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Huang Y, Ouyang C, He F, Zhong Y, Liu G, Lu Y, Chen Y. Bilateral parasternal and rectus sheath blocks reduce pain post-cardiac surgery: a pilot trial. Front Surg 2025; 12:1526890. [PMID: 40052097 PMCID: PMC11882555 DOI: 10.3389/fsurg.2025.1526890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2024] [Accepted: 01/24/2025] [Indexed: 03/09/2025] Open
Abstract
Objective This study aimed to investigate the effects of ultrasound-guided bilateral parasternal block (PSB) combined with rectus sheath block (RSB) on postoperative recovery quality in patients undergoing median sternotomy for cardiac surgery. Methods Eighty patients were randomly assigned to either the intervention group (receiving PSB + RSB, n = 40) or the control group (not receiving PSB + RSB, n = 40). The primary outcome was opioid consumption within the first 24 h postoperatively. Secondary outcomes included Visual Analog Scale (VAS) pain scores and various surgery and recovery-related parameters. Results The intervention group showed significantly reduced opioid consumption in the first 24 h postoperatively compared to the control group (P < 0.05), though no significant difference was observed at 48 h postoperatively. VAS pain scores at extubation and at 12, 24, and 48 h post-extubation were significantly lower in the intervention group (P < 0.05). The intervention group also demonstrated superior Quality of Recovery-15 (QoR-15) scores at all observed time points compared to the control group (P < 0.05), with no block-related adverse events. There were no significant differences in surgical and recovery-related parameters between the groups. Conclusion Ultrasound-guided bilateral PSB combined with RSB effectively enhances postoperative analgesia and the quality of recovery in patients undergoing median sternotomy for cardiac surgery. The application of ultrasound-guided bilateral parasternal block combined with rectus sheath block in median sternotomy cardiac surgery offers a new pain management strategy that is both safe and highly effective. This approach reduces postoperative analgesic requirements and improves recovery quality for cardiac surgery patients. Clinical Trial Registration https://www.chictr.org.cn/showproj.html?proj=180456, China Clinical Trial Registry (ChiCTR2200064733).
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Affiliation(s)
| | | | | | | | | | - Yizhi Lu
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yanhua Chen
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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Miazza J, Reuthebuch B, Bruehlmeier F, Camponovo U, Maguire R, Koechlin L, Vasiloi I, Gahl B, Vöhringer L, Reuthebuch O, Eckstein F, Santer D. First Report on Rigid Plate Fixation for Enhanced Sternal Closure in Minimally Invasive Cardiac Surgery: Safety and Outcomes. Bioengineering (Basel) 2024; 11:1280. [PMID: 39768097 PMCID: PMC11673957 DOI: 10.3390/bioengineering11121280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2024] [Revised: 12/11/2024] [Accepted: 12/13/2024] [Indexed: 01/11/2025] Open
Abstract
INTRODUCTION This study reports of the use of a rigid-plate fixation (RPF) system designed for sternal closure after minimally invasive cardiac surgery (MICS). METHODS This retrospective analysis included all patients undergoing MICS with RPF (Zimmer Biomet, Jacksonville, FL, USA) at our institution. We analyzed in-hospital complications, as well as sternal complications and sternal pain at discharge and at follow-up 7 to 14 months after surgery. RESULTS Between June and December 2023, 12 patients underwent RPF during MICS, of which 9 patients were included in the study. The median (IQR) age was 64 years (63 to 71) and two patients (22%) were female. All patients underwent aortic valve replacement, with two patients (22%) undergoing concomitant aortic surgery. RPF was successfully performed in all patients. ICU and in-hospital stay were 1 day (1 to 1) and 9 days (7 to 13), respectively. Patients were first mobilized in the standing position on postoperative day 2 (2 to 2). Four patients (44%) required opiates on the general ward. In-hospital mortality was 0%. At discharge, rates of sternal pain, sternal instability or infection were 0%. After a follow-up time of 343.6 days (217 to 433), median pain intensity using the Visual Analog Scale was 0 (0 to 2). Forty-four percent (n = 4) of patients reported pain at rest. No sternal complications (sternal dehiscence, sternal mal-union, sternal instability, superficial wound infections and deep sternal wound infections) were reported. CONCLUSIONS In the evolving landscape of cardiac therapies with incentives to reduce surgical burden, RPF showed safety and feasibility. It might become an important tool for sternal closure in minimally invasive cardiac surgery.
