Circulation October 5, 2021 Issue

This week's episode features highlights from
Circulation's 2021 Cardiovascular Surgery Themed Issue. Join
Executive Editor James de Lemos along with Associate Editors Marc
Ruel and Michael Fischbein as they discuss all of the articles
found in this special issue.


Dr. James de Lemos:


Hi, my name is James de Lemos. I'm a cardiologist at University
of Texas Southwestern Medical Center in Dallas, and the executive
editor for Circulation. And I'm standing in for Carolyn and Greg
today to host our annual cardiovascular surgery-themed issue
podcast. And I'm delighted to be joined by Marc Ruel, professor
and chairman of the Division of Cardiothoracic Surgery at the
Ottawa Heart Institute, and the director of cardiac surgery
content for Circulation, as well as Michael Fischbein, associate
professor of cardiothoracic surgery at Stanford and the director
of the thoracic and aortic programs there. Marc, thanks for all
that you do for Circulation with cardiovascular surgery content
and let me turn it over to you to introduce the issue.


Dr. Marc Ruel:


Well, James, thank you very much. We're very delighted to
introduce this 2021 cardiovascular surgery-themed issue. We
already feel that this is going to put together some of the very
best science at the interface between cardiac surgery or
cardiovascular surgery, I should say, because there's some
peripheral vascular topics as well, cardiology, and as well,
mechanistic research. I think you're going to find that this is
really a very jam-packed issue that has a lot of important
messaging that will change the field going forward.


Dr. Marc Ruel:


Also, this year, I want to highlight a couple of changes in the
preparation of the issue. I want to first thank the tremendous
contributions over the years to Circulation and to the entire
field of cardiac surgery of Tim Gardner. Really, Tim, is an
absolute giant. I think he's the only person known to me who was
both president of the American Heart Association and of the ATS
in the field of cardiac surgery.


Dr. Marc Ruel:


Tim has really paved the way for us to develop and enhance this
issue over the years, and I think 2021 is a testament to his
legacy, because I would argue it's our strongest issue ever. And
I also want to introduce Mike Fischbein, James and everybody,
who's associate professor at Stanford. Mike is a thoracic-aortic
surgery expert, also runs a translational lab, so has a very
dedicated, basic science and translational surgical science
expertise. So we're very, very happy to welcome Mike to the
themed issue of Circulation.


Dr. James de Lemos:


Well, thanks Marc. We'll do is follow the order of the issue so
that our readers and listeners can really get a sense of the
content and its various types that we're publishing this year.
And the issue starts with a provocative frame of reference piece
from Verma and colleagues discussing the surgical left atrial
appendage occlusion. Marc, what were your thoughts on that piece?


Dr. Marc Ruel:


It's obviously a game changer in cardiac surgery. I was
privileged to serve as a part of the BSMB for this trial, and we
can now say we toyed with the decision as to stop the trial at
the appropriate time. And that's always a very difficult BSMB
decision, which, frankly, you want to get it right, and you don't
want to err on either side. Anyways, LAAOS III was recently
published and we have a fantastic editorial in Circulation from
Subodh Verma, Deepak Bhatt, and Elaine Tseng saying, which
essentially highlights the importance of the trial for practice
of cardiac surgery.


Dr. Marc Ruel:


It probably is that no patient who comes to cardiac surgery with
a history of atrial fibrillation should, based on those findings,
not have their atrial appendage ablated. There's already very
little caveat, the trial has not shown what was feared prior with
regards to an increased incidence of heart failure or symptoms.
And really, the surgery has been effective. The ablation of the
left atrial appendage is very effective in diminishing the
primary outcome or of stroke, ischemic stroke or cerebral
hemorrhage.


Dr. Marc Ruel:


And essentially, this was, in most cases, a surgical ablation, so
cut and sew. So we don't have all the information about either
endovascular devices or even ablative devices at the time of
surgery. But it was a very large trial, it was a publicly funded
trial. It is really the authoritative information in the field
that's available so far.


Dr. Marc Ruel:


Mike, what are your thoughts around this? Do you now come to any
one of your patients needing a cardiac surgical cooperation with
a history of atrial fibrillation and thinking that I now need to
address the left atrial appendage? Is that what you get out of
this paper as well?


