Publications by authors named "Gosta B Pettersson"

181 Publications

Pursuing Excellence: Optimizing Lifelong Care for the Adult Congenital Heart Patient.

Ann Thorac Surg 2021 May 31. Epub 2021 May 31.

Lerner College of Medicine, Department of Thoracic & Cardiovascular Surgery, Cleveland Clinic 9500 Euclid Ave, JJ4-307A, 44195, Cleveland, OH. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2021.05.014DOI Listing
May 2021

Evolution of Recipient Characteristics Over 3 Decades and Impact on Survival After Lung Transplantation.

Transplantation 2021 Mar 18. Epub 2021 Mar 18.

1Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute 2 Department of Quantitative Health Sciences 3Departmet of Pulmonary Medicine, Respiratory Institute 4Department of Inflammation & Immunity, Lerner Research Institute.

Background: Lung transplantation (LTx) is a definitive treatment for end-stage lung disease. Herein, we reviewed our center experience over three decades to examine the evolution of recipient characteristics and contemporary predictors of survival for LTx.

Methods: We retrospectively reviewed the data of LTx procedures performed at our institution from 1/1990 to 1/2019 (n=1819). The cohort is divided into three eras; I: 1990-1998 (n=152), II: 1999-2008 (n=521), III: 2009-2018 (n=1146). Uni- and multivariate analyses of survival in era III were performed.

Results: Pulmonary fibrosis has become the leading indication for LTx (13% in Era I, 57% in Era III). Median recipient age increased (Era I: 46 years - Era III: 61 years) as well as intraoperative mechanical circulatory support (Era I: 0% - Era III: 6%). Higher lung allocation score (LAS) was associated with primary graft dysfunction (PGD) (p<0.0001), postoperative ECMO (p<0.0001), and in-hospital mortality (p=0.002). In Era III, hypoalbuminemia, thrombocytopenia, and high PGD grade were multivariate predictors of early mortality. The 5-year survival in Era II (55%) and III (55%) were superior to Era I (40%, p<0.001). Risk factors for late mortality in era III included recipient age, chronic allograft dysfunction, renal dysfunction, high MELD score, and single LTx.

Conclusions: In this longitudinal single-center study, recipient characteristics have evolved to include sicker patients with greater complexity of procedures and risk for postoperative complications but without significant impact on hospital mortality or long-term survival. With advancing surgical techniques and perioperative management, there is room for further progress in the field.Supplemental Visual Abstract; http://links.lww.com/TP/C191.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TP.0000000000003756DOI Listing
March 2021

Predictors of permanent pacemaker requirement after cardiac surgery for infective endocarditis.

Eur Heart J Acute Cardiovasc Care 2021 May;10(3):329-334

Department of Cardiovascular Medicine, Cleveland Clinic, USA.

Background: Infectious endocarditis is often complicated by conduction abnormalities at the time of presentation. Cardiac surgery is the treatment of choice for many infectious endocarditis patients, but carries an additional risk of persistent postoperative conduction abnormality. We sought to define the incidence and clinical predictors of significant postoperative conduction abnormalities necessitating permanent pacemaker implantation after cardiac surgery for infectious endocarditis.

Methods: All consecutive patients with infectious endocarditis who were surgically treated at Cleveland Clinic from 2007 to 2013 were identified using the Cleveland Clinic Infective Endocarditis Registry and the Cardiovascular Information Registry. Patients with a pre-existing cardiac implantable electronic device were excluded. The primary outcome was the need for permanent pacemaker placement postoperatively for atrioventricular block. Regression analysis was performed to identify risk factors for permanent pacemaker requirement.

Results: Among 444 infectious endocarditis patients who underwent cardiac surgery for infectious endocarditis, 57 (13%) required postoperative permanent pacemaker for atrioventricular block. Multivariable analysis identified that prolongation in preoperative PR and QRS intervals, Staphylococcus aureus as the infectious endocarditis organism, the presence of intracardiac abscess, tricuspid valve involvement, and prior valvular surgery independently predicted postoperative permanent pacemaker placement. The developed model exhibited excellent predictive ability (c-statistic 0.88) and calibration.

Conclusion: Infectious endocarditis cardiac surgery patients often require a postoperative permanent pacemaker. Preoperative conduction abnormality, S. aureus infection, abscess, tricuspid valve involvement, and prior valvular surgery are strong predictors of postoperative permanent pacemaker placement.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2048872619848661DOI Listing
May 2021

Invasive Aortic Valve Endocarditis: Clinical and Tissue Findings from a Prospective Investigation.

Ann Thorac Surg 2021 Apr 8. Epub 2021 Apr 8.

Department of Thoracic and Cardiovascular Surgery, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Advanced aortic valve infective endocarditis (IE) with progression and destruction beyond the valve cusps-invasive IE-is incompletely characterized. We aimed to further characterize invasive disease extent, location, and stage and correlate macroscopic operative findings with microscopic disease patterns and progression.

Methods: Forty-three patients with invasive aortic valve IE were prospectively enrolled from 8/2017 to 7/2018. Twenty-three (53%) had prosthetic valve, 2 (5%) allograft, and 18 (42%) native aortic valve IE. Surgical findings and intraoperative photography were analyzed for invasion location, extent, and stage. Surgical samples were formalin-fixed and analyzed histologically. Time course of disease and management was evaluated.

