Publications by authors named "Paul Kurlansky"

212 Publications

Society of Thoracic Surgeons 2021 Adult Cardiac Surgery Risk Models for Multiple Valve Operations.

Ann Thorac Surg 2021 Apr 9. Epub 2021 Apr 9.

Duke University, Durham, North Carolina.

Background: The STS Quality Measurement Task Force has developed risk models and composite performance measures for isolated coronary artery bypass grafting surgery (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement or repair (MVRR), AVR+CABG, and MVRR+CABG. To further enhance its portfolio of risk-adjusted performance metrics, STS has developed new risk models for multiple valve operations +/- CABG procedures.

Methods: Using July 2011 to June 2019 STS Adult Cardiac Surgery Database (ACSD) data, risk models for AVR+MVRR (n=31,968) and AVR+MVRR+CABG (n=12,650) were developed with the following endpoints: operative mortality, major morbidity (any one or more of the following: cardiac reoperation; deep sternal wound infection/mediastinitis; stroke; prolonged ventilation; and renal failure), and combined mortality and/or major morbidity. Data were divided into development (July 2011 - June 2017, n=35,109) and validation (July 2017 - June 2019, n=9,509) samples. Predictors were selected by assessing model performance and clinical face validity of full and progressively more parsimonious models. Performance of the resulting models was evaluated by assessing discrimination and calibration.

Results: C-statistics for the overall population of multiple valve +/- CABG procedures were 0.7086, 0.6734, and 0.6840 for mortality, morbidity, and combined mortality and/or morbidity in the development sample, and 0.6953, 0.6561, and 0.6634 for the same outcomes, respectively, in the validation sample.

Conclusions: New STS-ACSD risk models have been developed for multiple valve +/- CABG operations, and these models will be used in subsequent STS performance metrics.
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http://dx.doi.org/10.1016/j.athoracsur.2021.03.089DOI Listing
April 2021

Proximal aortic repair in dialysis patients: A national database analysis.

J Thorac Cardiovasc Surg 2021 Feb 27. Epub 2021 Feb 27.

Division of Cardiothoracic and Vascular Surgery, Department of Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY. Electronic address:

Objectives: Dialysis is a well-established risk factor for morbidity and mortality after cardiovascular procedures. However, little is known regarding the outcomes of proximal aortic surgery in this high-risk cohort.

Methods: Perioperative (in-hospital or 30-day mortality) and 10-year outcomes were analyzed for all the patients who underwent open proximal aortic repair with the diagnosis of nonruptured thoracic aortic aneurysm (aneurysm, n = 325) or type A aortic dissection (dissection, n = 461) from 1987 to 2015 using the US Renal Data System database.

Results: In patients with aneurysm, perioperative mortality was 12.6%. The 10-year mortality was 81% ± 3%. Age 65 years or more (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.03 to 1.78; P = .03), chronic obstructive pulmonary disease (HR, 1.68; 95% CI, 1.01-2.82; P = .047), and Black race (HR, 1.46; 95% CI, 1.09-1.97; P = .01) were independently associated with worse 10-year mortality. In patients with dissection, perioperative mortality was 24.3% and 10-year mortality was 87.9% ± 2.2%. Age 65 years or more (HR, 1.49; 95% CI, 1.19-1.86; P < .001), congestive heart failure (HR, 1.39; 95% CI, 1.11-2.57; P = .004), and diabetes mellitus as the cause of dialysis (HR, 1.75; 95% CI, 1.2-2.57; P = .004) were independently associated with worse 10-year mortality. Black race (HR, 0.74; 95% CI, 0.6-0.92; P = .008) was associated with a better outcome.

Conclusions: We described challenging perioperative and 10-year outcomes for dialysis patients undergoing proximal aortic repair. The present study suggests the need for careful patient selection in the elective repair of proximal aortic aneurysm for dialysis-dependent patients, whereas it affirms the feasibility of emergency surgery for acute type A aortic dissections.
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http://dx.doi.org/10.1016/j.jtcvs.2021.02.086DOI Listing
February 2021

Commentary: The National Institutes of Health and why we care.

Authors:
Paul Kurlansky

J Thorac Cardiovasc Surg 2021 Feb 16. Epub 2021 Feb 16.

Division of Cardiac Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2021.02.026DOI Listing
February 2021

Incidence, Cause, and Outcome of Reinterventions after Aortic Root Replacement.

Ann Thorac Surg 2021 Mar 8. Epub 2021 Mar 8.

Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY. Electronic address:

Background: This study aims to comprehensively characterize the details of the aortic and aortic valve reinterventions after aortic root replacement (ARR).

Methods: Between 2005 and 2019, 882 patients underwent ARR. The indication was for aneurysm in 666, aortic valve-related in 116, aortic dissection in 64, and infective endocarditis (IE) in 36. Valve-sparing root replacement was performed in 290 while Bio-Bentall was done in 528. Among them, 52 (5.9%) patients required reintervention. The incidence, cause, and time to reintervention, as well as outcomes after reintervention were investigated. Cause-Specific Cox hazard model was performed to identify predictors for reintervention after ARR.

Results: The 10-year cumulative incidence of aortic and aortic valve reintervention after ARR was 10.3% [95%CI, 7.3%-14.0%]. Age per year decrease was the only independent predictor for reintervention [sHR, 0.97; 95%CI, 0.95-0.99]. The causes for 52 reinterventions were: 29 (55.8%) for aortic valve causes including aortic stenosis/insufficiency, and prosthetic valve dysfunction; 15 (28.9%) for IE; 7 (13.5%) for aortic-related causes including pseudoaneurysm, development of aneurysm, and residual dissection; and 1 (1.9%) for coronary button pseudoaneurysm. Median times to reintervention were 11.0 [IQR, 2.0-20.5] months for IE, 24.0 [IQR, 3.7-46.1] months for aortic-related causes, 77.0 [IQR, 28.4-97.6] months for aortic valve-related causes (p=.005). Overall in-hospital mortality after the reinterventions was 7.7% (4/52) with 20.0% with IE (3/15) .

