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Khairallah S, Rahouma M, Gambardella I, Habib R, Gaudino M, Girardi L, Mick SL. Trends in the Management of Anterior Mitral Leaflet Regurgitation. JAMA Netw Open 2024; 7:e246726. [PMID: 38619838 PMCID: PMC11019396 DOI: 10.1001/jamanetworkopen.2024.6726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/17/2024] [Indexed: 04/16/2024] Open
Abstract
Importance The overall prevalence of mitral valve replacement (MVR) or MV repair at the time of cardiac surgery in the setting of isolated anterior mitral leaflet degenerative pathologic status in the US population is unknown. Objective To investigate the prevalence of MVR and MV repair using the Society of Thoracic Surgeons' Adult Cardiac Surgery Database. Design, Setting, and Participants In a cross-sectional study, all patients diagnosed with isolated anterior mitral leaflet degenerative regurgitation who underwent either surgical MVR or MV repair between July 1, 2011, and June 30, 2022, were identified. Linear regression analysis was used to assess trends over time. Main Outcomes and Measures Assessment of the trends in MV repair and MVR over time. Results A total of 16 259 patients (9624 [59.2%] men) were identified, and the median age was 68 (IQR, 58-74) years. A total of 7214 patients (44.4%) had MVR, and 9045 (55.6%) had MV repair. There was a declining trend of MV repair from 58.0% in 2011 to 51.6% in 2022 (P = .05). The MVR group was older (median [IQR] age, 70 [62-77] vs 67 [58-74] years; P < .001) and had more comorbidities. A total of 85.1% of all patients underwent concomitant procedures. In 81.7% of MVR cases, no attempt at MV repair was made. The median (IQR) annual hospital volume was lower with MVR vs MV repair (2.50 [1.50-5.00] vs 4.00 [2.00-7.00]; P < .001). Conventional surgical approaches were most common (91.5%) but with a declining trend (P < .001). Minimally invasive approaches were used in 13.1% (robotic, 4.6%), and with an inclining trend from 5.0% in 2011 to 12.0% in 2022 (P < .001). Annuloplasty was performed in 88.8% of MV repair cases. Its use as a sole mean of MV repair decreased from 48.0% in 2011 to 13.9% in 2022 (P < .001). Repair maneuvers in addition to annuloplasty were neochordae (overall 40.1%, increasing from 22.5% in 2011 to 62.3% in 2022; P < .001), leaflet resection (overall 10.2%, decreasing from 13.1% in 2011 to 7.9% in 2022, P = .002), edge-to-edge MV repair (overall 5.3%, decreasing from 6.9% in 2011 to 4.5% in 2022; P = 0.04), and chordal transfer (overall 2.4%, decreasing from 2.7% in 2011 to 0.7% in 2022; P = .004). Conclusions and Relevance In this cross-sectional study, MV repair was the preferred option for degenerative mitral valve disease but was only slightly more commonly performed than MVR for isolated anterior leaflet pathologic status. A large proportion of MVR was performed without an MV repair attempt, suggesting reluctance to repair this pathologic condition.
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Affiliation(s)
- Sherif Khairallah
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
- National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
- National Cancer Institute, Cairo University, Cairo, Egypt
| | | | - Robert Habib
- Society of Thoracic Surgeons Research Center, Chicago, Illinois
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Leonard Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Stephanie L. Mick
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
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Wagner CM, Fu W, Hawkins RB, Romano MA, Ailawadi G, Bolling SF. Alfieri versus conventional repair for bileaflet mitral valve prolapse. JTCVS OPEN 2023; 16:242-249. [PMID: 38204703 PMCID: PMC10775110 DOI: 10.1016/j.xjon.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/12/2023] [Accepted: 10/03/2023] [Indexed: 01/12/2024]
Abstract
Objective Mitral valve repair for bileaflet prolapse can be complex, involving multiple chords or resection. The Alfieri technique for bileaflet disease is simple but may be associated with mitral stenosis or recurrent mitral regurgitation. Outcomes of patients with bileaflet prolapse undergoing mitral valve repair using the Alfieri versus conventional chord/resection techniques were compared. Methods Adults undergoing mitral valve repair for bileaflet prolapse for degenerative disease from 2017 to 2023 were stratified by repair technique. Outcomes including operative mortality and echocardiogram data were compared. Time to event analysis was used to characterize freedom from recurrent mitral regurgitation (moderate or greater mitral regurgitation). Results Among 188 patients with bileaflet prolapse, 37% (70) were repaired with the Alfieri and the remaining patients were repaired with chords/resection. Compared with chords/resection, patients undergoing the Alfieri had shorter cardiopulmonary bypass and crossclamp times. Operative mortality (0% [0/70] vs 2% [2/118], P = .27) was similar between both techniques. The mean mitral gradient was low and similar for the Alfieri versus chords/resection (3 vs 3, P = .34). Development of recurrent mitral regurgitation at 2 years, incorporating the competing risk of death and mitral reintervention, was 4.3% (95% CI, 1.5%-9.3%) for the Alfieri technique and 5.8% (95% CI, 2.2%-11.8%) for chord/resection (P = .83). Conclusions Both the Alfieri and chord/resection techniques had low rates of recurrent mitral regurgitation at 2 years. The mitral valve gradient was low and similar regardless of technique; thus, those who received the Alfieri technique did not have an increased rate of mitral stenosis. The Alfieri may be an underused technique for bileaflet prolapse.
