Abstract
Objective:
To evaluate whether 5-m gait speed, an established marker of frailty, is associated with post-operative events following elective proximal aortic surgery.
Methods:
A retrospective review of 435 patients >60 years of age who underwent elective proximal aortic surgery, defined as surgery on the aortic root, ascending aorta, and/or aortic arch through median sternotomy. Patients completed a 5-m gait speed test within 30-days prior to surgery. We evaluated the association between categorical (slow, ≤0.83 m/s and normal, >0.83 m/s) and continuous gait speed and the likelihood of experiencing the composite outcome before and after adjustment for EuroSCORE II. The composite outcome included in-hospital mortality, renal failure, prolonged ventilation, and discharge location. Secondary outcomes were 1-year mortality and 5-year survival.
Results:
Of the study population, 30.3% (132/435) were categorized as slow. Slow walkers were significantly more likely to suffer in-hospital mortality, prolonged ventilation, renal failure, and were less likely to be discharged home (p’s<0.05). The composite outcome was 2 times more likely to occur for slow walkers (gait speed-categorical adjusted odds ratio (OR), 2.08; 95% confidence interval (CI), 1.27-3.40; p=0.0035). Moreover, a unit (1m/s) increase in gait speed (continuous) was associated with 73% lower risk of experiencing the composite outcome (OR 0.27, 95% CI: 0.11-0.68; p=0.0056).
Conclusion:
Slow gait speed is a preoperative indicator of risk for post-operative events following elective proximal aortic surgery. Gait speed may be an important tool to complement existing operative risk models, and its application may identify patients who may benefit from pre- and post-surgical rehabilitation.
Keywords: Proximal aortic surgery, frailty, gait speed, risk analysis
INTRODUCTION
The prevalence of thoracic aortic disease is 5-10 cases per 100,000 individuals per year,1,2 with surgical intervention warranted based on established guidelines.3,4 The Society of Thoracic Surgery-Predicted Risk of Mortality (STS-PROM) and European System for Cardiac Operative Risk Evaluation (EuroSCORE II),5 are existing risk models used to predict mortality and morbidity after cardiac surgery. In the setting of thoracic aortic disease, EuroSCORE II is the more appropriate risk model as it includes operations performed on the thoracic aorta.5,6 However, thoracic aortic surgeons often rely on the subjective “eyeball” test to assess operative risk and to counsel patients.7
Slow gait speed measured over 5-meters is recognized as a surrogate marker of frailty, and it is an established independent predictor of operative mortality and morbidity following coronary artery bypass grafting, aortic valve surgery, mitral valve surgery, and combined procedures.8,9 Gait speed as an indicator of operative risk has yet to be assessed in elective proximal aortic surgery, which is important given that its application may complement existing operative risk models and identify patients who may benefit from pre- and post-surgical rehabilitation. The purpose of this study was to evaluate whether 5-m gait speed, an established marker of frailty, is a preoperative indicator for adverse post-operative events following elective proximal aortic surgery.
METHODS
Study Design and Population
A retrospective observational study of 435 patients who underwent elective proximal aortic surgery due to an aortic aneurysm or chronic aortic dissection was performed. Elective proximal aortic surgery was defined as surgery on the aortic root, ascending aorta, and/or aortic arch through median sternotomy using cardiopulmonary bypass with or without hypothermic circulatory arrest10.
The Society of Thoracic Surgeons (STS) began collecting 5-meter (m) gait speed as of July 2011. Patients were excluded from the analysis if gait speed was not available. Five general explanations for incomplete data are provided: (1) patient refusal; (2) insufficient time in clinic or the test was inadvertently not conducted; (3) patients may have been unable to perform test; (4) test was not routinely performed until TAVR required the completion in 2012; and (5) test may not have been performed if the patient was admitted pre-operatively. A comparison between patients with gait and no gait speed is provided in Supplemental Table 1.
Patients presented herein were >60 years of age8 and completed 5-m gait speed testing within 30-days prior to elective proximal aortic surgery occurring between July 2011 and July 2018. A CONSORT diagram of the study population is shown in Figure 1. This article was prepared in accordance with the standards set forth by the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines.11 The analytical methods will be made available upon request to other researchers for purposes of reproducing the results or replicating the study procedures.
Figure 1. CONSORT diagram.