Dr. Michael Fischbein:


Yeah. Thanks, Marc. I think that's an excellent question. Yeah,
now, every patient after this trial, I talk to them ahead of time
and offer them to have their appendage ligated in this setting if
they have a history of atrial fibrillation. I don't think this
adds much to our operation, it doesn't increase much the clamp
time. And especially, although the trial was more surgically
excising with some of the newer clips out there, it really
doesn't add much time to the operation. So I think this is really
an important paper that will change what we do as surgeons.


Dr. James de Lemos:


Can I just comment that I think the trial has indirect
implications well beyond surgery, because the demonstration of
combined benefit for oral anticoagulation with left atrial
appendage occlusion really suggests that, even for patients not
going for cardiac surgery, at some point in the future, we may be
thinking about not and either/or between the devices and
anticoagulation, but maybe both.


Dr. James de Lemos:


Mike, let me come back to you. There's a really fascinating paper
by DeCarlo evaluating penetrating aortic ulcers that really
change my thinking on this. Can you talk a little bit about this
paper and your thoughts?


Dr. Michael Fischbein:


Thanks very much, James. I think this is really an important
paper that's going to change what we do as surgeons. As you know,
symptomatic penetrating aortic ulcers are grouped with
dissections in tremula hematoma where we treat those patients
immediately. None of us know what to do though with the
asymptomatic aortic ulcer, which is actually more common. A lot
of us are basing our reports on some observational studies. Many
of these studies are mixed, symptomatic and asymptomatic. And so
the treatment really varies, from watching them conservatively to
treating them with open or endovascular approaches.


Dr. Michael Fischbein:


However, this paper by DeCarlo's really excellent. They followed
273 asymptomatic penetrating ulcer patients over time following
their CT scans. And they really had two key important findings.
One that these ulcers really didn't change much over time, and
two, the risk of some complication occurring, whether that's
rupture, symptoms or progression of disease was very low at 6.5%
over 10 years. And so I think this is really going to be
important, because we know that these asymptomatic penetrating
ulcers, we can watch them conservatively. They do have to be
still followed, but we don't have to go immediately to perform
some surgical procedure.


Dr. James de Lemos:


Marc, any thoughts from you on this paper? Does this change what
you guys will be doing in Ottawa?


Dr. Marc Ruel:


Absolutely. Yeah, I think this is, as Mike was saying, a very
germane finding that's very helpful. I think the key word here,
as Mike was alluding to, is really the word asymptomatic and how
do you define that? Right? I mean, many of these findings are
incidental findings. Someone comes in with a bit of shortness of
breath or this or that, gets a PE protocol CT scan and then a
penetrating aortic ulcer is found.


Dr. Marc Ruel:


So where do you draw the line between symptoms that may be a
small left lateral effusion or a bit of shortness of breath. And
it's also, I think that nuance will have to be determined going
forward, what is truly asymptomatic versus a few symptoms that
may be less specific and perhaps not relate to the penetrating
aortic ulcer. But I think it's tremendously helpful in guiding
practice going forward.


Dr. James de Lemos:


Fantastic. Thank you both. Mike, I want to come back to you on
another really important paper from the vascular surgery
standpoint, which is the paper from the Voyager investigators on
the combination of rivaroxaban and aspirin for patients with
surgical treatment of peripheral arterial disease.


Dr. Michael Fischbein:


Yeah, no, I think this is another or provocative paper. And as
you know, peripheral arterial disease is a really
highly-significant clinical problem. We say that affects 200
million people globally. And this includes patients with
claudication, arrest pain, limb threat ischemia. And currently,
the treatment for this is to either a open surgical or
endovascular revascularization of the lower extremity. And the
problem is while these patients, they have immediate symptomatic
relief where you can save their limb, we say that one out of five
will develop some sort of symptom or limb ischemia by three
years.


Dr. Michael Fischbein:


And so the field is really looking for some sort of adjuvant
therapy to help prevent these occurrences later on. And so the
Voyager trial randomized over 6,000 patients who underwent
surgery, whether it was open or endovascular, and then they
randomized to either receiving rivaroxaban plus aspirin, versus
aspirin and a placebo. And they showed that if you received riva,
that those patients had a significant reduction in the instance
of their primary endpoint, which included ischemia, limb loss or
symptoms. And importantly, there was not an increase in major
bleeding risk in these individuals.


Dr. James de Lemos:


So fascinating. I mean, this does this change practice and is
this now the standard for surgically-treated peripheral arterial
disease?