Conclusions: Reintervention for IE occurs relatively early after ARR while aortic valve- and aortic-related reinterventions gradually increase over time. In-hospital mortality after the reintervention is low, unless it is for IE.
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http://dx.doi.org/10.1016/j.athoracsur.2021.03.004DOI Listing
March 2021

National outcomes of bridge to multiorgan cardiac transplantation using mechanical circulatory support.

J Thorac Cardiovasc Surg 2021 Feb 5. Epub 2021 Feb 5.

Division of Cardiothoracic Surgery, Department of Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY. Electronic address:

Background: Little is known regarding the profile of patients with multiorgan failure listed for simultaneous cardiac transplantation and secondary organ. In addition, few studies have reported how these patients are bridged with mechanical circulatory support (MCS). In this study, we examined national data of patients listed for multiorgan transplantation and their outcomes after bridging with or without MCS.

Methods: United Network for Organ Sharing data were reviewed for adult multiorgan transplantations from 1986 to 2019. Post-transplant patients and total waitlist listings were examined and stratified according to MCS status. Survival was assessed via Cox regression in the post-transplant cohort and Fine-Gray competing risk regression with transplantation as a competing risk in the waitlist cohort.

Results: There were 4534 waitlist patients for multiorgan transplant during the study period, of whom 2117 received multiorgan transplants. There was no significant difference in post-transplant survival between the MCS types and those without MCS in the whole cohort and heart-kidney subgroup. Fine-Gray competing risk regression showed that patients bridged with extracorporeal membrane oxygenation had significantly greater waitlist mortality compared with those without MCS when controlling for preoperative characteristics (subdistribution hazard ratio, 2.27; 95% confidence interval, 1.48-3.47; P < .001), whereas those bridged with a ventricular assist device had a decreased incidence of death compared with those without MCS (subdistribution hazard ratio, 0.78; 95% confidence interval, 0.63-0.96; P = .017).

Conclusions: MCS, as currently applied, does not appear to compromise the survival of multiorgan heart transplant patients. Waitlist data show that extracorporeal membrane oxygenation patients have profoundly worse survival irrespective of preoperative factors including organ type listed. Survival on the waitlist for multiorgan transplant has improved across device eras.
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http://dx.doi.org/10.1016/j.jtcvs.2021.01.114DOI Listing
February 2021

Commentary: Failure to rescue: "The medium is the message".

Authors:
Paul Kurlansky

J Thorac Cardiovasc Surg 2021 Feb 3. Epub 2021 Feb 3.

Division of Cardiac Surgery, Department of Surgery, Columbia University, New York, NY. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2021.01.107DOI Listing
February 2021

Influence of aneurysmal aortic root geometry on mechanical stress to the aortic valve leaflet.

Eur Heart J Cardiovasc Imaging 2021 Feb 21. Epub 2021 Feb 21.

Division of Cardiothoracic Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, 707 Fort Washington Avenue, New York, NY 10032, USA.

Aims: While mechanical stress caused by blood flow, e.g. wall shear stress (WSS), and related parameters, e.g. oscillatory shear index (OSI), are increasingly being recognized as key moderators of various cardiovascular diseases, studies on valves have been limited because of a lack of appropriate imaging modalities. We investigated the influence of aortic root geometry on WSS and OSI on the aortic valve (AV) leaflet.

Methods And Results: We applied our novel approach of intraoperative epi-aortic echocardiogram to measure the haemodynamic parameters of WSS and OSI on the AV leaflet. Thirty-six patients were included, which included those who underwent valve-sparing aortic root replacement (VSARR) with no significant aortic regurgitation (n = 17) and coronary artery bypass graft (CABG) with normal AV (n = 19). At baseline, those who underwent VSARR had a higher systolic WSS (0.52 ± 0.12 vs. 0.32 ± 0.08 Pa, respectively, P < 0.001) and a higher OSI (0.37 ± 0.06 vs. 0.29 ± 0.04, respectively, P < 0.001) on the aortic side of the AV leaflet than those who underwent CABG. Multivariate regression analysis revealed that the size of the sinus of Valsalva had a significant association with WSS and OSI. Following VSARR, WSS and OSI values decreased significantly compared with the baseline values (WSS: 0.29 ± 0.12 Pa, P < 0.001; OSI: 0.26 ± 0.09, P < 0.001), and became comparable to the values in those who underwent CABG (WSS, P = 0.42; OSI, P = 0.15).

Conclusions: Mechanical stress on the AV gets altered in correlation with the size of the aortic root. An aneurysmal aortic root may expose the leaflet to abnormal fluid dynamics. The VSARR procedure appeared to reduce these abnormalities.
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http://dx.doi.org/10.1093/ehjci/jeab006DOI Listing
February 2021

Bicuspid-Associated Aortic Root Aneurysm: Mid to Long-Term Outcomes of David V Versus the Bio-Bentall Procedure.

Semin Thorac Cardiovasc Surg 2021 Feb 17. Epub 2021 Feb 17.

Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York Presbyterian-Columbia University Medical Center, New York, New York. Electronic address:

David V valve-sparing root replacement (VSRR) and bio-Bentall (BB) are increasingly performed for aortic root aneurysms associated with a bicuspid aortic valve (BAV). However, durability remains a concern in both procedures. We compared the 10-year outcomes of VSRR vs BB for BAV-associated root aneurysms. A retrospective review identified 134 patients with a BAV-associated root aneurysm who underwent VSRR (n = 65) or BB (n = 69) from 2005 to 2019. Patients with aortic stenosis, endocarditis, previous aortic valve replacement, and emergent cases were excluded. Propensity-score matching was performed, resulting in 2 risk-adjusted groups (n = 40 per group). Median follow-up was 6.21 (1.43-8.28) years. The VSRR cohort was younger (46.0 years vs 56.0 years, P < 0.001) and had a lower incidence of at least moderate aortic insufficiency (AI) (78.5% vs 92.8%, P = 0.02). The incidence of Marfan syndrome, aortic root diameter, and ascending aortic diameter were similar. In-hospital mortality was 1.5% (n = 1) and 1.4% (n = 1) for VSRR and BB, respectively. There was no difference between VSRR and BB in 10-year survival (98.3% [95% confidence interval (CI): 88.6-99.8%] vs 96.2% [95% CI: 85.5-99.0%], P = 0.567) and aortic valve reintervention at 10 years (16.1% [95% CI: 6.3-29.8%] vs 12.9% [95% CI: 3.7-28.0%], P = 0.309). The most common reason for valve reintervention in both groups was AI. Survival and valve reintervention at 10 years were similar in the matched cohort. David V VSRR yields similar mid to long-term outcomes to BB for select patients with a BAV-associated aortic root aneurysm in regards to survival and reintervention rates. Further studies comparing longer term outcomes between root replacement techniques and native valve durability are needed.
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http://dx.doi.org/10.1053/j.semtcvs.2021.02.004DOI Listing
February 2021

Bleeding and Thrombotic Events During Extracorporeal Membrane Oxygenation for Postcardiotomy Shock.

Ann Thorac Surg 2021 Feb 17. Epub 2021 Feb 17.

Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY. Electronic address:

Background: Anticoagulation management during veno-arterial extracorporeal membrane oxygenation (ECMO) is particularly difficult in postcardiotomy shock patients given a significant bleeding risk. We sought to determine the effect of anticoagulation on bleeding and thrombosis risk for postcardiotomy shock patients on ECMO.

Methods: We retrospectively reviewed patients who received ECMO for postcardiotomy shock from July 2007 through July 2019. Characteristics of patients who developed bleeding and thrombosis were investigated and risk factors were assessed via multi-level logistic regression.

Results: Of the 152 patients who received ECMO for postcardiotomy shock, 33 (23%) developed 40 thrombotic events and 64 (45%) developed 86 bleeding events. Predictors of bleeding were intraoperative packed red blood cell transfusion (OR 1.05, 95% CI [1.01-1.09]), platelet transfusion (OR 1.10, 95% CI [1.05-1.16]), international normalized ratio (OR 1.18, 95% CI [1.02-1.37]), and activated partial thromboplastin time (aPTT) greater than 60 seconds (OR 2.32, 95% CI [1.14-4.73]). Predictors of thrombosis were anticoagulation use (OR 0.39, 95% CI [0.19-0.79]), surgical venting (OR 3.07, 95% CI [1.29-7.31]), hemoglobin (OR 1.38, 95% CI [1.06-1.79]), and central cannulation (OR 2.06, 95% CI [1.03-4.11]). The daily predicted probability of thrombosis was between 0.075 and 0.038 in those who did not receive anticoagulation and decreased to between 0.030 and 0.013 in those who received anticoagulation at aPTTs between 25 and 80 seconds.

Conclusions: Anticoagulation can reduce thromboembolic events in postcardiotomy shock patients on ECMO, but bleeding risk may outweigh this benefit at aPTTs greater than 60 seconds.
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http://dx.doi.org/10.1016/j.athoracsur.2021.02.008DOI Listing
February 2021

Administrative Claims Measure for Profiling Hospital Performance Based on 90-Day All-Cause Mortality Following Coronary Artery Bypass Graft Surgery.

Circ Cardiovasc Qual Outcomes 2021 Feb 4;14(2):e006644. Epub 2021 Feb 4.

Section of Rheumatology, Department of Internal Medicine (L.G.S.) Yale School of Medicine, New Haven, CT.

Background: Coronary artery bypass graft (CABG) surgery is a focus of bundled and alternate payment models that capture outcomes up to 90 days postsurgery. While clinical registry risk models perform well, measures encompassing mortality beyond 30 days do not currently exist. We aimed to develop a risk-adjusted hospital-level 90-day all-cause mortality measure intended for assessing hospital performance in payment models of CABG surgery using administrative data.

Methods: Building upon Centers for Medicare and Medicaid Services hospital-level 30-day all-cause CABG mortality measure specifications, we extended the mortality timeframe to 90 days after surgery and developed a new hierarchical logistic regression model to calculate hospital risk-standardized 90-day all-cause mortality rates for patients hospitalized for isolated CABG. The model was derived from Medicare claims data for a 3-year cohort between July 2014 to June 2017. The data set was randomly split into 50:50 development and validation samples. The model performance was evaluated with C statistics, overfitting indices, and calibration plot. The empirical validity of the measure result at the hospital level was evaluated against the Society of Thoracic Surgeons composite star rating.

Results: Among 137 819 CABG procedures performed in 1183 hospitals, the unadjusted mortality rate within 30 and 90 days were 3.1% and 4.7%, respectively. The final model included 27 variables. Hospital-level 90-day risk-standardized mortality rates ranged between 2.04% and 11.26%, with a median of 4.67%. C statistics in the development and validation samples were 0.766 and 0.772, respectively. We identified a strong positive correlation between 30- and 90-day risk-standardized mortality rates, with a regression slope of 1.09. Risk-standardized mortality rates also showed a stepwise trend of lower 90-day mortality with higher Society of Thoracic Surgeons composite star ratings.

