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1.
Ann Thorac Surg ; 2021 Dec 04.
Artigo em Inglês | MEDLINE | ID: mdl-34875263

RESUMO

BACKGROUND: We sought to characterize the current U.S. experience of aortic prosthetic valve endocarditis (PVE) compared to native valve endocarditis (NVE). METHODS: The Society of Thoracic Surgeons Database was queried for entries of active aortic infective endocarditis (IE). Two analyses were performed: 1) Trends of surgical volume and operative mortality (2011 to 2019) and 2) Descriptive and risk-adjusted comparisons between PVE and NVE (2014 to 2019), using multivariable logistic regression. RESULTS: From 2011 to 2019, there was a yearly increase in the proportion of PVE (20.9% to 25.9%; p<0.001) with a concurrent decrease in operative mortality (PVE=22.5% to 10.4%; p<0.001; NVE=10.9% to 8.5%; p<0.001). From 2014 to 2019, active aortic IE was identified in 9,768 patients (NVE=6,842; PVE=2,926). Aortic root abscess (50.1% versus 25.2%; p<0.001), aortic root replacement (50.1% versus 12.8%; p<0.001), homograft implantation (27.2% versus 4.1%; p<0.001), and operative mortality (12.2% versus 6.4%; p<0.001) were higher in PVE. Following risk-adjustment, PVE (odds ratio [OR]=1.5; 95% confidence interval (CI):1.16-1.94; p<0.01), aortic root replacement (OR=1.49; 95% CI:1.15-1.92; p<0.001), staphylococcus aureus (OR=1.5; 95% CI:1.23-1.82; p<0.001), and unplanned revascularization (OR=5.83; 95% CI:4.12-8.23; p<0.001) or mitral valve surgery (OR=2.29; 95% CI:1.5-3.51; p<0.001) correlated with a higher operative mortality, while prosthesis type (p=0.68) was not an independent predictor. CONCLUSIONS: IE in the U.S. has risen over the past decade. However, operative mortality has decreased for both PVE and NVE. PVE, extension of IE requiring aortic root replacement, and additional unplanned surgical interventions carry an elevated mortality risk. Prosthesis selection did not impact operative mortality.

2.
Artigo em Inglês | MEDLINE | ID: mdl-34887095

RESUMO

OBJECTIVE: This study sought to identify the optimal temperature for moderate hypothermic circulatory arrest in patients undergoing elective hemiarch replacement with antegrade brain perfusion. METHODS: The Society of Thoracic Surgeons adult cardiac surgery database was queried for elective hemiarch replacements using antegrade brain perfusion for aneurysmal disease (2014-2019). Generalized estimating equations and restricted cubic splines were used to determine the risk-adjusted relationships between temperature as a continuous variable and outcomes. RESULTS: Elective hemiarch replacement with antegrade brain perfusion occurred in 3898 patients at 374 centers with a median nadir temperature of 24.9 °C (first quartile, third quartile = 22.0 °C, 27.5 °C) and median circulatory arrest time of 19 minutes (first quartile, third quartile = 14.0 minutes, 27.0 minutes). After adjustment for comorbidities, circulatory arrest time, and individual surgeon, patients cooled between 25 and 28 °C had an early survival advantage compared with 24 °C, whereas those cooled between 21 and 23 °C had higher risks of mortality compared with 24 °C. A nadir temperature of 27 °C was associated with the lowest risk-adjusted odds of mortality (odds ratio, 0.62; 95% confidence interval, 0.42-0.91). A nadir temperature of 21 °C had the highest risk of mortality (odds ratio, 1.4; 95% confidence interval, 1.13-1.73). Risk of experiencing a major morbidity was elevated in patients cooled between 21 and 23 °C, with the highest risk occurring in patients cooled to 21 °C (odds ratio, 1.12; 95% confidence interval, 1.01-1.24). CONCLUSIONS: For patients with aneurysmal disease undergoing elective hemiarch with antegrade brain perfusion, circulatory arrest with a nadir temperature of 27 °C confers the greatest early survival benefit and smallest risk of postoperative morbidity.

