Early and long-term outcomes of open surgery after thoracic endovascular aortic repair

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1 Interactive CardioVascular and Thoracic Surgery 27 (2018) doi: /icvts/ivy139 Advance Access publication 25 April 2018 ORIGINAL ARTICLE Cite this article as: Ikeno Y, Miyahara S, Koda Y, Yokawa K, Gotake Y, Henmi S et al. Early and long-term outcomes of open surgery after thoracic endovascular aortic repair. Interact CardioVasc Thorac Surg 2018;27: Early and long-term outcomes of open surgery after thoracic endovascular aortic repair Yuki Ikeno, Shunsuke Miyahara, Yojiro Koda, Koki Yokawa, Yasuko Gotake, Soichiro Henmi, Hidekazu Nakai, Takashi Matsueda, Takeshi Inoue, Hiroshi Tanaka and Yutaka Okita* Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan * Corresponding author. Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kusunokicho Chuo-ku, Kobe , Japan. Tel: ; fax: ; yutakaokita@gmail.com (Y. Okita). Received 7 September 2017; received in revised form 7 March 2018; accepted 16 March 2018 Abstract OBJECTIVES: This study evaluated the early and long-term outcomes of open surgery after thoracic endovascular aortic repair. METHODS: We conducted a retrospective review of 41 patients who underwent open surgery following thoracic endovascular aortic repair between October 1999 and July The mean interval from primary intervention to open surgery was 3.1 ± 3.7 years. Indications for open repair were endoleak in 14 patients, graft infection in 10 patients, false lumen dilatation in 9 patients, retrograde dissection in 5 patients, migration in 1 patient and additional aneurysm in 2 patients. Eight patients underwent emergent surgical conversions. The mean follow-up period was 4.2 ± 4.0 years. RESULTS: Descending aortic replacement was performed in 15 patients; thoraco-abdominal aortic repair, in 14 patients; extensive arch to descending aortic replacement, in 5 patients; and total arch replacement, in 7 patients. Six (14.6%) patients died in the hospital. The 5-year survival rate was 73.7 ± 7.2%, and freedom from reintervention was 88.5 ± 6.4%. CONCLUSIONS: Early outcomes of open surgical procedures after thoracic endovascular aortic repair were still suboptimal. However, hospital survivors had excellent long-term outcomes. Keywords: Thoracic aorta Stent graft Thoracic endovascular aortic repair INTRODUCTION In recent years, thoracic endovascular aortic repair (TEVAR) has become an attractive strategy for high-risk patients. Commercially available devices were introduced in Japan in 2008, and an open stent graft went on the Japanese market in July 2014 (J Graft Open Stent VR graft: Japan Lifeline, Tokyo, Japan). The indications for TEVAR also have expanded as the debranching procedures have been developed. The Japanese Association of Thoracic Surgery reported a growing number of TEVAR procedures in this decade [1, 2]. There are some reports of good long-term outcomes from TEVAR [3]. However, problems were encountered in patients who required additional open surgery due to complications associated with TEVAR. Our previous report described good early and midterm outcomes from secondary interventions for TEVAR failure including secondary TEVAR [4]. In this report, we focused on the early and long-term outcomes of open surgery after TEVAR. Presented at the 31st Annual Meeting of the European Association for Cardio- Thoracic Surgery, Vienna, Austria, 7 11 October MATERIALS AND METHODS Patient population We conducted a retrospective review of 41 patients who underwent open surgery following TEVAR, including 17 patients with primary intervention at other hospitals, between October 1999 and July 2017 (Table 1). The study protocol was reviewed and approved by the institutional review board. An informed consent waiver was granted owing to the design of the study. Follow-up data were obtained by clinical visits, telephone calls or written correspondence and were available to all. The mean follow-up period was 4.2 ± 4.0 years. Patient characteristics and implanted materials The mean age at open surgery was 65.8 ± 11.9 years. The mean interval to open surgery was 3.1 ± 3.7 years. Nine patients underwent 14 reinterventions in 2.1 ± 1.9 years after the primary TEVAR. Eight of these patients underwent re-tevar for endoleaks, and 1 patient underwent embolization of the intercostal arteries. VC The Author(s) Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

