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Laven IEWG, van Polen EJ, Vissers YLJ, de Loos ER. Scapula alata, a rare complication after minimally invasive repair of pectus excavatum. BMJ Case Rep 2024; 17:e260788. [PMID: 38802259 DOI: 10.1136/bcr-2024-260788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
A male patient in his early 30s underwent minimally invasive repair of pectus excavatum. According to standard Nuss bar procedure, a 30-degree thoracoscope was introduced through a right midaxillary 10 mm trocar in the 4th intercostal space. Two bars and five stabilisers were placed in a retromuscular position. After discharge, the patient experienced right upper back pain requiring prolonged opioid usage for three months and right scapular winging limiting functional activities. After conservative treatment with physiotherapy for 11 months, the patient still suffered from residual scapula alata with pain and muscle weakness. On suspicion of long thoracic nerve neuropraxia related to the thoracoscope placement, an electromyogram was conducted 16 months following surgery, revealing mild polyphasic potentials of the serratus anterior muscle without abnormal muscle unit action potential. After extended conservative therapy for another year, physical examination 28 months after surgery showed almost complete resolution of scapular winging.
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Affiliation(s)
- Iris E W G Laven
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre Heerlen, Heerlen, the Netherlands
| | - Elise J van Polen
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre Heerlen, Heerlen, the Netherlands
| | - Yvonne L J Vissers
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre Heerlen, Heerlen, the Netherlands
| | - Erik R de Loos
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre Heerlen, Heerlen, the Netherlands
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Zeineddine RM, Botros M, Shawwaf KA, Moosavi R, Aly MR, Farina JM, Lackey JJ, Sandstrom BA, Jaroszewski DE. Does a high Haller index influence outcomes in pectus excavatum repair? J Thorac Cardiovasc Surg 2024:S0022-5223(24)00292-7. [PMID: 38608864 DOI: 10.1016/j.jtcvs.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/21/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE Severity for pectus excavatum includes Haller index (HI) > 3.25. An extremely high HI (≥8) may influence surgical approach and complications. This study reviews outcomes of patients with high HI after repair. METHODS A single institution retrospective analysis was performed on adult patients with HI ≥ 8 undergoing pectus excavatum repairs. For outcomes, a propensity score-matched control group with a HI ≤ 4 was utilized. RESULTS In total, 64 cases (mean age, 33.5 ± 10.9 years; HI, 13.1 ± 5.0; 56% women) were included. A minimally invasive repair was successful in 84%. A hybrid procedure was performed in the remaining either to repair fractures of the ribs (8 patients) and sternum (5 patients) or when osteotomy and/or cartilage resection was required (10 patients). In comparison with the matched cohort (HI ≤ 4), patients with high HI had longer operative times (171 vs 133 minutes; P < .001), more frequently required hybrid procedures (16% vs 2%; P = .005), experienced higher incidences of rib (22% vs 3%; P = .001) and sternal fractures (12% vs 0%; P = .003), and had increased repair with 3 bars (50% vs 19%; P < .001). There were no significant differences between the groups for length of hospital stay or postoperative 30-day complications. CONCLUSIONS Patients with an extremely high HI can be challenging cases with greater risks of fracture and need for osteotomy/cartilage resection. Despite this, minimally invasive repair techniques can be utilized in most cases without increased complications when performed by an experienced surgeon.
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Affiliation(s)
- Rawan M Zeineddine
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Michael Botros
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Kenan A Shawwaf
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Ryan Moosavi
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Mohamed R Aly
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Juan M Farina
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Jesse J Lackey
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Beth A Sandstrom
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz.