3.
Ann Thorac Surg ; 2021 Nov 13.
Artigo em Inglês | MEDLINE | ID: mdl-34785247

RESUMO

BACKGROUND: The relationship between institutional volume and operative mortality following SAVR remains unclear. METHODS: From 1/2013 to 6/2018, 234,556 patients underwent isolated SAVR (n=144,177) or SAVR+CABG (n=90,379) within the STS ACSD. The association between annualized SAVR volume [Group 1 (1-25 SAVR), Group 2 (26-50 SAVR), Group 3 (51-100 SAVR), and Group 4 (>100 SAVR)] and operative mortality and composite major morbidity/mortality was assessed. Random effects models were used to evaluate whether historic (2013-2015) SAVR volume or risk-adjusted outcomes explained future (2016-2018) risk-adjusted outcomes. RESULTS: The annualized median number of SAVRs per site was 35 [IQR: 22-59, isolated AVR: 20, AVR+CABG: 13]. Among isolated SAVR cases, the mean operative mortality and composite morbidity/mortality were 1.5% and 9.7%, respectively, at the highest volume sites (Group 4); with significantly higher rates among progressively lower volume groups (p-trend<0.001). After adjustment, lower volume centers experienced increased odds of operative mortality [Group 1 vs. 4 (Ref): AOR (SAVR), 2.24 (1.91-2.64); AOR (SAVR+CABG), 1.96 (1.67-2.30)] and major morbidity/mortality [AOR (SAVR), 1.53 (1.39-1.69); AOR (SAVR+CABG), 1.46 (1.32-1.61)] compared to the highest volume institutions. Substantial variation in outcomes was observed across hospitals within each volume category and prior outcomes explained a greater proportion of hospital operative outcomes than prior volume. CONCLUSIONS: Operative outcomes following SAVR±CABG is inversely associated with institutional procedure volumes; however, prior outcomes are more predictive than prior volume of future outcomes. Given excellent outcomes observed at many lower volume hospitals, procedural outcomes may be preferable to procedural volumes as a quality metric.

4.
J Healthc Qual ; 43(6): 347-354, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34734919

RESUMO

ABSTRACT: This retrospective, cross-sectional study of U.S. hospitals in Medicare's Inpatient Quality Reporting Program aimed to determine whether variation in Sepsis/Septic Shock (Bundle SEP-1) compliance is linked to hospital size and measures of safety and operational efficiency. Two thousand six hundred and fifty-three acute care hospitals in Medicare's Hospital Compare online database were included in the study. Relationships between SEP-1 bundle compliance, hospital size, and indices of operational excellence (including Patient Safety Index [PSI-90], average length of stay [ALOS] and readmission rate) were analyzed. SEP-1 compliance score was inversely associated with staffed bed number (r = -.14, p < .001), PSI-90 (r = -.01, p < .001), and ALOS (r = -.13, p < .001) in a multivariate analysis. Hospitals in the lowest versus highest quartile by bed number had SEP-1 compliance score of 49.8 ± 20.2% versus 46.9 ± 16.8%, p < .001. Hospitals in the lowest versus highest quartile for SEP-1 score had an ALOS of 5.0 ± 1.2 days versus 4.7 ± 1.1 days and PSI-90 rate of 1.03 ± 0.22 versus 0.98 ± 0.16, p < .001 for both. Although this does not establish a causal relationship, it supports the hypothesis that the ability of hospitals to successfully implement SEP-1 is associated with superior performance in key measures of operational excellence.


Assuntos
Medicare , Sepse , Idoso , Estudos Transversais , Hospitais , Humanos , Tempo de Internação , Estudos Retrospectivos , Sepse/terapia , Estados Unidos
5.
J Card Fail ; 27(12): 1462-1465, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34407451

RESUMO

The recently concluded prospective Portable Organ Care System (OCS) Heart trial to Evaluate the Safety and Effectiveness of The Portable Organ Care System Heart for Preserving and Assessing Expanded Criteria Donor Hearts for Transplantation (EXPAND) demonstrated that the use of ex vivo perfusion for expanded-criteria hearts may be a viable method for increasing the use of donor hearts. We sought to estimate the potential impact of ex vivo expanded-criteria heart perfusion on the donor pool in the United States by using a large national transplant registry. After applying the inclusion criteria of EXPAND, 8637 potentially eligible donors were identified in the U.S. between January 1, 2015, and June 30, 2019, representing a substantial potential increase in the donor pool.