Dr. Michael Fischbein:


Yeah, I think there's still some questions that we have to
answer. Yeah, I think definitely this, I think will be used after
the bypass surgery, but some of the things in the trial that we
would have to figure out is how applicable is this to everyone.
In the trial, the open surgical arm had patients with less risks.
Also, some patients received vein conduit versus a prosthetic
conduit. And so, I think we'll have to look at some of the
sub-analysis to see who we can apply this to.


Dr. James de Lemos:


Fantastic. Marc, any thoughts from your perspective on this one?


Dr. Marc Ruel:


Yeah. Mike provided a great summary. I think one other take-home
message to me is that, really, these patients should be viewed as
having panvascular disease, a little bit like our CABG patients.
And essentially rivaroxaban or DOACs in general have a role, like
in the COMPASS trial, in preventing other complications. So here,
part of the composite endpoint was myocardial infarction, right?
And we know that these peripheral vascular disease patients are
very much at risk of it. So it may have an effect locally, but it
really, probably, has most of its effect with regards to the
panvascular disease that these patients present.


Dr. James de Lemos:


Excellent. And I'll just point out that just today, the FDA
released news that they've granted an indication for this
combination therapy for patients with peripheral arterial
disease. Let me come back to Marc for a really interesting
randomized controlled trial, from China, evaluating no-touch vein
graft interventions for cardiac surgery. Marc, can you talk to us
about this trial and your impressions on this?


Dr. Marc Ruel:


Absolutely. Thank you, James. So this is a trial from seven
hospitals in China that randomized 2,600 patients between April,
2017 and June, 2019. And patients were randomized with the use of
saphenous vein grafts between a no-touch technique and a
conventional saphenous vein graft harvest technique. And I'll
explain a little bit what this no-touch technique is. It actually
consists of two things. You take the vein by a complete incision.
Often, in fact, it's more invasive, and you take the actual
saphenous vein with a surrounding layer of fat and connective
tissue around it. And because of that, it's not easily amenable
to endoscopic vein harvest or even using small incisions.


Dr. Marc Ruel:


The other component of no touch of vein harvesting is to really
preserve the anterior layer by not using any syringe inflation
and letting the conduit be rinsed, but flow naturally and not be
distended at all. So the trial was positive, and the trial
already showed a lesser incidence of saphenous vein graft closure
at both three months and 12 months on CT scan. So to give you an
example, the three months saphenous vein closure was 4.8% in the
conventional harvest group, versus 2.8% in the no-touch group.


Dr. Marc Ruel:


Now what's interesting to here is twofold. There may be a couple
of aspects in the benefits of the therapy, and one may relate, in
fact, to the lack of pressure syringe dilatation. So it's hard to
tease out, is it really the surrounding layer of fat or is it the
fact that the syringe dilatation procedure is not being performed
in the no-touch group? The second issue is the technique is
definitely more invasive. The authors found in the trial more
local complications, about 50 to a hundred percent increase in
terms of a local numbness, exudation, et cetera, delayed wound
healing. Because you have to make bigger incisions and you have
to take more tissue around where the vein that you're harvesting.


Dr. Marc Ruel:


So it is a very intriguing trial. Obviously, graph patency is
something that's tremendously important around the CABG
operation. But unfortunately, it steers us towards a more
invasive approach. In a nutshell, it is a positive trial, but it
does require the surgery to be slightly more invasive, albeit, in
most cases, with addressable issues with regards to delayed wound
healing and exudation. But it would be ideal if we could combine
the benefits of a no-touch technique with a less invasive
approach to harvesting.


Dr. James de Lemos:


Mike, this is fascinating to me because you've got a procedure
that probably improves the long-term outcomes of the operation,
but is associated with a longer surgical time and more local
complications. Mike, I'm wondering, what are your surgeon's going
to do at Stanford? Are they going to adopt this or is this too
difficult and associated with too much inconvenience for the
patient to become something that's done routinely?


Dr. Michael Fischbein:


Brilliant, great question, James. Because I think, often, our
patients, previous to endoscopic vein harvesting, they often
complained more issues with their leg incisions than their actual
sternotomy. And I always tell my patients now, though, one of the
incredible things is that we can take their vein endoscopically.
And now, we're talking about, while we do have improvement in
graft patency for the vein, we're going to go backwards and maybe
have some of these wound issues again. And I'd be curious what
Marc thinks, though. We are trying to do more and more arterial
grafts. And so, if we're just using one vein, is it worth
accepting these higher wound complications?


