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Lau C, Ram E, Harik L, Soletti G, Leith J, Mack CA, Gambardella I, Gaudino M, Girardi LN. Aortic valve degeneration after valve-sparing root replacement in patients with bicuspid aortopathy or connective tissue disorder. J Thorac Cardiovasc Surg 2025; 169:1696-1703. [PMID: 39084334 DOI: 10.1016/j.jtcvs.2024.07.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 07/14/2024] [Accepted: 07/22/2024] [Indexed: 08/02/2024]
Abstract
OBJECTIVE We sought to evaluate outcomes of valve-sparing root replacement (VSRR) in patients with bicuspid aortopathy (BAV) versus other connective tissue disorder (CTD). METHODS This was a single-center cohort study of consecutive patients undergoing VSRR via reimplantation from 2000 to 2023 with BAV or CTD. Operative outcomes, Kaplan-Meier survival estimates, and cumulative risk of reoperation and recurrent aortic insufficiency (AI) with the competing risk of death were assessed. RESULTS Of 516 patients who underwent VSRR, 109 (51.9%) had BAV and 101 (48.1%) had CTD. Patients with BAV were older (46.9 ± 10.4 vs 38.4 ± 14 years, P < .001) and more likely male (89.0% vs 56.4%, P < .001) and hypertensive (66.1% vs 28.7%, P < .001). Preoperative AI was similar (P = .57) between groups (30.3% mild, 18.3% moderate, 11.1% severe). Most patients had no/trivial immediate postoperative residual AI (96.3% vs 93.1%). Operative mortality was zero; postoperative adverse events were minimal. Mean clinical follow-up was 5.2 ± 4.4 years; 10-year survival was 95.6% versus 95.7% (P = .70). Echocardiographic follow-up was 3.9 ± 4.1 years; incidence of >2+ AI (9.7% vs 10.1%, P = 1.0) was similar between groups, whereas the incidence of moderate or greater aortic stenosis was greater with BAV (7.5% vs 0%, P = .02). Reoperation was low in both groups (3.7% vs 5.9%, P = .65). Competing risk analysis found no difference in reoperation hazard between BAV and CTD groups (hazard ratio, 0.36; 95% confidence interval, 0.07-1.81, P = .21). CONCLUSIONS Patients with BAV and CTD have excellent operative outcomes, no mortality, and minimal residual AI after VSRR. Although the incidence of recurrent AI was similar, patients with BAV are at risk for AS.
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Affiliation(s)
- Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
| | - Eilon Ram
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Jordan Leith
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Charles A Mack
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | | | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
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Schäfers HJ, Konstantinov IE. Surgical anatomy of aortic root: Toward precise and durable aortic, neo-aortic, and truncal valve repairs. J Thorac Cardiovasc Surg 2025; 169:1287-1295. [PMID: 39442865 DOI: 10.1016/j.jtcvs.2024.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2024] [Revised: 10/01/2024] [Accepted: 10/02/2024] [Indexed: 10/25/2024]
Affiliation(s)
- Hans-Joachim Schäfers
- Hospital Universitario Quironsalud Madrid, Madrid, Spain; Department of Thoracic and Cardiovascular Surgery, Westpfalz Klinikum, Kaiserslautern, Germany; Saarland University, Saarbrücken, Germany.
| | - Igor E Konstantinov
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia; Melbourne Children's Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia.
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3
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Schäfers HJ. Aortic root remodeling: A valid option. J Thorac Cardiovasc Surg 2025; 169:1210-1213.e1. [PMID: 38797431 DOI: 10.1016/j.jtcvs.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 05/13/2024] [Accepted: 05/19/2024] [Indexed: 05/29/2024]
Affiliation(s)
- Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Westpfalz Klinikum, Kaiserslautern, Germany; Faculty of Medicine, Saarland University, Homburg/Saar, Germany.