8.
Clin Transplant ; 35(9): e14414, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34218467

RESUMO

BACKGROUND: Organ procurement organizations (OPOs) vary in willingness to pursue and utilize non-ideal donor lungs; implications of these practices for lung transplant (LTx) recipients remain unclear. We examined associations between OPO-level behavior toward non-ideal donors and post-LTx outcomes. METHODS: Adult lung donors and corresponding adult first-time LTx recipients in the 2008-2019 UNOS registry were included. Non-ideal donors had any of age > 50, smoking history ≥20 pack-years, PaO2 /FiO2 ratio ≤350, donation after circulatory death, or increased risk status. OPOs were classified as least, moderately, or most aggressive based on non-ideal donor pursuit, consent attainment, lung recovery, and transplantation. Post-transplant outcomes were compared among aggressiveness strata. RESULTS: Of 22,795 recipients, 6229 (27.3%), 8256 (36.2%), and 8310 (36.5%) received lungs from least, moderately, and most aggressive OPOs, respectively. Moderately aggressive OPOs had the highest recipient rates of pre-discharge acute rejection, grade 3 primary graft dysfunction, postoperative extracorporeal membrane oxygenation, and longest lengths of stay. After adjustment, moderately and most aggressive OPOs had similar risks of recipient mortality as least aggressive OPOs. CONCLUSIONS: The most and least aggressive OPOs achieve similar patient survival and short-term post-LTx outcomes. Aggressive pursuit and utilization of non-ideal donor lungs by less aggressive OPOs would likely expand the donor pool, without compromising recipient outcomes.


Assuntos
Transplante de Pulmão , Obtenção de Tecidos e Órgãos , Adulto , Sobrevivência de Enxerto , Humanos , Pulmão , Doadores de Tecidos , Adulto Jovem
9.
Ann Thorac Surg ; 2021 Jul 16.
Artigo em Inglês | MEDLINE | ID: mdl-34280377

RESUMO

BACKGROUND: Female patients with coronary artery disease have inferior outcomes compared with male patients, including higher mortality after coronary artery bypass graft surgery (CABG). We aimed to evaluate the association of female sex with the use of guideline-concordant CABG revascularization techniques. METHODS: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for adult patients who underwent first-time isolated CABG in the United States from 2011 to 2019. The association between female sex and the odds of (1) receiving a left internal mammary artery graft for revascularization of the left anterior descending artery, (2) undergoing complete revascularization, and (3) undergoing multiarterial grafting was assessed, adjusting for procedural anatomy. RESULTS: Among 1,212,487 patients meeting inclusion criteria, 75% were male (n = 911,178) and 25% were female (n = 301,309). Female sex was associated with lower unadjusted rates of revascularization with an internal mammary artery graft (93.9% vs 95.9%, P < .001), bilateral internal mammary artery graft (2.9% vs 5.6%, P < .001), or radial artery graft (3.2% vs 5.6%, P < .001). After adjustment, female patients had lower odds than males of receiving a left internal mammary artery graft to the left anterior descending artery (adjusted odds ratio 0.79; 95% confidence interval, 0.75 to 0.83; P < .001), undergoing complete revascularization (adjusted odds ratio 0.86; 95% confidence interval, 0.83 to 0.90; P < .001), and undergoing multiarterial grafting (adjusted odds ratio 0.78; 95% confidence interval, 0.75 to 0.81; P < .001). CONCLUSIONS: Female sex was associated with 14% to 22% lower odds of undergoing guideline-concordant revascularization including left internal mammary artery to left anterior descending artery grafting, multiarterial grafting, and complete revascularization. Further investigation is necessary to determine why revascularization approaches differ by sex and to what degree sex disparities in coronary artery disease outcomes are due to surgical approach.

