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Jenkins DP, Martinez G, Salaunkey K, Reddy SA, Pepke-Zaba J. Perioperative Management in Pulmonary Endarterectomy. Semin Respir Crit Care Med 2023; 44:851-865. [PMID: 37487525 DOI: 10.1055/s-0043-1770123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH), provided lesions are proximal enough in the pulmonary vasculature to be surgically accessible and the patient is well enough to benefit from the operation in the longer term. It is a major cardiothoracic operation, requiring specialized techniques and instruments developed over several decades to access and dissect out the intra-arterial fibrotic material. While in-hospital operative mortality is low (<5%), particularly in high-volume centers, careful perioperative management in the operating theater and intensive care is mandatory to balance ventricular performance, fluid balance, ventilation, and coagulation to avoid or treat complications. Reperfusion pulmonary edema, airway hemorrhage, and right ventricular failure are the most problematic complications, often requiring the use of extracorporeal membrane oxygenation to bridge to recovery. Successful PEA has been shown to improve both morbidity and mortality in large registries, with survival >70% at 10 years. For patients not suitable for PEA or with residual PH after PEA, balloon pulmonary angioplasty and/or PH medical therapy may prove beneficial. Here, we describe the indications for PEA, specific surgical and perioperative strategies, postoperative monitoring and management, and approaches for managing residual PH in the long term.
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Affiliation(s)
- David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Guillermo Martinez
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Kiran Salaunkey
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - S Ashwin Reddy
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
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Benzidia I, Robitaille C, Abualsaud A, McDonald L, Lesenko L, Morin JF, Langleben D, Kahn SR, Hirsch A. Safety and efficacy of direct oral anticoagulants in patients with chronic thromboembolic pulmonary hypertension. Thromb Res 2023; 229:139-145. [PMID: 37453256 DOI: 10.1016/j.thromres.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 06/24/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Chronic thromboembolic pulmonary hypertension (CTEPH) remains an underdiagnosed disease. Anticoagulation is essential in its therapy to prevent recurrent venous thromboembolism (VTE). According to some international guidelines, vitamin K antagonists (VKA) remain the gold standard. Nevertheless, direct oral anticoagulants (DOAC) are widely used, partly because of numerous advantages. The objective of this study was to determine if DOAC is an effective and safe alternative to VKA in CTEPH patients. MATERIALS AND METHODS A retrospective observational study was conducted between 2001 and 2021 in a CTEPH Clinic of a tertiary care hospital. We recorded demographic characteristics, anticoagulant therapies and pulmonary hypertension treatments received. Safety outcomes were bleeding events and deaths while efficacy outcomes were recurrent VTE events. RESULTS Among the study population (N = 205), the distribution of anticoagulant used transitioned from majority on VKA to majority on DOAC. In 2020, 23 (19 %) were on VKA and 97 (78 %) on DOAC. Among 11 VTE events occurring during follow-up, 7 were in the VKA group (1.10 %/person-year) and 1 in the DOAC group (0.32 %/person-year). Rates of VTE recurrence were not significantly different in those treated with DOAC compared to VKA (P = 0.21). Total bleeding rate on VKA (2.52 %/person-year) and DOAC (2.52 %/person-year) were the same (P = 1.00). Among 27 patients who died, no deaths occurred as a consequence of bleeding or VTE events. CONCLUSION Bleeding and VTE events were not higher in CTEPH patients receiving DOAC compared to VKA which adds confidence to considering DOAC as an effective and safe alternative for long term anticoagulation in CTEPH patients.