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Carter M, Prendergast F, Krauss J, Zeineddin S, Pitt JB, Sullivan GA, Abdullah F, Gulack BC, Goldstein SD. Evaluating Skeletal Maturity at Time of Surgical Correction of Pectus Excavatum Based on Medial Clavicle Epiphyseal Ossification. Am Surg 2024; 90:631-639. [PMID: 37824167 DOI: 10.1177/00031348231207296] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Surgical correction of pectus excavatum (SCOPE) is dependent upon chest wall pliability with optimal timing prior to complete skeletal maturation. Measures of skeletal maturity are not readily available for operative planning; therefore, surgeons use age as proxy despite patient-specific rates of skeletal maturation. We aimed to determine whether preoperative skeletal maturity is associated with postoperative pain as surrogate for chest wall pliability. METHODS Children ≤18 years who underwent SCOPE from 2020 to 2022 were retrospectively identified. Preoperative CT within 3 months of procedure was reviewed by 2 radiologists and 1 surgeon. Skeletal maturity was determined by Schmeling-Kellinghaus classification which stages secondary epiphyseal ossification of the medial clavicle. Inter-rater reliability was evaluated. Schmeling-Kellinghaus stage and postoperative pain were compared. RESULTS Of twenty-eight records reviewed, 57% were Schmeling-Kellinghaus stage 1. High inter-rater reliability was identified (inter-radiologist: kappa = .95, P < .001, all raters: kappa = .78, P < .001). Median age at operation was 15.5 years (interquartile range: 14.8-16.0) and increased with skeletal maturity (P < .001). When comparing stage 1 (n = 16) to >1 (n = 12), stage 1 had lower maximum pain scores (P < .001), total morphine equivalents (P < .001), and benzodiazepine use (P < .001) after surgery. CONCLUSIONS The Schmeling-Kellinghaus classification system is a valid proxy of skeletal maturity that can be applied with high inter-rater reliability. SCOPE during stage 1 was found to have less postoperative pain and narcotic use than more mature stages. This is proof of concept that skeletal maturity should be considered when determining optimal timing of surgical correction. Future research will evaluate the impact of skeletal maturity on postoperative outcomes.
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Affiliation(s)
- Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Francis Prendergast
- Department of Radiology, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jillian Krauss
- Department of Radiology, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gwyneth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brian C Gulack
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Media AS, Christensen TD, Katballe N, Juhl-Olsen P, Vad H, Petersen RH, Højsgaard A, Vincenzo de Paoli F. Complication rates rise with age and Haller index in minimally invasive correction of pectus excavatum: A high-volume, single-center retrospective cohort study. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00107-7. [PMID: 38340954 DOI: 10.1016/j.jtcvs.2024.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 01/09/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVES The study objectives were to describe the compounded complication rate of minimally invasive repair of pectus excavatum, identify predisposing risk factors, and evaluate the optimal timing of correction. Minimally invasive repair of pectus excavatum is the standard treatment for pectus excavatum and consists of 2 invasive procedures, for example, correction with bar insertion followed by bar removal after 2 to 3 years. METHODS A retrospective cohort study identifying children, adolescents, and adults of both genders corrected for pectus excavatum with minimally invasive repair of pectus excavatum between 2001 and 2022. Information on complications related to bar insertion and removal procedures for each individual patient was compiled into a compounded complication rate. Complication severities were categorized according to the Clavien-Dindo classification. RESULTS A total of 2013 patients were corrected by minimally invasive repair of pectus excavatum with a median age (interquartile range) for correction of 16.6 (5) years. Overall compounded complication rate occurred at a frequency of 16.4%, of which 9.3% required invasive reinterventions (Clavien-Dindo classification ≥IIIa). The complication rate related to bar insertion was 2.6-fold higher compared with bar removal (11.8% vs 4.5%, respectively). Multivariable analysis revealed age (adjusted odds ratio, 1.05; P < .001), precorrection Haller Index (adjusted odds ratio, 1.10; P < .033), and early-phase institutional experience (adjusted odds ratio, 1.59; P < .002) as independent predisposing risk factors. The optimal age of correction was 12 years, and the compounded complication rate correlated exponentially with age with a doubling time of 7.2 years. Complications increased 2.2-fold when the Haller index increased to 5 or more units. CONCLUSIONS Minimally invasive repair of pectus excavatum is associated with a high compounded complication rate that increases exponentially with age and high Haller Index. Consequently, we recommend repair during late childhood and early adolescence, and emphasize the importance of informing patients and relatives about the significant risks of adult correction as well as the need of 2 consecutive procedures taking the complication profile into account before planning surgery.
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Affiliation(s)
- Ara S Media
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Katballe
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Juhl-Olsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Vad
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | | | - Anette Højsgaard
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Frank Vincenzo de Paoli
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Biomedicine, Aarhus University, Aarhus, Denmark.
