- Email: [email protected]
Composite Vein Graft Reconstruction for Infected Descending Aortic Prosthesis
Composite Vein Graft Reconstruction for Infected Descending Aortic Prosthesis Hiroshi Okamoto, MD, Akinori Tamenishi, MD, Yasumoto Matsumura, MD, and Takao Niimi, MD Department of Thoracic and Cardiovascular Surgery, Yokkaichi Municipal Hospital, Yokkaichi, Japan
We report a case of successful in situ replacement with a superficial femoropopliteal vein panel graft for Dacron graft infection of the thoracic aorta. A 75-year-old man presented with septicemia and pseudoaneurysm caused by methicillin resistant staphylococcus aureus 2 years after Dacron graft replacement of the mid-descending aortic aneurysm. The patient underwent in situ replacement with a panel graft constructed of 3 deep vein panels after excision of the infected Dacron graft. The patient is free of infection and doing well over 2 years after surgery. (Ann Thorac Surg 2012;93:2061–3) © 2012 by The Society of Thoracic Surgeons
P
rosthetic infection is a devastating complication of vascular surgery. After excision of an infected synthetic graft, there are several options to resume distal aortic blood flow. Extraanatomic bypass, one of the most common options, has intrinsic disadvantages such as the potential for aortic stump blowout and limitation of distal perfusion flow [1, 2]. In contrast, in situ replacement ensures distal perfusion flow but has concerns about graft material and reinfection. We report a case of successful in situ deep vein panel graft replacement for a Dacron graft infection of the descending thoracic aorta and give a brief review of the literature about aortic graft infection. A 75-year-old man presented with sustained fever of 1-month duration. He had undergone prosthetic graft replacement (24-mm Hemashield straight graft; Meadox Medicals Inc, Oakland, NJ) for an atherosclerotic aneurysm of the mid-descending aorta on September 11, 2007.
Accepted for publication Aug 24, 2011. Address correspondence to Dr Okamoto, Department of Thoracic and Cardiovascular Surgery, Yokkaichi Municipal Hospital, 2-2-37 Shibata, Yokkaichi 510-0822, Japan; e-mail: [email protected].
CASE REPORT OKAMOTO ET AL SFPV FOR DACRON GRAFT INFECTION
2061
Since the end of December 2008, the patient had been suffering from fluctuating fever and general fatigue. He was readmitted to our hospital on January 28, 2009. Admission laboratory values included a white blood cell count of 12,700 mm3, C-reactive protein of 20.3 mg/dL, and serum creatinine of 2.2 mg/dL. An enhanced computed tomographic scan showed a pseudoaneurysm of 6 cm in diameter, perigraft fluid collections, and leakage of contrast media around the graft. Staphylococcus aureus resistant to methicillin was identified from a perigraft bloody effusion obtained with computed tomographicguided puncture as well as blood culture. The operation was performed on January 31, 2009. At first, bilateral superficial femoropopliteal vein panels (SFPVs) were harvested. The left one, 30-cm long, was divided into 2 segments that were opened in a longitudinal direction. The right one was bifurcated at the midportion and a proximal portion of adequate size was harvested and opened in the same manner. Three panels of opened SFPVs were sutured to one another lengthwise to make an aortic substitute 15-cm long and 2.2 cm in diameter. A short segment of greater saphenous vein was additionally harvested from the left shank as a substance to reinforce the anastomotic line of the SFPV panel graft. Then the patient’s position was changed from supine to a right lateral decubitus and the left chest entered through the fifth intercostal space. Tough adhesion around the pseudoaneurysm was freed from the left lung (Fig 1A). Under partial femoro-femoral cardiopulmonary bypass, the aorta was clamped and the aneurysm was opened. The proximal posterior suture line was disrupted and the infected Dacron graft, necrotic tissue, and diseased aortic edge were thoroughly excised. After irrigation with plenty of saline containing crystal violet, the SFPV panel graft was sutured to both proximal and distal aortic cuffs (Fig 1B). A saphenous vein strip was placed externally around the panel graft to reinforce the proximal suture line. The distal end of the graft was everted not only to adjust the graft length but also to reinforce the suture line. This new graft was wrapped with an omental flap being mobilized as a pedicle of the left gastroepiploic artery, tunneled through the diaphragm, and introduced into the left pleural cavity. Vancomycin was administered for 6 weeks until values of C-reactive protein and white blood cell count became normalized. The patient was discharged in good condition on postoperative day 44. Two years after surgery he
Fig 1. (A) Pseudoaneurysm of the mid-descending aorta around an infected Dacron graft. (B) In situ replacement with the superficial femoropopliteal vein panel graft being stained with crystal violet (the proximal side is on the right).