Results: Pathogens included Staphylococcus aureus in 17 (40%). Invasion predominantly affected the non-left commissure (76%) and was circumferential in 15 (35%; 14 were prosthetic valves). Extra-aortic cellulitis was present in 29 (67%), abscess in 13 (30%), abscess cavity in 29 (67%), and pseudoaneurysm in 8 (19%); 7 (16%) had fistulae. Histopathology revealed acute inflammation, abscess formation, and lysis of connective tissue, but not myocardium or elastic tissue. Median time from onset of symptoms to antibiotics was 5 days, invasion confirmation 15 days, and surgery 37 days. S. aureus cases had a 21-day shorter time course than non-S. aureus cases. Eight patients developed new/worsening heart block.

Conclusions: Advanced invasive aortic valve IE demonstrates consistent gross patterns and stages correlating with histopathologic findings. Invasion results from a confluence of factors, pathogen, time, host immune response and other and primarily affects the fibrous skeleton of the heart and expands to low-pressure regions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2021.03.072DOI Listing
April 2021

Role of Cardiac CT in Infective Endocarditis: Current Evidence, Opportunities, and Challenges.

Radiol Cardiothorac Imaging 2021 Feb 18;3(1):e200378. Epub 2021 Feb 18.

Section of Cardiovascular Imaging, Imaging Institute (M.B.S., T.K.M.W., P.C., M.A.B.), Section of Cardiovascular Imaging, Heart and Vascular Institute (T.K.M.W., P.C., M.A.B.), and Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute (S.U., G.B.P.), Cleveland Clinic, 9500 Euclid Ave, J1-4, Cleveland, OH 44915; Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands (A.R.W., R.P.J.B.); Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands (A.R.W.); and Department of Cardiology, Haga Hospital, The Hague, the Netherlands (A.R.W.).

Infective endocarditis (IE) can present with variable clinical and imaging findings and is associated with high morbidity and mortality. Substantial improvement of CT technology, most notably improved temporal and spatial resolution, has resulted in increased use of this modality in the evaluation of IE. The aim of this article is to review the potential role of cardiac CT in evaluating IE. Supplemental material is available for this article. © RSNA, 2021.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1148/ryct.2021200378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7977690PMC
February 2021

Modern practice and outcomes of reoperative cardiac surgery.

J Thorac Cardiovasc Surg 2021 Jan 23. Epub 2021 Jan 23.

Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.

Objectives: To evaluate recent practice and outcomes of reoperative cardiac surgery via re-sternotomy. Use of early versus late institution of cardiopulmonary bypass (CPB) before sternal re-entry was of particular interest.

Methods: From January 2008 to July 2017, 7640 patients underwent reoperative cardiac surgery at Cleveland Clinic. The study group consisted of 6627 who had a re-sternotomy and preoperative computed tomography scans; 755 and 5872 were in the early and late institution of CPB groups, respectively. Patients were stratified into high (n = 563) or low (n = 6064) anatomic risk of re-entry on the basis of computed tomography criteria. Weighted propensity-balanced operative mortality and morbidity were compared with surgeon as a random effect.

Results: Reoperative procedures most commonly incorporated aortic valve replacement (n = 3611) and coronary artery bypass grafting (n = 2029), but also aortic root (n = 1061) and arch procedures (n = 527). Unadjusted operative mortality was 3.5% (235/6627), and major sternal re-entry and mediastinal dissection injuries were uncommon (2.8%). In the propensity-weighted analysis, similar mortality (3.1% vs 4.5%; P = .6) and major morbidity, including stroke (1.8% vs 3.2%) and dialysis (0 vs 2.6%), were noted in the high anatomic risk cohort between early and late CPB groups. Similar trends were observed in the low anatomic risk cohort (mortality 3.5% vs 2.1%; P = .2).

Conclusions: Reoperative cardiac surgery is associated with low operative morbidity and mortality at an experienced center. Early and late CPB strategies have comparable outcomes in the context of an image-guided, team-based strategy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jtcvs.2021.01.028DOI Listing
January 2021

Aortic allograft for endocarditis of the intervalvular fibrosa.

Ann Thorac Surg 2021 Feb 20. Epub 2021 Feb 20.

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk J4-1, Cleveland, OH 44195.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2020.11.085DOI Listing
February 2021

Patient characteristics and surgical variables associated with intraoperative reduced right ventricular function.

J Thorac Cardiovasc Surg 2020 Dec 1. Epub 2020 Dec 1.

Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of Outcomes Research, Anesthesiology Institute, Cleveland, Ohio. Electronic address:

Objective: Perioperative right ventricular function is a significant predictor of patient outcomes after cardiac surgery. This prospective study aimed to identify perioperative factors associated with reduced intraoperative right ventricular function.

Methods: Right ventricular function was assessed at the beginning and end of surgery by standardized transesophageal echocardiographic measurements, including tricuspid annular plane systolic excursion, peak systolic longitudinal right ventricular strain, and fractional area change, in 109 adult patients undergoing cardiac surgery at Cleveland Clinic. Associations between right ventricular function and 33 patient characteristics and perioperative factors were analyzed by random forest machine learning. The relative importance of each variable in predicting right ventricular function at the end of surgery was determined.

Results: Longer aortic clamp duration and lower baseline right ventricular function were highly important variables for predicting worse right ventricular function measured by tricuspid annular plane systolic excursion, right ventricular strain, and fractional area change at the end of surgery. For example, right ventricular function after longer aortic clamp times of 100-120 minutes was worse (median [Q1, Q3] tricuspid annular plane systolic excursion 1.0 [0.9, 1.1] cm) compared with right ventricular function after shorter aortic clamp times of 50 to 70 minutes (tricuspid annular plane systolic excursion 1.5 [1.3, 1.7]; P = .001). Right ventricular strain at the end of surgery was reduced in patients with worse baseline right ventricular function compared with those with higher baseline right ventricular function (end of surgery right ventricular strain in lowest quartile -13.7 [-16.6, -12.4]% vs highest quartile -17.7 [-18.6, -15.3]% of baseline right ventricular function; P = .043).