Dr. Marc Ruel:


It's a great point, Mike, and perhaps exactly, as you say,
perhaps an increased use of arterial grafts can be combined with
lack of a pressure syringe dilatation of the vein after harvest,
right? And there's already some data suggesting, as provided in
the excellent editorial by Vidal, that this may be
mechanistically important to enhance patency. So the study is
very intriguing and still remains to completely unfold.


Dr. James de Lemos:


Excellent. Really important contribution to the surgical science.
Marc, I want to come back to you with another important
randomized control trial, this with a really novel therapeutic
compound designed to address kidney injury after cardiac surgery.
Marc, can you talk about the trial with the small interfering
mRNA for renal protection?


Dr. Marc Ruel:


Absolutely. Thank you, James. This is an important trial, in my
opinion. It's a Phase II study of a compound named, teprasiran,
which is a interfering RNA, which modifies the p53 mediated cell
death response in the renal tubal cells. So what does that do,
essentially, is that the thought is that it may prevent acute
renal injury after cardiac surgery. We know that's a tremendous
problem. Most busy cardiosurgical ICUs would have at least
between 15 to 25% of the patients requiring dialysis postop,
depending on the level of risk acuity that your unit is
presenting.


Dr. Marc Ruel:


And it's no different whether you're in Stanford or Ottawa or
Germany, in my opinion. So we need solutions here. And this is a
relatively simple compound, which is administered within four
hours of completion of surgery. So for instance, if the surgery
was performed on pump, it was given within four hours of
completion of surgery. So, for instance, if the surgery was
on-pump, it was given within four of hours completion of CPB,
cardiopulmonary bypass. If it had been performed off-pump, it was
within four hours of the last anastomosis.


Dr. Marc Ruel:


It's a two-minute infusion, 10 milligrams per kilo, and
essentially in the trial, it was not associated with any safety
concerns. And quite conversely, it was actually associated with
the benefit, with regards to the development of early acute
kidney injury, which was 50% prevalence in the patients who were
treated with placebo, versus 37% in patients who received the
compound, again, named teprasiran. So I think this is quite
important. It has led to a Phase III which is currently ongoing,
and I think this is a very instrumental finding in the field.


Dr. James de Lemos:


Fantastic. I mean really a testament to the progress in clinical
science for cardiac surgery, that we've got these randomized
controlled trials moving through a development phase that may be
actionable in years to come. Let's finish the discussion of the
original research articles, Mike, with a review of the Yang
paper, really, which also, I think, is in Circulation's real
sweet spot, where we're highlighting the very best of basic and
translational science coming from Surgeon Laboratories. Can you
talk about that paper for us?


Dr. Michael Fischbein:


Thanks very much, James. I think this is really an exciting
paper. Qiong Yang's lab at University of Michigan, they're
studying Loeys-Dietz syndrome. As you know, Loeys-Dietz syndrome
is one of the connective tissue disorders. There's five subtypes,
and these individuals form aortic root aneurysms. Importantly,
it's specific to the aortic root that these aneurysms primarily
develop. Although later on, you can see them in other locations,
including intracranial and some of the branch vessels.


Dr. Michael Fischbein:


But these root aneurysms can dissect and this is life
threatening. Currently, the only treatment strategy for these
individuals is surgical, where you perform a prophylactic
replacement of the aortic root. Unfortunately, there are no real
medical therapies, primarily because we don't understand the
mechanisms why these aneurysms form. So Dr. Yang's lab, they
model this disease using a induced pluripotent stem cell model,
where cells are differentiated into the different embryologic
origins of the aorta.


Dr. Michael Fischbein:


The aortic group comes primarily from the second heart field. And
so, when they studied these smooth muscle cells, they were able
to show that there is lineage-specific smooth muscle cell
defects, and they discovered some interesting pathways that might
explain why aneurysms form specifically in the root in these in
individuals. They also came up with some potential pharmacologic
strategies to block some of these mechanisms.


Dr. Michael Fischbein:


And so, I think this is really exciting because this is using
pluripotent stem cells more as a model to study disease states.
And I could see the potential, also, for precision medicine,
where you take an individual cells, make their iPSCs and study
that individual's mechanisms, and perhaps come up with unique
medical strategies for that individual.


