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Castro-Varela A, Schaff HV, Oh JK, Ghoniem K, Crestanello JA, Daly RC, Dearani JA, King KS, Greason KL. Diagnosis and surgical management of pericardial constriction after cardiac surgery. J Thorac Cardiovasc Surg 2024; 168:845-852. [PMID: 37295645 DOI: 10.1016/j.jtcvs.2023.05.032] [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: 04/08/2023] [Revised: 05/12/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Previous cardiac surgery is an increasingly common etiology of constrictive pericarditis, but there is a paucity of data on clinical presentation and outcome of surgical treatment. METHODS We reviewed data of 263 patients who underwent pericardiectomy for postoperative constriction from January 1, 1993, through July 1, 2017. Outcomes of interest were early and late mortality, as well as features of clinical presentation. RESULTS Median patient age was 64 (56-72) years, and the median interval between previous operation and pericardiectomy was 2.7 years (range, 0-54 years). Previous operations included coronary artery bypass grafting in 114 (43%), valve surgery in 85 (32%), combined coronary artery bypass grafting and valve surgery in 33 (13%), and other procedures in 31 (12%). Common presentations were symptoms of right heart failure in 221 (84%) or dyspnea in 42 (16%). Moderate-to-severe tricuspid valve regurgitation was present in 108 (41%) patients. There were 14 (5.5%) deaths within 30 days postoperatively, and survival at 5 and 10 years postoperatively was 61% and 44%. On multivariate analysis, older age (P = .013), diabetes (P = .019), and nonelective pericardiectomy within 2 years of cardiac surgery (P < .001) were associated with decreased long-term survival. CONCLUSIONS Pericardial constriction after cardiac surgery can present at any interval postoperatively. Symptoms and signs of right heart failure in patients with previous cardiac surgery should alert physicians to the possibility of pericardial constriction followed by a correct diagnosis. Pericardiectomy performed urgently following cardiac operation has poor long-term outcomes.
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Affiliation(s)
| | | | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Khaled Ghoniem
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minn
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
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2
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Al-Kazaz M, Klein AL, Oh JK, Crestanello JA, Cremer PC, Tong MZ, Koprivanac M, Fuster V, El-Hamamsy I, Adams DH, Johnston DR. Pericardial Diseases and Best Practices for Pericardiectomy: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 84:561-580. [PMID: 39084831 DOI: 10.1016/j.jacc.2024.05.048] [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: 03/15/2024] [Revised: 04/09/2024] [Accepted: 05/01/2024] [Indexed: 08/02/2024]
Abstract
Remarkable advances have occurred in the understanding of the pathophysiology of pericardial diseases and the role of multimodality imaging in this field. Medical therapy and surgical options for pericardial diseases have also evolved substantially. Pericardiectomy is indicated for chronic or irreversible constrictive pericarditis, refractory recurrent pericarditis despite optimal medical therapy, or partial agenesis of the pericardium with a complication (eg, herniation). A multidisciplinary evaluation before pericardiectomy is essential for optimal patient outcomes. Overall, given the good outcomes reported, radical pericardiectomy on cardiopulmonary bypass, if feasible, is the preferred approach. Due to patient complexity, as well as the technical aspects of the surgery, pericardiectomy should be performed at high-volume centers that have the required expertise. The current review highlights the essential features of this multidisciplinary approach from diagnosis to recovery in patients undergoing pericardiectomy.
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Affiliation(s)
- Mohamed Al-Kazaz
- Bluhm Cardiovascular Institute, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul C Cremer
- Bluhm Cardiovascular Institute, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Bluhm Cardiovascular Institute, Division of Cardiology, Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael Z Tong
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Valentin Fuster
- The Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David H Adams
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Douglas R Johnston
- Bluhm Cardiovascular Institute, Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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3
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Moros D, Zaki A, Tong MZY. Surgical Approaches for Pericardial Diseases: What Is New? Curr Cardiol Rep 2023; 25:1705-1713. [PMID: 37938424 DOI: 10.1007/s11886-023-01986-4] [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] [Accepted: 10/18/2023] [Indexed: 11/09/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the evolving techniques and approaches for pericardiectomy, with a focus on the use of cardiopulmonary bypass (CPB) and the extent of radical pericardial resection. The review aims to highlight the benefits and considerations associated with these modifications in radical pericardiectomy. RECENT FINDINGS Recent studies have demonstrated that the use of CPB during pericardiectomy does not increase procedural risk or negatively impact survival. In fact, it has been shown to contribute to a more radical resection and improve postoperative outcomes, which is associated with less recurrence and better survival. The review emphasizes the importance of radical pericardiectomy and the use of CPB in achieving successful outcomes. Radical resection of the pericardium, facilitated by CPB, helps minimize the risk of recurrent constrictions and the need for reinterventions. The findings highlight the correlation between postoperative outcomes and survival, further supporting the use of CPB.