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4
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David TE, Park J, Steve Fan CP. Mitral valve surgery in patients with Marfan syndrome. J Thorac Cardiovasc Surg 2025; 169:599-605. [PMID: 38678476 DOI: 10.1016/j.jtcvs.2024.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/14/2024] [Accepted: 01/30/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVE To review the pathology of the mitral valve (MV) and long-term outcomes of surgery in patients with Marfan syndrome (MFS). PATIENTS AND METHODS From 1988 through 2020, 60 patients with MFS had surgery to correct mitral regurgitation (MR): 19 had isolated MV surgery, 32 had combined MV and aortic root surgery, and 9 had MV surgery after aortic root surgery. Follow-up was complete for a median of 16.1 years. RESULTS MV pathology was myxomatous degeneration in all patients and of advanced degree in 78.6% with bileaflet prolapse in 65.5%, mitral annulus disjunction in 57.5%, and mitral annulus calcification in 8.2% of patients. The MV was repaired in 47 patients and replaced in 13. Kaplan-Meier estimates of cumulative mortality at 20 years 21.3% for all patients, 6.7% after MV repair, and 57.8% after replacement (P < .001). MV reoperations were performed in 5 patients: 2 after repair and 3 after replacement. The cumulative incidence rate of reoperations on the MV was 3.8% at 10 years and 11.0% at 20 years in the entire cohort. Among 47 patients who had MV repair, moderate MR developed in 11 patients and severe in 2. Both patients with severe MR underwent MV reoperation. The cumulative incidence rate of recurrent moderate or severe MR after MV repair was 20.4% at 10 years, and 36.5% at 20 years. CONCLUSIONS MV repair was associated with better survival than MV replacement, but recurrent MR after repair occurred in approximately one-third of the patients at 20 years after surgery.
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Affiliation(s)
- Tirone E David
- Division of Cardiovascular Surgery of the Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada.
| | - Joy Park
- Division of Cardiovascular Surgery of the Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Chun-Po Steve Fan
- Division of Cardiovascular Surgery of the Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada
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5
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Accord RE, Koster C, Dulfer E, du Marchie Sarvaas GJ, Maass SWMC, Berger RMF, van den Berg MP. Diagnostic yield and therapeutic implications of 25 years of specialized pediatric Marfan clinic. Eur J Pediatr 2024; 184:25. [PMID: 39557716 DOI: 10.1007/s00431-024-05857-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2024] [Revised: 10/06/2024] [Accepted: 10/15/2024] [Indexed: 11/20/2024]
Abstract
The purpose of this study is to evaluate the diagnostic and therapeutic yield of a specialized clinic for children with suspicion of a hereditary thoracic aortic disease (HTAD), including Marfan Syndrome (MFS), and to investigate the diagnostic value of presenting symptoms and findings during evaluation. This retrospective observational study included all patients younger than 18 years old at initial referral between 1998 and 2018. Clinical data, medical treatment, surgical interventions, and clinical events during surveillance were collected until December 2023. A case-control comparison between patients with and without an eventual diagnosis of HTAD was performed using logistic regression analysis to investigate the diagnostic value of collected variables. A total of 355 children were referred and evaluated at the clinic, resulting in 89 new diagnoses, with a diagnostic yield of 21% HTAD, including 59 cases of MFS. Younger age at referral, ectopia lentis, aortic dilatation, and facial features were among the strongest predictors of MFS and other HTAD, while pectus excavatum and arm span-height ratio had no predictive value at childhood age. Of patients with MFS, 65% received antihypertensive medication, and 8% of patients with HTAD underwent prophylactic aortic surgery, in some cases even during childhood. Conclusion: Evaluation of children for HTAD in our specialized Marfan clinic resulted in a high diagnostic yield and subsequent therapeutic implications. Indeed, early recognition of symptoms and signs and referral to such a specialized clinic may lead to early diagnosis, surveillance, and timely treatment, thereby possibly limiting acute aortic events and even mortality.