10.
Artigo em Inglês | MEDLINE | ID: mdl-34175116
11.
Ann Surg ; 2021 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-34091506

RESUMO

BACKGROUND: The outcomes associated with receipt of adjuvant radiation in patients following surgery for malignant pleural mesothelioma (MPM) are poorly understood. OBJECTIVE: The objective of this study was to use two registries to compare the outcomes of patients receiving adjuvant radiation or no radiation following definitive surgery for pathologic stage I-III MPM. METHODS: Patients with resected pathologic stage I-III MPM were identified from the Duke University registry (1996-2016) and National Cancer Database (2004-2015). The primary outcome was overall survival (OS). Propensity score-matched and landmark subgroup analyses were performed. A total of 212 institutional and 1615 NCDB patients met criteria. In both cohorts, patients who underwent radiation were more likely to have margin-negative resection and more advanced pathologic stage. At a landmark time of 4.4 and 4.7 months from surgery, Duke (HR 1.14; 95%CI 0.62-2.11) and NCDB patients (HR 0.97; 95%CI 0.81-1.17) who received adjuvant radiation did not experience improved survival compared to those who did not receive radiation in multivariable analysis. Duke patients who received radiation had similar incidence of recurrence and time to both overall recurrence and ipsilateral recurrence (HR 0.87; 95%CI 0.43-1.77) compared to those who did not. Duke patients experienced 100 grade 1/2, 21 grade 3/4, and one grade 5 toxicity events during radiation. CONCLUSION: In this dual registry analysis of patients with resected stage I-III MPM, the receipt of adjuvant hemithoracic radiation was not associated with improved survival compared to no radiation.

12.
J Thorac Dis ; 13(4): 2116-2127, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-34012562

RESUMO

Background: Magnetic sphincter augmentation (MSA) is a promising minimally invasive surgical technique for management of gastroesophageal reflux disease (GERD); however, device implantation after transplantation has not been studied and may be concerning in these immunosuppressed patients. We explored the safety of the LINX Reflux Management System (MSA device) for management of GERD following lung transplantation (LTx). Methods: Lung transplant recipients who underwent LINX implantation at our institution between 2017 and 2019 were followed prospectively in the Reflux Following Lung Transplantation and Associated Treatment Registry. Ambulatory pH testing and acid-suppressing medication use were compared before and after LINX implantation. One-year outcomes and change in pulmonary function were compared between matched LINX and fundoplication groups. Results: Of 17 patients who underwent post-lung transplant LINX implantation, 8 (47.1%) agreed to undergo post-LINX pH testing. Three/eight (37.5%) patients achieved normal esophageal acid exposure time; 14 (82.4%) remained on acid-suppressing medication at one-year under the direction of their transplant teams. One-year patient survival and change in pulmonary function were similar between groups. LINX patients experienced more early side effects. Conclusions: Use of the LINX MSA device in a cohort of lung transplant recipients at our institution was associated with similar short-term safety compared to traditional fundoplication, however assessment of efficacy was limited. Further investigation is needed to characterize the long-term efficacy of LINX implantation after LTx.

15.
Ann Surg ; 2021 Mar 03.
Artigo em Inglês | MEDLINE | ID: mdl-33914478

RESUMO

OBJECTIVES: We describe utilization trends and center volume-outcomes relationship of endoscopic resection of early stage esophageal cancer using a large hospital-based registry. SUMMARY BACKGROUND DATA: Endoscopic resection is increasingly accepted as the preferred treatment for early stage esophageal cancer, however its utilization and the center volume-outcomes relationship in the United States is unknown. METHODS: The National Cancer Database was used to identify patients with cT1N0M0 esophageal cancer treated with endoscopic resection or esophagectomy between 2004 and 2015. Relative frequencies were plotted over time. Restricted cubic splines and maximally selected rank statistics were used to identify an inflection point of center volume and survival. RESULTS: 1136 patients underwent ER and 2829 patients underwent esophagectomy during the study period. Overall utilization of ER, as well as relative use compared to esophagectomy, increased throughout the study period. Median annualized center ER volume was 1.9 cases per year (IQR 0.5-5.8). Multivariable Cox regression showed increasing annualized center volume by one case per year was associated with improved survival. Postoperative 30- or 90-day mortality, 30-day readmission, and pathologic T upstaging rates were similar irrespective of center volume. CONCLUSIONS: Utilization of ER compared to esophagectomy for stage I esophageal cancer has increased over the past decade, though many individual centers perform fewer than 1 case annually. Increasing annualized center volume by one procedure per year was associated with improved survival. Increased volume beyond this was not associated with survival benefit. Referral to higher volume centers for treatment of superficial esophageal cancer should be considered.