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Affiliation(s)
- Catherine M. Wagner
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
- National Clinician Scholar's Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Mich
| | - Whitney Fu
- Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Robert B. Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Matthew A. Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Steven F. Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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Khairallah S, Rahouma M, Dabsha A, Demetres M, Gaudino MF, Mick SL. Comparison of meta-analytical estimates of outcomes after Alfieri or neochordal repair in isolated anterior mitral prolapse. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2023; 63:6984718. [PMID: 36629477 DOI: 10.1093/ejcts/ezac587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 12/07/2022] [Accepted: 01/10/2023] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Repair of the isolated degenerative anterior mitral leaflet has been considered more challenging and associated with compromised durability compared with isolated posterior leaflet in major series. Implantation of neochordae or Alfieri edge-to-edge is the most employed repair technique for isolated anterior repair currently, but little data exist comparing their relative durability. We sought to investigate this issue with this meta-analysis. METHODS A literature search was performed (Ovid MEDLINE, Ovid Embase and The Cochrane Library). The primary outcome was the incidence rate (IR) of reoperation, the secondary outcomes were recurrent moderately severe/severe mitral regurgitation (MR), in-hospital/30-day reoperation and mortality and follow-up mortality. A random-effect model was used. Leave-one-out, subgroup analysis (Alfieri versus neochordae) and meta-regression were done. RESULTS Seventeen studies (including 1358 patients) were included. At a weighted mean follow-up of 5.56 ± 3.31 years, the IR for reoperation was 14.45 event per 1000 person-year and significantly lower in Alfieri than neochordae repair (9.40 vs 18.61, P = 0.04) on subgroup analysis. The IR of follow-up moderately severe/severe MR was 19.89 event per 1000 person-year and significantly lower in Alfieri than neochordae repair (10.68 and 28.63, P = 0.01). In a sensitivity analysis comparing homogenous studies, a significant difference in the recurrence of regurgitation in favour of the Alfieri approach remained. There were no differences in operative outcomes or survival. There were significant associations between increased incidence of late reoperation and New York Heart Association class III/IV and associated coronary artery bypass graft procedure for whole cohort. CONCLUSIONS Alfieri repair may be associated with a lower incidence of recurrent MR compared with neochordae-based repair in the setting of isolated degenerative anterior mitral pathology. This is the first such meta-analysis and further inquiry into this area is needed.
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Affiliation(s)
- Sherif Khairallah
- Cardiothoracic Surgery Department, Weill Cornell Medicine New York-Presbyterian Hospital (WCM), New York, NY, USA
| | - Mohamed Rahouma
- Cardiothoracic Surgery Department, Weill Cornell Medicine New York-Presbyterian Hospital (WCM), New York, NY, USA
| | - Anas Dabsha
- Cardiothoracic Surgery Department, Weill Cornell Medicine New York-Presbyterian Hospital (WCM), New York, NY, USA
| | - Michelle Demetres
- Scholarly Communications Librarian, Weill Cornell Medicine (WCM), Samuel J. Wood Library & C.V. Starr Biomedical Information Center, New York, NY, USA
| | - Mario Fl Gaudino
- Cardiothoracic Surgery Department, Weill Cornell Medicine New York-Presbyterian Hospital (WCM), New York, NY, USA
| | - Stephanie L Mick
- Cardiothoracic Surgery Department, Weill Cornell Medicine New York-Presbyterian Hospital (WCM), New York, NY, USA
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Lee H, Kim J, Jung JH, Yoo JS. Surgical edge-to-edge repair for tricuspid regurgitation: Impact of the concomitant annuloplasty. Int J Cardiol 2023; 372:85-90. [PMID: 36455700 DOI: 10.1016/j.ijcard.2022.11.055] [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: 07/04/2022] [Revised: 11/17/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Surgical edge-to-edge repair has been suggested for tricuspid regurgitation (TR) with complex tricuspid valve (TV) pathologies. Nevertheless, the impact of concomitant TAP has not been well established. This study aimed to compare the outcomes of tricuspid edge-to-edge repair according to the implementation of concomitant TAP. METHODS A total of 264 patients who underwent tricuspid edge-to-edge repair between January 2001 and December 2020 were enrolled in the study, and 23 patients who had undergone previous TV repair were excluded. The remaining 241 patients were categorized into two groups: TAP (n = 190) and non-TAP (n = 51). Inverse probability of treatment weighting (IPTW) was used to adjust the baseline differences between the two groups. RESULTS Early mortality and morbidity did not differ between the two groups. The mean follow-up duration was 111.5 ± 72.4 months. IPTW-adjusted survival analysis did not reveal a difference between the two groups in late significant tricuspid stenosis (trans-tricuspid pressure gradient ≥5 mmHg) and TV reoperations. However, freedom from overall mortality and late severe TR were significantly higher in the TAP group (p = 0.033 and 0.006, respectively). The sensitivity analysis, including propensity score matching, showed consistent results. CONCLUSION The long-term outcomes of surgical tricuspid edge-to-edge repair were better when performed with concomitant TAP.