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Affiliation(s)
- Ilham Benzidia
- Division of Internal Medicine and Division of Clinical Epidemiology, Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada; Center of Excellence in Thrombosis and Anticoagulation Care (CETAC), Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Chantal Robitaille
- Division of Pulmonary Diseases, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Ali Abualsaud
- Center for Pulmonary Vascular Disease, Division of Cardiology, Azrieli Heart Center, and Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Laura McDonald
- Division of Internal Medicine and Division of Clinical Epidemiology, Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada
| | - Lyda Lesenko
- Center for Pulmonary Vascular Disease, Division of Cardiology, Azrieli Heart Center, and Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Jean-François Morin
- Division of Cardiac Surgery, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - David Langleben
- Center for Pulmonary Vascular Disease, Division of Cardiology, Azrieli Heart Center, and Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Susan R Kahn
- Division of Internal Medicine and Division of Clinical Epidemiology, Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada; Center of Excellence in Thrombosis and Anticoagulation Care (CETAC), Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Andrew Hirsch
- Division of Pulmonary Diseases, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada; Center of Excellence in Thrombosis and Anticoagulation Care (CETAC), Jewish General Hospital, McGill University, Montreal, QC, Canada.
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Jujo Sanada T, Manz XD, Symersky P, Pan X, Yoshida K, Aman J, Bogaard HJ. Riociguat inhibits ultra-large VWF string formation on pulmonary artery endothelial cells from chronic thromboembolic pulmonary hypertension patients. Pulm Circ 2022; 12:e12146. [PMID: 36568694 PMCID: PMC9768460 DOI: 10.1002/pul2.12146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/03/2022] [Indexed: 12/27/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by elevated pulmonary arterial pressure and organized thrombi within pulmonary arteries. Riociguat is a soluble guanylate cyclase stimulator and is approved for patients with inoperable CTEPH or residual pulmonary hypertension after pulmonary endarterectomy (PEA). Previous work suggested that riociguat treatment is associated with an increased risk of bleeding, although the mechanism is unclear. The aim of this study is to assess how riociguat affects primary hemostasis by studying its effect on the interaction between platelets and endothelial cells derived from CTEPH patients. Pulmonary artery endothelial cells (PAECs) were isolated from thrombus-free regions of PEA material. Purified PAECs were cultured in flow chambers and were stimulated with 0.1 and 1 µM riociguat for 24 h before flow experiments. After stimulation with histamine, PAECs were exposed to platelets under shear stress. Platelet adhesion and expression of von Willebrand Factor (VWF) were evaluated to assess the role of riociguat in hemostasis. Under dynamic conditions, 0.1 and 1.0 µM of riociguat suppressed platelet adhesion on the surface of PAECs. Although riociguat did not affect intracellular expression and secretion of VWF, PAECs stimulated with riociguat produced fewer VWF strings than unstimulated PAECs. Flow cytometry suggested that decreased VWF string formation upon riociguat treatment may be associated with suppressed cell surface expression of P-selectin, a protein that stabilizes VWF anchoring on the endothelial surface. In conclusion, Riociguat inhibits VWF string elongation and platelet adhesion on the surface of CTEPH-PAECs, possibly by reduced P-selectin cell surface expression.
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Affiliation(s)
- Takayuki Jujo Sanada
- Department of Pulmonary Medicine, Amsterdam UMCVU University Medical CenterAmsterdamThe Netherlands,Department of Respirology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Xue D. Manz
- Department of Pulmonary Medicine, Amsterdam UMCVU University Medical CenterAmsterdamThe Netherlands
| | - Petr Symersky
- Department of Cardio‐Thoracic SurgeryAmsterdam UMC, VU University Medical CenterAmsterdamThe Netherlands,Department of Cardio‐thoracic SurgeryOLVG HospitalAmsterdamThe Netherlands
| | - Xiaoke Pan
- Department of Pulmonary Medicine, Amsterdam UMCVU University Medical CenterAmsterdamThe Netherlands
| | - Keimei Yoshida
- Department of Pulmonary Medicine, Amsterdam UMCVU University Medical CenterAmsterdamThe Netherlands,Kyushu University Faculty of Medicine Graduate School of Medical Sciences School of MedicineFukuokaJapan
| | - Jurjan Aman
- Department of Pulmonary Medicine, Amsterdam UMCVU University Medical CenterAmsterdamThe Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam UMCVU University Medical CenterAmsterdamThe Netherlands