16.
Ann Thorac Surg ; 2021 Apr 20.
Artigo em Inglês | MEDLINE | ID: mdl-33857493

RESUMO

BACKGROUND: Endoscopic resection (ER) is the preferred treatment for superficial esophageal cancer; however, a safe time frame for performing ER has not been established. This study evaluated the period in which ER can be performed for patients with stage I esophageal adenocarcinoma without compromising outcomes. METHODS: The 2004-2015 National Cancer Database was used to identify patients with cT1 N0 M0 esophageal adenocarcinoma who underwent upfront ER. The primary outcome was overall survival, which was evaluated using Kaplan-Meier and multivariable Cox proportional hazards methods. The secondary outcome was rate of margin-positive resection, which was evaluated using a multivariable logistic regression. RESULTS: A total of 983 patients met study criteria. The median time from diagnosis to ER was 34 days (interquartile range, 5-70 days). Patients in the highest quartile of time to ER were more likely to be treated at a high-volume center and at a center different from that of diagnosis compared with those in the lowest quartile. Increasing time to ER was not independently associated with survival (adjusted hazard ratio per 10 days, 1.02; 95% confidence interval, 0.98-1.05; P = .32) or margin-positive resection (odds ratio per 10 days 1.01; 95% confidence interval, 0.96-1.06; P = .60). CONCLUSIONS: In this National Cancer Database analysis, increasing time to endoscopic resection, up to 180 days from diagnosis, was not associated with worsened survival or increased odds of margin-positive resection in patients with cT1 N0 M0 esophageal adenocarcinoma. Given these findings, patients may be afforded time to be seen in specialty centers without risk of tumor progression.

17.
Eur J Cardiothorac Surg ; 60(2): 314-321, 2021 07 30.
Artigo em Inglês | MEDLINE | ID: mdl-33624004

RESUMO

OBJECTIVES: The impact of hypothermic circulatory arrest (HCA) temperature on postoperative acute kidney injury (AKI) has not been evaluated. This study examined the association between circulatory arrest temperatures and AKI in patients undergoing proximal aortic surgery with HCA. METHODS: A total of 759 consecutive patients who underwent proximal aortic surgery (ascending ± valve ± root) including arch replacement requiring HCA between July 2005 and December 2016 were identified from a prospectively maintained institutional aortic surgery database. The primary outcome was AKI as defined by Risk, Injury, Failure, Loss, End Stage Renal Disease (ESRD) criteria. The association between minimum nasopharyngeal (NP) and bladder temperatures during HCA and postoperative AKI was assessed, adjusting for patient-level factors using multivariable logistic regression. RESULTS: A total of 85% (n = 645) of patients underwent deep hypothermia (14.1-20.0°C), 11% (n = 83) low-moderate hypothermia (20.1-24.0°C) and 4% (n = 31) high-moderate hypothermia (24.1-28.0°C) as classified by NP temperature. When analysed by bladder temperature, 59% (n = 447) underwent deep hypothermia, 22% (n = 170) low-moderate, 16% (n = 118) high-moderate and 3% mild (n = 24) (28.1-34.0°C) hypothermia. The median systemic circulatory arrest time was 17 min. The incidence of AKI did not differ between hypothermia groups, whether analysed using minimum NP or bladder temperature. In the multivariable analysis, the association between degree of hypothermia and AKI remained non-significant whether analysed as a categorical variable (hypothermia group) or as a continuous variable (minimum NP or bladder temperature) (all P > 0.05). CONCLUSIONS: In patients undergoing proximal aortic surgery including arch replacement requiring HCA, degree of systemic hypothermia was not associated with the risk of AKI. These data suggest that moderate hypothermia does not confer increased risk of AKI for patients requiring circulatory arrest, although additional prospective data are needed.


