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In this study, we sought to compare protein concentrations obtained from a high-throughput proteomics platform (Olink) on samples collected using capillary blood self-collection (with the Tasso+ device) versus standard venipuncture (control). Blood collection was performed on 20 volunteers, including one sample obtained via venipuncture and two via capillary blood using the Tasso+ device. Tasso+ samples were stored at 2°C-8°C for 24-hs (Tasso-24) or 48-h (Tasso-48) prior to processing to simulate shipping times from a study participant's home. Proteomics were analyzed using Olink (384 Inflammatory Panel). Tasso+ blood collection was successful in 37/40 attempts. Of 230 proteins included in our analysis, Pearson correlations (r) and mean coefficient of variation (CV) between Tasso-24 or Tasso-48 versus venipuncture were variable. In the Tasso-24 analysis, 34 proteins (14.8%) had both a correlation r > 0.5 and CV < 0.20. In the Tasso-48 analysis, 68 proteins (29.6%) had a correlation r > 0.5 and CV < 0.20. Combining the Tasso-24 and Tasso-48 analyses, 26 (11.3%) proteins met these thresholds. We concluded that protein concentrations from Tasso+ samples processed 24-48 h after collection demonstrated wide technical variability and variable correlation with a venipuncture gold-standard. Use of home capillary blood self-collection for large-scale proteomics should be limited to select proteins with good agreement with venipuncture., (© 2024 The Authors. Proteomics published by Wiley‐VCH GmbH.)

Abstract: Renal cortical echogenicity represents a marker of renal function. However, evaluation of the renal echotexture is subjective and thus disposed to error and interrater variability. Computer-aided image analysis may be used to objectively assess renal cortical echogenicity by comparing the echogenicity of the left kidney to that of the spleen; the resultant ratio is referred to as the splenorenal index (SRI). We performed a retrospective review of all adult patients who received a renal ultrasound over a 45-day period at our institution. Demographic data and kidney function laboratory values were documented for each patient. Regions of interest (ROIs) were selected in the left renal cortex and spleen using ImageJ software. The SRI was calculated as a ratio of the mean pixel brightness of the left kidney cortex ROI to the mean pixel brightness of the spleen ROI. The SRI was then correlated with serum creatinine, blood urea nitrogen, and estimated glomerular filtration rate. We found that among the 94 patients included in the study, the SRI had a significant positive correlation with serum creatinine ( r = 0.43, P < 0.001) and serum blood urea nitrogen ( r = 0.45, P < 0.001) and negative correlation with estimated glomerular filtration rate ( r = -0.47, P < 0.001). Our data indicate that SRI may serve as a valuable tool for sonographic evaluation of renal parenchymal disease., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Depression and cognitive dysfunction (CD) are not routinely screened for in patients before transcatheter aortic valve replacement (TAVR) and their association with postprocedural outcomes is poorly understood. The objectives of this study are to determine the prevalence of depression and CD in patients with aortic stenosis undergoing TAVR and evaluate their association with mortality and quality of life., Methods: We analyzed a prospective, multicenter TAVR registry that systematically screened patients for preexisting depression and CD with the Patient Health Questionnaire-2 and Mini-Cog, respectively. The associations with mortality were assessed with Cox proportional hazard models and quality of life (Kansas City Cardiomyopathy Questionnaire and EuroQol visual analogue scale) were evaluated using multivariable ordinal regression models., Results: A total of 884 patients were included; median follow-up was 2.88 years (interquartile range=1.2-3.7). At baseline, depression was observed in 19.6% and CD in 31.8%. In separate models, after adjustment, depression (HR, 1.45 [95% CI, 1.13-1.86]; P <0.01) and CD (HR, 1.27 [95% CI, 1.02-1.59]; P =0.04) were each associated with increased mortality. Combining depression and CD into a single model, mortality was greatest among those with both depression and CD (n=62; HR, 2.06 [CI, 1.44-2.96]; P <0.01). After adjustment, depression was associated with 6.6 (0.3-13.6) points lower on the Kansas City Cardiomyopathy Questionnaire 1-year post-TAVR and 6.7 (0.5-12.7) points lower on the EuroQol visual analogue scale. CD was only associated with lower EuroQol visual analogue scale., Conclusions: Depression and CD are common in patients that undergo TAVR and are associated with increased mortality and worse quality of life. Depression may be a modifiable therapeutic target to improve outcomes after TAVR., Competing Interests: Disclosures Dr Fearon receives institutional research support from Edwards, Abbott, Boston Scientific, and Medtronic. Dr Elmariah has received research grants from Edwards Lifesciences, Medtronic, and Abbott and consulting fees from Edwards Lifesciences. Dr Gillam is an advisor to Bracco Diagnostics, Philips and Edwards Lifesciences and directs an imaging core laboratory with contracts with Edwards Lifesciences, Medtronic, and Abbott (no direct compensation). Dr Whisenant is a consultant at Edwards Lifescience and Medtronic. Dr Zajarias is a consultant at Edwards Lifescience. Dr Welt formerly sat on the Medtronic Advisory Board. Dr Coylewright received research funding from Edwards LifeSciences and received consulting fees and serves on an executive steering committee for Medtronic. Dr Piana serves on the data safety monitoring boards for Abbott Medical and Baim Cardiovascular Research Institute and Dr Lindman has received research grants from Edwards Lifesciences and Roche Diagnostics. The other authors report no conflicts.