The final cohort consisted of 435 patients residing within the institution’s STS Adult Cardiac Surgery Databases. Patients were excluded (N=691) if the study team was unable to decipher if the patient was unable to complete the 5-m gait speed or if the 5-m gait speed test was not conducted.
5-m Gait Speed Test
Patients performed the 5-m gait speed test according to standardized instructions. The patient was positioned with feet behind and just touching the 0-m start line, instructed to “walk at your comfortable pace” until a few steps past the 5-m mark (should not start to slow down before), and to begin each trial on the word “go”. The timer was started with the first footfall after the 0-m line and the timer was stopped with the first footfall after the 5-m line. Three trials were repeated, sufficient time for recuperation was permitted between trials, and average gait speed was calculated. Gait speed was defined as the ratio between distance and time measured with a chronometer, and cutoffs were defined with walking times ≤0.83 m/s classified as “slow gait speed” and >0.83 m/s classified as “normal gait speed”.8
Outcomes
We evaluated the association between categorical and continuous gait speed and the likelihood of experiencing the composite outcome before and after adjustment for EuroSCORE II. The composite outcome was the primary outcome, which was comprised of in-hospital mortality, renal failure, prolonged ventilation, and discharge to a location other than home. Secondary outcomes were 1-year mortality and 5-year survival. Discharge location other than home was categorized and defined as discharge to a post-acute care facility, extended care, rehabilitation, or transitional care. Reoperation was categorized and defined as a sternotomy following an initial index sternotomy. Patients undergoing reoperation were included in the analysis as our prior work shows that reoperation is not a risk factor for operative mortality.12,13 Patient characteristics and comorbidities were extracted from the STS Adult Cardiac Surgery Database and supplemented with electronic medical record review to verify findings as previously described.8 Investigators utilized the National Death Index database through December 31, 2018. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was utilized to calculate risk of operative mortality as surgical procedure to the aorta is factored in the model.5
Statistical Analysis
A cutoff of 0.83 m/s was used to categorize patients as slow or normal walkers as previously reported.8 Initial analysis provided descriptive information on the demographic, clinical, and surgical characteristics. Continuous variables are expressed as medians (25th – 75th percentiles) and categorical variables as n (%) in frequency tables. Univariate comparisons between groups were performed using chi-square tests for categorical data and Wilcoxon rank sum tests or t tests for continuous data.
There was no missing data for gait speed, post-operative events, in-hospital mortality, discharge location, length of hospital admission, EuroSCORE II, and 1-year mortality. Univariable and multivariable logistic regression models were used to assess the association of gait speed as a categorical variable and the composite outcome. Composite outcome was defined as any postoperative event including prolonged ventilation, renal failure, in-hospital mortality, and discharge location not home. The multivariable model included EuroSCORE II. EuroSCORE II was calculated based on age, gender, chronic pulmonary disease, poor mobility, previous cardiac surgery, active endocarditis, critical preoperative state, renal impairment, diabetes, Canadian Cardiovascular Society Angina Grade, left ventricular function, recent myocardial infarction, pulmonary hypertension, New York Heart Association class, surgery on the thoracic aorta, surgical urgency, and weight of the operation.5,6 Results are reported as odds ratios (ORs) with 95% confidence interval (CIs). Modeling gait speed as a continuous variable was performed. Crude survival curves of all patients since surgery were estimated using the non-parametric Kaplan-Meier method. A log-Rank test was used to compare the survival curves between the two groups. All statistical calculations used SAS 9.4 (SAS Institute, Cary, NC) and were considered significant at p<0.05.
RESULTS
Baseline Characteristics
This study was comprised of 435 patients with a median age was 68 years and 25.7% of patients were female. Of these patients, 132 (30.3%) were categorized as slower walkers with a 5-m gait speed ≤0.83 m/s. The slow group had significantly more comorbidities including obesity (52.3% versus 38.6%), hypertension (89.4% versus 77.2%), dyslipidemia (86.4% versus 77.2%), peripheral (23.5% versus 12.2%) and cerebral (24.2% versus 15.8%) vascular disease, moderate-to-severe heart failure (27.3% versus 9.0%), and elevated pulmonary artery systolic pressure (36mmHg [30,41] versus 32mmHg [28, 37]) (p values < 0.05). EuroSCORE II for the slow group was 5.1% (3.0%, 11.0%) compared to 3.9% (2.8%, 6.3%) for the normal group (p=0.0005) (Table 1).