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Affiliation(s)
- David Moros
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Anthony Zaki
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Michael Zhen-Yu Tong
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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4
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Affiliation(s)
- Gurleen Kaur
- From the Department of Medicine (G.K., M.S.S., Y.-P.S., J.L.), TIMI Study Group, Division of Cardiovascular Medicine (M.S.S.), and the Department of Pathology (I.-M.S.), Brigham and Women's Hospital, Boston
| | - Marc S Sabatine
- From the Department of Medicine (G.K., M.S.S., Y.-P.S., J.L.), TIMI Study Group, Division of Cardiovascular Medicine (M.S.S.), and the Department of Pathology (I.-M.S.), Brigham and Women's Hospital, Boston
| | - Inga-Marie Schaefer
- From the Department of Medicine (G.K., M.S.S., Y.-P.S., J.L.), TIMI Study Group, Division of Cardiovascular Medicine (M.S.S.), and the Department of Pathology (I.-M.S.), Brigham and Women's Hospital, Boston
| | - Yee-Ping Sun
- From the Department of Medicine (G.K., M.S.S., Y.-P.S., J.L.), TIMI Study Group, Division of Cardiovascular Medicine (M.S.S.), and the Department of Pathology (I.-M.S.), Brigham and Women's Hospital, Boston
| | - Joseph Loscalzo
- From the Department of Medicine (G.K., M.S.S., Y.-P.S., J.L.), TIMI Study Group, Division of Cardiovascular Medicine (M.S.S.), and the Department of Pathology (I.-M.S.), Brigham and Women's Hospital, Boston
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5
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Castro-Varela A, Schaff HV. The Surgical Management of Pericardial Disease. Can J Cardiol 2023; 39:1136-1139. [PMID: 36738857 DOI: 10.1016/j.cjca.2023.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Affiliation(s)
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Oh NA, Hennecken C, Van den Eynde J, Doulamis IP, Avgerinos DV, Kampaktsis PN. Pericardiectomy and Pericardial Window for the Treatment of Pericardial Disease in the Contemporary Era. Curr Cardiol Rep 2022; 24:1619-1631. [PMID: 36029363 DOI: 10.1007/s11886-022-01773-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2022] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW To summarize the contemporary practice of pericardiectomy and pericardial window. We discuss the indications, preoperative planning, procedural aspects, postprocedural management, and outcomes of each procedure. RECENT FINDINGS Surgical approaches for the treatment of pericardial disease have been around even before the emergence of cardiopulmonary bypass. Since the forthcoming of cardiopulmonary bypass, there have been significant changes in the epidemiology and diagnostic approach of pericardial diseases as well as advancements in the surgical techniques and perioperative management used in the care of these patients. Pericardiectomy has an average mortality of almost 7% and is typically performed in patients with advanced symptoms from constrictive pericarditis and relatively few comorbidities. Pericardial window is a safe procedure for the treatment of pericardial effusion that can be performed with different approaches.
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Affiliation(s)
- Nicholas A Oh
- Department of Cardiothoracic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Carolyn Hennecken
- Division of Cardiology, New York Presbyterian Hospital, Columbia University Irving Medical Center, 177 Fort Washington Av, New York, NY, 10032, USA
| | - Jef Van den Eynde
- The Johns Hopkins Hospital and School of Medicine, Helen B. Taussig Heart Center, Baltimore, MD, USA
- Department of Cardiovascular Sciences, KU Leuven, Louvain, Belgium
| | - Ilias P Doulamis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dimitrios V Avgerinos
- Third Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - Polydoros N Kampaktsis
- Division of Cardiology, New York Presbyterian Hospital, Columbia University Irving Medical Center, 177 Fort Washington Av, New York, NY, 10032, USA.
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Castro-Varela A, Schaff HV. Dr Stuart Harrington: Historical challenges and success in pericardiectomy. JTCVS OPEN 2022; 10:303-307. [PMID: 36004268 PMCID: PMC9390389 DOI: 10.1016/j.xjon.2022.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/22/2022] [Accepted: 04/27/2022] [Indexed: 11/18/2022]
Affiliation(s)
| | - Hartzell V. Schaff
- Address for reprints: Hartzell V. Schaff, MD, Department of Cardiovascular Surgery, Mayo Clinic, 1216 2nd St. SW, Rochester, MN 55902.