2 Y. Ikeno et al. / Interactive CardioVascular and Thoracic Surgery 575 Table 1: Patient characteristics Table 2: Details of initial thoracic endovascular aortic repair The mean number of stent grafts (SGs) used was 1.8 ± 1.0 per person (range 1 5) (Table 2). Forty-nine commercially available SGs were used: GORE TAG (WL Gore & Associates, Flagstaff, AZ, USA; n = 31), Zenith TX2 (Cook Medical Inc., Bloomington, IN, USA; n = 8), Valiant (Medtronic, Santa Rosa, CA, USA; n =3), Relay (Bolton Medical, Sunrise, FL, USA; n =4), Talent (Medtronic; n = 2) and J Graft Open Stent (Japan Lifeline; n =1). This study also included 30 homemade SGs: 13 Gianturco Z-based stent grafts, 10 Matsui Kitamura (MK) stent grafts, 2 Inoue stent grafts, 2 homemade open stent grafts, 1 homemade fenestrated stent graft and 2 bare stents. The location of the proximal landing was Zone 0 in 1 patient, Zone 1 in 3 patients, Zone 2 in 4 patients, Zone 3 in 24 patients and Zone 4 in 9 patients. Indications for open surgery n (%) or mean ± SD Age (years) 65.8 ± 11.9 Male 32 (78.0) Hypertension 38 (92.7) Diabetes 5 (12.2) COPD 10 (24.4) CKD 17 (41.5) TEVAR at another hospital 17 (41.5) TEVAR for a ruptured aneurysm 8 (19.5) Reintervention 9 (22.0) Re-reintervention 3 (7.3) Interval to reintervention (years) 2.1 ± 1.9 Emergent open surgery 8 (19.5) Interval to open surgery (years) 3.1 ± 3.7 EuroSCORE II at open surgery 8.8 ± 11.2 Indication for open surgery Endoleak type 14 (34.1) Ia 8 Ib 3 III 3 Infection 10 (24.4) Stent graft infection 2 Aortobronchial fistula 2 Aorto-oesophagus fistula 6 Dilatation of false lumen 9 (22.0) Retrograde Type A aortic dissection 5 (12.2) Adjacent aortic aneurysm 2 (4.9) Stent graft migration 1 (2.4) CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; SD: standard deviation; TEVAR: thoracic endovascular aortic repair. Indications for open surgery included endoleaks in 14 patients (Type Ia in 8 patients, Type Ib in 3 patients and Type III in 3 patients), SG infections in 10 patients including aortobronchial fistulas (ABFs) in 2 patients and aorto-oesophageal fistulas (AEFs) in 6 patients, dilatation of the false lumen in 9 patients, retrograde dissection in 5 patients, additional aortic aneurysms in 2 patients and SG migration in 1 patient. The mean EuroSCORE II score for in-hospital mortality was 8.8 ± 11.2%, and emergent open surgery was performed in 8 (19.5%) patients. Preoperative computed tomography assessment In preoperative 3-dimensional enhanced computed tomography analysis, the mean length of the implanted SGs was 17.6 ± 8.2 cm. The mean diameter of the aneurysm was 49.7 ± 13.4 mm for the primary TEVAR and 55.8 ± 17.7 mm for the open surgery. The mean proximal expanding rate was 15.1 ± 11.7%. Type II endoleak was detected in 7 patients after primary TEVAR. Statistical analysis All continuous variables are expressed as the mean ± standard deviation. P-values <0.05 were regarded as statistically significant. The values of survival and freedom from aortic reintervention were determined using the Kaplan Meier technique and expressed as the survival rate ± standard error. The data analyses were performed with JMP 11.0 (SAS Institute, Cary, NC, USA). Management of stent grafts n (%) or mean ± SD Stent grafts used (number) 79 Commercial stent graft 49 (62.0) GORE TAG 31 Cook Zenith 8 Medtronic valiant 3 Bolton Medical relay 4 Medtronic talent 2 J Graft Open Stent graft 1 Homemade stent graft 30 (38.0) Gianturco Z-based stent graft 13 Matsui Kitamura stent graft 10 Others 7 Landing zone 0 1 (2.4) 1 3 (7.3) 2 4 (9.8) 3 24 (58.5) 4 9 (22.0) Debranching 10 (24.4) Aortic