Table 1.
Baseline Characteristics by Gait Speed Group
| Variables | All Patients n=435 |
Slow n=132 |
Normal n=303 |
P Value |
|---|---|---|---|---|
| Demographics | ||||
| Age (years) | 68 (64, 73) | 70 (65, 75) | 67 (63, 73) | .0060 |
| Age > 70 years | 177 (40.7) | 68 (51.5) | 109 (36.0) | .0024 |
| Female (% yes) | 112 (25.7) | 33 (25.0) | 79 (26.1) | .8140 |
| BMI (kg/m2) | 28.8 (25.8, 32.9) | 30.4 (26.7, 34.9) | 28.5 (25.7, 32.4) | .0047 |
| Comorbidities | ||||
| Obese (>30 kg/m2) | 186 (42.8) | 69 (52.3) | 117 (38.6) | .0081 |
| Hypertension | 357 (82.1) | 118 (89.4) | 239 (78.9) | .0086 |
| Diabetes | 75 (17.2) | 28 (21.2) | 47 (15.5) | .1478 |
| Dyslipidemia | 348 (80.0) | 114 (86.4) | 234 (77.2) | .0285 |
| Peripheral vascular disease | 68 (15.6) | 31 (23.5) | 37 (12.2) | .0029 |
| Cerebral vascular disease | 80 (18.4) | 32 (24.2) | 48 (15.8) | .0376 |
| Severe coronary artery disease † | 48 (11.0) | 16 (12.1) | 32 (10.6) | .6330 |
| Mod- or severe chronic lung disease | 29 (6.7) | 11 (8.3) | 18 (5.9) | .3577 |
| Liver disease | 8 (1.8) | 4 (3.0) | 4 (1.3) | .2524 |
| NYHA III, IV | 64 (14.7) | 36 (27.3) | 28 (9) | <.0001 |
| PASP, mmHg | 33 (28, 39) | 36 (30, 41) | 32 (28, 37) | 0.0001 |
| LVEF, % | 60 (55, 65) | 60 (55, 65) | 60 (56, 65) | .3439 |
| Severe aortic stenosis | 110 (25.3) | 30 (22.7) | 80 (26.4) | .4175 |
| Laboratory | ||||
| Creatinine, mg/dL | 1.0 (.8, 1.1) | .9 (.8, 1.1) | 1.0 (.8, 1.1) | .0875 |
| Hemoglobin g/dL | 14.1 (13.3, 15.1) | 13.8 (13.2, 14.8) | 14.4 (13.4, 15.3) | .0016 |
| Albumin g/dL | 4.4 (4.2, 4.5) | 4.3 (4.1, 4.5) | 4.4 (4.2, 4.5) | .0008 |
| Thoracic aortic aneurysm location | ||||
| Root | 197 (45.3) | 60 (45.5) | 137 (45.2) | .9631 |
| Ascending | 399 (91.7) | 121 (91.7) | 278 (91.7) | .9771 |
| Arch | 160 (36.8) | 47 (35.6) | 113 (37.3) | .7372 |
| Descending | 23 (5.3) | 7 (5.3) | 16 (5.3) | .9923 |
| BAV | 158 (36.3) | 41 (31.1) | 117 (38.6) | .1321 |
| Chronic dissection | 14 (3.2) | 6 (4.5) | 8 (2.6) | .3751 |
| Euroscore II | 4.3 (2.9, 7.5) | 5.1 (3.0, 11.0) | 3.9 (2.8, 6.3) | .0005 |
Data presented as median (interquartile range: 25%, 75%) for continuous data and n (%) for categorical data.
Overall p value
Abbreviations: BMI=Body mass index, NYHA=New York Heart Association Class, LVEF=left ventricular ejection fraction, PASP=Pulmonary artery systolic pressure.
Severe coronary artery disease was defined as 3 vessel or left main occlusion >50%.