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.08.056
FEATURE ARTICLES
Ann Thorac Surg 2012;93:2061–3
2062
CASE REPORT OKAMOTO ET AL SFPV FOR DACRON GRAFT INFECTION
FEATURE ARTICLES Fig 2. Postoperative magnetic resonance image. (A) Sagittal view; (B) axial view. Arrows indicate the superficial femoropopliteal vein panel graft that is functioning well.
is doing well without any sign of recurrent infection or aneurysm formation, and magnetic resonance imaging showed satisfactory repair (Fig 2A,B).
Comment Graft infection of the thoracic aorta is most often fatal because it may lead to massive bleeding due to anastomotic disruption or aortoesophageal or aortobronchial fistula and sepsis with multisystem failure [1]. Current surgical options
Ann Thorac Surg 2012;93:2061–3
after excision of the infected graft include extraanatomic bypass and in situ replacement with a new graft [1]. Extraanatomic bypass with oversewing of the aortic stump traditionally has been used to manage graft infection [2]. This approach might be complicated with aortic stump blow out, infection of a new bypass graft, and inadequate distal perfusion or limb loss due to graft occlusion [2]. In contrast, in situ replacement ensures distal perfusion flow, but there are concerns about graft material and reinfection. Synthetic grafts (such as Dacron or polytetrafluoroethylene) placed in the contaminated area have a higher risk of reinfection, even if they are soaked in antibiotics [1]. Likewise, persistent infection is unavoidable after endovascular stent graft treatment [3]. A cryopreserved allograft is reported to be more resistant to infection than a synthetic graft [4]. However, its resistance is not always warranted because it is a foreign material; and it is not often available in Japan. The SFPV itself is autologous tissue most resistant to reinfection and has been used in the abdominal aortoiliac territories [5]. However, its caliber is far less than that of the thoracic aorta. Therefore, for this patient we planned to make an adequate-sized tube graft composed of SFPV panels [6]. The SFPV wall is too thin and weak, to hold tensile strength at the anastomotic suture line, therefore it is essential to keep specific surgical principles, including tension-free anastomosis and circumferential anastomotic reinforcement with saphenous vein strips or eversion of the venous wall itself [4]. Although SFPV is certainly a superior material to protect from reinfection, it has some intrinsic drawbacks [1]. One of these is the potential development of lower extremity edema as a result of deep vein harvest. Probably preservation of profunda femoris vein is critical. Fortunately, this patient has never suffered from this complication. The other drawback is the time required for venous harvesting, adding to the main operation. A two-team approach to shorten total operation time was not applicable for this patient because a change of position was mandatory for the procedure of the descending aorta. The SFPV panel graft made in manners mentioned above is relatively short, from 15-cm to 17-cm long at most, therefore is unsuitable in situations where the thoracic aorta should be replaced extensively. Replacement of the thoracic aorta with a tube graft made up of deep veins has not been reported yet, so its durability remains unknown. Careful observation needs to be kept.
References 1. Galt SW, Kraiss LW. Treatment of aortic graft infection. In: Gawertz BL, Schwartz LB, eds. Surgery of the aorta and its branches. Philadelphia: WB Saunders; 2000;397– 404. 2. Yeager RA, Taylor LM Jr, Moneta GL, et al. Improved results with conventional management of infrarenal aortic infection. J Vasc Surg 1999;30:76 – 83. 3. Kan C-H, Lee H-L, Yang Y-J. Outcome after endovascular stent graft treatment for mycotic aneurysm: a systematic review. J Vasc Surg 2007;46:906 –12. 4. Vogt PR, Brunner-LaRocca H-P, Lachat M, Ruef C, Turina MI. Technical details with the use of cryopreserved arterial allo-
grafts for aortic infection: Influence on early and midterm mortality. J Vasc Surg 2002;35:80 – 6. 5. Clagett GP, Valentine RJ, Hagino RT. Autogenous aortoiliac/ femoral reconstruction from superficial femoral–popliteal veins: feasibility and durability. J Vasc Surg 1997;25:255–70. 6. Rosen SF, Ledesma DF, Lopez JA, Jackson MR. Repair of saccular aortic aneurysm with superficial femoral–popliteal vein in the presence of a pancreatic abscess. J Vasc Surg 2000;32:1215– 8.