Conclusions: We present a measure of hospital-level 90-day risk-standardized mortality rates following isolated CABG. This measure complements Centers for Medicare and Medicaid Services' existing 30-day CABG mortality measure by providing greater insight into the postacute recovery period. It offers a balancing measure to ensure efforts to reduce costs associated with CABG recovery and rehabilitation do not result in unintended consequences.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.120.006644DOI Listing
February 2021

Serial assessment of HeartMate 3 pump position and inflow angle and effects on adverse events.

Eur J Cardiothorac Surg 2021 Feb 1. Epub 2021 Feb 1.

Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA.

Objectives: This study analyses the position of the HeartMate 3 left ventricular assist device on serial radiographs to assess positional change and possible correlation with adverse events.

Methods: We retrospectively analysed 59 left ventricular assist device recipients who had serial chest radiographs at 1 month, 6 months and 12 months post-implantation between November 2014 and June 2018. We measured pump angle, pump-spine distance and pump-diaphragm depth and investigated their relationship to a composite outcome of heart failure readmission, low flow alarms, stroke or inflow/outflow occlusion requiring surgical repositioning through recurrent event survival modelling.

Results: Between 1 and 6 months, the absolute pump-spine distance changed by 10.00 mm (P < 0.01) and the absolute pump-diaphragm depth changed by 18.80 mm (P < 0.01). These parameters did not change significantly between 6 and 12 months post-implantation. Pump angle did not change significantly over any period. Twenty-six patients experienced the composite outcome; in these patients, the median 1-month pump angle was 66.2° (interquartile range 54.5-78.0) as compared to 59.0° (interquartile range 47.0-65.0) in the 33 patients who did not have adverse events (P = 0.04). Pump depth and pump-spine distance at 1 month were not associated with the composite outcome. Change in pump depth between 1 and 6 months [hazard ratio (HR) 1.019; 95% confidence interval (CI) 1.000-1.039] and between 6 and 12 months (HR 1.020; 95% CI 1.000-1.040) were weakly associated with the composite outcome.

Conclusions: Larger pump angles are associated with the composite outcome of position-related adverse events. Pump depth movement is weakly associated with the composite outcome.
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http://dx.doi.org/10.1093/ejcts/ezaa475DOI Listing
February 2021

Sex differences in patients with cardiogenic shock requiring extracorporeal membrane oxygenation.

J Thorac Cardiovasc Surg 2020 Dec 23. Epub 2020 Dec 23.

Division of Cardiac Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY. Electronic address:

Objective: Our study assesses differences between male and female patients placed on venoarterial extracorporeal membrane oxygenation for cardiogenic shock.

Method: We retrospectively analyzed 574 adult patients placed on venoarterial extracorporeal membrane oxygenation for cardiogenic shock at our institution between January 2007 and December 2018. Baseline characteristics and outcomes were assessed. Propensity score matching was used to compare outcomes. The primary end point was in-hospital mortality. Secondary outcomes include limb ischemia, limb ischemia interventions, distal perfusion cannula placement, stroke, bleeding, and continuous venovenous hemofiltration initiation.

Results: There were 394 male patients (69%) and 180 female patients (31%). After adjusting for baseline differences, propensity score matching compared 171 male patients with 171 female patients. No difference was seen between men and women in in-hospital mortality (60.2% vs 56.7%; P = .59), limb ischemia (47.4% vs 45.6%; P = .83), limb ischemia surgery (15.2% vs 12.9%; P = .64), bleeding (49.7% vs 49.1%; P = 1), continuous venovenous hemofiltration initiation (39.2% vs 32.7%; P = .26), and stroke (8.2% vs 9.4%; P = .85). Multivariable logistic regression showed that female patients who died were more likely to have had chronic kidney disease (odds ratio [OR], 2.67; 95% confidence interval [CI], 1.09-6.53; P = .032) than surviving women. Male patients who died were more likely to have had coronary artery disease (OR, 2.25; 95% CI, 1.34-3.78; P = .002) and higher lactate levels (OR, 1.14; 95% CI, 1.08-1.21; P < .001) than surviving men. Women with cardiac transplant primary graft dysfunction were more likely to survive (OR, 0.04; 95% CI, 0.01-0.27; P = .001), whereas men with cardiac transplant primary graft dysfunction were less likely to survive (OR, 0.28; 95% CI, 0.11-0.71; P = .007), than patients with other shock etiologies.

Conclusions: After adjusting for baseline difference, there was no difference in outcomes between male and female patients despite differing risk profiles for in-hospital mortality. (supplementary video).
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http://dx.doi.org/10.1016/j.jtcvs.2020.12.044DOI Listing
December 2020

Rationale for Inverse Probability Treatment Weight Variables in Left Sided Infective Endocarditis Patients Treated with Primary Surgical or Medical Therapy.

Ann Thorac Surg 2021 Jan 21. Epub 2021 Jan 21.

Columbia University, Surgery, Milstein 7GN-435, 177 Fort Washington Ave New York, NY 10032. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2020.11.058DOI Listing
January 2021

Cardiac transplantation in adult congenital heart disease with prior sternotomy.

Clin Transplant 2021 Apr 6;35(4):e14229. Epub 2021 Mar 6.

Department of Cardiovascular Surgery, Columbia University Medical Center, New York, NY, USA.

Background: Adult congenital heart disease (ACHD) patients who require orthotopic heart transplantation are surgically complex due to anatomical abnormalities and multiple prior surgeries. In this study, we investigated these patients' outcomes using our institutional database.