Conclusions: Intraoperative decline in right ventricular function is associated with longer aortic clamp time and worse baseline right ventricular function. Efforts to optimize these factors, including better myocardial protection strategies, may improve perioperative right ventricular function.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jtcvs.2020.11.075DOI Listing
December 2020

Cardiogenic Shock From an Acute Rupture of an Infectious Saphenous Vein Graft Aneurysm.

Ann Thorac Surg 2021 Jun 5;111(6):e419-e420. Epub 2021 Jan 5.

Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Untreated infectious aneurysms of native coronary artery and aortocoronary bypass grafts are associated with high mortality. Early diagnosis proves difficult given nonspecific presenting symptoms; however, once recognized, early intervention is essential to mitigate complications such as myocardial ischemia or pericardial tamponade. In this case report, we describe the successful surgical management of a patient who presented 2 months after diagnosis of Staphylococcus aureus bacteremia with cardiogenic shock from rupture of an infected saphenous vein graft aneurysm resulting in pericardial tamponade.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2020.09.072DOI Listing
June 2021

Serious Gastrointestinal Complications After Cardiac Surgery and Associated Mortality.

Ann Thorac Surg 2020 Nov 18. Epub 2020 Nov 18.

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.

Background: Severe gastrointestinal (GI) complications (GICs) after cardiac surgery are associated with poor outcomes. Herein, we characterize the severe forms of GICs and associated risk factors of mortality.

Methods: We retrospectively analyzed the clinically significant postoperative GICs after cardiac surgical procedures performed at our institution from January 2010 to April 2017. Multivariable analysis was used to identify predictors for in-hospital mortality.

Results: Of 29,909 cardiac surgical procedures, GICs occurred in 1037 patients (3.5% incidence), with overall in-hospital mortality of 14% compared with 1.6% in those without GICs. GICs were encountered in older patients with multiple comorbidities who underwent complex prolonged procedures. The most lethal GICs were mesenteric ischemia (n = 104), hepatopancreatobiliary (HPB) dysfunction (n = 139), and GI bleeding (n = 259), with mortality rates of 45%, 27%, and 17%, respectively. In the mesenteric ischemia subset, coronary artery disease (odds ratio [OR], 4.57; P = .002], coronary bypass grafting (OR, 6.50; P = .005), reoperation for bleeding/tamponade (OR, 12.07; P = .01), and vasopressin use (OR, 11.27; P < .001) were predictors of in-hospital mortality. In the HPB complications subset, hepatic complications occurred in 101 patients (73%), pancreatitis in 38 (27%), and biliary disease in 31 (22%). GI bleeding occurred in 20 patients (31%) with HPB dysfunction. In the GI bleeding subset, HPB disease (OR, 10.99; P < .001) and bivalirudin therapy (OR, 12.84; P = .01) were predictors for in-hospital mortality.

Conclusions: Although relatively uncommon, severe forms of GICs are associated with high mortality. Early recognition and aggressive treatment are mandatory to improve outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2020.09.034DOI Listing
November 2020

Outcomes of mitral valve re-replacement for bioprosthetic structural valve deterioration.

J Thorac Cardiovasc Surg 2020 Aug 25. Epub 2020 Aug 25.

Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Objectives: Reoperation for structural valve deterioration (SVD) of bioprosthetic mitral valves carries a presumed high operative risk, and transcatheter mitral valve-in-valve implantation has emerged as an alternative. However, surgical risk and long-term outcome following mitral valve re-replacement in these patients remain ill-defined. Hence, we sought to evaluate outcomes and long-term survival following surgical mitral valve re-replacement and to identify risk factors for mortality.

Methods: From January 1990 to January 2017, 525 patients underwent surgical mitral valve re-replacement at Cleveland Clinic for bioprosthetic SVD: 133 (25%) isolated operations and 392 (75%) with concomitant procedures. Surgical complications and modes of death were compiled, long-term mortality assessed, and risk factors identified using a multivariable nonproportional hazards model and random forest analysis.

Results: SVD was characterized by bioprosthetic regurgitation in 81% (425 out of 525) and stenosis in 44% (231 out of 525). One in-hospital death occurred after isolated valve re-replacement (0.75%) and 28 deaths occurred (7.1%; P = .003) after nonisolated re-replacement, 19 (68%) of which were from coagulopathy, vasoplegia, and multisystem organ failure. In the nonisolated group, incremental risk factors for time-related death after re-replacement included New York Heart Association functional class IV symptoms, concomitant coronary artery bypass grafting, prolonged cardiopulmonary bypass time, and transfusions.

Conclusions: Mitral valve re-replacement for bioprosthetic SVD was associated with low surgical risk and excellent long-term survival. Isolated mitral valve re-replacement for bioprosthetic SVD had near-zero surgical risk. Excessive cardiopulmonary bypass duration and multiple transfusions correlated with increased early mortality in nonisolated procedures, as did preoperative severe heart failure. Optimal surgical plan and timing of surgery are keys to success.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jtcvs.2020.08.067DOI Listing
August 2020

Durability and Performance of 2298 Trifecta Aortic Valve Prostheses: A Propensity-Matched Analysis.

Ann Thorac Surg 2021 04 1;111(4):1198-1205. Epub 2020 Oct 1.

Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Reports of early failure of the Trifecta externally wrapped, bovine pericardial aortic valve prosthesis (Abbott Laboratories, Abbott Park, IL) raise concerns about its durability. This study evaluated the hemodynamic performance and explant of Trifecta valves compared with the PERIMOUNT bovine pericardial prosthesis (Edwards Lifesciences, Irvine, CA).