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Carter M, Linton S, Zeineddin S, Pitt JB, Figueroa A, Perez A, Park E, DeTella M, Kwon S, Goldstein SD, Ghomrawi H, Abdullah F. Consumer Wearables Define a Normative Recovery Trajectory Following the Modified Nuss Procedure. J Surg Res 2023; 292:7-13. [PMID: 37567031 DOI: 10.1016/j.jss.2023.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 06/23/2023] [Accepted: 07/05/2023] [Indexed: 08/13/2023]
Abstract
INTRODUCTION The modified Nuss procedure is an elective procedure associated with a lengthy recovery, uncontrolled pain, and risk of infrequent, yet life-threatening complications. The absence of objective measures of normative postoperative recovery creates uncertainty about the postdischarge period, which remains highly dependent on the patients' and their caregivers' expectations and management of recovery. We aimed to describe an objective-normative, physical activity recovery trajectory after the modified Nuss procedure, using step counts from the Fitbit. METHODS This observational study enrolled children ≤18 y with pectus excavatum who underwent the modified Nuss procedure from 2021 to 2022. The Fitbit was worn for 21 postoperative days. Postdischarge outcomes and health-care utilization were evaluated. For patients without postoperative complications, piecewise linear regression analysis was conducted to generate a normative recovery trajectory model of daily step counts. RESULTS Of 80 patients enrolled, 66 (86%) met eligibility criteria (mean age, 15.1 ± 1.3 y; 89.4% male, 62.1% non-Hispanic White). The mean number of telephone and electronic message encounters regarding concerns with the patient's recovery within 30 d postoperatively was 2.1 (standard deviation = 2.7). Ten patients (15.2%) returned to the emergency department (ED) within the 30-d postoperative period. Seven patients (10.6%) presented to the ED one time, and three patients (4.5%) presented to the ED twice. Thirty-day readmission rate was four patients (6.0%). Piecewise regression model showed that patients without complications steadily increased their daily step count on each postoperative day and plateaued on day 18. CONCLUSIONS We have developed a normative recovery trajectory following the modified Nuss procedure using step count data collected by a consumer wearable device. This offers the potential to inform preoperative patient expectations and reduce avoidable health-care utilization through informed preoperative counseling, thus laying the ground work for the use of consumer wearable devices as a postdischarge remote monitoring tool.
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Affiliation(s)
- Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Samuel Linton
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Angie Figueroa
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Amparo Perez
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Erica Park
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Mia DeTella
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Soyang Kwon
- The Smith Child Health Research Program, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Hassan Ghomrawi
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Medicine (Rheumatology) and Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
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Cujiño-Álvarez IF, Torres-Salazar D, Velásquez-Galvis M. Cardiorespiratory arrest during and after nuss procedure: case report. J Cardiothorac Surg 2023; 18:166. [PMID: 37118746 PMCID: PMC10148508 DOI: 10.1186/s13019-023-02262-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 04/03/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Pectum excavatum is a congenital thoracic alteration that can present important physiological alterations depending on the severity of the case. The Nuss procedure is a minimally invasive technique for managing chest wall deformity, in which there is a risk of perioperative complications. CASE PRESENTATION This article presents the case of a 16-year-old patient who underwent placement of a Nuss bar and suffered intraoperative and postoperative cardiorespiratory arrest. CONCLUSIONS it is important to consider the possible early and late complications scenarios as well as their treatment in patients with pectum excavatum scheduled for a Nuss procedure.
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Affiliation(s)
- Indira F Cujiño-Álvarez
- Anesthesiology Department, Anesthestiologist. Fundación Valle del Lili, Cra 98 No. 18-49, Cali, 760032, Colombia.