Methods: ACHD patients who had prior intracardiac repair and subsequent heart transplant were included (2008-2018). Adult patients without ACHD were extracted as a control. A comparison of patients with functional single ventricular (SV) and biventricular (BV) hearts was performed.

Results: There were 9 SV and 24 BV patients. The SV group had higher central venous pressure/pulmonary capillary wedge pressure (P = .028), hemoglobin concentration (P = .010), alkaline phosphatase (P = .022), and were more likely to have liver congestion (P = .006). Major complications included infection in 16 (48.5%), temporary dialysis in 12 (36.4%), and graft dysfunction requiring perioperative mechanical support in 7 (21.2%). Overall in-hospital mortality was 15.2%. Kaplan-Meier analysis showed a higher, but not statistically significant, survival after 10 years between the ACHD and control groups (ACHD 84.9% vs. control 67.5%, P = .429). There was no significant difference in 10-year survival between SV and BV groups (78% vs. 88%, P = .467).

Conclusions: Complex ACHD cardiac transplant recipients have a high incidence of early morbidities after transplantation. However, long-term outcomes were acceptable.
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http://dx.doi.org/10.1111/ctr.14229DOI Listing
April 2021

Influence of Atrial Fibrillation on Functional Tricuspid Regurgitation in Patients With HeartMate 3.

J Am Heart Assoc 2021 Feb 8;10(3):e018334. Epub 2021 Jan 8.

Division of Cardiothoracic Surgery Department of Surgery Columbia University Medical Center New York NY.

Background Functional tricuspid regurgitation (TR) can occur secondary to atrial fibrillation (AF). The impact of AF on functional TR and cardiovascular events is uncertain in patients with left ventricular assist devices. This study aimed to investigate the effect of AF on functional TR and cardiovascular events in patients with a HeartMate 3 left ventricular assist device. Methods and Results We retrospectively reviewed 133 patients who underwent HeartMate 3 implantation at our center between November 2014 and November 2018. We excluded patients who had undergone previous or concomitant tricuspid valve procedures and those whose echocardiographic images were of insufficient quality. The primary end point was death and the presence of a cardiovascular event at 1 year. We defined cardiovascular event as a composite of death, stroke, and hospital readmission due to recurrent heart failure and significant residual TR as vena contracta width ≥3 mm. In total, 110 patients were included in this analysis. Patients were divided into 3 groups: no AF (n=51), paroxysmal AF (n=40), and persistent AF (PeAF) (n=19). Kaplan-Meier analysis showed that patients with PeAF had the worst survival (no AF 98%, paroxysmal AF 98%, PeAF 84%, log-rank =0.038) and event-free rate (no AF 93%, paroxysmal AF 89%, PeAF 72%, log-rank =0.048) at 1 year. Thirty-one (28%) patients had residual TR 1 month after left ventricular assist device implantation. Patients with residual TR had a significantly poor prognosis compared with those without residual TR (log-rank =0.014). Conclusions PeAF was associated with increased mortality, cardiovascular events, and residual TR compared with no AF and paroxysmal AF.
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http://dx.doi.org/10.1161/JAHA.120.018334DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955423PMC
February 2021

Chronic kidney disease stage stratifies short- and long-term outcomes after aortic root replacement.

Interact Cardiovasc Thorac Surg 2021 Apr;32(4):573-581

Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA.

Objectives: Chronic kidney disease (CKD) is prevalent in patients undergoing cardiovascular surgery, and it negatively impacts procedural outcomes; however, its influence on the outcomes of aortic surgery has not been well studied. This study aims to elucidate the importance of CKD on the outcomes of aortic root replacement (ARR).

Methods: Patients who underwent ARR between 2005 and 2019 were retrospectively reviewed (n = 882). Patients were divided into 3 groups based on the Kidney Disease: Improving Global Outcomes criteria: Group 1 [estimated glomerular filtration rate (eGFR) ≥ 60 ml/min/1.73 m2, n = 421); Group 2 (eGFR = 30-59 ml/min/1.73 m2, n = 424); and Group 3 (eGFR < 30 ml/min/1.73 m2, n = 37). To reduce potential confounding, a propensity score matching was also performed between Group 1 and the combined group of Group 2 and Group 3. The primary end point was 10-year survival. Secondary end points were in-hospital mortality and perioperative morbidity.

Results: Severe CKD patients presented with more advanced overall chronic and acute illnesses. Kaplan-Meier analysis showed a significant correlation between CKD stage and 10-year survival (log-rank P < 0.001). The number of events for Group 1 was 15, Group 2 was 49 and Group 3 was 11 in 10 years. Group 3 had significantly higher in-hospital mortality (13.5% vs 3.5% in Group 2 vs 0.7% in Group 1, P < 0.001) and stroke (8.1% vs 7.1% vs 1.2%, P < 0.001) as well as introduction to new dialysis (27.0% vs 5.4% vs 1.7%, P < 0.001). eGFR was shown to be an independent predictor of mortality (hazard ratio, 0.98; 95% confidence interval, 0.96-0.99). Comparison between propensity matched groups showed similar postoperative outcomes, and eGFR was still identified as a predictor of mortality (hazard ratio, 0.97; 95% confidence interval, 0.95-0.99).

Conclusions: Higher stage in CKD negatively impacts the long-term survival in patients who are undergoing ARR.
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http://dx.doi.org/10.1093/icvts/ivaa320DOI Listing
April 2021

A Randomized Controlled Trial Examining the Impact of an Anorectal Surgery Multimodal Enhanced Recovery Program on Opioid Use.

Ann Surg 2020 Dec 18;Publish Ahead of Print. Epub 2020 Dec 18.