Methods: From October 2007 to July 2017, 2305 patients received a Trifecta bioprosthesis during aortic valve replacement at Cleveland Clinic. Trends in postoperative valve hemodynamics were assessed from 4971 transthoracic echocardiograms and valve explants by systemic follow-up. To compare outcomes, 2298 patients receiving a Trifecta valve were 1:1 propensity matched from 17,281 patients receiving a PERIMOUNT bioprosthesis.

Results: Mean age at implant was 69 years in both matched groups. Compared with PERIMOUNT valves, early transvalvular mean gradient of Trifecta valves was lower (11 vs 15 mm Hg at 1 year, P < .001); however, its longitudinal rate of rise was greater (P < .001), resulting in 5-year mean gradients of 17 vs 16 mm Hg, and more patients experienced severe aortic regurgitation (2.4% vs 0.81%; P < .001). At 5 years, 35 Trifecta valves had been explanted vs 14 PERIMOUNT valves; freedom from explant at 1, 3, and 5 years was 98.9%, 98.0%, and 95.9%, respectively, for the Trifecta group vs 99.3%, 99.0%, and 98.7% for the PERIMOUNT group (P < .001).

Conclusions: Compared with an older-generation internally mounted bovine pericardial valve, the Trifecta externally wrapped bioprosthesis exhibits superior early hemodynamic performance, but has a rapid increase in transvalvular gradient and more aortic regurgitation, with lower freedom from explant at 5 years. These findings raise concern regarding long-term Trifecta durability despite favorable early hemodynamics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2020.07.040DOI Listing
April 2021

Performance and Durability of Cryopreserved Allograft Aortic Valve Replacements.

Ann Thorac Surg 2021 Jun 25;111(6):1893-1900. Epub 2020 Sep 25.

Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: The value of allografts for aortic root replacement is controversial, with recent concern about limited durability. Currently, we prefer allografts for invasive infective endocarditis. Purposes of this study were to assess allograft performance and durability in our cumulative experience with aortic allografts.

Methods: From January 1987 to January 2017, 2042 adults received 2110 aortic allograft root replacements at our institution: 986 (47%) for infective endocarditis (669 [68%] for prosthetic valve endocarditis) and 1124 (53%) for other indications. Mean recipient age was 54 ± 15 years, and mean allograft donor age was 35 ± 13 years. Follow-up was 85% complete and comprised 17,253 patient-years of data. Longitudinal allograft performance was extracted from 6339 available echocardiographic studies. Durability was assessed by explant for allograft structural failure.

Results: Allograft mean gradient at hospital discharge was 6 mm Hg and 9, 13, and 15 mm Hg at 5, 10, and 15 years post-implant, respectively. Severe aortic regurgitation was 0% at hospital discharge, but 14%, 25%, and 35% at 5, 10, and 15 years, respectively. A total of 405 allografts were explanted for structural failure, actuarially 2%, 14%, 34%, and 51% at 5, 10, 15, and 20 years, respectively. Risk factors for structural failure were younger recipient age, larger body surface area, hypertension, and thoracic aorta disease; donor factors were older age and larger allograft size. Implant for infective endocarditis was not associated with accelerated structural failure.

Conclusions: This study affirms allografts' long-term acceptable hemodynamic performance and durability. Concern about structural failure should not limit allograft use. Recipient hypertension, allograft size, and donor age are modifiable risk factors.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2020.07.033DOI Listing
June 2021

Relationships between mitral annular calcification and cardiovascular events: A meta-analysis.

Echocardiography 2020 11 19;37(11):1723-1731. Epub 2020 Sep 19.

Section of Cardiovascular Imaging, Heart and Vascular Institute Cleveland Clinic, Cleveland, OH, USA.

Background: Mitral annular calcification (MAC) is prevalent in the aging population, with recent renewed interest regarding its associations with cardiovascular risk factors, outcomes, and influence on valvular heart disease and interventions. This meta-analysis aimed to report the relationships between MAC and cardiovascular mortality and morbidity events.

Methods: Relevant studies were searched from PubMed, Cochrane, and Embase databases until November 30, 2019. Associations between MAC as a binary variable with death and cardiovascular events were pooled using random-effects models. The main outcomes of interest were all-cause and cardiovascular mortality, myocardial infarction, stroke, heart failure, atrial fibrillation, and procedural outcomes.

Results: Among 799 article abstracts and 122 full-text articles screened, 26 (16 prospective and 10 retrospective) studies totaling 35 070 subjects were analyzed. MAC was associated with higher all-cause death, hazard ratio (95% confidence interval) 1.76 (1.43-2.22), and cardiovascular mortality 1.85 (1.45-23.5). It also positively correlated with myocardial infarction 1.48 (1.22-1.79), stroke 1.51 (1.22-2.05), incidental heart failure 1.55 (1.30-1.84), atrial fibrillation 1.75 (1.43-2.15), and their composite, major adverse cardiovascular events (MACE). Finally, conversion to mitral valve replacement at time of cardiac surgery was more in patients with MAC than without MAC, with odds ratio (95% confidence interval) 2.82 (1.28-6.18).

Conclusion: Mitral annular calcification was overall associated with higher rates of death, and both individual and composite cardiovascular events. The presence of increasingly encountered MAC has significant clinical implications for cardiovascular risk assessment and valvular interventions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/echo.14861DOI Listing
November 2020

Outcomes of Early Coronary Angiography or Revascularization After Cardiac Surgery.

Ann Thorac Surg 2021 05 16;111(5):1494-1501. Epub 2020 Sep 16.