pathology Degenerative atherosclerotic aneurysm 16 (39.0) Aortic dissection 23 (56.1) Acute dissection 8 Chronic dissection 15 Aortic trauma 1 (2.4) False aneurysm 1 (2.4) Aneurysm diameter at TEVAR (mm) 49.7 ± 13.4 Aneurysm diameter at open surgery (mm) 55.8 ± 17.7 Number of implanted stent grafts 1.8 ± 1.0 Length of implanted stent grafts (cm) 17.6 ± 8.2 Proximal expanding rate (%) 15.1 ± 11.7 Type II endoleak after initial TEVAR 7 (17.1) SD: standard deviation; TEVAR: thoracic endovascular aortic repair. According to the surgical indications, removal of whole SGs was required in cases of infection. Even if open surgery was indicated for other aetiologies, SGs were removed in cases in which the initial TEVAR was performed for a ruptured aneurysm and homemade SGs were implanted. VASCULAR

3 576 Y. Ikeno et al. / Interactive CardioVascular and Thoracic Surgery Figure 1: Open surgery strategies. Left: median sternotomy, selective antegrade cerebral perfusion with lower body circulating arrest. Middle: left thoracotomy, lower body perfusion by partial cardiopulmonary bypass. Right: left thoracotomy, selective antegrade cerebral perfusion and lower body perfusion by partial cardiopulmonary bypass. On the other hand, preservation of SGs was indicated in cases of endoleak, false lumen dilatation or additional aneurysm. In addition, in patients with retrograde dissection, we repaired the entry lesion prior to SG resection and replaced the ascending aorta and aortic arch. To increase the haemostasis, we exclusively anastomosed the remnant SGs and the Dacron graft by incorporating the aortic wall and Teflon felt using 3-0 polypropylene sutures. Surgical approaches Because of the differences in pathological diagnoses and indications for open surgery, the optimal approach was determined by assessment of the culprit lesions and the need for SG removal (Fig. 1A C). With the first strategy, if there were problems in the aortic arch but the distal portion of the SG was intact, for example, retrograde dissection, Type Ia endoleak and proximal additional aneurysm, we adopted a median sternotomy approach, using selective antegrade cerebral perfusion (ACP) with lower body circulating arrest under moderate hypothermia (rectal temperature <30 C and tympanic temperature <23 C): median sternotomy with ACP. This strategy was performed in 7 (17.0%) patients. With the second strategy, if there were lesions in the descending aorta, regardless of the necessity of removing the SG, we adopted a left thoracotomy approach, perfusing the lower body using extracorporeal circulation (left thoracotomy). This strategy was performed in 30 (68.3%) patients. We usually used cerebrospinal fluid drainage and motor-evoked potential in elective patients to prevent spinal cord injury. Twelve patients underwent reconstruction of the intercostal arteries. With the third strategy, if there were problems in the aortic arch and removal of SGs was required, for example, infection and massive endoleak caused by homemade SGs, we adopted a left thoracotomy approach, using ACP under moderate hypothermia (tympanic temperature <28 C) and perfusing the lower body via extracorporeal circulation (left thoracotomy with ACP). This strategy was performed in 6 (14.6%) patients. RESULTS Operative data Operative data are shown in Table 3. We performed total arch replacement for 7 (17.1%) patients, extensive replacement of the aortic arch and descending aorta for 5 (12.2%) patients, descending aortic replacement for 15 (36.6%) patients and thoracoabdominal aortic replacement for 14 (34.1%) patients. One patient underwent descending aortic replacement through a left thoracotomy with ACP. The mean operating time was ± min, mean cardiopulmonary bypass time was ± 99.0 min, mean aortic clamping time (n = 14) was 76.0 ± 46.6 min and mean ACP time (n = 13) was 90.5 ± 37.6 min. In 21 (51.2%) patients, the implanted SGs were removed. In 5 (12.2%) patients, partial removal of SGs was performed and in 15 (36.6%) patients, SGs were preserved.

