interact Cardiovasc Thorac Surg 2018; 27:365-371. [PMID: 29596584 DOI: 10.1093/icvts/ivy038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 12/30/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Alan D L Sihoe
- Department of Thoracic Surgery, Tongji University Shanghai Pulmonary Hospital, Shanghai, China
- Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shenzhen, China
- Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Diego Gonzalez-Rivas
- Department of Thoracic Surgery, Tongji University Shanghai Pulmonary Hospital, Shanghai, China
| | - Timothy Y Yang
- Department of Thoracic Surgery, Tongji University Shanghai Pulmonary Hospital, Shanghai, China
| | - Yuming Zhu
- Department of Thoracic Surgery, Tongji University Shanghai Pulmonary Hospital, Shanghai, China
| | - Gening Jiang
- Department of Thoracic Surgery, Tongji University Shanghai Pulmonary Hospital, Shanghai, China
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Mery CM, Kane LC. The ACGME Fellowship in Congenital Cardiac Surgery: The Graduates' Perspective. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2017; 20:70-76. [PMID: 28007069 DOI: 10.1053/j.pcsu.2016.09.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 09/14/2016] [Indexed: 06/06/2023]
Abstract
The creation of structured fellowship programs in congenital heart surgery (CHS) in the United States appears to have improved the training of congenital heart surgeons. However, the transition process between fellowship and clinical practice and the lack of senior mentorship continue to be major problems. We report the results of a survey of all graduates of accredited programs in CHS. A total of 35/51 (69%) graduates responded to the survey. Of 34 that are in practice, 31 (91%) did not feel ready to engage in solo CHS after completion of training. Even though 33 (97%) considered mentorship in the first few years of practice very important, almost 40% indicated inadequate mentorship. Several graduates continue to mainly assist and do not seem to be independent several years after graduating from their fellowship. On an open-ended question for additional comments, 15 respondents volunteered that a 1-year fellowship duration was not enough and seven stressed the importance of mentorship and the need for an adequate transition from fellowship to practice. Based on the results of the survey and our own experience, we propose the creation of a 1- or 2-year transitional junior faculty period to follow the 1-year formal training in CHS. We believe innovative approaches to improve the transition to clinical practice are required to maximize the likelihood of success among congenital heart surgery graduates.
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Affiliation(s)
- Carlos M Mery
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Lauren C Kane
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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Shapira OM, Sahar G, Raanani E. Cardiothoracic surgery training in Israel: A critical look at the past, aiming for a better future. J Thorac Cardiovasc Surg 2016; 151:1508-15. [DOI: 10.1016/j.jtcvs.2016.01.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 11/21/2015] [Accepted: 01/03/2016] [Indexed: 11/30/2022]
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Sihoe ADL. Opportunities and challenges for thoracic surgery collaborations in China: a commentary. J Thorac Dis 2016; 8:S414-26. [PMID: 27195139 DOI: 10.21037/jtd.2016.03.98] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Through a unique combination of factors-including a huge population, rapid social development, and concentration of resources in its mega-cities-China is witnessing phenomenal developments in the field of thoracic surgery. Ultra-high-volume centers are emerging that provide fantastic new opportunities for surgical training and clinical research to surgeons in China and partners from other countries. However, there are also particular shortcomings that are limiting clinical and academic developments. To realize the potential and reap the rewards, the challenges posed by these limitations must be overcome. Thoracic surgeons from Europe may be particularly well-placed to achieve this through multi-dimensional exchanges with their Chinese counterparts.
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Affiliation(s)
- Alan D L Sihoe
- Department of Surgery, The Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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14
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Günther S, Beckmann A, Emrich AL, Harringer W, Noack T, Welz A. Modulares Curriculum 6+. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2016. [DOI: 10.1007/s00398-015-0058-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ilonen IK, McElnay PJ. Research and education in thoracic surgery: the European trainees' perspective. J Thorac Dis 2015; 7:S118-21. [PMID: 25984356 DOI: 10.3978/j.issn.2072-1439.2015.03.14] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 03/27/2015] [Indexed: 11/14/2022]
Abstract
Thoracic surgery training within Europe is diverse and a consensus may help to harmonise the training. Currently, training for thoracic surgery compromises thoracic, cardiothoracic and aspects of general surgical training. The recognition of specialist degrees should be universal and equal. Between different nations significant differences in training exist, especially in general surgery rotations and in the role of oesophageal surgery. The European board examination for thoracic surgery is one of the key ways to achieve harmonisation within the European Union (EU) and internationally. Further support and encouragement may be beneficial to promote diverse and engaging fellowships and clinical exchange programmes between nations. International fellowships may even benefit young residents, in both clinical and academic settings. Many studies currently would benefit from multi-centre and multi-national design, enhancing the results and giving better understanding of clinical scenarios. Educational content provided by independent organisations should be more recognised as an integral part in both resident training and continuing development throughout surgeons' careers. During annual society meetings, trainees should have some sessions that are aimed at enhancing their training and establishing networks of international peers.
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Affiliation(s)
- Ilkka K Ilonen
- 1 Clinic of General Thoracic and Oesophageal Surgery, Heart and Lung Centre, Helsinki University Central Hospital, Helsinki, Finland ; 2 Department of Cardiothoracic Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Philip J McElnay
- 1 Clinic of General Thoracic and Oesophageal Surgery, Heart and Lung Centre, Helsinki University Central Hospital, Helsinki, Finland ; 2 Department of Cardiothoracic Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Beyersdorf F. Great Debate: a new section in the EJCTS. Eur J Cardiothorac Surg 2014; 46:155. [PMID: 25015971 DOI: 10.1093/ejcts/ezu255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany
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Bajona P. The time has come for a common European training programme: caveat lector. Eur J Cardiothorac Surg 2013; 45:763. [PMID: 23832832 DOI: 10.1093/ejcts/ezt351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Pietro Bajona
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Affiliation(s)
- Mahmoud Loubani
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull, UK
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Affiliation(s)
- Leslie Hamilton
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne, UK.
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