Objectives: The aim of this study was to determine the safety of eliminating the pre-discharge transthoracic echocardiogram (TTE) on 30-day outcomes in patients undergoing transcatheter aortic valve replacement (TAVR)., Background: TTE is utilized before, during, and after TAVR. Post-procedural, pre-discharge TTE assists in assessment of prosthesis function and detection of clinically significant paravalvular leak (PVL) after TAVR., Methods: Patients who underwent TAVR at Mayo Clinic from July 2018 to July 2019 were included in a prospective institutional registry. Patients undergoing TAVR prior to February 2019 received a pre-discharge TTE, while those undergoing TAVR after February 2019 did not. Both cohorts were evaluated with TTE at 30 days post-TAVR., Results: A total of 330 consecutive patients were included. Of these, 160 patients (age 81.1 ± 7.6) had routine pre-discharge TTE, while 170 patients (age 78.9 ± 7.5) were dismissed without routine pre-discharge TTE. Mortality at 30 days was similar between the two groups (0% and 1.2%, respectively). One episode of PVL requiring intervention (0.6%) occurred in the pre-discharge TTE group and none in the group without pre-discharge TTE at 30-day follow-up. There was a similar incidence of total composite primary and secondary adverse events between the cohort receiving a pre-discharge TTE and those without (28.1% vs. 25.3%, P = 0.56) at 30 days. The most common event was need for permanent pacemaker or ICD implantation in both groups (13.1% vs. 11.8%, P = 0.71)., Conclusions: Elimination of the pre-discharge TTE is safe and associated with comparable 30-day outcomes to routine pre-discharge TTE. These findings have implication for TAVR practice cost-efficiency and health care utilization., (© 2021 Wiley Periodicals LLC.)

Objectives: To determine the incidence, characteristics, and outcomes of patients with hemolysis after transcatheter mitral valve replacement (TMVR)., Background: Hemolysis is an increasingly recognized complication of TMVR. Clinical outcomes and optimal management for patients with hemolysis after TMVR are unclear., Methods: Patients that underwent mitral valve-in-valve (MViV), valve-in-ring (MViR), and valve-in-mitral annular calcification (ViMAC) at a single center were retrospectively assessed., Results: A total of 101 patients had TMVR, including 69 with MViV, 14 with MViR, and 18 with ViMAC. ViMAC patients had an increased frequency of mild or greater paravalvular leak (PVL) (ViMAC, 72.2%; MViR, 14.3%; MViV, 13.0%; p < .001). Hemolysis occurred in eight patients and was more common after ViMAC (ViMAC, 33.3%; MViR, 7.1%; MViV, 1.5%; p < .001). This required transfusion in five (ViMAC, 4; MViV, 1) and was associated with acute kidney injury in five with ViMAC. Among the ViMAC patients, four had transcatheter re-intervention to treat hemolysis with resolution of anemia in three and mild residual anemia in one with persistent mild PVL. The two ViMAC patients without re-intervention had persistent anemia and died within 6 months. Both MViV and MViR patients with hemolysis did not have PVL but had turbulent flow from left ventricular outflow tract narrowing and their hemolysis was self-limited., Conclusions: Hemolysis occurs with greater frequency and increased clinical severity after ViMAC as compared to MViV or MViR and is likely related to increased incidence of PVL. These findings demonstrate the need to investigate novel strategies that can reduce the burden of hemolysis with ViMAC., (© 2021 Wiley Periodicals LLC.)