4 Y. Ikeno et al. / Interactive CardioVascular and Thoracic Surgery 577 Table 3: We clamped SGs in 21 (51.2%; 12 TAG, 3 MK, 2 Gianturco Z-based stent grafts, 1 TX2, 1 Valiant, 1 Talent and 1 homemade fenestrated stent graft) patients. We transected SGs in 5 (12.2%; 2 MK, 1 Valiant, 1 TX2 and 1 Gianturco Z-based stent graft) patients and anastomosed previous SGs and new artificial grafts in 17 (41.5%; 8 TAG, 4 TX2, 2 MK, 1 Valiant, 1 Gianturco Z-based stent graft and 1 open stent graft) patients. Early outcomes Operative data n (%) Approach Median sternotomy with ACP 7 (17.1) Left thoracotomy 28 (68.3) Left thoracotomy with ACP 6 (14.6) Replacement Aortic arch 7 (17.1) Arch descending aorta 5 (12.2) Descending aorta 15 (36.6) Thoracoabdominal aorta 14 (34.1) Removal of SG 21 (51.2) Partial removal of SG 5 (12.2) Preservation of SG 15 (36.6) SG clamp 22 (51.2) Transection of SG 5 (12.2) Anastomosis of SG 17 (41.5) Operating time (min) ± CPB time (min) ± 99.0 Aortic clamping time (n = 14, min) 76.0 ± 46.6 ACP time (n = 13, min) 90.5 ± 37.6 Early outcomes 30-Day mortality 3 (7.3) Hospital mortality 6 (14.6) Stroke 2 (4.9) Spinal cord injury 1 (2.9) Tracheostomy 6 (14.6) Myocardial infarction 1 (2.9) Pulmonary embolism 1 (2.9) ICU stay (days) 9.0 ± 17.3 Hospital stay (days) 35.7 ± 26.1 ACP: antegrade cerebral perfusion; CPB: cardiopulmonary bypass; ICU: intensive care unit; SD: standard deviation; SG: stent graft. Six (14.6%) patients died in the hospital. Stratified according to indications for open surgery, hospital mortality in patients who underwent open surgery for endoleak, infection and others was 7.1% (1 patient), 40.0% (4 patients) and 5.9% (1 patient), respectively. One patient was an 83-year-old man who underwent TEVAR for the rupture of a descending aortic aneurysm. He experienced SG (Gianturco Z) migration. Although we performed emergent surgery, the patient died of multiorgan failure caused by lower body ischaemia. The 2nd patient was an 81-year-old woman who had 5 SGs implanted in stages (1 MK and 4 TAG) for an atherosclerotic descending aortic aneurysm presenting with haemoptysis. She underwent open surgery 22 months after her first TEVAR due to SG infection. The moment we removed 1 SG, copious bleeding from the lung occurred. It appeared that another SG had migrated and tore the aortic wall and lung. She died of bleeding. The 3rd patient was a 67-year-old man who underwent open surgery for AEF with descending aortic replacement using a cryopreserved allograft with omental wrapping and resection of the oesophagus. He experienced rupture of the anastomosis and required reoperation because of reinfection 17 days after open surgery. However, he died of sepsis. The 4th patient was a 73-year-old man who underwent branched thoraco-abdominal stent grafting (Crawford extent II) for an aortic aneurysm. He developed Type III endoleak caused by fenestrated abdominal branches. We performed thoracoabdominal aortic repair (Crawford extent III) and partial removal of the SGs. He died of bleeding from the brain 3 months after open surgery. Two patients who had open surgery for graft infection and AEF died of pneumonia during rehabilitation. Perioperative complications Perioperative complications occurred in 7 patients. Stroke occurred in 2 (4.9%) patients, and both underwent resection of the SGs implanted in Zone 3 for Type Ia endoleaks. Perioperative myocardial infarction occurred in 1 (2.4%) patient who underwent urgent TEVAR for a ruptured descending aorta. Pulmonary embolism occurred on the 18th postoperative day in 1 (2.4%) patient with an ABF. Spinal cord injury occurred in another patient who also underwent thoraco-abdominal aortic replacement (Crawford extent II) in addition to removal of the SG mentioned above. Six (14.6%) patients needed tracheostomy because of respiratory failure. Long-term outcomes Late death occurred in 7 patients: 2 patients died of pneumonia, 1 of dehydration, 1 of bowel obstruction, 1 of sepsis, 1 of senile decay and 1 of sudden death. The 5- and 10-year survival rates were 73.7 ± 7.2% and 63.8 ± 9.0%, respectively (Fig. 2A). Stratified according to indications for open surgery, 5-year survival rates in patients who underwent open surgery for endoleak, infection and others were 85.7 ± 9.4%, 46.7 ± 16.6% and 79.5 ± 10.7%, respectively (log-rank P = 0.136) (Fig. 2B). There were no significant differences between surgical approaches and late deaths. Aortic-related reintervention occurred in 5 patients. Two patients underwent re-tevar due to a Type III and a Type Ib endoleak of