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Affiliation(s)
- Heemoon Lee
- Department of Thoracic and Cardiovascular Surgery, Bucheon Sejong Hospital, Bucheon, Gyeonggi-do, Republic of Korea
| | - Jihoon Kim
- Department of Thoracic and Cardiovascular Surgery, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Ji-Hyun Jung
- Division of Cardiology, Department of Internal Medicine, Bucheon Sejong Hospital, Bucheon, Gyeonggi-do, Republic of Korea
| | - Jae Suk Yoo
- Department of Thoracic and Cardiovascular Surgery, Bucheon Sejong Hospital, Bucheon, Gyeonggi-do, Republic of Korea.
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Castaño M, Maiorano P, Castillo L, Laguna G, Martín-Gutiérrez E, Gualis Cardona J, Guevara A. Reparación mitral en prolapso de velo anterior: técnicas, indicaciones y resultados. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Eqbal A, Gupta S, Fam N, Ong G, Bisleri G. The impact of transcatheter edge-to-edge repair on mitral valve annular geometry. Curr Opin Cardiol 2022; 37:150-155. [PMID: 35058414 DOI: 10.1097/hco.0000000000000950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Mitral valve transcatheter edge-to-edge repair (TEER) is becoming increasingly common to treat severe mitral regurgitation. However, the lack of concomitant annuloplasty raises concerns regarding its durability. As a result, there is an emerging body of literature evaluating the impacts of TEER on mitral annular geometry. In this review, we summarize the most recent literature evaluating the impacts of TEER on annular geometry in the acute, intermediate and long-term. We also review the relationship between changes in annular geometry and clinical endpoints. RECENT FINDINGS Current evidence suggests that TEER acutely induces favourable changes in mitral annular size and shape, which may persist for at least up to 1 year. Few studies suggest that TEER-induced annular remodelling is associated with positive clinical outcomes. SUMMARY The current body of literature is sparse and limited to primarily small case series. Data from the surgical literature suggest that ringless edge-to-edge repair is associated with eventual failure. Unfortunately, few studies evaluate TEER-induced annular changes beyond the acute postprocedural phase. Future research needs to focus on and evaluate the significance of TEER-induced changes in annular dimensions in the long-term.
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Affiliation(s)
- Adam Eqbal
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton
| | - Saurabh Gupta
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton
| | - Neil Fam
- Structural Heart Program, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Géraldine Ong
- Structural Heart Program, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gianluigi Bisleri
- Structural Heart Program, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Abstract
PURPOSE OF REVIEW To provide a critical review of the application and outcomes of surgical edge-to-edge (E2E) or Alfieri repair for mitral valvulopathy. RECENT FINDINGS The E2E repair is a surgical technique to address mitral regurgitation, particularly suited when the responsible mechanism is bileaflet prolapse combined with enlarged annular area. It can also be used for a range of mitral valve pathologies. Surgically, the technique has been employed as a bailout for unsuccessful repair including residual mitral regurgitation because of systolic anterior motion (SAM). E2E repair should be accompanied by a ring annuloplasty for long-term repair durability. The simplicity of this approach makes it an ideal strategy during minimally-invasive mitral valve repair. It may also be performed via a transaortic approach at the time of aortic valve surgery to address less-than-severe mitral regurgitation or to address residual SAM following myectomy for hypertrophic obstructive cardiomyopathy. We review the surgical indication, potential complications including risk of mitral stenosis and the long-term outcomes of E2E repair. SUMMARY The E2E surgical repair is a simple and effective surgical strategy to address a wide range of mitral regurgitation. This is an important technique in the surgical armamentarium especially in cases of minimally-invasive mitral valve surgery.