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Early coronary ischemic events are uncommon after cardiac surgery, with little known about their management or associated outcomes. We evaluated clinical outcomes of patients undergoing coronary angiography ± percutaneous coronary intervention or redo coronary artery bypass grafting for suspected coronary ischemia within 3 weeks after index cardiac surgery.

Methods: This is a retrospective observational study based on data from 53,287 patients who underwent cardiac surgery at our institution (1996-2017); 180 patients (0.34%) satisfied the inclusion criteria. The primary outcome was 1-year all-cause mortality. Statistical evaluation involved χ, analysis of variance, Kaplan-Meier, and receiver operating characteristic curve analyses.

Results: Most coronary angiography ± percutaneous coronary intervention and redo coronary artery bypass grafting procedures occurred in the first 2 weeks after index cardiac surgery. Patients presenting with ST elevation myocardial infarction (STEMI)/non-STEMI had the lowest 1-year mortality (13.5%), followed by patients with ventricular tachycardia/fibrillation (28.1%), and patients with non-ventricular tachycardia/fibrillation arrest or hemodynamic instability alone the worst (38.6%) (χ = 17.3, P = .001). Peak troponin T level after cardiac surgery was strongly predictive of 1-year mortality (area under the curve, 0.74; 95% confidence interval, 0.65-0.84; P < .001) but did not predict the presence of coronary compromise. For acute graft failure, 1-year mortality was better with percutaneous coronary intervention (18.2%) than redo coronary artery bypass grafting (23.5%) or no indicated/feasible intervention (29.2%).

Conclusions: Although suspected myocardial ischemia requiring coronary angiography or intervention early after cardiac surgery was rare, mortality was high, particularly in presentations other than STEMI/non-STEMI. In patients with overt signs and symptoms of myocardial ischemia after index cardiac surgery, troponin T was not a reliable marker of underlying coronary or graft obstruction but was a robust predictor of 1-year mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2020.06.113DOI Listing
May 2021

Factors associated with local invasion in infective endocarditis: a nested case-control study.

Clin Microbiol Infect 2020 Sep 9. Epub 2020 Sep 9.

Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH, USA.

Objective: A substantial proportion of infective endocarditis (IE) cases are complicated by local invasion. The purpose of this study was to identify patient and disease characteristics associated with local invasion in surgically treated IE patients.

Methods: This was a nested case-control study. All episodes of IE for patients admitted to Cleveland Clinic from 1 January 2013 to 30 June 2016 were identified from the Cleveland Clinic IE Registry. Patients ≥18 years of age who underwent surgery for IE were included. Among these, cases were those with local invasion, controls were those without. Local invasion, defined as periannular extension, paravalvular abscess, intracardiac fistula or pseudoaneurysm, was ascertained from the surgical operative note. Associations of selected factors with local invasion were examined in a multivariable logistic regression model.

Results: Among 511 patients who met inclusion criteria, 215 had local invasion. Mean age was 56 years; 369 were male. Overall 345 (68%) had aortic valve, 228 (45%) mitral valve, and 66 (13%) tricuspid or pulmonic valve involvement. Aortic valve involvement (OR 6.23, 95% CI 3.55-11.44), bioprosthetic valve (OR 3.88, 95% CI 2.36-6.44), significant paravalvular leak (OR 3.80, 95% CI 1.60-9.89), new atrioventricular nodal block (OR 3.77, 95% CI 1.87-7.90), infection with streptococci other than viridans group streptococci (OR 7.54, 95% CI 2.42-24.87) and presence of central nervous system emboli (OR 1.85, 95% CI 1.13-3.04) were associated with local invasion.

Discussion: Intracardiac and microorganism factors, but not comorbid conditions, are associated with local invasion in IE.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cmi.2020.09.003DOI Listing
September 2020

Complementary Diagnostic and Prognostic Contributions of Cardiac Computed Tomography for Infective Endocarditis Surgery.

Circ Cardiovasc Imaging 2020 09 9;13(9):e011126. Epub 2020 Sep 9.

Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (T.K.M.W., N.C., B.X., P.C., R.A.G., B.P.G., S.D.F., Z.B.P., M.A.B.), Cleveland Clinic, OH.

Background: Cardiac computed tomography (CT) is emerging as an adjunctive modality to echocardiography in the evaluation of infective endocarditis (IE) and surgical planning. CT studies in IE have, however, focused on its diagnostic rather than prognostic utility, the latter of which is important in high-risk diseases like IE. We evaluated the associations between cardiac CT and transesophageal echocardiography (TEE) findings and adverse outcomes after IE surgery.

Methods: Of 833 consecutive patients with surgically proven IE during May 1, 2014 to May 1, 2019, at Cleveland Clinic, 155 underwent both preoperative ECG-gated contrast-enhanced CT and TEE. Multivariable analyses were performed to identify CT and TEE biomarkers that predict adverse outcomes after IE surgery, adjusting for EuroSCORE II (European System for Cardiac operative Risk Evaluation II).

Results: CT and TEE were positive for IE in 123 (75.0%) and 124 (75.6%) of patients, respectively. Thirty-day mortality occurred in 3 (1.9%) patients and composite mortality or morbidities in 72 (46.5%). Pseudoaneurysm or abscess detected on TEE was the only imaging biomarker to show independent association with composite mortality or morbidities in-hospital, with odds ratio (95% CI) of 3.66 (1.76-7.59), =0.001. There were 17 late deaths, and both pseudoaneurysm or abscess detected on CT and fistula detected on CT were the only independent predictors of total mortality during follow-up, with hazards ratios (95% CI) of 3.82 (1.25-11.7), <0.001 and 9.84 (1.89-51.0), =0.007, respectively.