Transapical Endovascular Deployment of a Stent-Graft in the Thoracic Descending Aorta Utz Kappert, MD, PhD, Ahmed Ouda, MD, Tamer Ghazy, MD, Gregor Simonis, MD, PhD, and Klaus Matschke, MD, PhD Departments of Cardiac Surgery and Cardiology, Dresden Heart Center, Dresden, Germany
We report the case of a 74-year-old man with a large aneurysm (60 mm) of the descending thoracic aorta. Because of severe calcification and kinking of the iliac vessels, the expected access-related complication during the endovascular repair urged us to search for an alternative strategy. Having good experience with transcatheter aortic valve implantation, we thought that the transapical approach may be the best option in this case. The stent-graft was successfully deployed through the heart apex without any complications. The postoperative imaging showed an excellent result. (Ann Thorac Surg 2012;93:2063–5) © 2012 by The Society of Thoracic Surgeons
S
ince the report by Dake and associates [1] in 1994, endovascular repair for thoracic aortic aneurysm has been used as an alternative to conventional open surgical procedures in the treatment of thoracic aortic aneurysm, especially in high-risk patients. Advantages of endovascular procedures include less blood loss, shorter hospital stays, and quicker recovery [2]. Despite the fact that it has
Accepted for publication Oct 25, 2011. Address correspondence to Dr Ouda, Department of Cardiac Surgery, Dresden Heart Center, Dresden University of Technology, Fetscherstrasse 76, 01307 Dresden, Germany; e-mail: [email protected].
CASE REPORT KAPPERT ET AL TRANSAPICAL REPAIR OF THORACIC AORTA
2063
been proved feasible and safe, many related complications have been recognized [3]. Access-related complications may be more frequent in patients with complex anatomy of access vessels and these complications can lead to devastating sequelae 4]. In this report we present a case of thoracic descending aortic aneurysm with severe calcification and tortuosity of femoral and iliac vessels that underwent a successful endovascular repair using the transapical approach. A 74-year-old man was admitted to hospital because of intermittent left-sided chest pain. A chest roentgenogram revealed a widened mediastinum and a double shadow distal to the aortic knuckle. Chest computed tomography (CT) showed this to be caused by a 60-mm partially thrombosed aneurysm of the thoracic descending aorta (Fig 1). Because of the massive calcification of the whole aorta, the decision was made for endovascular repair. Unfortunately the iliac vessels were found to be tortuous and severely calcified by preoperative CT-angiography (Fig 2). Having good experience with transcatheter aortic valve implantation, we believed that the best option in this case was the transapical approach. Surgery was performed in our hybrid operating room and imaging was provided by a floor-mounted angiographic C-arm system. The patient was induced under general anesthesia and intubated with a double-lumen endotracheal tube. A radial artery line and central venous line were placed for hemodynamic monitoring. The patient was placed in a supine position and draped in the standard sterile technique. A diagnostic angiographic catheter was placed in the right brachial artery percutaneously. A left minithoracotomy incision was made in the fifth intercostal space at the midclavicular line. After exposure of the left ventricular apex, epicardial ventricular pacemaker wire and 2 pledgeted purse-string sutures were placed. To provide the required length of delivery system (90 cm) to reach the descending aorta through the convexity of the aortic arch, the choice was to use a 36 mm ⫻ 154 mm Relay NBS Thoracic Stent-Graft (Bolton Medical España S.L.U, Barcelona, Spain). After heparin (5,000 units) administration, the left ventricular apex was accessed with an 18-gauge needle. Under fluoroscopic guidance, a soft wire was advanced across the aortic valve and into the descending abdominal Fig 1. (A) Preoperative computed tomography showing aneurysm of the descending thoracic aorta. (B) Cross section showing massive calcification of the aorta and the partially thrombosed aneurysm.