residual SGs after 5.8 and 7.0 years, respectively. Two patients underwent graft replacement of the descending aorta due to secondary AEF after 2.6 and 5.4 years. The aetiology of AEF was related to a prosthetic graft of the descending aorta in 1 patient and to a residual SG in the other patient. One patient underwent thoraco-abdominal aortic repair because of dilation of the downstream aorta after 2.3 years. There were no hospital deaths related to reintervention, and 5 of 6 AEF survivors underwent oesophageal reconstruction. Freedom from reintervention at 5 and 10 years was 88.5 ± 6.4% and 70.1 ± 10.9%, respectively (Fig. 3A). Stratified with indications for open surgery (endoleak, infection and others), freedom from reintervention at 5 years was 91.7 ± 8.0%, 88.9 ± 10.5% and 87.5 ± 11.7%, respectively (log-rank P = 0.827) (Fig. 3B). None of the patients, including 6 survivors of infection repair, required reintervention for the first 5 years. VASCULAR

5 578 Y. Ikeno et al. / Interactive CardioVascular and Thoracic Surgery Figure 2: Survival after open surgery following thoracic endovascular aneurysm repair (A) and survival stratified by indications for open surgery (endoleak, infection and others) (B). Shaded band shows 95% confidence interval. Figure 3: Freedom from reintervention after open surgery following thoracic endovascular aneurysm repair (A) and that of reintervention stratified by indications for open surgery (endoleak, infection and others) (B). Shaded band shows 95% confidence interval. DISCUSSION The incidence of TEVAR failure requiring open surgery ranges from 2.2% to 7.2% [5 9]. In our institution, 24 out of a series of 302 (7.9%) patients underwent open surgical repair after TEVAR. This rate was relatively high, but implanted homemade SGs (n = 16) were a significant risk factor for open surgery compared with commercially available SGs (n = 8): 19.8% (16/81) vs 3.6% (8/ 221) (P < 0.001). With the commercial SGs, the rate of secondary open surgery was comparable to those in recent reports. However, compared with our previous report (n = 16), in the latest 5 years, the number of open surgeries following TEVAR has increased dramatically (n = 25). We hypothesized that this increase was due to the facts that the total number of patients who underwent TEVAR had increased and that the indications for TEVAR had been extended, especially for younger patients or for patients with dissection. Although homemade SGs were not available in other countries and have not been used exclusively in Japan, we included this cohort because different strategies were required in these patients. Actually, in this 5-year period, 5 additional patients with homemade SGs required open surgery. It is important to classify and optimize the strategy for each case, because in open surgery following TEVAR, there are multiple diseases and lesions. Endoleak occurs in as many as 29% of patients after TEVAR [10 12]. Parmer et al. [11] reported that endoleak was not uncommon after TEVAR. In addition, endoleak was demonstrated to be a significant risk factor for aortic rupture [10]. Conventional endoleak management consists of aggressive repair of Type I and Type III endoleaks and observation of Type II endoleaks. For Type I and Type III endoleaks, if an adequate landing zone for additional SG placement exists, we considered redoing TEVAR as the first intervention. However, several patients required open surgery. Ricotta [13] reported, in their review of 3002 patients, that the incidence of Type I endoleaks was 8.4%, and that 3.6% of these patients required open repair. Moreover,

6 Y. Ikeno et al. / Interactive CardioVascular and Thoracic Surgery 579 a report that coverage of the left subclavian artery was one of the significant risk factors for endoleaks implied that more aortic arch-related surgery would be required [14]. According to our strategy, patients for whom a repeat endovascular procedure was not feasible for anatomical or pathological reasons were better candidates for open surgery in the event of endoleaks. There were Type I endoleaks in 11 patients (Type Ia in 8 patients and Type Ib in 3 patients) and Type III endoleaks in 3 patients. We performed complete removal of SGs in 8 patients, partial removal in 3 patients, and preservation in 2 patients. Where appropriate, it is possible to reduce operative invasion by repairing endoleaks. Although the diameter of the aneurysms did not expand in the follow-up period, there was 1 patient who required re-tevar for a Type III endoleak at a residual homemade SG. Our strategy