Intra- and post-operative outcomes
Aortic and concomitant procedures were similar between groups. Concomitant procedures were defined as a concurrent cardiac procedure including coronary artery bypass grafting and mitral or tricuspid valve repair/replacement. The slow group was significantly more likely to be undergoing reoperation following an initial index cardiac procedure (15.9% versus 6.3%, p=0.0014; Table 2). The slow group was ventilated longer (>24 hours) (6.9% versus 1.7%, p=0.0137), experienced more renal failure (3.8% versus 0.7%, p=0.0292), and was more likely to be discharged to a location other than home (28.0% versus 15.5%, p=0.0024). Duration of hospital admissions was 7 days (5, 9) for the slow group versus 6 days (5, 8) for the normal group (p=0.0545). In-hospital mortality was significantly higher for the slow group versus the normal group (3.0% versus 0.3%, p=0.0313). One-year mortality was 4.5% for the slow group and 1.0% for the normal group (p=0.0255). (Table 3)
Table 2.
Intraoperative Data
| Variables | All Patients n=435 |
Slow n=132 |
Normal n=303 |
P Value |
|---|---|---|---|---|
| Aortic root procedure | .748 | |||
| None | 47 (10.8) | 15 (11.4) | 32 (10.6) | .8042 |
| Aortic valve replacement | 138 (31.7) | 42 (31.8) | 96 (31.7) | .9778 |
| Bioprosthetic | 138 (31.7) | 42 (31.8) | 96 (31.7) | - |
| Mechanical | 0 (0) | 0 (0) | 0 (0) | - |
| Root replacement | 192 (44.1) | 61 (46.2) | 131 (43.2) | .5653 |
| Bentall | 59 (13.6) | 25 (18.9) | 34 (11.2) | - |
| Bioprosthetic | 57 (13.1) | 23 (17.4) | 34 (11.2) | - |
| Mechanical | 2 (0) | 2 (1.5) | 0 (0) | - |
| Inclusion root | 111 (25.5) | 29 (22.0) | 82 (27.1) | - |
| VSARR | 22 (5.1) | 7 (5.3) | 15 (1.6) | - |
| Root repair | 58 (13.3) | 14 (10.6) | 44 (14.5) | .2694 |
| Ascending replacement | 398 (91.5) | 121 (91.7) | 277 (91.4) | .9322 |
| Any arch replacement | 179 (41.1) | 51 (38.6) | 128 (42.2) | .4821 |
| Hemiarch | 135 (31.0) | 37 (28.0) | 98 (32.3) | .3714 |
| Total Arch | 58 (13.3) | 14 (10.6) | 44 (14.5) | .2694 |
| Cardiopulmonary bypass time (min) | 193 (161, 240) | 195 (166, 239) | 190 (156, 230) | .2897 |
| Cross clamp time (min) | 144 (111, 182) | 145 (112, 186) | 140 (106, 173) | .1245 |
| Reoperation † | 40 (9.2) | 21 (15.9) | 19 (6.3) | .0014 |
| Concomitant Surgery ‡ | ||||
| CABG | 48 (11.0) | 15 (11.4) | 33 (10.9) | .8850 |
| MV repair or replacement | 29 (6.7) | 10 (7.6) | 19 (6.3) | .6159 |
| TV repair or replacement | 9 (2.1) | 3 (2.3) | 6 (2.0) | 1.000 |
| CABG + MV or TV repair or replacement | 6 (1.4) | 2 (1.5) | 4 (1.3) | 1.000 |
Data presented as median (25%, 75%) for continuous data and n (%) for categorical data.
Overall p value
Abbreviations: CABG=Coronary artery bypass grafting; MV=mitral valve repair or replacement; TV=tricuspid valve repair or replacement
Reoperation was defined as a sternotomy or thoracotomy following an initial index procedure .
Concomitant surgery was defined as aortic plus one or more of the following: coronary artery bypass grafting and mitral or tricuspid valve repair or replacement.
Table 3.
Postoperative Data
| Variables | All Patients n=435 |
Slow n=132 |
Normal n=303 |
P Value |
|---|---|---|---|---|
| Reoperation any reason within 30-days | 16 (3.7) | 7 (5.3) | 9 (3.0) | .2697 |
| Prolonged ventilation (>24 hours) | 14 (3.2) | 9 (6.9) | 5 (1.7) | .0137 |
| Stroke | 17 (3.9) | 6 (4.5) | 11 (3.6) | .6507 |
| Renal failure | 7 (1.6) | 5 (3.8) | 2 (0.7) | .0292 |
| Sepsis | 4 (0.9) | 3 (2.3) | 1 (0.3) | .0854 |
| Acute limb ischemia | 1 (0.2) | 0 (0.3) | 1 (0.7) | 1.000 |
| Hospital admission (days) | 6 (5, 9) | 7 (5, 9) | 6 (5, 8) | .0545 |
| Discharge location, not home | 84 (19.3) | 37 (28.0) | 47 (15.5) | .0024 |
| In-hospital mortality | 5 (1.1) | 4 (3.0) | 1 (0.3) | .0313 |
| 1-year mortality | 9 (2.1) | 6 (4.5) | 3 (1.0) | .0255 |
Data presented as median (25%, 75%) for continuous data and n (%) for categorical data.