Coronary artery fistulas (CAFs) are rare coronary anomalies that are usually diagnosed incidentally with cardiac imaging. Small CAFs are generally asymptomatic and can close over time, while some untreated medium or large CAFs can enlarge, leading to clinical sequelae such as cardiac chamber enlargement or myocardial ischemia. With the advancement of transcatheter equipment and techniques, CAFs have been increasingly closed using a percutaneous approach. However, the procedure is not free of limitations given the risk for myocardial infarction, device embolization, and fistula recanalization. In this review, the authors illustrate the contemporary procedural considerations, techniques, and outcomes of transcatheter CAF closure., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background The temporal incidence of high-grade atrioventricular block (HAVB) after transcatheter aortic valve replacement (TAVR) is uncertain. As a result, periprocedural monitoring and pacing strategies remain controversial. This study aimed to describe the temporal incidence of initial episode of HAVB stratified by pre- and post-TAVR conduction and identify predictors of delayed events. Methods and Results Consecutive patients undergoing TAVR at a single center between February 2012 and June 2019 were retrospectively assessed for HAVB within 30 days. Patients with prior aortic valve replacement, permanent pacemaker (PPM), or conversion to surgical replacement were excluded. Multivariable logistic regression was performed to assess predictors of delayed HAVB (initial event >24 hours post-TAVR). A total of 953 patients were included in this study. HAVB occurred in 153 (16.1%). After exclusion of those with prophylactic PPM placed post-TAVR, the incidence of delayed HAVB was 33/882 (3.7%). Variables independently associated with delayed HAVB included baseline first-degree atrioventricular block or right bundle-branch block, self-expanding valve, and new left bundle-branch block. Forty patients had intraprocedural transient HAVB, including 16 who developed HAVB recurrence and 6 who had PPM implantation without recurrence. PPM was placed for HAVB in 130 (13.6%) (self-expanding valve, 23.7% versus balloon-expandable valve, 11.9%; P <0.001). Eight (0.8%) patients died by 30 days, including 1 unexplained without PPM present. Conclusions Delayed HAVB occurs with higher frequency in patients with baseline first-degree atrioventricular block or right bundle-branch block, new left bundle-branch block, and self-expanding valve. These findings provide insight into optimal monitoring and pacing strategies based on periprocedural ECG findings.

Objectives: The aim of this study was to assess the 30 day incidence of paravalvular leak (PVL) and need for aortic valve reintervention of a fourth generation balloon expandable transcatheter valve with enhanced skirt (4G-BEV) (SAPIEN 3 Ultra) compared with a third generation balloon expandable transcatheter valve (3G-BEV) (SAPIEN 3)., Background: The incidence of PVL has steadily declined with iterative improvements in transcatheter aortic valve replacement (TAVR) technology and implantation strategies., Methods: Patients who underwent TAVR at Mayo Clinic from 7/2018 to 7/2019 were included in a prospective institutional registry. 4G-BEV has been utilized since 2/2019, and, after this date, 3G-BEV and 4G-BEV were simultaneously used. 4G-BEV had three sizes (20, 23, and 26 mm) while 3G-BEV included four sizes (20, 23, 26, and 29 mm). Both cohorts were evaluated at 30 days post-TAVR with a transthoracic echocardiogram to assess for PVL., Results: A total of 260 consecutive patients were included. Of these, 101 patients received a 4G-BEV and 159 patients received a 3G-BEV. There were more females (p = .0005) and a lower aortic valve calcium score (p = .02) in the 4G-BEV cohort at baseline. Age, STS risk score, NYHA Class, and aortic valve mean gradient did not differ between groups. 4G-BEV was associated with a lower incidence of mild PVL (10.8 vs. 36.5%; p < .0001) and moderate PVL (0 vs. 5.8%) compared to the 3G-BEV at 30 days. There was no association between PVL and valve size in either cohort., Conclusions: Utilization of 4G-BEV is associated with reduced PVL at 30 days post-TAVR compared with 3G-BEV., (© 2021 Wiley Periodicals LLC.)