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Zhu YJ, Zhou YP, Wei YP, Xu XQ, Yan XX, Liu C, Zhu XJ, Liu ZY, Sun K, Hua L, Jiang X, Jing ZC. Association Between Anticoagulation Outcomes and Venous Thromboembolism History in Chronic Thromboembolic Pulmonary Hypertension. Front Cardiovasc Med 2021; 8:628284. [PMID: 34095244 PMCID: PMC8175786 DOI: 10.3389/fcvm.2021.628284] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 04/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The association between anticoagulation outcomes and prior history of venous thromboembolism (VTE) in chronic thromboembolic pulmonary hypertension (CTEPH) has not been established. This study aimed to compare the efficacy and safety of anticoagulation treatment in CTEPH patients with and without prior history of VTE. Methods: A total of 333 CTEPH patients prescribed anticoagulants were retrospectively included from May 2013 to April 2019. The clinical characteristics were collected at their first admission. Incidental recurrent VTE and clinically relevant bleeding were recorded during follow-up. The Cox proportional regression models were used to identify potential factors associated with recurrent VTE and clinically relevant bleeding. Results: Seventy patients (21%) without a prior history of VTE did not experience recurrent VTE during anticoagulation. Compared to CTEPH patients without a prior history of VTE, those with a prior history of VTE had an increased risk of recurrent VTE [2.27/100 person-year vs. 0/100 person-year; hazard ratio (HR), 8.92; 95% confidence interval (CI), 1.18–1142.00; P = 0.029] but a similar risk of clinically relevant bleeding (3.90/100 person-year vs. 4.59/100 person-year; HR, 0.83; 95% CI, 0.38–1.78; P = 0.623). Multivariate Cox analyses suggested that a prior history of VTE and interruption of anticoagulation treatments were significantly associated with an increased risk of recurrent VTE, while anemia and glucocorticoid use were significantly associated with a higher risk of clinically relevant bleeding. Conclusions: This study is the first to reveal that a prior history of VTE significantly increases the risk of recurrent VTE in CTEPH patients during anticoagulation treatment. This finding should be further evaluated in prospective studies.
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Affiliation(s)
- Yong-Jian Zhu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Ping Zhou
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yun-Peng Wei
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Qi Xu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin-Xin Yan
- Department of Pulmonary Vascular Disease and Thrombosis Medicine, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, FuWai Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chao Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Jie Zhu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zi-Yi Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kai Sun
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Hua
- Department of Pulmonary Vascular Disease and Thrombosis Medicine, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, FuWai Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Jiang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Cheng Jing
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Tian Z, Jiang X, Jing ZC. How should a physician approach the pharmacological management of chronic thromboembolic pulmonary hypertension? Expert Opin Pharmacother 2020; 22:557-563. [PMID: 33016151 DOI: 10.1080/14656566.2020.1828349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by the presence of organized thromboembolic material and proliferative fibrous intima occluding varying degrees of the pulmonary arteries, and is also accompanied by small vessel vasculopathy in occluded and non-occluded pulmonary vasculature. The similarity in hemodynamics and pathophysiology between CTEPH and group 1 pulmonary arterial hypertension provides the rationale for clinical use of pulmonary arterial hypertension (PAH)-specific therapy. AREAS COVERED The authors present the current knowledge concerning the updated therapeutic strategies in CTEPH, and try to illustrate the established and uncertain role of PAH-specific therapy and anticoagulation therapy. The real-world observational registries and landmark randomized controlled trials of PAH-specific drugs in CTEPH are emphasized in the manuscript. EXPERT OPINION Despite surgical and interventional therapies, which could provide effective and potential curable treatments, medical therapies are still the substantial and irreplaceable option for patients with CTEPH. More and more PAH-specific drugs have demonstrated favorable efficacy and safety profiles in patients with CTEPH. Additionally, anticoagulation therapy is also a substantial medical treatment in all CTEPH patients without contradiction. However, the benefit-to-risk balance in life-long anticoagulation and whether more individualized anticoagulation strategies are needed warrants further investigation.