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.10.069
FEATURE ARTICLES
Ann Thorac Surg 2012;93:2063–5
We report a case of successful in situ replacement with a superficial femoropopliteal vein panel graft for Dacron graft infection of the thoracic aorta. A 75-year-old man presented with septicemia and pseudoaneurysm caused by methicillin resistant staphylococcus aureus 2 years after Dacron graft replacement of the mid-descending aortic aneurysm. The patient underwent in situ replacement with a panel graft constructed of 3 deep vein panels after excision of the infected Dacron graft. The patient is free of infection and doing well over 2 years after surgery. (Ann Thorac Surg 2012;93:2061–3) © 2012 by The Society of Thoracic Surgeons
P
rosthetic infection is a devastating complication of vascular surgery. After excision of an infected synthetic graft, there are several options to resume distal aortic blood flow. Extraanatomic bypass, one of the most common options, has intrinsic disadvantages such as the potential for aortic stump blowout and limitation of distal perfusion flow [1, 2]. In contrast, in situ replacement ensures distal perfusion flow but has concerns about graft material and reinfection. We report a case of successful in situ deep vein panel graft replacement for a Dacron graft infection of the descending thoracic aorta and give a brief review of the literature about aortic graft infection. A 75-year-old man presented with sustained fever of 1-month duration. He had undergone prosthetic graft replacement (24-mm Hemashield straight graft; Meadox Medicals Inc, Oakland, NJ) for an atherosclerotic aneurysm of the mid-descending aorta on September 11, 2007.
Accepted for publication Aug 24, 2011. Address correspondence to Dr Okamoto, Department of Thoracic and Cardiovascular Surgery, Yokkaichi Municipal Hospital, 2-2-37 Shibata, Yokkaichi 510-0822, Japan; e-mail: [email protected].
CASE REPORT OKAMOTO ET AL SFPV FOR DACRON GRAFT INFECTION
2061
Since the end of December 2008, the patient had been suffering from fluctuating fever and general fatigue. He was readmitted to our hospital on January 28, 2009. Admission laboratory values included a white blood cell count of 12,700 mm3, C-reactive protein of 20.3 mg/dL, and serum creatinine of 2.2 mg/dL. An enhanced computed tomographic scan showed a pseudoaneurysm of 6 cm in diameter, perigraft fluid collections, and leakage of contrast media around the graft. Staphylococcus aureus resistant to methicillin was identified from a perigraft bloody effusion obtained with computed tomographicguided puncture as well as blood culture. The operation was performed on January 31, 2009. At first, bilateral superficial femoropopliteal vein panels (SFPVs) were harvested. The left one, 30-cm long, was divided into 2 segments that were opened in a longitudinal direction. The right one was bifurcated at the midportion and a proximal portion of adequate size was harvested and opened in the same manner. Three panels of opened SFPVs were sutured to one another lengthwise to make an aortic substitute 15-cm long and 2.2 cm in diameter. A short segment of greater saphenous vein was additionally harvested from the left shank as a substance to reinforce the anastomotic line of the SFPV panel graft. Then the patient’s position was changed from supine to a right lateral decubitus and the left chest entered through the fifth intercostal space. Tough adhesion around the pseudoaneurysm was freed from the left lung (Fig 1A). Under partial femoro-femoral cardiopulmonary bypass, the aorta was clamped and the aneurysm was opened. The proximal posterior suture line was disrupted and the infected Dacron graft, necrotic tissue, and diseased aortic edge were thoroughly excised. After irrigation with plenty of saline containing crystal violet, the SFPV panel graft was sutured to both proximal and distal aortic cuffs (Fig 1B). A saphenous vein strip was placed externally around the panel graft to reinforce the proximal suture line. The distal end of the graft was everted not only to adjust the graft length but also to reinforce the suture line. This new graft was wrapped with an omental flap being mobilized as a pedicle of the left gastroepiploic artery, tunneled through the diaphragm, and introduced into the left pleural cavity. Vancomycin was administered for 6 weeks until values of C-reactive protein and white blood cell count became normalized. The patient was discharged in good condition on postoperative day 44. Two years after surgery he
Fig 1. (A) Pseudoaneurysm of the mid-descending aorta around an infected Dacron graft. (B) In situ replacement with the superficial femoropopliteal vein panel graft being stained with crystal violet (the proximal side is on the right).