Conclusions: We identified cardiac CT and TEE features that predicted separate adverse outcomes after IE surgery. Imaging biomarkers can play important roles incremental to conventional clinical factors for risk stratification in patients undergoing IE surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCIMAGING.120.011126DOI Listing
September 2020

Perioperative Management of a Patient With Profound Thrombocytopenia Secondary to MYH9-RD Presenting for Thoracic Aortic Aneurysm Repair and Aortic Valve Replacement.

J Cardiothorac Vasc Anesth 2021 Apr 1;35(4):1154-1160. Epub 2020 Aug 1.

Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.jvca.2020.07.076DOI Listing
April 2021

Contemporary Outcomes of Pulmonary Valve Endocarditis: A 16-Year Single Centre Experience.

Heart Lung Circ 2020 Dec 11;29(12):1799-1807. Epub 2020 Jun 11.

Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Background: Limited data exist regarding the clinical characteristics and contemporary outcomes of patients with pulmonary valve (PoV) infective endocarditis (IE).

Methods: This is a retrospective cohort study of patients with a confirmed diagnosis of IE affecting the PoV at our centre between January 2002 and October 2018. Electronic medical records were reviewed to gather the clinical and echocardiographic variables. The population was subdivided according to risk factor profiles: group 1: miscellaneous risk factors; group 2: patients with congenital heart disease (CHD); and group 3: patients who inject drugs (PWID). The primary outcome was all-cause mortality.

Results: Out of 2,124 cases of IE during the study period, 24 (1.1%) patients had PoV IE. The majority of cases of PoV IE occurred in patients with prosthetic valves (54.2%). Coagulase-negative Staphylococci species were the most common micro-organisms. Seventy-five per cent (75%) of the patients required surgical management. The median follow-up was 2.8 years (interquartile range: 0.2-5.3 years). Patients with miscellaneous risk factors were older (p<0.01), and had higher rates of hypertension (p=0.01) and hyperlipidaemia (p=0.04). There was a statistically significant difference in survival between the groups (p=0.03), mainly driven by better outcomes of patients with CHD, compared to those with miscellaneous risk factors.

Conclusions: In a contemporary 16-year series, a high proportion of patients with PoV IE required surgical management. Patients with PoV IE and CHD had better survival, compared to patients with miscellaneous risk factors at a median follow-up of 2.8 years.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hlc.2020.04.015DOI Listing
December 2020

Proteomics identifies a convergent innate response to infective endocarditis and extensive proteolysis in vegetation components.

JCI Insight 2020 07 23;5(14). Epub 2020 Jul 23.

Department of Biomedical Engineering, Lerner Research Institute.

Infective endocarditis is a life-threatening infection of heart valves and adjacent structures characterized by vegetations on valves and other endocardial surfaces, with tissue destruction and risk of embolization. We used high-resolution mass spectrometry to define the proteome of staphylococcal and non-staphylococcal vegetations and Terminal Amine Isotopic Labeling of Substrates (TAILS) to define their proteolytic landscapes. These approaches identified over 2000 human proteins in staphylococcal and non-staphylococcal vegetations. Individual vegetation proteomes demonstrated comparable profiles of quantitatively major constituents that overlapped with serum, platelet, and neutrophil proteomes. Staphylococcal vegetation proteomes resembled one another more than the proteomes of non-staphylococcal vegetations. TAILS demonstrated extensive proteolysis within vegetations, with numerous previously undescribed cleavages. Several proteases and pathogen-specific proteins, including virulence factors, were identified in most vegetations. Proteolytic peptides in fibronectin and complement C3 were identified as potential infective endocarditis biomarkers. Overlap of staphylococcal and non-staphylococcal vegetation proteomes suggests a convergent thrombotic and immune response to endocardial infection by diverse pathogens. However, the differences between staphylococcal and non-staphylococcal vegetations and internal variance within the non-staphylococcal group indicate that additional pathogen- or patient-specific effects exist. Pervasive proteolysis of vegetation components may arise from vegetation-intrinsic proteases and destabilize vegetations, contributing to embolism.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1172/jci.insight.135317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453909PMC
July 2020

Coronary Artery Bypass Graft Patency and Survival in Patients on Dialysis.

J Surg Res 2020 10 7;254:1-6. Epub 2020 May 7.

Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Little is known about graft patency after coronary artery bypass grafting (CABG) performed in patients on dialysis. Our aim was to assess patency of internal thoracic artery (ITA) grafts and saphenous vein grafts (SVGs) in these patients.

Methods: From 1/1997 to 1/2018, 500 patients on dialysis underwent primary CABG with or without concomitant procedures at Cleveland Clinic, 40 of whom had 48 postoperative angiograms for recurrent ischemic symptoms. Complete follow-up was obtained on all but 1 patient lost to follow-up 1 y after CABG. Thirty-six ITA grafts and 65 SVGs were evaluable for stenosis and occlusion.

Results: Two of 40 patients (5%) had emergency CABG; 3 (7.5%) with calcified aortas had a change in operative strategy to avoid ascending aortic manipulation, 2 (5%) had poor conduit quality, and 12 (30%) had severe diffuse atherosclerotic disease with calcification of the coronary targets causing technical difficulties. Thirty-three patients (82%) were bypassed with an in situ ITA and 3 (7.5%) had a free ITA graft. Three of 36 ITA grafts were occluded at 0.78, 1.8, and 9.4 y (too few to model). SVG patency was 52% and 37% at 1 and 2 y, respectively.