Dr. James de Lemos:


So let's, Marc, finish, that's really all of the original
research articles we covered. Really, an amazing spectrum of
clinical translational and basic science that is a Testament,
both to what you all have done to recruit content, but the
tremendous growth in science and the surgical specialties. Marc,
let's talk a little bit about the two terrific in-depth reviews
that you picked for this issue and what their contributions are.


Dr. Marc Ruel:


Thank you again, James. We have two excellent reviews in this
themed issue of Circulation. One is a frontiers piece about
cardiac surgery in women in the current era, going over what are
the gaps in care. And this is spearheaded by Leslie Cho, from the
Cleveland Clinic, and it really goes over, very comprehensively,
many of the issues around not only clinical trial enrollment of
women, but specific issues pertaining to the care, and which goes
back even to basic science of the sex and gender of animals being
used in research for reasons that I said, that are very
comprehensively, again, I want to emphasize highlighted by the
authors.


Dr. Marc Ruel:


And I'll give you an example, for instance. In off-pump surgery,
there are some discrepancies with regards to the use of off-pump
versus on-pump surgery between males and females. And we off-pump
surgeons know that there are really two very different ways from
the surgery. Women, for instance, have a smaller heart which is
easier to expose, for instance, for lateral and inferior
territories. But in the same token, the coronary targets can be
smaller. So there's really a number of discrepancies here, which
can be anatomic, it can be sometimes due to the disease
presentations.


Dr. Marc Ruel:


For instance, women have more tricuspid valve disease, and at a
certain age start having an increased incidence of aortic
problems versus males. And there's also some what I would call
logistical issues with regards, for instance, to clinical trial
recruitments from VA centers that typically have very, very few
women being eligible for enrollment there. So these issues,
again, are comprehensively addressed by Dr. Cho and her
colleagues. And it's a very interesting read.


Dr. Marc Ruel:


The other piece you were referring to is a state-of-the-art paper
around the use of transit time flow measurements during coronary
bypass. And I think our cardiology colleagues and everyone in the
cardiovascular field will be very interested to learn a bit more
about this. Because essentially, when we perform bypass surgery,
we don't have a validated easy way to ascertain whether the
grafts that we just built are doing their job. And you may say,
"Well, the surgeon's great at cutting and doing anastomosis," but
as I like to tell my trainees, there's much more than suturing
that might be happening.


Dr. Marc Ruel:


An anastomosis may have an unforeseen flap into it. There could
be a small clot that's blocking something. There could be a kink
or a twist in the graft that's not readily recognized. So I think
it's very important to have a thorough assessment in everybody.
I'm the last author of this piece, so I'm obviously somewhat
partial to it. But I think it is important for the field to have
quality checking of all grafts that are performed at something,
especially something as invasive as bypass surgery. The patient
should come out with functional grafts and that should be
validated and objectively verified.


Dr. James de Lemos:


Fantastic. Marc, and we also have two research letters in this
issue of Circulation. These are small pieces, but they pack a
really powerful punch. Do you want to just briefly tell us about
those two?


Dr. Marc Ruel:


Absolutely. Thank you, James. As a surgeon, I love research
letters. I think they are a great venue. They're under a thousand
words. Certain, sometimes we're busy, we don't want to always
read a 5,000-word manuscript. And they're really, they are
well-suited to what I would say are surgical follow-up studies.
Once a technique has been described and you want to look at what
are the late outcomes of this technique, I think they're an
excellent format for that. And precisely, this corresponds to the
two research letters that we have in the 2021-themed issue.


Dr. Marc Ruel:


One is a long-term, 10 year analysis of the SAVE RITA trial by
Kim and Kim in South Korea. The SAVE RITA trial is a fairly
famous trial in our specialty, which essentially, randomized
patients to have a Y graft on the left internal thoracic artery,
using either a saphenous vein conduit or the right internal
thoracic itself. And essentially the early results were neutral.
So the two groups were comparable, which is naturally neutral. I
would say non-inferior for the saphenous vein graft.


Dr. Marc Ruel:


Now we have 10-year data in over 200 patients, equally randomized
between receiving a saphenous vein graft versus the right
internal thoracic artery. And the results are 10 years are
equally excellent between the saphenous vein graft and the right
internal thoracic artery. So this is quite non-intuitive to many.
Essentially, what we're showing here is that a vein graft at 10
years has amazing patency. We're talking 90%-plus in those
patients who received an angiogram. So I think there's a couple
of messages to remember here.