Objectives: To evaluate the outcomes of transcatheter coronary artery fistula (CAF) closure and to identify anatomic/procedural factors that may impact outcomes., Background: Due to the rarity of CAF, reported experience with transcatheter closure remains limited and anatomic and procedural factors that may lead to unsuccessful closure, complications, or recanalization of CAF are unclear., Methods: All patients who underwent transcatheter CAF closure at Mayo Clinic from 1997 to 2018 were retrospectively reviewed. CAF anatomic characteristics, procedural techniques, and clinical/angiographic outcomes were assessed., Results: A total of 45 patients underwent transcatheter closure of 56 CAFs. The most commonly used devices were embolization coils in 40 (71.4%) CAFs, vascular occluders in 10 (17.8%), or covered stent in 2 (3.6%). Acute procedural success with no or trivial residual flow occurred in 50 (89.3%) CAFs. Residual flow was small in three (5.4%) and large in three (5.4%). Eight (17.8%) patients had complications, including device migration in three, intracranial hemorrhage from anticoagulation in one, and myocardial infarction (MI) in four. MI was a result of covered stent thrombosis or stagnation of flow after closure of large distal CAF. Twenty-two patients with 27 CAFs had follow-up angiography after successful index procedure at median time of 423 (IQ 97-1348) days. Of these, 23 (85.2%) had no/trace flow and 4 had large flow from recanalization., Conclusions: Transcatheter CAF closure is associated with a favorable acute procedural success and complication rate in selected patients. Procedural success and risk for complication are highly dependent on CAF anatomy and closure technique., (© 2020 Wiley Periodicals, Inc.)

Objective: To describe the hemodynamic and early clinical outcomes of percutaneous alcohol septal ablation in patients with concomitant dynamic left ventricular outflow tract (LVOT) obstruction and aortic valvular stenosis (AS)., Background: Alcohol septal ablation is an established method to relieve dynamic LVOT obstruction in patients with hypertrophic cardiomyopathy (HCM). However, the feasibility, safety, and efficacy of alcohol septal ablation in patients with serial obstructions from HCM and AS remain unclear., Methods: In this case series, we describe the early outcomes of alcohol septal ablation in six patients with significant dynamic LVOT obstruction and AS. All patients had evidence of severe dynamic LVOT obstruction (resting or provoked gradient ≥50 mmHg), mild to severe AS, and NYHA class III symptoms or greater., Results: Four (66.7%) patients had septal ablation performed in the setting of concomitant native valvular AS and two (33.3%) patients had TAVR performed prior to septal ablation. Successful alcohol septal ablation was performed in all patients and was associated with an immediate reduction of the dynamic LVOT gradient with a residual fixed obstruction related to AS. Four (66.7%) patients had follow-up at 1 month and of these, three (75%) had NYHA Class I-II symptoms and one (25%) Class III., Conclusions: Alcohol septal ablation is a feasible method of relieving dynamic LVOT obstruction in patients with concomitant HCM and AS. Further study is required to determine the optimal treatment approach in these patients., (© 2019 Wiley Periodicals, Inc.)

Background: The temporal occurrence of arrhythmic complications after alcohol septal ablation (ASA) is unclear. As a result, the appropriate time to monitor patients after ASA is controversial. The purpose of this study is to determine the temporal occurrence of complete heart block (CHB) and ventricular tachyarrhythmia (VT) after ASA to better understand when patients can be safely discharged., Methods: Consecutive patients treated with ASA for hypertrophic cardiomyopathy from 2003 to 2019 at a tertiary referral center were reviewed retrospectively. The incidence and timing of CHB or sustained VT within 30 days post-ASA were assessed., Results: A total of 243 patients were included in this study. Mean maximal septal thickness was 19.0±3.9 mm, and total volume of ethanol injected was 1.7±0.6 mL. CHB occurred in 59 (24.3%) patients, including transient CHB in 33 (13.6%) and permanent in 26 (10.7%). The initial episode of CHB occurred within 24 hours post-ASA in 51 (21.0%) patients, between 24 and 48 hours in 3 (1.2%), between 48 and 72 hours in 3 (1.2%), and after 72 hours in 2 (0.8%). New permanent pacemaker was placed in 46 (18.3%). Presence of baseline bundle branch block and age ≥70 were significantly associated with CHB but not CHB presenting after 24 hours. VT occurred in 3 (1.2%) patients, including 1 (0.4%) within 24 hours, 1 (0.4%) between 24 and 48 hours, and 1 (0.4%) after 72 hours. VT required cardioversion in 2 patients and new implantable cardioverter-defibrillator placement in 2., Conclusions: The incidence of CHB or VT presenting after 72 hours post-ASA was low. These findings suggest that timely discharge of patients without evidence of early conduction disturbances after ASA can be considered as a potentially safe management strategy, especially in patients without preexisting conduction abnormalities.