Division of Colorectal Surgery, Department of Surgery, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, New York Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, New York Division of Colorectal Surgery, Department of Surgery, New York Presbyterian Hospital-Columbia University Medical Center, New York, NY Department of Anesthesia, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York Division of Colorectal Surgery, Department of Surgery, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York.

Background: Anorectal cases may be a common gateway to the opioid epidemic. Opioid reduction is inherent in enhanced recovery after surgery (ERAS) protocols, but little work has evaluated ERAS in these cases.

Objective: To determine if ERAS could reduce postoperative opioid utilization in ambulatory anorectal surgery without sacrificing patient pain or satisfaction.

Methods: A randomized controlled trial assigned ambulatory anorectal patients to ERAS (experimental) or routine care (surgeon's choice) for pain management (control) over 30-days postoperatively. Primary outcome was overall days of opioid use. Secondary outcomes included pain and satisfaction scores over multiple time points and new persistent opioid use. The Visual Analog Scale, Functional Pain Scale, and EQ-5D-3L measured patient-reported pain and satisfaction. Univariate analysis compared outcomes overall and at individual time points. Two-way mixed ANOVA evaluated pain and satisfaction measures between groups and over time.

Results: Thirty-two patients were randomized into each arm (64 total). The control group consumed significantly more opioids after discharge(median 121.3MME vs 23.5MME, P < 0.001). Significantly more control patients requested additional narcotics (P  =  0.004), made unplanned calls (P = 0.009), and had unplanned clinic visits (P = 0.003). The control group had significantly more days on opioids (mean 14.4 vs 2.2, P < 0.001). Three control patients (9.4%) versus no experimental patients had new persistent opioid use. The mean global health, EQ5D-3L, Visual Analog Scale, and Functional Pain scores were comparable between groups over time.

Conclusions: An ERAS protocol in ambulatory anorectal surgery is feasible, and resulted in reduced opioid use, and healthcare utilization, with no difference in pain or patient satisfaction. This challenges the paradigm that extended opioids are needed for effective postoperative pain management.
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http://dx.doi.org/10.1097/SLA.0000000000004701DOI Listing
December 2020

The use of the radial artery for coronary artery bypass grafting improves long-term outcomes: And now what?

J Thorac Cardiovasc Surg 2020 Nov 10. Epub 2020 Nov 10.

Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1016/j.jtcvs.2020.09.143DOI Listing
November 2020

Randomized trials, observational studies, and the illusive search for the source of truth.

J Thorac Cardiovasc Surg 2020 Nov 10. Epub 2020 Nov 10.

Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, NY. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.10.120DOI Listing
November 2020

Commentary: Statistics: Embracing the ignorance.

Authors:
Paul Kurlansky

J Thorac Cardiovasc Surg 2020 Oct 29. Epub 2020 Oct 29.

Division of Cardiac Surgery, Columbia University, New York, NY. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.10.086DOI Listing
October 2020

Assessment of long-term outcomes: aortic valve reimplantation versus aortic valve and root replacement with biological valved conduit in aortic root aneurysm with tricuspid valve.

Eur J Cardiothorac Surg 2021 Apr;59(3):658-665

Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA.

Objectives: We compared the long-term outcomes between aortic valve reimplantation [David V (DV)] and aortic valve and root replacement with biological valved conduit [Bentall-De Bono (BD)] for the patients with aortic root aneurysm with tricuspid valve.

Methods: Among 876 patients who underwent aortic root replacement in our institution between 2005 and 2018, 371 patients who underwent DV (n = 199) or BD (n = 172) for aortic root aneurysm with tricuspid valve were retrospectively reviewed. Exclusion criteria included aortic stenosis, infective endocarditis, previous prosthetic aortic valve, bicuspid aortic valve, aortic dissection and mechanical Bentall procedure. Propensity score matching was performed based on the patient characteristics, matching 90 patients in each group. The primary end point was all-cause mortality. Secondary end points were reoperation for any cause and specifically for aortic valve-related cause.

Results: After propensity score matching, DV and BD groups each had 1 in-hospital mortality (1.1%). Survival at 10 years was 95.3% [95% confidence interval (CI) 85.8-98.5] in DV and 98.6% (95% CI 90.8-99.8) in BD (P = 0.345). The cumulative incidences of reoperation at 10 years in DV versus BD were 3.9% (95% CI 0.7-11.8) vs 18.1% (95% CI 6.9-33.4) for any cause (P = 0.046) and 1.9% (95% CI 0.1-8.8) vs 15.9% (95% CI 5.5-31.4) for aortic valve-related causes (P = 0.032). The reasons for valve-related reoperation were aortic insufficiency (3/5 in DV vs 5/10 in BD), aortic stenosis (0/5 vs 2/10) and infective endocarditis (2/5 vs 3/10).

Conclusions: Both DV and BD procedures for patients with aortic root aneurysm with tricuspid valve resulted in excellent 10-year survival. All-cause and aortic valve-related reoperations were significantly less frequent with valve-sparing root replacement, suggesting an advantage of DV over biological BD.
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http://dx.doi.org/10.1093/ejcts/ezaa389DOI Listing
April 2021

Commentary: Readmission risk reduction and the new age of data integration.

Authors:
Paul Kurlansky

J Thorac Cardiovasc Surg 2020 Oct 17. Epub 2020 Oct 17.

Division of Cardiac Surgery, Columbia University, New York, NY. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.10.031DOI Listing
October 2020

Higher Institutional Volume Reduces Mortality in Reoperative Proximal Thoracic Aortic Surgery.

Aorta (Stamford) 2020 Jun 5;8(3):59-65. Epub 2020 Nov 5.

Department of Surgery, New York-Presbyterian Hospital, Columbia University Aortic Surgery Center, Columbia University Irving Medical Center, New York, New York.