Conclusions: Among patients on dialysis who underwent CABG, coronary angiography for ischemic symptoms in a select subset revealed that SVG patency was lower than expected from published reports in the general CABG population and may contribute to the poor prognosis of this cohort. Further work is needed to guide graft selection and improve graft patency in dialysis patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2020.03.069DOI Listing
October 2020

Isolated surgical tricuspid repair versus replacement: meta-analysis of 15 069 patients.

Open Heart 2020 17;7(1):e001227. Epub 2020 Mar 17.

Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.

Objectives: Tricuspid valve disease is increasingly encountered, but surgery is rarely performed in isolation, in part because of a reported higher operative risk than other single-valve operations. Although guidelines recommend valve repair, there is sparse literature for the optimal surgical approach in isolated tricuspid valve disease. We performed a meta-analysis examining outcomes of isolated tricuspid valve repair versus replacement.

Methods: We searched Pubmed, Embase, Scopus and Cochrane from January 1980 to June 2019 for studies reporting outcomes of both isolated tricuspid valve repair and replacement, excluding congenital tricuspid aetiologies. Data were extracted and pooled using random-effects models and Review Manager 5.3 software.

Results: There were 811 article abstracts screened, from which 52 full-text articles reviewed and 16 studies included, totalling 6808 repairs and 8261 replacements. Mean age ranged from 36 to 68 years and females made up 24%-92% of these studies. Pooled operative mortality rates and odds ratios (95% confidence intervals) for isolated tricuspid repair and replacement surgery were 8.4% vs 9.9%, 0.80 (0.64 to 1.00). Tricuspid repair was also associated with lower in-hospital acute renal failure 12.4% vs 15.6%, 0.82 (0.72 to 0.93) and pacemaker implantation 9.4% vs 21.0%, 0.37 (0.24 to 0.58), but higher stroke rate 1.5% vs 0.9%, 1.63 (1.10 to 2.41). There were no differences in rates of prolonged ventilation, mediastinitis, return to operating room or late mortality.

Conclusion: Isolated tricuspid valve repair was associated with significantly reduced in-hospital mortality, renal failure and pacemaker implantation compared with replacement and is therefore recommended where feasible for isolated tricuspid valve disease, although its higher stroke rate warrants further research.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/openhrt-2019-001227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7078937PMC
June 2020

Coronary Artery Target Selection and Survival After Bilateral Internal Thoracic Artery Grafting.

J Am Coll Cardiol 2020 01;75(3):258-268

Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.

Background: The importance of a coronary artery, based on the myocardial mass it perfuses, is well documented, but little is known about the importance of a vessel that has been bypassed and its effect on survival in the context of bilateral internal thoracic artery (BITA) grafting.

Objectives: This study determined the effect of a dominant left anterior descending (LAD) artery and important non-LAD targets on outcomes after BITA grafting.

Methods: From January 1972 to January 2011, of 6,127 patients who underwent BITA grafting, 2,551 received 1 ITA grafted to the LAD and had an evaluable coronary angiogram. A dominant LAD was defined as one that was wrapped around the left ventricular apex. Non-LAD targets were graded based on their terminal reach toward the apex: important: >75% (n = 1,698); and less important: ≤75% (n = 853). Mean follow-up was 14 ± 8.7 years. Multivariable analysis was performed to identify risk factors for time-related mortality.

Results: A dominant LAD was present more frequently in patients with less important additional targets (51% vs. 35%; p < 0.0001). A total of 179 patients (7.0%) received a second ITA to multiple targets, 77 (43%) of which were to multiple important target vessels. Unadjusted late survival was similar regardless of degree of importance of the second ITA target-77% at 15 years (p = 0.70) for the important and less important targets, respectively. In the multivariable model, grafting the second ITA to multiple important targets was associated with better long-term survival (p = 0.005). In patients with a nondominant LAD, a second ITA grafted to a less important artery was associated with higher risk of operative mortality (2.4% vs. 0.51%; p = 0.007). A saphenous vein graft to an important or less important target did not influence long-term survival.

Conclusions: In BITA grafting, bypassing multiple important targets to maximize myocardium supplied by ITAs improved long-term survival. In patients with a nondominant LAD, selecting an important target for the second ITA lowered operative mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacc.2019.11.026DOI Listing
January 2020

Percutaneous cardioplegic arrest before repeat sternotomy in patients with retrosternal aortic aneurysm.

J Thorac Cardiovasc Surg 2021 May 16;161(5):1724-1730. Epub 2019 Nov 16.

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Objective: Redo sternotomy in patients with arterial cardiac structures adherent to the sternum carries a risk of catastrophic bleeding. In some of those cases, particularly if they have undergone multiple previous operations, deep hypothermic circulatory arrest alone may not provide sufficient time for a controlled dissection.

Methods: We present a series of 6 cases at risk for exsanguination during sternal re-entry successfully reoperated using percutaneous cardioplegic cardiac arrest induced before completed sternal re-entry to avoid or minimize the hypothermic circulatory arrest time.

Results: All patients survived their complex operations.

Conclusions: Percutaneous cardioplegic arrest allows safer repeat sternotomy in patients with arterial cardiac structures adherent to the sternum.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jtcvs.2019.09.191DOI Listing
May 2021

Current AATS guidelines on surgical treatment of infective endocarditis.

Ann Cardiothorac Surg 2019 Nov;8(6):630-644

Department of Cardiovascular and Thoracic Surgery, Northwell Health/Southside Hospital, Bay Shore, NY, USA.