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.08.056
FEATURE ARTICLES
Ann Thorac Surg 2012;93:2061–3
2062
CASE REPORT OKAMOTO ET AL SFPV FOR DACRON GRAFT INFECTION
FEATURE ARTICLES Fig 2. Postoperative magnetic resonance image. (A) Sagittal view; (B) axial view. Arrows indicate the superficial femoropopliteal vein panel graft that is functioning well.
is doing well without any sign of recurrent infection or aneurysm formation, and magnetic resonance imaging showed satisfactory repair (Fig 2A,B).
Comment Graft infection of the thoracic aorta is most often fatal because it may lead to massive bleeding due to anastomotic disruption or aortoesophageal or aortobronchial fistula and sepsis with multisystem failure [1]. Current surgical options
Ann Thorac Surg 2012;93:2061–3
after excision of the infected graft include extraanatomic bypass and in situ replacement with a new graft [1]. Extraanatomic bypass with oversewing of the aortic stump traditionally has been used to manage graft infection [2]. This approach might be complicated with aortic stump blow out, infection of a new bypass graft, and inadequate distal perfusion or limb loss due to graft occlusion [2]. In contrast, in situ replacement ensures distal perfusion flow, but there are concerns about graft material and reinfection. Synthetic grafts (such as Dacron or polytetrafluoroethylene) placed in the contaminated area have a higher risk of reinfection, even if they are soaked in antibiotics [1]. Likewise, persistent infection is unavoidable after endovascular stent graft treatment [3]. A cryopreserved allograft is reported to be more resistant to infection than a synthetic graft [4]. However, its resistance is not always warranted because it is a foreign material; and it is not often available in Japan. The SFPV itself is autologous tissue most resistant to reinfection and has been used in the abdominal aortoiliac territories [5]. However, its caliber is far less than that of the thoracic aorta. Therefore, for this patient we planned to make an adequate-sized tube graft composed of SFPV panels [6]. The SFPV wall is too thin and weak, to hold tensile strength at the anastomotic suture line, therefore it is essential to keep specific surgical principles, including tension-free anastomosis and circumferential anastomotic reinforcement with saphenous vein strips or eversion of the venous wall itself [4]. Although SFPV is certainly a superior material to protect from reinfection, it has some intrinsic drawbacks [1]. One of these is the potential development of lower extremity edema as a result of deep vein harvest. Probably preservation of profunda femoris vein is critical. Fortunately, this patient has never suffered from this complication. The other drawback is the time required for venous harvesting, adding to the main operation. A two-team approach to shorten total operation time was not applicable for this patient because a change of position was mandatory for the procedure of the descending aorta. The SFPV panel graft made in manners mentioned above is relatively short, from 15-cm to 17-cm long at most, therefore is unsuitable in situations where the thoracic aorta should be replaced extensively. Replacement of the thoracic aorta with a tube graft made up of deep veins has not been reported yet, so its durability remains unknown. Careful observation needs to be kept.
References 1. Galt SW, Kraiss LW. Treatment of aortic graft infection. In: Gawertz BL, Schwartz LB, eds. Surgery of the aorta and its branches. Philadelphia: WB Saunders; 2000;397– 404. 2. Yeager RA, Taylor LM Jr, Moneta GL, et al. Improved results with conventional management of infrarenal aortic infection. J Vasc Surg 1999;30:76 – 83. 3. Kan C-H, Lee H-L, Yang Y-J. Outcome after endovascular stent graft treatment for mycotic aneurysm: a systematic review. J Vasc Surg 2007;46:906 –12. 4. Vogt PR, Brunner-LaRocca H-P, Lachat M, Ruef C, Turina MI. Technical details with the use of cryopreserved arterial allo-
grafts for aortic infection: Influence on early and midterm mortality. J Vasc Surg 2002;35:80 – 6. 5. Clagett GP, Valentine RJ, Hagino RT. Autogenous aortoiliac/ femoral reconstruction from superficial femoral–popliteal veins: feasibility and durability. J Vasc Surg 1997;25:255–70. 6. Rosen SF, Ledesma DF, Lopez JA, Jackson MR. Repair of saccular aortic aneurysm with superficial femoral–popliteal vein in the presence of a pancreatic abscess. J Vasc Surg 2000;32:1215– 8.