of complete removal of the SG might be valid, especially for homemade SGs. Infection-related TEVAR failure, with or without fistula formation, is an indication for emergent or urgent open conversion to extract the contaminated source. Moulakakis et al. [15] reported in their review of 96 patients with SG infections that patients who underwent SG explantation had fewer overall deaths than those who underwent SG preservation (46.3% vs 81.8%). In terms of fistulae, Czerny et al. [16] reported, in their registry of ABF and AEF [17] after TEVAR, that radical surgical treatment improved overall survival in patients with fistulae. We performed a left thoracotomy in all patients with infection to remove the entire SG. For AEF, we recommend single-stage surgery consisting of oesophageal resection, in situ reconstruction of the aorta and omental flap installation [18]. TEVAR as an initial bridging intervention before open surgery is useful for haemodynamically unstable patients, despite the excision of a bridging SG implantation in this study. Our study included 6 patients with AEF after TEVAR and 1 patient with ABF. Although more hospital deaths still occurred among patients with this disease, hospital survivors achieved excellent long-term survival without reinfection. We believe that our strategies and aggressive removal of SGs contributed to the positive outcome even in patients with infections. The indications for primary TEVAR in patients with chronic Type B aortic dissection including dilatation of the false lumen after surgery for Type A dissection are controversial. Nienaber et al. [19] did not demonstrate 2-year survival benefits for prophylactic TEVAR performed in the early chronic phase, but they reported an improvement in 5-year survival rates and evidence of aortic remodelling, expansion of the true lumen and thrombosis of the false lumen. However, in the long-term analysis after frozen elephant trunk insertion, the rate of false lumen remodelling was low in the distal abdominal aorta in patients with both acute and chronic dissection [20]. Several authors proposed the effectiveness of hybrid staged repair salvaging previous SGs [21]. Coselli et al. [22] suggested that it was possible to fully salvage SGs due to de novo progression of aortic disease into an adjacent aortic section. In this study, no hospital deaths and 1 spinal cord injury were found in 9 patients who underwent open surgery for the dilatation of the downstream aorta. Retrograde Type A dissection occurs in 1 2% of TEVAR procedures for Type B dissection [6, 7, 9, 23, 24]. Despite the rarity of this complication, treatment usually requires open surgery because of the high mortality rate [24]. For the 3 patients with retrograde Type A dissection, we performed total arch replacement using the median sternotomy approach and selective cerebral perfusion. In all cases, the SG was partially resected, because the primary object of the surgery was the exclusion of the entry tear. Early death following open surgery after TEVAR is reported to range from 6% to 19% [6, 9, 25, 26]. In their review of 50 patients, Eric et al. [26] reported hospital deaths of 3 (6%) patients and a 5-year survival rate of 56%. Compared with our study, there were some differences in the patients backgrounds, including the inclusion of only 6 (12%) patients with infection. In the present study, we emphasized that, from a long-term prospective, open surgery promised acceptable survival without reintervention. Limitations One limitation of this study is its retrospective nature. In addition, commercial SGs have only been available since 2008, and this study included homemade SGs in about half of the patients. CONCLUSION We analysed the outcomes of 41 patients who underwent open surgery after TEVAR. Homemade SGs were significant risk factors for open surgery in Japan. Early outcomes of open surgical procedures after TEVAR were comparable to those in recent reports. Open surgery for infection was associated with death in the hospital. However, in hospital survivors, our strategies resulted in excellent long-term survival and freedom from reintervention. Conflict of interest: none declared. REFERENCES [1] Okita Y. Surgery for thoracic aortic disease in Japan: evolving strategies toward the growing enemies. Gen Thorac Cardiovasc Surg 2015;63: [2] Masuda M, Okumura M, Doki Y, Endo S, Hirata Y, Kobayashi J. Thoracic and cardiovascular surgery in Japan during 2014: annual report by the Japanese Association for Thoracic Surgery. 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