Background:  Although lipedema is often clinically distinguished from lymphedema, there is considerable overlap between the two entities. The purpose of this study was to evaluate lymphoscintigraphic findings in patients with lipedema to better characterize lymphatic flow in this patient population., Methods:  Patients with lipedema receiving lymphoscintigraphy between January 2015 and October 2017 were included. Patient demographics, clinical characteristics, and lymphoscintigraphic findings were extracted. Klienhan's transport index (TI) was utilized to assess lymphatic flow in patient's lower extremities (LEs).Scores ranged from 0 to 45, with values > 10 denoting pathologic lymphatic transport., Results:  A total of 19 total patients with lipedema underwent lymphoscintigraphic evaluation. Mean age was 54.8 years and mean body mass index was 35.9 kg/m 2 . Severity of lipedema was classified as stage 1 in five patients (26.3%), stage 2 in four patients (21.1%), stage 3 in four patients (21.1%), and stage 4 in six patients (31.6%). The mean TI for all extremities was 12.5; 24 (63.2%) LEs had a pathologic TI, including 7 LEs with stage 1 (29.2%), 3 LEs with stage 2 (12.5%), 6 LEs with stage 3 (25.0%), and 8 LEs with stage 4 lipedema (33.3%). The mean TI was significantly greater for extremities with severe (stage 3/4) lipedema than those with mild or moderate (stage 1/2) lipedema (15.1 vs. 9.7, p  = 0.049). Mean difference in TI scores between each LE for individual patients was 6.43 (standard deviation +7.96)., Conclusion:  Our results suggest that patients with lipedema have impaired lymphatic transport, and more severe lipedema may be associated with greater lymphatic transport abnormalities., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Patients with lymphedema refractory to medical treatment often have unrealistic expectations for lymphedema surgery. The purpose of this study was to assess patient expectations following lymphedema surgery., Methods: Patients presenting to the clinic for initial evaluation for lymphedema surgery were offered to complete a survey designed to evaluate their expectations for limb appearance, limb function, and overall well-being following lymphedema surgery. The patients were instructed to score each item using a five-point scale for improvement. A mean expectation score was calculated, which was then used to estimate the effects of preoperative variables on patients expectations using multiple regression analysis., Results: A total of 21 women and two men with a mean age of 60 years completed the survey. The upper limbs were affected in 10 patients and the lower limbs were affected in 13 patients. Physicians were the initial source of information about lymphedema surgery as a potential treatment option in 10 patients (43 percent), and a majority of the patients [n = 15 (65.2 percent)] thought that the physicians had fair or poor knowledge about lymphedema surgery. Significant or complete improvement was expected by 43.4 to 73.9 percent of patients. Patients' level of education, the disease duration, and the initial source of information about lymphedema surgery had a statistically significant impact on patients' expectations., Conclusions: Early data suggest that most patients learn about lymphedema surgery from nonphysicians, with many expecting complete or significant improvement of lymphedema-associated symptoms with surgery. These findings emphasize the importance of addressing patient expectations and providing appropriate counseling before surgery.