| | - Daniela Torres-Salazar
- Anesthesiology Resident. Universidad Icesi, Facultad de Ciencias de la Salud, Calle 18 No. 122- 135, Cali, Colombia
| | - Mauricio Velásquez-Galvis
- Thoracic Surgery Department, Thoracic Surgeon. Fundación Valle del Lili, Cra 98 No. 18-49, Cali, 760032, Colombia
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Complications following metal bar removal after Nuss repair are rare in a duocentric retrospective evaluation. Pediatr Surg Int 2022; 38:1919-1924. [PMID: 36138322 PMCID: PMC9653328 DOI: 10.1007/s00383-022-05250-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE Minimally invasive pectus excavatum repair has gained widespread acceptance and its results and complications are well-described. However, there is a substantial debate on the risks and frequencies of complications following metal bar removal. We, therefore, aimed to analyse all complications that occurred during and after metal bar removal at our two paediatric surgical centres. METHODS Bar removal surgeries were identified via procedural codes and electronic records were reviewed using a pre-specified data extraction chart. Both intra- and postoperative complications were included and the latter scored according to Clavien-Dindo. We analysed the influence of the pre-specified potential predictors age, sex, and the number of implanted metal bars on the occurrence of complications using logistic regression. RESULTS We included 279 patients with a median age of 19 years (interquartile range 17-20 years). 15 patients experienced 17 complications. Of 11 postoperative complications, only an enlarging pleural effusion required a chest drain in local anaesthesia, resulting in a Claven-Dindo grade IIIa, whereas the remainder were classified as grade I. Neither age (adjusted odds ratio (aOR) 0.97, 95% confidence interval (CI) 0.84-1.13, P = 0.73), nor sex (aOR 0.88, 95% CI 0.19-4.07, P = 0.87) or the number of bars (aOR 0.64, 95% CI 0.15-2.71, P = 0.547) did influence the occurrence of complications. CONCLUSION Complications following metal bar removal were scarce in our duocentric retrospective series and usually of minor relevance. However, to address the perceived paucity of data on the frequency and severity of complications following metal bar removal, further studies, including large database research is necessary.
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Chavoin JP, Facchini F, Leyx P, Hunt I, Benjoar MD, Molins L, Tiffet O, Ratdke C, Dornseifer U, Giovannini M, Chaput B, Redmond K. [Place of 3D custom-made implants after failure of modeling steno-chondro-plasties]. ANN CHIR PLAST ESTH 2022; 67:414-424. [PMID: 35933312 DOI: 10.1016/j.anplas.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Most common congenital malformation of the thorax, Pectus Excavatum affects about one in 500 people. Several surgical or medical techniques have been proposed. Some are followed by complications or insufficient results even though their constant functional value is highly controversial. Secondary surgery with a deep customized 3D elastomer implant, may be an elegant effective and safe solution compared to others; it allows a good aesthetic result expected by patients in the absence of any respiratory or cardio-vascular functional context.
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Affiliation(s)
- J-P Chavoin
- Service de chirurgie plastique reconstructrice et esthétique, CHU Toulouse Rangueil, 1, avenue Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France.
| | - F Facchini
- Service de chirurgie infantile, Hopital pédiatrique Meyer, Viale Gaetano Pieraccini 24, 50139 Florence, Italie
| | - P Leyx
- Recherche et développement, Anatomik Modeling SAS, 19, rue Jean Mermoz, 31100 Toulouse, France
| | - I Hunt
- Pectus Clinic, service de chirurgie thoraciqueSpire St. Anthony's Hospital Worcester Park, Sutton SM3, 9DW Londres, Royaume Uni
| | | | - L Molins
- Hôpital Clinique universitaire du Sacré-cœur, C. de Viladomat 288, 08029 Barcelone, Espagne
| | - O Tiffet
- Service de chirurgie Thoracique, CHU de St.Etienne, hôpital Nord, avenue Albert Raimond, 42270 Saint-Etienne, France
| | - C Ratdke
- Service de chirurgie plastique reconstructrice et esthétique, clinique universitaire de Vienne, 18-20 Waringer Gurtel, 1090 Vienne, Autriche
| | - U Dornseifer
- Service de chirurgie plastique reconstructrice et esthétique, Isar Klinikum, Sonnenstrasse 24-26, 80331 Munich, Allemagne
| | - M Giovannini
- Chirurgie Générale et thoracique, via di Roncrio 25, 40100 Bologne, Italie
| | - B Chaput
- Service de chirurgie plastique reconstructrice et esthétique, CHU Toulouse Rangueil, 1, avenue Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France
| | - K Redmond
- Service de Chirurgie cardio-thoracique Hôpital Universitaire Mater Misericordia, Ecole street, Dublin 7, Irlande
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