Assuntos
Injúria Renal Aguda , Aneurisma da Aorta Torácica , Hipotermia Induzida , Hipotermia , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/prevenção & controle , Aorta Torácica/cirurgia , Parada Circulatória Induzida por Hipotermia Profunda/efeitos adversos , Humanos , Hipotermia/epidemiologia , Hipotermia/etiologia , Hipotermia/prevenção & controle , Hipotermia Induzida/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
18.
Ann Surg ; Publish Ahead of Print2021 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-33417330

RESUMO

BACKGROUND: While stereotactic ablative radiotherapy (SABR) is increasingly emerging as an alternative to surgery for node-negative non-small cell lung cancer (NSCLC), there is poor understanding of patients who may most benefit SABR compared to surgery. OBJECTIVE: This study examined the relationship between tumor size and the comparative outcomes of SABR and sublobar resection in patients with node-negative NSCLC. RESULTS: A total of 59,949 patients met study criteria: 19,888 (33%) underwent SABR, 33,052 (55%) wedge resection, and 7009 (12%) segmental resection. In multivariable regression, a significant three-way interaction was found between histology, tumor size, and type of treatment. After stratification by histology, a significant interaction between tumor size and treatment was preserved for patients with adenocarcinoma and squamous cell carcinoma. Sublobar resection was associated with greater survival compared to SABR for tumor sizes greater than 6 and 8 mm for patients with adenocarcinoma and squamous cell carcinoma, respectively. SABR was associated with similar survival compared to sublobar resection for patients with papillary and large cell histology. CONCLUSIONS: In this NCDB analysis, sublobar resection was associated with greater survival compared to SABR for lesions >6 or 8 mm in patients with adenocarcinoma or squamous cell carcinoma; however, SABR was associated with similar survival compared to sublobar resection in patients with aggressive tumors including papillary and large cell histology. Histologic diagnosis in patients with even small tumors may enable better treatment selection in those who cannot tolerate lobectomy.

20.
Surgery ; 169(6): 1493-1499, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33494946

RESUMO

BACKGROUND: There are conflicting reports in the literature comparing outcomes after open Ravitch and minimally invasive Nuss procedures for pectus excavatum repair, and there is relatively little data available comparing the outcomes of these procedures performed by thoracic surgeons. METHODS: The 2010 to 2018 Society of Thoracic Surgeons General Thoracic Surgery Database was queried for patients age 12 or greater undergoing open or minimally invasive repair of pectus excavatum. Patients were stratified by operative approach. Multivariable logistic regression was performed with a composite outcome of 30-day complications. RESULTS: A total of 1,767 patients met inclusion criteria, including 1,017 and 750 patients who underwent minimally invasive pectus repair and open repair, respectively. Open repair patients were more likely to be American Society of Anesthesiologists (ASA) class III or greater (24% vs 14%; P < .001), have a history of prior cardiothoracic surgery (26% vs 14%; P < .001), and require longer operations (median 268 vs 185 minutes; P < .001). Open repair patients were more likely to require greater than 6 days of hospitalization (18% vs 7%; P < .001), undergo transfusion (7% vs 2%; P < .001), and be readmitted (8% vs 5%; P = .004). After adjustment, open repair was not associated with an increased risk of a composite of postoperative complications (odds ratio 0.99, 95% confidence interval 0.67-1.46). This finding persisted after propensity score matching (odds ratio 1.11, 95% confidence interval 0.74-1.67). CONCLUSION: Pectus excavatum repair procedure type was not associated with the risk of postoperative complications after adjustment. Further investigation is necessary to determine the impact of pectus excavatum repair type on recurrence and patient reported outcomes, including satisfaction, quality of life, and pain control.


Assuntos
Tórax em Funil/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Adulto , Feminino , Humanos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Satisfação do Paciente , Pontuação de Propensão , Qualidade de Vida , Estudos Retrospectivos , Fatores de Risco , Esterno/cirurgia , Procedimentos Cirúrgicos Torácicos/métodos , Adulto Jovem
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