Overall p value
In-hospital mortality was defined as mortality in the hospital before discharge.
The frequency of the composite outcome was 31.1% and 16.2% for the slow and normal groups, respectively. In the unadjusted logistics model, slow gait speed was associated with an increase in the composite outcome (OR 2.34; 95% CI, 1.45-3.77; p=0.00005). In the adjusted model, the composite outcome was 2 times more likely to occur within the slow group (gait speed- categorical adjusted OR, 2.08; 95% CI, 1.27-3.40; p=0.0035) (Table 4, Figure 2/Graphical Abstact). We assessed gait speed as a continuous variable and report that a unit (1 m/s) increase in gait speeds was associated with 73% less risk of experiencing the composite outcome (OR 0.27; 95% CI:0.108-0.68; p=0.0056) (Table 4). The 5-year survival was similar between slow (85.5% [95% CI: 73.5%, 92.3%]) and normal (85.0% [95% CI: 77.9%, 89.9%]), p=0.4079) groups (Figure 3).
Table 4.
Gait Speed is a Preoperative Indicator for Post-Operative Events After Adjusting for EuroSCORE II Predicted Risk
| Variables | 95% Wald Confidence Limits |
|||
|---|---|---|---|---|
| OR | Lower | Upper | P Value | |
| Composite Outcome | ||||
| Gait Speed (Categorical Variable) | ||||
| Unadjusted gait speed | 2.34 | 1.45 | 3.77 | 0.0005 |
| Adjusted gait speed | 2.08 | 1.27 | 3.40 | 0.0004 |
| EuroSCORE II | 1.05 | 1.01 | 1.09 | 0.0107 |
| Gait Speed (Continuous Variable) | ||||
| Unadjusted gait speed | .23 | 0.09 | 0.58 | 0.0018 |
| Adjusted gait speed | .27 | 0.11 | 0.68 | 0.0056 |
| EuroSCORE II | 1.05 | 1.01 | 1.10 | 0.0061 |
Logistic regression model with gait speed as a categorical (slow versus normal) and continuous variable
Figure 2/Graphical Abstract.
Gait speed is a preoperative indicator of the composite outcome, which included prolonged ventilation, renal failure, discharge location, and in-hospital mortality.
Figure 3.
Kaplan-Meier survival analysis shows no difference in long-term survival for slow and normal walkers following elective thoracic aortic surgery (p=0.4079).
DISCUSSION
Risk assessment is critical for surgeons as its application guides perioperative care and identifies which patients may be at an increased risk for adverse outcomes. Patients with slow gait speed were older with more obesity, hypertension, dyslipidemia, heart failure, and peripheral/cerebral vascular disease. Slow gait speed was a preoperative indicator of risk for post-operative events, including renal failure, prolonged ventilation, in-hospital mortality, and discharge location following proximal aortic surgery. Moreover, an increase in gait speed of one unit (1 m/s) was associated with 73% less risk of experiencing the composite outcome (OR 0.27; 95% CI:0.11-0.68; p=0.0056)
Earlier work by Ganapathi et al. showed that frailty, using a 6 component frailty index comprised of preoperative variables was independently associated with discharge to a location, 30-day and 1-year mortality following elective and nonelective proximal aortic (root, ascending, and/or arch) surgery.10 This study builds on this initial work indicating that frail patients prior to elective proximal aortic surgery appear to be at an increased risk of adverse post-operative events including mortality around 30-days and 1-year. Our findings also align with the well-established body of evidence showing slow gait speed as a predictor of 30-day mortality, longer hospital admissions, and lower probability to be discharged home.8,14,15 Taken together, gait speed is an easy-to-obtain measure of risk and may be used to guide pre- and post-operative patient care.