Objective:  This study aims to determine the impact of institutional volume on mortality in reoperative proximal thoracic aortic surgery patients using national outcomes data.

Methods:  The Nationwide Inpatient Sample was queried from 1998 to 2011 for patients with diagnoses of thoracic aneurysm and/or dissection who underwent open mediastinal repair. A total of 103,860 patients were identified. A total of 1,430 patients had prior cardiac surgery. Patients were further stratified into groups by institutional aortic volume: low (<12 cases/year), medium (12-39 cases/year), and high (40+ cases/year) volume. Multivariable risk-adjusted analysis accounting for emergent status and aortic dissection among other factors was performed to determine the impact of institutional volume on mortality.

Results:  Overall mortality was 12% in the reoperative population. When the redo cohort was divided into tertiles, high-volume group had a 5% operative mortality compared with 9 and 15% for the medium- and low-volume groups, respectively. Multivariable analysis revealed that patients operated on at low- (odds ratio [OR] = 5.0, 95% confidence interval [CI]: 2.6-9.6,  < 0.001) and medium-volume centers (OR = 2.1, 95% CI: 1.1-4.2,  = 0.03) had higher odds of mortality when compared with patients operated on at high-volume centers.

Conclusions:  High-volume aortic centers can significantly reduce mortality for reoperative aortic surgery, compared with lower volume institutions.
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http://dx.doi.org/10.1055/s-0040-1713860DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7644294PMC
June 2020

Ten-year outcomes of extracorporeal life support for in-hospital cardiac arrest at a tertiary center.

J Artif Organs 2020 Dec 3;23(4):321-327. Epub 2020 Oct 3.

Division of Cardiothoracic Surgery, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, 177 Fort Washington Ave, Milstein Hospital Building, 7GN-435, New York, NY, 10032, USA.

Extracorporeal cardiopulmonary resuscitation (ECPR) is controversial, given both the lack of evidence for improved outcomes and clarity on appropriate candidacy during time-sensitive cardiac arrest situations. The primary objective of our study was to identify factors predicting successful outcomes in ECPR patients.Between March 2007 and November 2018, 112 patients were placed on extracorporeal life support (ECLS) during active CPR (ECPR) at our institution. The primary outcome was survival to hospital discharge. Survivors and non-survivors were compared in terms of pre-cannulation comorbidities, laboratory values, and overall outcomes. Multivariable logistic regression was used to identify pre-cannulation predictors of in-hospital mortality. Among 112 patients, 44 (39%) patients survived to decannulation and 31 (28%) survived to hospital discharge. The median age was 60 years (IQR 45-72) with a median ECLS duration of 2.2 days (IQR 0.6-5.1). Patients who survived to discharge had lower rates of chronic kidney disease than non-survivors (19% vs. 41%, p = 0.046) and lower baseline creatinine values [median 1.2 mg/dL (IQR 0.8-1.7) vs. 1.7 (0.7-2.7), p = 0.008]. Median duration from CPR initiation to cannulation was 40 min (IQR 30-50) with no difference between survivors and non-survivors (p = 0.453). When controlling for age and CPR duration, multivariable logistic regression with pre-procedural risk factors identified pre-arrest serum creatinine as an independent predictor of mortality [OR 3.25 (95% CI 1.22-8.70), p = 0.019] and higher pre-arrest serum albumin as protective [OR 0.32 (95% CI 0.14-0.74), p = 0.007]. In our cohort, pre-arrest creatinine and albumin were independently predictive of in-hospital mortality during ECPR, while age and CPR duration were not.
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http://dx.doi.org/10.1007/s10047-020-01217-5DOI Listing
December 2020

Consequences of functional mitral regurgitation and atrial fibrillation in patients with left ventricular assist devices.

J Heart Lung Transplant 2020 12 3;39(12):1398-1407. Epub 2020 Sep 3.

Division of Cardiothoracic Surgery. Electronic address:

Background: Functional mitral regurgitation (MR) (FMR) and atrial fibrillation (AF) are common in patients undergoing left ventricular assist device (LVAD) implantation. However, the impact of FMR and AF on clinical outcomes is uncertain. This study aimed to investigate the characteristics and prognostic significance of FMR and AF in patients with LVADs.

Methods: We retrospectively reviewed all patients who underwent LVAD implantation at our center between January 2010 and December 2017. We defined significant FMR as the ratio of MR color jet area to left atrial area of >20% and persistent or permanent AF (PeAF) as persistent or permanent AF at LVAD implantation.

Results: A total of 380 patients were included in this analysis. Patients were divided into 6 groups: patients with no PeAF and no significant FMR (Group 1), patients with no PeAF but with significant FMR (Group 2), patients with PeAF but no significant FMR (Group 3), patients with PeAF and significant FMR (Group 4), patients with concomitant mitral valve surgery (MVS) at LVAD implantation and without PeAF (Group 5), and patients with concomitant MVS and with PeAF (Group 6). A total of 56 patients (15%) died within 2 years. Kaplan-Meier curve analysis demonstrated a 2-year survival of 81% in Group 1, 89% in Group 2, 87% in Group 3, 47% in Group 4, 87% in Group 5, and 79 % in Group 6 (log-rank test, p < 0.001). The multivariable Cox proportional-hazards model showed that classification in Group 4 was an independent predictor of mortality (hazard ratio, 4.31; 95% CI: 2.19-8.46; p < 0.001).

Conclusions: The coexistence of significant FMR and PeAF may represent a poor prognostic marker in patients undergoing LVAD implantation.
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http://dx.doi.org/10.1016/j.healun.2020.08.020DOI Listing
December 2020

Outcomes of Heart Transplantation in Adult Congenital Heart Disease With Prior Intracardiac Repair.