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Affiliation(s)
- Jules Miazza
- Department of Cardiac Surgery, University Hospital of Basel, 4031 Basel, Switzerland; (J.M.); (B.R.); (F.B.); (U.C.); (R.M.); (L.K.); (I.V.); (B.G.); (L.V.); (O.R.); (F.E.)
| | - Benedikt Reuthebuch
- Department of Cardiac Surgery, University Hospital of Basel, 4031 Basel, Switzerland; (J.M.); (B.R.); (F.B.); (U.C.); (R.M.); (L.K.); (I.V.); (B.G.); (L.V.); (O.R.); (F.E.)
| | - Florian Bruehlmeier
- Department of Cardiac Surgery, University Hospital of Basel, 4031 Basel, Switzerland; (J.M.); (B.R.); (F.B.); (U.C.); (R.M.); (L.K.); (I.V.); (B.G.); (L.V.); (O.R.); (F.E.)
| | - Ulisse Camponovo
- Department of Cardiac Surgery, University Hospital of Basel, 4031 Basel, Switzerland; (J.M.); (B.R.); (F.B.); (U.C.); (R.M.); (L.K.); (I.V.); (B.G.); (L.V.); (O.R.); (F.E.)
| | - Rory Maguire
- Department of Cardiac Surgery, University Hospital of Basel, 4031 Basel, Switzerland; (J.M.); (B.R.); (F.B.); (U.C.); (R.M.); (L.K.); (I.V.); (B.G.); (L.V.); (O.R.); (F.E.)
| | - Luca Koechlin
- Department of Cardiac Surgery, University Hospital of Basel, 4031 Basel, Switzerland; (J.M.); (B.R.); (F.B.); (U.C.); (R.M.); (L.K.); (I.V.); (B.G.); (L.V.); (O.R.); (F.E.)
| | - Ion Vasiloi
- Department of Cardiac Surgery, University Hospital of Basel, 4031 Basel, Switzerland; (J.M.); (B.R.); (F.B.); (U.C.); (R.M.); (L.K.); (I.V.); (B.G.); (L.V.); (O.R.); (F.E.)
| | - Brigitta Gahl
- Department of Cardiac Surgery, University Hospital of Basel, 4031 Basel, Switzerland; (J.M.); (B.R.); (F.B.); (U.C.); (R.M.); (L.K.); (I.V.); (B.G.); (L.V.); (O.R.); (F.E.)
| | - Luise Vöhringer
- Department of Cardiac Surgery, University Hospital of Basel, 4031 Basel, Switzerland; (J.M.); (B.R.); (F.B.); (U.C.); (R.M.); (L.K.); (I.V.); (B.G.); (L.V.); (O.R.); (F.E.)
| | - Oliver Reuthebuch
- Department of Cardiac Surgery, University Hospital of Basel, 4031 Basel, Switzerland; (J.M.); (B.R.); (F.B.); (U.C.); (R.M.); (L.K.); (I.V.); (B.G.); (L.V.); (O.R.); (F.E.)
- Medical Faculty, University Basel, 4056 Basel, Switzerland
| | - Friedrich Eckstein
- Department of Cardiac Surgery, University Hospital of Basel, 4031 Basel, Switzerland; (J.M.); (B.R.); (F.B.); (U.C.); (R.M.); (L.K.); (I.V.); (B.G.); (L.V.); (O.R.); (F.E.)
- Medical Faculty, University Basel, 4056 Basel, Switzerland
| | - David Santer
- Department of Cardiac Surgery, University Hospital of Basel, 4031 Basel, Switzerland; (J.M.); (B.R.); (F.B.); (U.C.); (R.M.); (L.K.); (I.V.); (B.G.); (L.V.); (O.R.); (F.E.)