Transapical Endovascular Deployment of a Stent-Graft in the Thoracic Descending Aorta Utz Kappert, MD, PhD, Ahmed Ouda, MD, Tamer Ghazy, MD, Gregor Simonis, MD, PhD, and Klaus Matschke, MD, PhD Departments of Cardiac Surgery and Cardiology, Dresden Heart Center, Dresden, Germany
We report the case of a 74-year-old man with a large aneurysm (60 mm) of the descending thoracic aorta. Because of severe calcification and kinking of the iliac vessels, the expected access-related complication during the endovascular repair urged us to search for an alternative strategy. Having good experience with transcatheter aortic valve implantation, we thought that the transapical approach may be the best option in this case. The stent-graft was successfully deployed through the heart apex without any complications. The postoperative imaging showed an excellent result. (Ann Thorac Surg 2012;93:2063–5) © 2012 by The Society of Thoracic Surgeons
S
ince the report by Dake and associates [1] in 1994, endovascular repair for thoracic aortic aneurysm has been used as an alternative to conventional open surgical procedures in the treatment of thoracic aortic aneurysm, especially in high-risk patients. Advantages of endovascular procedures include less blood loss, shorter hospital stays, and quicker recovery [2]. Despite the fact that it has
Accepted for publication Oct 25, 2011. Address correspondence to Dr Ouda, Department of Cardiac Surgery, Dresden Heart Center, Dresden University of Technology, Fetscherstrasse 76, 01307 Dresden, Germany; e-mail: [email protected].
CASE REPORT KAPPERT ET AL TRANSAPICAL REPAIR OF THORACIC AORTA
2063
been proved feasible and safe, many related complications have been recognized [3]. Access-related complications may be more frequent in patients with complex anatomy of access vessels and these complications can lead to devastating sequelae 4]. In this report we present a case of thoracic descending aortic aneurysm with severe calcification and tortuosity of femoral and iliac vessels that underwent a successful endovascular repair using the transapical approach. A 74-year-old man was admitted to hospital because of intermittent left-sided chest pain. A chest roentgenogram revealed a widened mediastinum and a double shadow distal to the aortic knuckle. Chest computed tomography (CT) showed this to be caused by a 60-mm partially thrombosed aneurysm of the thoracic descending aorta (Fig 1). Because of the massive calcification of the whole aorta, the decision was made for endovascular repair. Unfortunately the iliac vessels were found to be tortuous and severely calcified by preoperative CT-angiography (Fig 2). Having good experience with transcatheter aortic valve implantation, we believed that the best option in this case was the transapical approach. Surgery was performed in our hybrid operating room and imaging was provided by a floor-mounted angiographic C-arm system. The patient was induced under general anesthesia and intubated with a double-lumen endotracheal tube. A radial artery line and central venous line were placed for hemodynamic monitoring. The patient was placed in a supine position and draped in the standard sterile technique. A diagnostic angiographic catheter was placed in the right brachial artery percutaneously. A left minithoracotomy incision was made in the fifth intercostal space at the midclavicular line. After exposure of the left ventricular apex, epicardial ventricular pacemaker wire and 2 pledgeted purse-string sutures were placed. To provide the required length of delivery system (90 cm) to reach the descending aorta through the convexity of the aortic arch, the choice was to use a 36 mm ⫻ 154 mm Relay NBS Thoracic Stent-Graft (Bolton Medical España S.L.U, Barcelona, Spain). After heparin (5,000 units) administration, the left ventricular apex was accessed with an 18-gauge needle. Under fluoroscopic guidance, a soft wire was advanced across the aortic valve and into the descending abdominal Fig 1. (A) Preoperative computed tomography showing aneurysm of the descending thoracic aorta. (B) Cross section showing massive calcification of the aorta and the partially thrombosed aneurysm.
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.10.069
FEATURE ARTICLES
Ann Thorac Surg 2012;93:2063–5