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Lee H, Kim J, Oh SS, Yoo JS. Long-term Clinical and Hemodynamic Outcomes of Edge-to-Edge Repair for Tricuspid Regurgitation. Ann Thorac Surg 2020; 112:803-808. [PMID: 33157062 DOI: 10.1016/j.athoracsur.2020.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 09/07/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The edge-to-edge technique (Alfieri stitch) has been widely adopted in mitral valve but not tricuspid valve (TV) repair. We evaluated long-term clinical and hemodynamic outcomes of tricuspid edge-to-edge repair. METHODS We retrospectively reviewed 237 patients (mean age, 58.4 ± 13.9 years) who had undergone tricuspid edge-to-edge repair from January 2001 to March 2019 in our institution. Tricuspid annuloplasty was performed in 175 patients (73.8%) using ring (91 [38.4%]) or suture (84 [35.4%]) annuloplasty. Concomitant procedures were mitral valve replacement (133 [56.1%]), mitral valve repair (52 [21.9%]), aortic valve replacement (41 [17.3%]), and maze operation (138 [58.2%]). RESULTS Postoperative echocardiography revealed mild or less tricuspid regurgitation (TR) in 220 patients (92.8%). Early mortality (<30 days) occurred in 9 patients (3.8%), reoperation for bleeding in 16 (6.8%), and low cardiac output syndrome in 15 (6.4%). Freedom from all-cause mortality was 87.2% at 5 years and 80.6% at 10 years. Freedom from moderate or severe TR was 97.1% at 5 years and 84.9% at 10 years. Transtricuspid pressure gradient was 3.8 ± 4.2 mm Hg at discharge and 3.2 ± 5.6 mm Hg at the last follow-up (P = .60). Freedom from significant tricuspid stenosis (transtricuspid pressure gradient ≥5 mm Hg) was 96.4% and 88.4% at 5 and 10 years, respectively. There was 1 early TV reoperation for severe TR on postoperative day 3 (0.4%). Freedom from TV reoperation was 99.1% at 10 years. CONCLUSIONS Tricuspid edge-to-edge repair showed acceptable long-term clinical and hemodynamic results and is an effective and safe option in TV surgery.
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Affiliation(s)
- Heemoon Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Gyeonggi-do, Republic of Korea
| | - Jihoon Kim
- Department of Thoracic and Cardiovascular Surgery, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Sam Sae Oh
- Department of Thoracic and Cardiovascular Surgery, Kangbuk Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Suk Yoo
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Gyeonggi-do, Republic of Korea.
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Hirji SA, Guetter CR, Trager L, Yazdchi F, Landino S, Lee J, Anastasopulos A, Percy E, McGurk S, Pelletier MP, Aranki S, Shekar PS, Kaneko T. Sex-based differences in mitral valve Re-operation after mitral valve repair: Truth or myth? Am J Surg 2020; 220:1344-1350. [PMID: 32788080 DOI: 10.1016/j.amjsurg.2020.06.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 04/24/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Outcomes after mitral valve (MV) repair are known to be worse in women. Less is known about sex-based differences in MV repair durability. METHODS All adult patients undergoing MV repair from 2002 to 2016 were reviewed. Of 2463 cases, 947 (39%) were women. Re-operation risk was defined as any intervention for repair failure or MV disease progression. Median follow-up was 8.2 years. RESULTS Women were older with higher STS-risk scores and were more likely to have rheumatic disease (RHD). Operative mortality was clinically higher in women (2.7% vs 1.7%; P = 0.09). Although women had significantly higher 10-year re-operation risk (7% vs 4%), adjusted longitudinal analysis showed that this was associated with RHD in women (HR 4.04; P = 0.001). Female sex alone was not a significant predictor (P = 0.21). CONCLUSIONS Re-operation following MV repair was infrequent. Women had increased re-operation risk that was largely attributable to their worse preoperative profiles rather than female sex alone.
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Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Camila R Guetter
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lena Trager
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Farhang Yazdchi
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samantha Landino
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jiyae Lee
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexandra Anastasopulos
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward Percy
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Siobhan McGurk
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marc P Pelletier
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sary Aranki
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Prem S Shekar
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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