- Medical Faculty, University Basel, 4056 Basel, Switzerland
- Center for Biomedical Research and Translational Surgery, Medical University of Vienna, 1090 Vienna, Austria
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Gerdisch MW, Johns CM, Barksdale A, Parikshak M. Rigid Sternal Fixation and Enhanced Recovery for Opioid-Free Analgesia After Cardiac Surgery. Ann Thorac Surg 2024; 118:931-939. [PMID: 39004198 DOI: 10.1016/j.athoracsur.2024.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 06/12/2024] [Accepted: 06/17/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND We evaluated the individual contributions of rigid-plate fixation (RPF) and an enhanced recovery protocol (ERP) on postoperative pain, opioid use, and other outcomes after median sternotomy as they were sequentially adopted into practice. METHODS This single-center, retrospective, case-cohort study compared outcomes between median sternotomy patients (all comers) who underwent operation before implementation of RPF or ERP ("controls"), patients closed with RPF before ERP implementation ("RPF-only"), and patients managed with RPF and ERP during early "RPF+ERP-2020" and late "RPF+ERP-2022" implementation. RESULTS The analysis included 608 median sternotomy patients (mean age, 65.7 ± 10.8 years; 29.6% women). Of those, 59.2% were isolated coronary artery bypass grafting, 7.7% were isolated valve procedures, and the rest were mixed/concomitant procedures. Median in-hospital, postoperative opioid administration was 172.5 morphine milligram equivalents (MMEs) in the control cohort vs 0 MMEs for RPF+ERP-2022 (P < .0001), despite similar or slightly reduced patient-reported pain scores. The proportion of patients discharged directly to home was 66.2% for controls, 79.6% for RPF-only (P = .010), and 93.5% for RPF+ERP-2022 (P < .0001). Median opioids prescribed at discharge were 600 MMEs for controls and 0 for RPF+ERP-2020 and RPF+ERP-2022 (P < .0001). At discharge, 86.7% of RPF-only patients received prescription opioids vs 5% in RPF+ERP-2020 and 4.3% RPF+ERP-2022 (P < .0001). These outcomes occurred without increased readmissions. CONCLUSIONS Systematic implementation of RPF and ERP was associated with a significant and clinically meaningful decrease in opioid use in this large, real-world patient population.
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Affiliation(s)
- Marc W Gerdisch
- Department of Cardiothoracic Surgery, Franciscan Health Heart Center, Indianapolis, Indiana.
| | - Chanice M Johns
- Department of Cardiothoracic Surgery, Franciscan Health Heart Center, Indianapolis, Indiana
| | - Andrew Barksdale
- Department of Cardiothoracic Surgery, Franciscan Health Heart Center, Indianapolis, Indiana
| | - Manesh Parikshak
- Department of Cardiothoracic Surgery, Franciscan Health Heart Center, Indianapolis, Indiana
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Miazza J, Vasiloi I, Koechlin L, Gahl B, Reuthebuch O, Eckstein FS, Santer D. Combined Band and Plate Fixation as a New Individual Option for Patients at Risk of Sternal Complications after Cardiac Surgery: A Single-Center Experience. Biomedicines 2023; 11:1946. [PMID: 37509585 PMCID: PMC10377508 DOI: 10.3390/biomedicines11071946] [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: 05/18/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
Due to the advent of interventional therapies for low- and intermediate-risk patients, case complexity has increased in cardiac surgery over the last decades. Despite the surgical progress achieved to keep up with the increase in the number of high-risk patients, the prevention of sternal complications remains a challenge requiring new, individualized sternal closure techniques. The aim of this study was to evaluate the safety and feasibility, as well as the in-hospital and long-term outcomes, of enhanced sternal closure with combined band and plate fixation using the new SternaLock® 360 (SL360) system as an alternative to sternal wiring. From 2020 to 2022, 17 patients underwent enhanced sternal closure using the SL360 at our institution. We analyzed perioperative data, as well as clinical and radiologic follow-up data. The results were as follows: In total, 82% of the patients were treated with the SL360 based on perioperative risk factors, while in 18% of cases, the SL360 was used for secondary closure due to sternal instability. No perioperative complications were observed. We obtained the follow-up data of 82% of the patients (median follow-up time: 141 (47.8 to 511.5) days), showing no surgical revision, no sternal instability, no deep wound infections, and no sternal pain at the follow-up. In one case, a superficial wound infection was treated with antibiotics. In conclusion, enhanced sternal closure with the SL360 is easy to perform, effective, and safe. This system might be considered for both primary and secondary sternal closure in patients at risk of sternal complications.