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Affiliation(s)
- Zhuang Tian
- Department of Cardiology, Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy Medical Sciences, Beijing, China
| | - Xin Jiang
- Department of Cardiology, Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy Medical Sciences, Beijing, China
| | - Zhi-Cheng Jing
- Head of Cardiology Department, Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy Medical Sciences, Beijing, China
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Bunclark K, Newnham M, Chiu YD, Ruggiero A, Villar SS, Cannon JE, Coghlan G, Corris PA, Howard L, Jenkins D, Johnson M, Kiely DG, Ng C, Screaton N, Sheares K, Taboada D, Tsui S, Wort SJ, Pepke-Zaba J, Toshner M. A multicenter study of anticoagulation in operable chronic thromboembolic pulmonary hypertension. J Thromb Haemost 2020; 18:114-122. [PMID: 31557382 DOI: 10.1111/jth.14649] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 09/23/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is an uncommon complication of acute pulmonary emboli necessitating lifelong anticoagulation. Despite this, few data exist on the safety and efficacy of vitamin K antagonists (VKAs) in CTEPH and none for direct oral anticoagulants (DOACs). OBJECTIVES To evaluate outcomes and complication rates in CTEPH following pulmonary endarterectomy (PEA) for individuals receiving VKAs or DOACs. METHODS Consecutive CTEPH patients undergoing PEA between 2007 and 2018 were included in a retrospective analysis. Postoperative outcomes, recurrent venous thromboembolism (VTE), and bleeding events were obtained from patient medical records. RESULTS Seven hundred ninety-four individuals were treated with VKAs and 206 with DOACs following PEA. Mean observation period was 612 (standard deviation: 702) days. Significant improvements in hemodynamics and functional status were observed in both groups following PEA (P < .001). Major bleeding events were equivalent (P = 1) in those treated with VKAs (0.67%/person-year) and DOACs (0.68%/person-year). The VTE recurrence was proportionately higher (P = .008) with DOACs (4.62%/person-year) than VKAs (0.76%/person-year), although survival did not differ. CONCLUSIONS Post-PEA functional and hemodynamic outcomes appear unaffected by anticoagulant choice. Bleeding events were similar, but recurrent VTE rates significantly higher in those receiving DOACs. Our study provides a strong rationale for prospective registry data and/or studies to evaluate the safety of DOACs in CTEPH.
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Affiliation(s)
| | - Michael Newnham
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Yi-Da Chiu
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
- MRC BSU, University of Cambridge, Cambridge, UK
| | | | - Sofia S Villar
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
- MRC BSU, University of Cambridge, Cambridge, UK
| | - John E Cannon
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | - Paul A Corris
- Institute of Cellular Medicine, Newcastle upon Tyne, UK
| | - Luke Howard
- National Heart and Lung Institute, London, UK
| | - David Jenkins
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | | | - Choo Ng
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | - Karen Sheares
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | - Steven Tsui
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | | | - Mark Toshner
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
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Ikeda N. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. Cardiovasc Interv Ther 2019; 35:130-141. [DOI: 10.1007/s12928-019-00637-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/19/2019] [Indexed: 12/16/2022]
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Kratzert WB, Boyd EK, Saggar R, Channick R. Critical Care of Patients After Pulmonary Thromboendarterectomy. J Cardiothorac Vasc Anesth 2019; 33:3110-3126. [PMID: 30948200 DOI: 10.1053/j.jvca.2019.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/19/2019] [Accepted: 03/01/2019] [Indexed: 12/16/2022]
Abstract
Pulmonary thromboendarterectomy (PTE) remains the only curative surgery for patients with chronic thromboembolic pulmonary hypertension (CTEPH). Postoperative intensive care unit care challenges providers with unique disease physiology, operative sequelae, and the potential for detrimental complications. Central concerns in patients with CTEPH immediately after PTE relate to neurologic, pulmonary, hemodynamic, and hematologic aspects. Institutional experience in critical care for the CTEPH population, a multidisciplinary team approach, patient risk assessment, and integration of current concepts in critical care determine outcomes after PTE surgery. In this review, the authors will focus on specific aspects unique to this population, with integration of current available evidence and future directions. The goal of this review is to provide the cardiac anesthesiologist and intensivist with a comprehensive understanding of postoperative physiology, potential complications, and contemporary intensive care unit management immediately after pulmonary endarterectomy.
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Affiliation(s)
- Wolf B Kratzert
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Eva K Boyd
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Rajan Saggar
- Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Richard Channick
- Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
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