Pre-operative targeted intervention, such as a multimodal pre-habilitation program, has the potential to mitigate the physiological insult of a major surgical operation, thereby reducing the risk of adverse outcomes after surgery. Our institution has established the Michigan Surgical Home & Optimization Program (MSHOP) which is a home-based clinical prehabilitation program centered on optimizing the preoperative time period (i.e., time of surgical decision-making until the operative procedure) through exercise and patient education by providing spirometry instruction and information on nutrition, stress reduction, and smoking cessation. The efficacy of this prehabilitation program demonstrated a 31% decrease in the length of hospital admission and a 28% decrease in healthcare costs following major elective general and thoracic surgery compared to controls that received routine care.16 We believe that the implementation of MSHOP or other prehabilitation programs17,18 could serve as valuable tools for improving clinical outcomes and decreasing risk following a major cardiac surgery.
Regular moderate-intensity aerobic exercise training is the most promising treatment approach with the potential to improve or reverse the frailty phenotype in older adults with cardiovascular disease,19,20 mostly through improvements in cardiorespiratory fitness. Recently, we reported that cardiorespiratory fitness (peak oxygen consumption [VO2peak]) was 36% less than predicted normative values (19.2 mL.kg−1.min−1 versus 29.3 mL.kg−1.min−1, p<0.0001) three months following thoracic aortic surgery for a thoracic aortic aneurysm and/or acute type A aortic dissection.21,22 In the present study, we identified slow gait speed in 30.3% of our cohort with 28.0% of patients discharged to a location other than home. As such, post-operative exercise training offered through cardiac rehabilitation may be an effective strategy to reverse the observed frailty phenotype as well as to improve cardiorespiratory fitness, which is clinically important considering both frailty and reduced cardiorespiratory fitness are independently associated with an increased risk of morbidity and mortality.23,24
There are important limitations to consider when interpreting the findings of our study. Our sample size is small (n=435) compared to many studies examining gait speed in cardiac surgery populations, which potentially limits the statistical power to sufficiently assess the relationship between gait speed and postoperative mortality and morbidity. Supplemental Table 1 provides univariate comparisons of pre-operative and mortality outcomes for patients with gait speed compared to no gait speed. Thirty-three percent of patients did not have the gait speed test, and the patients who did not have the test, compared with those that did, were significantly more likely to have cerebrovascular disease, chronic lung disease, elevated pulmonary artery systolic pressure, reduced ejection fraction, elevated creatinine, and decreased hemoglobin and albumen. We acknowledge that the results presented herein may not be applicable to a population for whom the gait speed test was more broadly applied.
CONCLUSION
We provide initial evidence to show that slow gait speed was a preoperative indicator for adverse post-operative events following elective proximal aortic surgery. Slow gait speed is an established surrogate marker of frailty and routine preoperative testing prior to elective proximal aortic surgery may assist with the identification of patients who are at an increased risk. Early risk stratification may improve patient education and better guide those patients who may benefit from pre- and post-surgical rehabilitation.
Supplementary Material
VIDEO
Discussion of study outcomes for slow vs. normal walkers following following elective proximal aortic surgery.
CENTRAL PICTURE.
Gait speed is an indicator for post-operative events following proximal aortic surgery.
CENTRAL MESSAGE
Slow gait speed is a preoperative indicator for post-operative events, including in-hospital mortality, discharge location, prolonged ventilation, and renal failure following proximal aortic surgery.
PERSPECTIVE STATEMENT
Slow gait speed is a preoperative indicator for post-operative events, and thus, routine gait speed testing prior to surgery may assist with the identification of higher risk patients. Early risk stratification may help with patient education and to identify patients who may benefit from pre- and post-surgical rehabilitation.
Funding Source:
Dr. Yang is supported by the NHLBI of NIH K08HL130614, Phil Jenkins and Darlene & Stephen J. Szatmari Funds.
GLOSSARY OF ABBREVIATIONS
- BMI
Body mass index
- CI
Confidence interval
- IQR
Interquartile range
- HR
Hazard ratio
- OR
Odds ratio
- STS
Society of Thoracic Surgeons
- STROBE
Strengthening the Reporting of Observational Studies in Epidemiology
Footnotes
Conflict of Interest: None
Date and Number of IRB approval: 4/11/2016 and HUM00112530
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Discussion of study outcomes for slow vs. normal walkers following following elective proximal aortic surgery.