Dr. Marc Ruel:


There may be a biologic role of connecting a saphenous vein graft
onto the left internal thoracic artery with regards to nitric
oxide dilution. Also, technically, the authors have readily
acknowledged that the harvest the vein, again, back to this
saphenous vein harvest issue, they harvest it from the lower leg.
Therefore, the diameter of the vein is more suited to a Y graft.
And, in fact, using a vein over right internal thoracic artery
may have technical advantages, because the diameter is a little
bit more facile to use with regards to complex composite
grafting. So it may actually be something that, if you can
maintain it with patency based on say, nitric oxide dilution, is
a little bit easier to maneuver and build at the time of surgery.


Dr. James de Lemos:


Marc, can I ask a question here? Does this change your practice
with regard to how often you're using Y graphs, in general, and
the vein on artery Y? Because, Mike, outsiders experiences that
these graphs aren't used and do these data suggest that we should
be using why Y graphs, in general, and this particular type of Y
more often in surgery?


Dr. Marc Ruel:


Absolutely. I think these data suggest precisely that. Whether
the adoption will follow is another story. There's not a lot of
groups, much to your point, that are using this configuration,
but it's used commonly as a bailout strategy. Let's say, one of
the arteries has been injured or is not available, or you have a
porcelain aorta, I think based on these important data, you can
now know that you can, if well-constructed, use a saphenous vein
graft as a Y graft onto the LITA with relative impunity. In fact,
excellent results, if done in the way that Kim and Kim are
reporting.


Dr. Marc Ruel:


Our second research letter is actually a follow-up of hybrid
palliation for hypoplastic left heart syndrome. This comes from
the UK, where a number of centers had used several years ago the
concept of a hybrid palliation in patients who were mostly high
risk for hypoplastic left heart. So here, again, much to the
research letter format, we have a follow-up series with regards
to following all these children who had received either a initial
Norwood approach or a hybrid approach progressing to a Norwood
stage two. And essentially, the overall survival, which is about,
between two thirds to 75% of children at three, four years, is no
different between an initial Norwood stage one approach versus
hybrid palliation.


Dr. Marc Ruel:


So I think this is obviously very intriguing data. It's used to
be that a hybrid palliation would only be used in very high-risk
cases. I think this would provide credence to using it in a more
liberal fashion. There's still the possible caveat that the
centers that use hybrid palliation have a little bit of a
"expertise bias," if you will, because they have both modalities
being available. But I think this is a very important and very
intriguing data for this extremely challenging condition.


Dr. James de Lemos:


Well, thank you. And I'd like to thank both you, Marc, and Mike
for just tremendous insight. I think for somebody that doesn't
live in the cardiac surgery world, having the privilege, not just
to hear you explain these terrific studies, but also provide your
insights in pearls about cardiac surgery and vascular surgery
care in 2021 has been invaluable. And I think our listeners will
feel the same way. I'd like to turn it over to you, Marc, as our
leader in cardiovascular surgery to close us out today from a
wonderful podcast.


Dr. Marc Ruel:


Well, thank you very much, James. Again, I want to reiterate, I
think this is really a tremendous issue. It's our best ever. And
I want to thank you, James and Joe Hill, as well, our
Editor-in-Chief, for your support of surgery within Circulation.
I also want to thank Sarah, Molly, Nick, and Augie, really, for
their in their indefatigable support of our issue. I want to,
again, extend our gratitude to Tim Gardner and to Mike for their
tremendous help with this issue. I think this is, again, very
important. Do send your best work, and I'm speaking to our
readership community and all surgeons to Circulation.


Dr. Marc Ruel:


Circulation is our premier journal and surgery's tremendously
important. And the interface together is a strong one, because
Circulation realizes that surgery provides, and I'm a bit biased
when I say this, but I think it is true. It provides the most
robust and durable treatment for advanced heart disease, so it is
very important to be featured prominently in Circulation. And I
think this is what our current leadership and staff at
Circulation are supporting, and I'm tremendously thankful on
behalf of all surgeons.


Dr. Greg Hundley:


Well, on behalf of Carolyn and myself, we want to wish you a
great week and we will catch you next week On the Run. This
program is copyright of the American Heart Association, 2021. The
opinions expressed by speakers in this podcast are their own and
not necessarily those of the editors or of the American Heart
Association. For more, visit ahajournals.org.