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8
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Tabucanon RS, Wang TKM, Chetrit M, Furqan MM, Chan N, Pande A, Jellis CL, Cremer PC, Kwon DH, Johnston D, Klein AL. Worsened Tricuspid Regurgitation Following Pericardiectomy for Constrictive Pericarditis. Circ Cardiovasc Imaging 2021; 14:e012948. [PMID: 34607446 DOI: 10.1161/circimaging.121.012948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Worsening tricuspid regurgitation (TR) severity may occur after pericardiectomy surgery for constrictive pericarditis patients; however, its mechanisms and predictors are not well established. We evaluated the clinical characteristics, associated factors, and outcomes of worsening TR after pericardiectomy. METHODS Consecutive patients undergoing pericardiectomy for constrictive pericarditis without tricuspid valve surgery and with pre- and postoperative echocardiography available during 2000 to 2017 were retrospectively studied. Clinical, imaging, hemodynamic, and mortality characteristics were analyzed by those with and without worsening TR by at least one grade. RESULTS Among 381 patients (age 61 [17] years, 318 [83.5%] male), 193 (50.7%) had worsening TR post-operatively, and 75 died during the 2.5 (5.4) years follow-up. In univariable analysis, worsening TR was associated with a history of congestive heart failure (47.2% versus 31.9%, P=0.003), increased left atrial volume indexed (23 versus 20 mL/m2, P=0.020), reduced right ventricular fractional area change (47% versus 54%, P<0.001), and worsening mitral regurgitation (39.7% versus 16.6%, P<0.001). Worsened TR had a trend toward reduced survival during follow-up (log-rank P=0.080), especially those with worsened TR but no recovery of TR grade on subsequent echocardiography within the first year compared with those without worsened TR (log-rank P=0.02). In multivariable analysis, right ventricular fractional area change, left atrial volume indexed, left ventricular mass indexed, pulmonary artery systolic pressure, and right atrial pressure/pulmonary capillary wedge pressure ratio were most associated with worsened TR, while blood urea nitrogen, hematocrit, lateral and medial e' tissue Doppler and heart rate were most associated with mortality during follow-up. CONCLUSIONS Worsening TR severity was prevalent after pericardiectomy and had a trend toward reduced survival, especially if TR severity did not recover on subsequent echocardiography. Presence of parameters associated with worsened TR and reduced survival should alert clinicians to carefully manage these patients during follow-up.
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Affiliation(s)
- Ray S Tabucanon
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Tom Kai Ming Wang
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Michael Chetrit
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Muhammad M Furqan
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Nicholas Chan
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Amol Pande
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Christine L Jellis
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Paul C Cremer
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Deborah H Kwon
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Douglas Johnston
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (R.S.T., T.K.M.W., M.C., M.M.F., N.C., C.L.J., P.C.C., D.H.K., A.L.K.), Cleveland Clinic, OH.,Department of Thoracic and Cardiovascular Surgery (A.P., D.J.), Cleveland Clinic, OH
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Liu VC, Fritz AV, Burtoft MA, Martin AK, Greason KL, Ramakrishna H. Pericardiectomy for Constrictive Pericarditis: Analysis of Outcomes. J Cardiothorac Vasc Anesth 2021; 35:3797-3805. [PMID: 33722460 DOI: 10.1053/j.jvca.2021.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 01/17/2023]
Abstract
Constrictive pericarditis is caused by pericardial inflammation and fibrosis, leading to diastolic heart failure. The diagnosis requires a high index of suspicion because it often can mimic restrictive myocardial disease and cardiac tamponade and can be associated with severe tricuspid regurgitation and chronic liver disease. Patients who remain undiagnosed can experience a 90% mortality rate, and for those who undergo pericardiectomy, the survival rate varies significantly, depending on the underlying etiology and preoperative functional class of the patient. In this article, the authors review the pathophysiology, echocardiographic findings, management, and surgical outcomes of constrictive pericarditis to aid the cardiothoracic anesthesiologist in the perioperative management of this disorder.
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Affiliation(s)
- Victor C Liu
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Ashley V Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Melissa A Burtoft
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Archer K Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Goodwin ML, Mokadam NA. Commentary: Pick's Disease Picks the Chicken. Or the Egg? Semin Thorac Cardiovasc Surg 2020; 32:729. [PMID: 32464178 DOI: 10.1053/j.semtcvs.2020.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 05/16/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Matthew L Goodwin
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nahush A Mokadam
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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