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Affiliation(s)
- Ryan E Accord
- Center for Congenital Heart Diseases, Department of Cardiothoracic Surgery, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Chris Koster
- Center for Congenital Heart Diseases, Department of Cardiothoracic Surgery, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Eelco Dulfer
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gideon J du Marchie Sarvaas
- Center for Congenital Heart Diseases, Department of Pediatric Cardiology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Saskia W M C Maass
- Department of Primary and Long-term Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Department of Pediatric Cardiology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten P van den Berg
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Samman B, Mazine A, Ouzounian M. The 10 Commandments for Valve-Sparing Aortic Root Replacement. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024; 19:594-599. [PMID: 39586820 DOI: 10.1177/15569845241298251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2024]
Affiliation(s)
- Bana Samman
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, ON, Canada
| | - Amine Mazine
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, ON, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, ON, Canada
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Tajeddini F, Romero DA, Huang YX, David TE, Ouzounian M, Amon CH, Chung JC. Type B aortic dissection in Marfan patients after the David procedure: Insights from patient-specific simulation. JTCVS OPEN 2024; 21:1-16. [PMID: 39534345 PMCID: PMC11551291 DOI: 10.1016/j.xjon.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 04/03/2024] [Accepted: 04/17/2024] [Indexed: 11/16/2024]
Abstract
Objective An elevated risk of acute type B aortic dissection exists in patients with Marfan syndrome after the David procedure. This study explores hemodynamic changes in the descending aorta postsurgery. Methods A single-center retrospective review identified 5 patients with Marfan syndrome who experienced acute type B aortic dissection within 6 years after the David procedure, alongside 5 matched patients with Marfan syndrome without dissection more than 6 years postsurgery. Baseline and postoperative computed tomography and magnetic resonance scans were analyzed for aortic geometry reconstruction. Computational fluid dynamic simulations evaluated preoperative and postoperative hemodynamics. Results Patients with acute type B aortic dissection showed lower blood flow velocities, increased vortices, and altered velocity profiles in the proximal descending aorta compared with controls. Preoperatively, median time-averaged wall shear stress in the descending aorta was lower in patients with acute type B aortic dissection (control: 1.76 [1.50-2.83] Pa, dissection: 1.16 [1.06-1.30] Pa, P = .047). Postsurgery, neither group had significant time-averaged wall shear stress changes (dissection: P = .69, control: P = .53). Localized analysis revealed surgery-induced time-averaged wall shear stress increases near the subclavian artery in the dissection group (range, +0.30 to +1.05 Pa, each comparison, P < .05). No such changes were observed in controls. Oscillatory shear index and relative residence time were higher in patients with acute type B aortic dissection before and after surgery versus controls. Conclusions Hemodynamics likely play a role in post-David procedure acute type B aortic dissection. Further investigation into aortic geometry, hemodynamics, and postoperative acute type B aortic dissection is vital for enhancing outcomes and refining surgical strategies in patients with Marfan syndrome.
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Affiliation(s)
- Farshad Tajeddini
- Department of Mechanical & Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - David A. Romero
- Department of Mechanical & Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Yu Xuan Huang
- Department of Engineering Science, University of Toronto, Toronto, Ontario, Canada
| | - Tirone E. David
- Division of Cardiovascular Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Cristina H. Amon
- Department of Mechanical & Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C.Y. Chung
- Division of Cardiovascular Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
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Sá MP, Sultan I, Chu D. Invited Commentary: Annular Stabilization Is the Key to Connective Tissue Disorders. Am J Cardiol 2024; 215:87-88. [PMID: 38224727 DOI: 10.1016/j.amjcard.2023.12.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 12/29/2023] [Indexed: 01/17/2024]
Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Division of Cardiac Surgery, University of Pittsburgh Medical Center Heart & Vascular Institute, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Division of Cardiac Surgery, University of Pittsburgh Medical Center Heart & Vascular Institute, Pittsburgh, Pennsylvania
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Division of Cardiac Surgery, University of Pittsburgh Medical Center Heart & Vascular Institute, Pittsburgh, Pennsylvania.