Ann Thorac Surg 2020 Sep 17. Epub 2020 Sep 17.

Department of Cardiovascular Surgery, Columbia University Medical Center, New York, New York. Electronic address:

Background: The number of patients with adult congenital heart disease (ACHD) who require orthotopic heart transplantation has increased rapidly in the past 2 decades. This study examined heart transplant outcomes of patients with ACHD who had previous cardiac surgery by using data from the United Network for Organ Sharing database.

Methods: Between January 2008 and March 2019, patients with ACHD who underwent previous cardiac surgery and subsequent heart transplantation were identified from the United Network for Organ Sharing database. As a control group, adult patients without congenital heart disease who had previous sternotomy and subsequent heart transplantation were extracted from the database. Propensity score matching was then used to compare outcomes between the 2 groups.

Results: There were 793 patients in the ACHD group and 8400 patients in the control group. Among well-matched groups of 486 patients each, 30-day mortality (8.2% vs 3.9%; P = .004) and perioperative need for dialysis (22.7% vs 13.3%; P < .001) were significantly higher in the ACHD group compared with the control group. However, there was no difference in 10-year survival between the groups (ACHD 66.0% vs control 64.1%; log-rank P = .353).

Conclusions: Compared with well-matched patients without ACHD but with previous sternotomy, patients with ACHD and previous intracardiac repair had a higher operative risk but similar 10-year survival.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.116DOI Listing
September 2020

Early venoarterial extracorporeal membrane oxygenation improves outcomes in post-cardiotomy shock.

J Artif Organs 2021 Mar 14;24(1):7-14. Epub 2020 Sep 14.

Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, 177 Fort Washington Avenue, New York, NY, 10032, USA.

Post-cardiotomy shock (PCS) is associated with substantial morbidity and mortality. We reviewed our 12-year experience of venoarterial extracorporeal membrane oxygenation (VA-ECMO) therapy for PCS. Between July 2007 and June 2018, 156 consecutive patients underwent VA-ECMO for PCS. We retrospectively investigated patient characteristics, indications, and management to determine factors affecting outcomes. Secondary analysis was performed by dividing the cohort into Era 1 (2007-2012, n = 52) and Era 2 (2013-2018, n = 104) for comparison. After a median of 4.70 days (interquartile range [IQR] 2.76-8.53) of ECMO support, 72 patients (46.1%) survived to discharge. In-hospital mortality decreased in Era 2 from 75 to 43.3% (P < 0.001). Survivors were cannulated at lower serum lactate (5.3 [IQR 2.8-8.2] versus 7.5 [4.7-10.7], P = 0.003) and vasoactive-inotropic score (22.7 [IQR 11.3-35.5] versus 28.1 [IQR 20.8-42.5], P = 0.017). Patients in Era 2 were more frequently cannulated intraoperatively (63.5% versus 34.6%, P = 0.002), earlier in their hospital course, and at lower levels of serum lactate and vasoactive-inotropic score than in Era 1. Independent risk factors for mortality included increased age (odds ratio [OR] 1.06, P = 0.002), serum lactate at cannulation (OR 1.17, P = 0.009), and vasoactive-inotropic score (OR 1.04, P = 0.009). Bleeding and limb ischemia were less common in Era 2. Overall, outcomes of ECMO for PCS improved over the study period. The survival benefit appears to be associated with earlier ECMO initiation before prolonged hypoperfusion occurs.
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http://dx.doi.org/10.1007/s10047-020-01212-wDOI Listing
March 2021

Methylene Blue Does Not Improve Vasoplegia After Left Ventricular Assist Device Implantation.

Ann Thorac Surg 2021 03 3;111(3):800-808. Epub 2020 Aug 3.

Department of Anesthesiology, Division of Adult Cardiothoracic Anesthesiology, Columbia University Irving Medical Center, New York, New York. Electronic address:

Background: Vasoplegia is a frequent complication of left ventricular assist device (LVAD) implantation. We investigated the effectiveness of methylene blue (MB) for vasoplegia in LVAD recipients.

Methods: Twenty-seven patients received MB for vasoplegia after LVAD implantation and met study criteria between March 2015 and May 2018. Propensity score inverse probability weighting identified 41 controls who did not receive MB for post-LVAD vasoplegia. Clinical outcomes were compared between control and MB groups and between patients who received doses during (n = 15) and after surgery (n = 12). Hemodynamics and vasopressor requirements were analyzed using analysis of covariance.

Results: Median total MB dose was 1.9 mg/kg (interquartile range, 1.2-2.2 mg/kg). Methylene blue recipients experienced a transient initial decline in norepinephrine requirement from 141 ng/kg per min (95% confidence interval [CI], 81-201 ng/kg per min) to 117 ng/kg per min (95% CI, 58-176 ng/kg per min; P = .022) and a delayed decline in vasopressin from 4.8 U/h (95% CI, 3.8-5.8 U/h) to 4.0 U/h (95% CI, 2.8-5.1 U/h) (P = .004). In-hospital mortality, postoperative complications, and end-organ dysfunction did not differ from those of controls. There were no observed differences in mean arterial pressure, vasopressor requirements, or outcomes between patients who received doses during or after surgery. Weighted overall mortality in the entire study cohort was 8.8%.

Conclusions: Although MB may affect vasopressor requirements, clinical outcomes in vasoplegia after LVAD implantation did not improve and were not affected by the timing of administration.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.172DOI Listing
March 2021

Multiple Arterial Grafting: A Critical Analysis.

Am J Cardiol 2020 10 12;132:178-179. Epub 2020 Jul 12.

Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 E 68th St, New York, New York 10065. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2020.07.001DOI Listing
October 2020