Background: The impact of post-mastectomy radiotherapy (PMRT) on patient-centered outcomes of breast reconstruction remains unclear. This comprehensive review aims to consolidate the available data regarding aesthetic outcomes, patient satisfaction, and the BREAST-Q © following breast reconstruction in the setting of PMRT to facilitate the informed consent and shared decision-making process., Materials and Methods: A systematic search of the literature published from 2000 to 2016 in the PubMed/MEDLINE database was performed to identify all manuscripts reporting aesthetic outcome, patient satisfaction, or BREAST-Q © scores of patients undergoing PMRT and breast reconstruction., Results: The initial search identified 1604 potential titles. Ultimately, 29 manuscripts fit inclusion criteria and were included in this review. A total of 21 studies reported measures of aesthetic outcomes (1611 patients). Positive aesthetic outcomes ("good" or "better") widely varied in patients with prosthetic reconstruction and ranged from 36% to 100%. In addition, positive aesthetic outcomes following autologous reconstruction ranged from 70% to 90%. Measures of patient satisfaction were evaluated in eight studies (722 patients). Satisfaction rates ranged from 41% to 90% following prosthetic reconstruction and 74%-75% following autologous reconstruction. BREAST-Q © findings were reported in four studies (575 patients), all evaluating outcomes following prosthetic reconstruction. The range of satisfaction with breasts was 48.9-57.2; satisfaction with outcome, 63.8-70.2; psychosocial well-being, 63.9-72.3; sexual well-being, 45.4-55.4; and physical well-being, 71.7-75.1., Conclusions: Breast reconstruction in the setting of PMRT is associated with poorer outcomes. However, the majority of studies indicate that acceptable rates of positive aesthetic outcomes and patient satisfaction can be achieved in the setting of PMRT., (Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Surgical telementoring is a concept within telemedicine that involves the use of information technology to provide real-time guidance and technical assistance for surgical procedures from an expert physician at a different geographical location. It is a means to overcome the logistic obstacles associated with traditional mentoring and can aid in the distribution of advanced surgical techniques. In addition to its perceived educational benefits, it has the potential to directly impact patient care by providing immediate access to specialized surgical expertise in areas lacking access to qualified surgeons. With advances in technology, surgical telementoring has made significant strides in the past two decades and a breadth of positive experiences have been published in the literature. Despite this growth, questions remain regarding ideal videoconferencing methodology, resolution and latency requirements, security and liability issues, and telementoring in combination with emerging technology. This review addresses the history and progression, current applications, and future directions of surgical telementoring as a means to distribute advanced surgical expertise around the world., Competing Interests: The authors have no conflicts of interest to declare.

Postmastectomy radiation (PMRT) in the setting of immediate breast reconstruction has been associated with increased complications and poorer aesthetic outcomes for both autologous and implant reconstructions. Many centers have attempted to mitigate the deleterious effects associated with radiation by implementing an algorithmic approach to breast reconstruction. Although the literature regarding the optimal timing of radiotherapy and breast reconstruction remains controversial, reported outcomes following various algorithms have been encouraging and warrant further consideration. J. Surg. Oncol. 2016;113:906-912. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Background and Objectives: The impact of adjuvant therapy on the surgical outcomes following breast reconstruction is poorly understood. The purpose of this systematic review was to evaluate surgical outcomes following autologous and prosthetic reconstruction in the setting of post-mastectomy radiation therapy (PMRT) and adjuvant chemotherapy., Methods: A systematic review of the English literature published from 2000 to 2015 in the Pubmed/MEDLINE database was performed to identify all manuscripts reporting outcome of breast reconstruction in patients receiving PMRT and/or adjuvant chemotherapy., Results: Sixty-two manuscripts met the criteria for inclusion. This included 56 manuscripts (5437 patients) evaluating patients treated with PMRT and 11 manuscripts (820 patients) evaluating patients treated with chemotherapy. Pooled analysis of the PMRT cohort revealed significantly higher weighted incidences of re-operation (P < 0.0001), total complications (P < 0.0001), and reconstructive failure (P < 0.0001) in prosthetic reconstruction compared to autologous. There was little evidence to suggest that postoperative chemotherapy is associated with poorer overall outcomes., Conclusions: PMRT was associated with an increased incidence of adverse events when compared to chemotherapy. There was little evidence to suggest that adverse events following breast reconstruction were related to adjuvant chemotherapy. Manipulating the method and timing of reconstruction may mitigate some of the undesirable outcomes associated with PMRT., (© 2015 Wiley Periodicals, Inc.)