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Burton S, Reynolds AC, King N, Modi A, Asopa S. Midterm Clinical Outcomes of Reimplantation Versus Remodeling Valve-Sparing Aortic Root Replacement in Patients With Connective Tissue Disorders: A Meta-Analysis. Am J Cardiol 2024; 213:28-35. [PMID: 38104753 DOI: 10.1016/j.amjcard.2023.11.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/13/2023] [Accepted: 11/29/2023] [Indexed: 12/19/2023]
Abstract
This meta-analysis aimed to compare the midterm clinical outcomes of reimplantation versus remodeling techniques for valve-sparing aortic root replacement (VSARR) in patients with connective tissue disorders (CTDs). Studies were screened and identified after the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines from the PubMed, Web of Science, and Embase databases. Forest plots were produced using Review Manager 5.3 (Cochrane, UK). Studies comparing early and midterm clinical outcomes of reimplantation versus remodeling VSARR in patients with CTD with a mean age ≥18 years were included. The sensitivity analysis excluded studies and subgroups of patients that received ring or suture annuloplasty in addition to remodeling surgery. The study selection identified 9 eligible studies. After analysis of the study period and location for patient crossover, 7 retrospective studies consisting of 597 patients (301 reimplantation and 296 remodeling) were pooled. The pooling revealed no significant difference in postoperative mortality (estimated mean follow-up of 10.5 years) (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.30 to 1.48, I2 = 30%, p = 0.32), reoperation (OR 0.35, CI 0.04 to 3.30, I2 = 81%, p = 0.36), or occurrence of postoperative aortic regurgitation of ≥2 (OR 0.56, CI 0.31 to 1.02, I2 = 47%, p = 0.06). The sensitivity analysis excluding annuloplasty demonstrated improved mortality (OR 0.19, CI 0.06 to 0.64, I2 = 0%, p = 0.007) and decreased aortic regurgitation of ≥2 (OR 0.23, CI 0.10 to 0.53, I2 = 47%, p = 0.0005) in reimplantation VSARR. The rates of reoperation remained insignificant in the sensitivity analysis (OR 0.43, CI 0.05 to 3.53, I2 = 71%, p = 0.43). In conclusion, this meta-analysis has demonstrated no significant difference in the midterm clinical outcomes of reimplantation versus remodeling techniques of VSARR. The sensitivity analysis excluding studies and patient subgroups that received remodeling and annuloplasty suggests remodeling alone to be inferior to reimplantation in patients with CTDs. Further research is required to assess remodeling and annuloplasty against reimplantation in patients of this demographic because the current body of knowledge does not allow sufficient analysis.
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Affiliation(s)
- Samuel Burton
- Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom.
| | | | - Nicola King
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | - Amit Modi
- Wessex Cardiac Centre, Southampton, United Kingdom
| | - Sanjay Asopa
- Southwest Cardiothoracic Centre, Plymouth, United Kingdom
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David TE. Aortic Valve Reimplantation or Aortic Root Replacement With a Valved Conduit? Ann Thorac Surg 2024; 117:76-77. [PMID: 37558150 DOI: 10.1016/j.athoracsur.2023.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/19/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Tirone E David
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, 200 Elizabeth St, 4N453, Toronto, ON M5G 2C4, Canada.
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Abstract
Aortic valve-sparing operations were developed >3 decades ago and have become part of the surgical armamentarium to treat patients with aortic root and ascending aortic aneurysms. Although remodeling of the aortic root is physiologically sounder than reimplantation of the aortic valve, most surgeons seem to prefer the latter. This review summarizes the views of one of the pioneers of aortic valve-sparing operation and includes their development, the various modifications that occurred over the years, comparative outcomes with aortic root replacement with valved conduits, outcomes from several recently reported series, and the future directions. The author argues that comparisons between aortic valve-sparing operations and aortic root replacement with valved conduits based on retrospective studies are inappropriate because these 2 types of surgery are performed in patients with different aortic valve pathology. Late outcomes after aortic valve-sparing operations have not been consistent among various reports and raise the question of surgical expertise and patients' selection. Aortic valve-sparing operations are the best treatment for young patients with aortic root aneurysm and normal aortic cusps. Further studies are needed to define their role in the management of patients with diseased aortic cusps.
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Affiliation(s)
- Tirone E David
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
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Coselli JS, Barron LM. Lifetime Aortic Management in Marfan Syndrome: Puzzle Pieces and Rare Diseases. J Am Coll Cardiol 2023; 82:1077-1079. [PMID: 37673509 DOI: 10.1016/j.jacc.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 09/08/2023]
Affiliation(s)
- Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas, USA.
| | - Lauren M Barron
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA
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