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Affiliation(s)
- Jules Miazza
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| | - Ion Vasiloi
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| | - Luca Koechlin
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| | - Brigitta Gahl
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| | - Oliver Reuthebuch
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4031 Basel, Switzerland
| | - Friedrich S Eckstein
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4031 Basel, Switzerland
| | - David Santer
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4031 Basel, Switzerland
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Chatterjee S, Arora RC, Crisafi C, Crotwell S, Gerdisch MW, Katz NM, Lobdell KW, Morton-Bailey V, Pirris JP, Reddy VS, Salenger R, Varelmann D, Engelman DT. State of the art: Proceedings of the American Association for Thoracic Surgery Enhanced Recovery After Cardiac Surgery Summit. JTCVS OPEN 2023; 14:205-213. [PMID: 37425466 PMCID: PMC10328971 DOI: 10.1016/j.xjon.2023.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/08/2023] [Accepted: 03/31/2023] [Indexed: 07/11/2023]
Abstract
Despite the benefits established for multiple surgical specialties, enhanced recovery after surgery has been underused in cardiac surgery. A cardiac enhanced recovery after surgery summit was convened at the 102nd American Association for Thoracic Surgery annual meeting in May 2022 for experts to convey key enhanced recovery after surgery concepts, best practices, and applicable results for cardiac surgery. Topics included implementation of enhanced recovery after surgery, prehabilitation and nutrition, rigid sternal fixation, goal-directed therapy, and multimodal pain management.
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Affiliation(s)
- Subhasis Chatterjee
- Baylor College of Medicine & Thoracic Surgery ICU/ECMO, Texas Heart Institute, Baylor St Lukes Medical Center, Houston, Tex
| | - Rakesh C. Arora
- Perioperative and Cardiac Critical Care, Harrington Heart Vascular Institute at University Hospitals, Cleveland, Ohio
| | - Cheryl Crisafi
- Cardiac Surgery, Baystate Medical Center, Springfield, Mass
| | - Shannon Crotwell
- Cardiac Surgery Program Development, Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC
| | | | - Nevin M. Katz
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Kevin W. Lobdell
- Cardiovascular Quality, Education and Research, Sanger Heart & Vascular Institute, Charlotte, NC
| | - Vicki Morton-Bailey
- Clinical and Quality Outcomes, Providence Anesthesiology Associates, Charlotte, NC
| | - John P. Pirris
- Cardiothoracic Surgery, University of Florida Health, Jacksonville, Fla
| | - V. Seenu Reddy
- Cardiac Surgery, ERAS Program, TriStar Centennial Medical Center, Nashville, Tenn
| | - Rawn Salenger
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Dirk Varelmann
- Cardiac Surgery Intensive Care Unit, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Daniel T. Engelman
- Department of Surgery, Baystate Medical Center, University of Massachusetts-Baystate, Springfield, Mass
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Pengelly J, Royse C, Williams G, Bryant A, Clarke-Errey S, Royse A, El-Ansary D. Effects of 12-Week Supervised Early Resistance Training (SEcReT) Versus Aerobic-Based Rehabilitation on Cognitive Recovery Following Cardiac Surgery via Median Sternotomy: A Pilot Randomised Controlled Trial. Heart Lung Circ 2021; 31:395-406. [PMID: 34627672 DOI: 10.1016/j.hlc.2021.08.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/21/2021] [Accepted: 08/25/2021] [Indexed: 01/13/2023]
Abstract
AIMS To investigate the effects of a 12-week early moderate-intensity resistance training program compared to aerobic-based rehabilitation on postoperative cognitive recovery following cardiac surgery via median sternotomy. METHODS This was a multicentre, prospective, pragmatic, non-blinded, pilot randomised controlled trial (1:1 randomisation) of two parallel groups that compared a 12-week early moderate-intensity resistance training group to a control group, receiving aerobic-based rehabilitation. English-speaking adults (≥18 years) undergoing elective cardiac surgery via median sternotomy were randomised using sealed envelopes, with allocation revealed before surgery. The primary outcome was cognitive function, assessed using the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog), at baseline, 14 weeks and 6 months postoperatively. RESULTS The ADAS-cog score at 14 weeks was significantly better for the resistance training group (n=14, 7.2±1.4; 95% CI 4.3, 10.2, vs n=17, 9.2±1.3; 95% CI 6.6, 11.9, p=0.010). At 14 weeks postoperatively, 53% of the aerobic-based rehabilitation group (n=9/17) experienced cognitive decline by two points or more from baseline ADAS-cog score, compared to 0% of the resistance training group (n=0/14; p=0.001). CONCLUSION Early resistance training appears to be safe and may improve cognitive recovery compared to standard, aerobic-based rehabilitation following cardiac surgery via median sternotomy, however as this was a pilot study, the sample size was small and further research is needed to determine a causal relationship.