The 2016 American Association for Thoracic Surgery (AATS) guidelines for surgical treatment of infective endocarditis (IE) are question based and address questions of specific relevance to cardiac surgeons. Clinical scenarios in IE are often complex, requiring prompt diagnosis, early institution of antibiotics, and decision-making related to complications, including risk of embolism and timing of surgery when indicated. The importance of an early, multispecialty team approach to patients with IE is emphasized. Management issues are divided into groups of questions related to indications for and timing of surgery, pre-surgical work-up, preoperative antibiotic treatment, surgical risk assessment, intraoperative management, surgical management, surveillance, and follow up. Standard indications for surgery are severe heart failure, severe valve dysfunction, prosthetic valve infection, invasion beyond the valve leaflets, recurrent systemic embolization, large mobile vegetations, or persistent sepsis despite adequate antibiotic therapy for more than 5-7 days. The guidelines emphasize that once an indication for surgery is established, the operation should be performed as soon as possible. Timing of surgery in patients with strokes and neurologic deficits require close collaboration with neurological services. In surgery infected and necrotic tissue and foreign material is radically debrided and removed. Valve repair is performed whenever possible, particularly for the mitral and tricuspid valves. When simple valve replacement is required, choice of valve-mechanical or tissue prosthesis-should be based on normal criteria for valve replacement. For patients with invasive disease and destruction, reconstruction should depend on the involved valve, severity of destruction, and available options for cardiac reconstruction. For the aortic valve, use of allograft is still favored.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/acs.2019.10.05DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6892713PMC
November 2019

Systematic review and meta-analysis of surgical outcomes comparing mechanical valve replacement and bioprosthetic valve replacement in infective endocarditis.

Ann Cardiothorac Surg 2019 Nov;8(6):587-599

Department of Cardiovascular Surgery, Hospital Clinic, University of Barcelona, Barcelona, Spain.

Background: Infective endocarditis (IE) is an infection involving either native or prosthetic heart valves, the endocardial surface of the heart or any implanted intracardiac devices. IE is a rare condition affecting 3-15 patients per 100,000 population. In-hospital mortality rates in patients with IE remain high at around 20% despite treatment advances. There is no consensus recommendation favoring either bioprosthetic valve or mechanical valve implantation in the setting of IE; patient age, co-morbidities and preferences should be considered selecting the replacement prosthesis.

Methods: A systematic review and meta-analysis of studies reporting the outcomes of patients undergoing bioprosthetic or mechanical valve replacement for infective endocarditis with data extracted for overall survival, valve reinfection rates and valve reoperation.

Results: Eleven relevant studies were identified, with 2,336 patients receiving a mechanical valve replacement and 2,057 patients receiving a bioprosthetic valve replacement. There was no significant difference for overall survival between patients treated with mechanical valves and those treated with bioprosthetic valves [hazard ratio (HR) 0.94, 95% confidence interval (CI): 0.73-1.21, P=0.62]. There was no significant difference in reoperation rates between patients treated with a bioprosthetic valve and those treated with a mechanical valve (HR 0.82, 95% CI: 0.34-1.98, P=0.66) and there was no significant difference in the rate of valve reinfection rates (HR 0.95, 95% CI: 0.48-1.89, P=0.89).

Conclusions: The presence of infective endocarditis alone should not influence the decision of which type of valve prosthesis that should be implanted. This decision should be based on patient age, co-morbidities and preferences.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/acs.2019.10.03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6892732PMC
November 2019

Carcinoid Tricuspid Valve Disease: Applications of Three Dimensional Transesophageal Echocardiography.

Circ Cardiovasc Imaging 2019 12 26;12(12):e009555. Epub 2019 Nov 26.

Cleveland Clinic Foundation, OH.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCIMAGING.119.009555DOI Listing
December 2019

Surgical palliation or primary transplantation for aortic valve atresia.

J Thorac Cardiovasc Surg 2020 04 25;159(4):1451-1461.e7. Epub 2019 Sep 25.

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Objective: The study objective was to describe the surgical pathway progression through adolescence of an inception cohort of neonates with aortic valve atresia managed initially with surgical palliation or primary transplantation, comparing survival and self-reported health-related quality of life.

Methods: From 1994 to 2000, 565 neonates with aortic atresia were admitted to 26 Congenital Heart Surgeons' Society hospitals and followed annually for vital status. Initial management included surgical palliation (n = 453) and primary cardiac transplantation (n = 68). PedsQL health-related quality of life questionnaires were sent cross-sectionally to a subgroup of 198 patients alive at previous follow-up, with 80 responses.

Results: Risk of death was initially high for both treatment strategies. However, compared with initial surgical palliation, survival with primary transplantation, including wait-list mortality, was greater and persisted long-term (65% vs 40% at 15 years; P = .002). Survival after secondary transplantation (48% at 9 years) was lower than after primary transplantation (74%). Health-related quality of life total score was lower overall than that of the general adolescent population (71 ± 16 vs 84 ± 13; P = .0001; normal = 100), but similar to that of adolescents with chronic diseases. It was similar in the surgical palliation and primary transplantation groups (70 ± 16 vs 75 ± 15; P = .3). Patients who received surgical palliation reported more symptoms (76 ± 15 vs 63 ± 18; P = .02).

Conclusions: Patients receiving primary heart transplantation for aortic atresia in 1994 to 2000 experienced better survival, fewer symptoms, and equivalent quality of life compared with those undergoing initial surgical palliation. Notwithstanding the limited availability of neonatal and infant donor hearts, primary transplantation may be considered for those neonates with risk factors predictive of exceptionally poor survival after surgical palliation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jtcvs.2019.08.104DOI Listing
April 2020

Invited Commentary.

Ann Thorac Surg 2020 04 31;109(4):1225-1226. Epub 2019 Oct 31.

The Cleveland Clinic, 9500 Euclid Ave, F25, Cleveland, OH 44195. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2019.10.003DOI Listing
April 2020