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Affiliation(s)
- Jacqueline Pengelly
- Department of Nursing and Allied Health, Swinburne University of Technology, Melbourne, Vic, Australia; School of Science, Psychology and Sport, Federation University Australia, Ballarat, Vic, Australia.
| | - Colin Royse
- Department of Nursing and Allied Health, Swinburne University of Technology, Melbourne, Vic, Australia; Department of Surgery, University of Melbourne, Melbourne, Vic, Australia; Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Vic, Australia; Outcomes Research Consortium Cleveland Clinic, Cleveland, OH, USA
| | - Gavin Williams
- Department of Physiotherapy, University of Melbourne, Melbourne, Vic, Australia
| | - Adam Bryant
- Department of Physiotherapy, University of Melbourne, Melbourne, Vic, Australia
| | - Sandy Clarke-Errey
- Statistical Consulting Centre, University of Melbourne, Melbourne, Vic, Australia
| | - Alistair Royse
- Department of Nursing and Allied Health, Swinburne University of Technology, Melbourne, Vic, Australia; Department of Surgery, University of Melbourne, Melbourne, Vic, Australia; Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Doa El-Ansary
- Department of Nursing and Allied Health, Swinburne University of Technology, Melbourne, Vic, Australia; Department of Surgery, University of Melbourne, Melbourne, Vic, Australia; Clinical Research Institute, Westmead Private Hospital, Sydney, NSW, Australia
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Boudreaux JC, Urban M, Berkheim DB, Moulton MJ, Small BL, Strah HM, Siddique A. Combination plate and band fixation for primary closure in bilateral lung transplantation. J Card Surg 2021; 36:3085-3091. [PMID: 34133049 DOI: 10.1111/jocs.15729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Sternal complications are common following transverse thoracosternotomy in patients undergoing bilateral lung transplantation. We present a single-institution experience using a next generation rigid fixation system for primary sternal closure following transverse sternotomy for bilateral lung transplantation. METHODS Retrospective review was performed on all patients who had bilateral sequential lung transplants utilizing a transverse thoracosternotomy from 2016 to 2020. Demographics, baseline characteristics, peri-operative data, and outcomes were collected, reviewed and summarized. Two groups of patients were identified: wire cerclage (Group A), combination plate-and-band rigid fixation (Group B). The primary outcome was sternal complications, which were divided into mechanical and non-mechanical. RESULTS Twenty-two patients met inclusion criteria. Three patients (13.6%) were in Group A, nineteen patients (86.4%) in Group B. Two patients in each Group A (66.6%) and Group B (10.5%) experienced a sternal complication. Sternal complications included sternal dehiscence (2), sternal malunion (1), and surgical site infection (1). One patient with plate-and-band fixation (5.2%) had a mechanical sternal complication. Three patients required reoperation secondary to sternal complication. CONCLUSIONS The utilization of a combination plate-and-band rigid fixation system for primary closure is safe and may be an effective method to reduce sternal complications following transverse thoracosternotomy for lung transplantation.
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Affiliation(s)
- Joel C Boudreaux
- University of Nebraska Medical Center, College of Medicine, Omaha, Nebraska, USA
| | - Marian Urban
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - David B Berkheim
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Michael J Moulton
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Bronwyn L Small
- Department of Internal Medicine, Pulmonary Critical Care, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Heather M Strah
- Department of Internal Medicine, Pulmonary Critical Care, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Aleem Siddique
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
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